By Amy Goldstein
Washington Post Staff Writer
Wednesday, May 20, 1998; Page A1

The decades-old struggle for gender equity in health care has come down to this question: Why have many insurance companies moved so swiftly to pay for the male sex drug Viagra when they have been far slower to pick up the bill for birth control?

Less than two months after it exploded onto the market, more than half the prescriptions for the new drug are being subsidized by health plans. That immediate acceptance by the insurance industry is producing howls of frustration from many physicians and women's rights advocates who have been waging a long, arduous campaign – in legislatures and in the court of public opinion – to coax insurers to cover prescription contraceptives that enable women to enjoy sex without worrying about whether they'll become pregnant.

Viagra's potential to overcome impotence and enhance male sexual performance has made it the fastest seller of any drug ever introduced. Viagra went on sale last month.

But if its effect on sex lives seems revolutionary, women's advocates say, it's worth remembering that other drugs have been just as transformational.

"I don't think [Viagra] made any more of a splash than the Pill," said Gloria Feldt, president of the Planned Parenthood Federation of America, which yesterday became the latest group to complain. Yet for many years after the advent of birth control pills in 1960, Feldt said, many insurers did not pay for them.

Today, slightly more than half of all prescriptions for the pill are covered, although some health plans charge employers extra for the benefit, and most still do not cover other forms of contraception.

Planned Parenthood's protest was made a week after the 39,000-strong organization representing the nation's obstetricians and gynecologists said it believed health plans' reticence to cover contraceptives represented a form of bias against women.

The emerging Viagra-pill wars highlight the gender sensitivities that linger within the nation's health care system more than four decades after concerns surfaced that medical researchers often failed to study women and their health needs when conducting clinical experiments of new therapies. Today, the research agenda is somewhat less imbalanced, but the economic disparities persist.

Women of child-bearing age spend an average of 68 percent more out-of-pocket on health costs than men in the same age group, recent research has suggested. It is unclear how much of that disparity arises because women consume more health care, and how much occurs because insurance fails to pay for the services that women alone use.

In deciding which drugs and other benefits to cover, public and private insurance plans weigh a variety of factors, including effectiveness, popularity and cost. Traditionally, insurers have paid for drugs that remedy a true medical problem, but as more therapies are developed – some of which are largely intended to improve the quality of people's lives rather than treat ailments – insurers are facing harder questions. Does it make sense, for instance, to pay for diet pills or smoking cessation classes, services that address no immediate disorder but may lower health costs in the long run?

Where contraceptives fit on that spectrum is a matter of intense debate.

But in the case of Viagra, the discussion has been less about whether to cover the drug and more about when. The result is that for the week ending May 1, 47 percent of the nearly 270,000 Viagra prescriptions sold across the United States were subsidized by some form of health insurance, according to IMS HEALTH, which tracks prescriptions sold nationwide.

That is less insurance coverage than prