Smart Money Podcast: Behind the Rising Health Care Costs of Bodily Autonomy

Welcome to NerdWallet’s Smart Money podcast, where we answer your real-world money questions. In this episode: the rising health care prices at the intersection of law, policy and personal health decisions.

Investing Nerd Sam Taube interviews Vina Smith-Ramakrishnan, a senior policy associate on the health care equity and reform team at the Century Foundation, about barriers to health care and how they affect the LGBTQ+ community, people of color and low-income individuals. Sam also talks with Jose Abrigo, the director of the HIV project at Lambda Legal, about recent court cases.

The conversation highlights the legal battles over issues like abortion, birth control and gender-affirming health care, which affect insurance coverage and overall health care spending. It also looks at financial hardships associated with health care and their long-term effects on marginalized communities.

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NerdWallet stories related to this episode:

Is Birth Control Free?

How to Get PrEP With or Without Insurance

How to Find an LGBTQ-Supportive Financial Advisor

Have a money question? Text or call us at 901-730-6373. Or you can email us at [email protected]. To hear previous episodes, go to the podcast homepage.

Episode transcript

Sean Pyles: Health care is one of those things we all have in common. Pretty much everybody goes to the doctor and most of us pay something to get that health care. But recently, in large part due to court decisions and new state laws, it's becoming more and more difficult for portions of the population to afford the care they seek and need.

Vina Smith-Ramakrishnan: A lot of the folks who are being impacted by these bans and restrictions, especially at the federal level but also at the state level, they're disproportionately impacting people who are already struggling to make ends meet.

Sean Pyles: Welcome to NerdWallet's Smart Money Podcast. I'm Sean Pyles.

Sam Taube: And I'm Sam Taube.

Sean Pyles: This episode kicks off our Nerdy deep dive into the cost of bodily autonomy. This is all about health care, specifically reproductive, sexual and gender-affirming health care.

Sam Taube: That's right, Sean. Gender, sexuality and reproduction are fundamental to our bodily autonomy. They're fundamental parts of who we are, but they sometimes require a type of health care that's prohibitively expensive for millions of Americans, and several recent court decisions could put it out of reach for millions more.

Sean Pyles: OK, Sam, for listeners who might be a little confused right now, tell me why are we doing this series? Don't you typically cover the autonomy of the stock market?

Sam Taube: I do, and I love it. But Sean, before I joined NerdWallet, I was a freelance reporter for two years, and I struggled a lot with the cost of health care.

Sean Pyles: As do a lot of people. But what got you interested in reproductive, sexual and gender-affirming health care in particular?

Sam Taube: Well, I kept running into really annoying insurance problems with a medication that I take to protect myself against HIV, as do a lot of other LGBTQ+ people.

Sean Pyles: You're talking about pre-exposure prophylaxis or PrEP?

Sam Taube: Yeah, PrEP. I was paying thousands of dollars a year in PrEP related bills that I never should have gotten in the first place. And I was spending hours on the phone with insurance companies to try to figure out why. And during all those frustrating experiences, I kept thinking, for lack of a better way to put this, I wouldn't have to deal with these problems if I were straight. And that experience made me think about the inequalities that some groups face in affording health care that meets their needs. Health care is expensive for everyone in America, but it's especially expensive if you need certain kinds of sexual-, reproductive- or gender-related health care.

Sean Pyles: That sounds like a problem a lot of people will run into at some point.

Sam Taube: Definitely. Most of us will need some kind of bodily autonomy health care at some point in our lives. And in many cases, whether we're talking about birth control or HIV prevention or hormone therapy, this means monthly prescriptions which create ongoing costs for patients. So in this series we're looking at how recent events have changed the cost and accessibility of these kinds of services, and we'll also talk to some experts about how you can make autonomy care more affordable for yourself.

Sean Pyles: All right, well, listener, we want to hear what you think, too. To share your thoughts, ideas, concerns around the cost of bodily autonomy, leave us a voicemail or text the Nerd hotline at 901-730-6373. That's 901-730-NERD. Or email a voice memo to [email protected].

So Sam, to get started, you keep using the phrase bodily autonomy. Can you define that please?

Sam Taube: Yeah. In simple terms, bodily autonomy is just the idea that your body belongs only to you and you're the only person who makes decisions about it, and no one else gets to decide what happens to your body. It's a pretty universally accepted idea. I think you'd be hard-pressed to find someone who says they are against bodily autonomy in principle.

Sean Pyles: But?

Sam Taube: But in practice, we obviously don't all agree about the limits of bodily autonomy. We can all think of some things that you can do with your body that are controversial, and a lot of these things involve gender identity or sexual orientation or reproduction in some way.

So on the one hand, this is a simple concept that underpins a lot of our basic human rights. But on the other, people get uncomfortable talking about what it actually means in practice. Last September, Dr. Natalia Kanem, who is the executive director of the United Nations Population Fund, gave a speech about this tension at the U.N. General Assembly, and I think she lays it out really well.

Dr. Natalia Kanem: Without the fundamental abilities for a person to make decisions about their own bodies, about their sexuality, about their reproduction, women and girls’ agency is stifled, other rights fade away and gender equality becomes more out of reach. The term bodily autonomy itself is taboo because discussions of the body, of menstruation, of disability are difficult in many situations, many societies.

Sam Taube: And here in the States, when you seek out health care related to this kind of bodily autonomy, you often hit some kind of political barrier.

Sean Pyles: Can you be a little more specific? Maybe give some examples of what you mean.

Sam Taube: Yeah. So suppose you're a trans person and you want to medically change your gender, or you're a gay man who wants to protect himself against HIV, or you're someone who wants to prevent a pregnancy by using birth control or you're someone who wants to terminate a pregnancy. All of these things are hot button political issues right now and in certain parts of the country, getting them taken care of is easier said than done.

Sean Pyles: That all makes sense to me. But I have to ask, Sam, this is NerdWallet's Smart Money podcast. Where does money come into this?

Sam Taube: Very prominently, Sean, particularly when it comes to insurance. Here's the thing, politicians are fighting about these issues. They're passing state laws about abortion, birth control, gay health care, trans health care. Meanwhile, legal groups are fighting about these things in court, trying to get this abortion drug banned or this medical transition procedure restricted or whatever, right?

Sean Pyles: Right. Still with you.

Sam Taube: So one effect of all this legal back and forth is that it creates a ton of uncertainty about the insurance coverage situation for these medications or procedures or whatever else. And that can have a huge effect on how much you spend on health care because this kind of health care tends to be expensive to begin with.

We talked with Vina Smith-Ramakrishnan. She's a senior policy associate on the health care equity and reform team at the Century Foundation, which is a progressive think tank. And she points out that these kinds of restrictions also have the greatest impact on people who can least afford to navigate around them.

Vina Smith-Ramakrishnan: A lot of the folks who are being impacted by these bans and restrictions, especially at the federal level but also at the state level, they're disproportionately impacting people who are already struggling to make ends meet, especially when we're looking at things like insurance coverage. Folks who are Medicaid recipients, for example, can't access abortion outside of some really slim exceptions, that is going to affect people who are already low income and receiving this federal health insurance. And so that's just one small look at it.

But looking across the country, folks who are being impacted the most are always going to be people who, even before these bans and restrictions are going into effect, were already low income, already struggling to make ends meet, and these bans and restrictions are just adding further burden to their financial outcomes.

Sam Taube: Smith-Ramakrishnan says the problem is especially difficult for women of color, who are disadvantaged in health care even before these new laws.

Vina Smith-Ramakrishnan: We are looking at the intersection of maternal health access and abortion care. We specifically are looking at the Black maternal health crisis, and we do a lot of work looking at the federal level, looking at Medicaid and health insurance. Folks who are trying to seek abortion care, who are Medicaid recipients. There is due to what we call riders, through the appropriation bill, riders such as the Hyde Amendment, prevents federal dollars from being spent on abortion outside of those exceptions for rape, incest and endangerment of the mother's life. It's become really hard for Medicaid recipients to have abortion care covered by their health insurance.

And so then we have this racial injustice that we're seeing across the country where not only are Black women disproportionately impacted by the maternal health crisis, the abortion bans and the abortion care crisis that exists in the U.S. is also disproportionately impacting Black and indigenous birthing people in the U.S.

Sam Taube: And for the LGBTQ+ community, especially trans people, the restrictions just keep piling up without many good options for help.

Vina Smith-Ramakrishnan: 2023 is actually the fourth consecutive year in a row that we've seen with record breaking anti-trans legislation. And a lot of these bills are specifically targeting young people. I know a lot of folks will hear the common phrase, "Well, if these bans are happening, why can't you just move states?" Without understanding that for a lot of families and young people especially, it's not so simple, especially if you are already not particularly well off, just up and moving to another state where the bans aren't as extreme or there aren't as many restrictions isn't really a feasible option for most Americans.

And these are harming people who are living in these states that are being particularly impacted by not only these anti-trans bills, but also usually these, it coincides with the same states that are affected by the maternal mortality crisis, anti-abortion legislation. And so we're really seeing the impact of this legislation, particularly harming women, LGBTQ folks, young people and low-income people.

Sam Taube: Smith-Ramakrishnan says the effects of these restrictions also aren't temporary. For example, the ramifications of not being able to terminate an unwanted pregnancy can follow a woman throughout her earning years in the workforce. She cites research called the Turnaway Study, which over a span of more than 10 years, followed the lives of women who had either received abortions or been denied them.

Vina Smith-Ramakrishnan: I think the out-of-pocket costs for the care specifically on the insurance side is what most people tend to think about. What a lot of folks are not thinking about are the somewhat unrelated, but still impactful financial costs of accessing care. The Turnaway Study showed a really great example of this, by Dr. Diana Greene Foster. This research that was conducted on the real life impact faced by women who were unable to access the abortion care they were seeking. The study found that over the next following years after being unable to access that care, women who were denied abortions, experienced economic hardships that were not experienced by their peers who received their wanted abortions. And this is for a number of reasons, whether it's the ability to participate in the workforce or seeing that, especially for women who are unable to access the abortion care or the birth control that they need and are now being denied the ability to participate in the workforce to the degree that they would like to.

And usually these are again, people who already have children. Most people who seek abortions are already parents. So that additional child being introduced to family can sometimes prevent people being able to go back to work in a timely fashion. Also, just to access the care for folks who are living in states that have these bans, whether it's for anti-trans legislation or anti-abortion bans, going to have to travel to another state, that's travel costs that a lot of people can't make. If they already have existing children, which I mentioned in the case of abortion, most folks already do, now you'd have to find childcare, you have to take time off of work.

And if you're unable to take time off of work, you have to be able to withstand those lost wages that you're now going to be experiencing due to the travel to make your appointments in another state, that for a lot of folks can be several states away. Looking at the South right now, there's really no states remaining in the South as of this moment that don't at least have a severe abortion restriction. So that can be a long distance of travel for someone to get the health care that they need.

Sam Taube: So Sean, clearly there is a cost to these restrictions, and if you're looking at them on a cash basis, well, just as an example, the Commonwealth Fund did a study last year and found that a quarter of American women spend at least $2,000 on out-of-pocket medical bills for themselves and their family every year. And many of those bills are related to reproductive care in some way.

Sean Pyles: $2,000 a year is a lot.

Sam Taube: It really is. And you can find similar statistics around LGBTQ+ health care issues as well. Like the Human Rights Campaign Foundation says the total cost of transgender specific care for one person can be up to $75,000.

Sean Pyles: That's luxury car money.

Sam Taube: Yeah, just about.

Sean Pyles: And what about the cost of HIV prevention? You mentioned earlier that your own struggles with affording PrEP were insurance-related.

Sam Taube: They were. And there's a good chance that a lot more LGBTQ+ people are going to have insurance problems with PrEP in the near future. One of the motivations for this series was a court case called Braidwood Management v. Becerra. I talked to Jose Abrigo, the director of the HIV project at Lambda Legal about this case earlier this year, and he can explain it better than I can.

Jose Abrigo: Braidwood v. Becerra is a case where two companies and six individual plaintiffs — the two companies are Braidwood Management, which is a closely held for-profit organization, and then the other business plaintiff is Kelly Orthodontics, which is a Christian professional association. They sued the Department of Health and Human Services, which oversees the ACA, the Affordable Care Act, saying that by forcing them to purchase insurance that covers certain preventative health care services like PrEP, violates various constitutional rights and the Religious Freedom Restoration Act.

Sam Taube: And the judge in that case ruled in favor of the employers. He said that if they have a religious objection to homosexuality, they cannot be forced to provide insurance coverage for a medication that caters to a primarily homosexual health need, like HIV prevention.

Sean Pyles: And since that's a federal ruling, it could apply nationwide, right?

Sam Taube: It could. There are still appeals in progress, but if the plaintiffs get their way, we might see a lot of employers drop PrEP coverage from their insurance plan soon. And that has potentially huge fiscal impacts on patients because PrEP is absurdly expensive without insurance, as are HIV tests for that matter.

Sean Pyles: Yeah, PrEP can cost like $2,000 a month out of pocket.

Sam Taube: So the Braidwood Management v. Becerra case could drop a completely unmanageable bill on a lot of LGBTQ+ people's heads, depending on how it goes. And the Braidwood case is also a really good example of how different bodily autonomy issues fit together. Because as Abrigo told me, it was actually decided based on another recent case that was about birth control, not HIV prevention.

Jose Abrigo: The Religious Freedom Restoration Act basically says the government must basically tailor any regulations to have the least burden on religion as possible. Now, they're relying on a case, Burwell v. Hobby Lobby, where if a closely held corporation, which is relevant here because both of the plaintiffs are closely held corporations, are forced to cover contraceptives that violates their religious rights. Here, the plaintiffs are asking the court to take it a step further because they're saying by forcing them to pay for medication that could possibly encourage certain behaviors, then that violates their religious rights.

Sam Taube: So the Burwell v. Hobby Lobby decision on birth control was an important precedent for the Braidwood decision on PrEP coverage. And in the same way, Braidwood could open up even more legal avenues for employers to opt out of providing insurance coverage for certain things.

Jose Abrigo: Previously under Burwell v. Hobby Lobby, where contraception was at issue, it was directly related to their religious objections. Here it's taking it a step further, where medications that could possibly encourage homosexuality, prostitution, promiscuity, therefore that violates the Religious Freedom Restoration Act by forcing them to pay for insurance that covers that. So that's basically the ruling.

Sean Pyles: OK, Sam, you're painting a pretty clear picture of how all these bodily autonomy issues are legally related to each other and also how the legal fights around these things can put insurance coverage in limbo. So I guess the moral of the story here is that culture war issues aren't just about culture, they can also affect the prices you pay for health care.

Sam Taube: Particularly when it comes to medications for reproductive care, sexual health care and gender-affirming health care, yeah. Bodily autonomy is a simple concept, but the economics behind it aren't.

Sean Pyles: So what's coming up in our next episode?

Sam Taube: We're going to be talking about reproductive health care costs, especially in light of recent court cases involving birth control and abortion.

Daily Garcia: Barriers to accessing abortion and other health care services can be finding childcare, taking time off work, navigating the cost of transportation and lodging associated with that travel, and oftentimes hundreds if not thousands of miles.

Sam Taube: That's all we have for this episode of the Smart Money podcast. If you want the Nerds to answer your money questions, call or text us on the Nerd hotline at 901-730-6373. That's 901-730-NERD. You can also email us at [email protected].

Visit nerdwallet.com/podcast for more info on this episode. And remember to follow, rate and review us wherever you're getting this podcast.

Sean Pyles: This episode was produced by Tess Vigeland and Sam Taube. I helped with editing, as did Liz Weston. Arielle O'Shea helped with fact-checking. Kevin Tidmarsh and Kaely Monahan mixed our audio. And a big thank you to the folks on the NerdWallet copy desk for all their help.

Sam Taube: And here's our brief disclaimer. We are not financial or investment advisors. This Nerdy info is provided for general educational and entertainment purposes and may not apply to your specific circumstances.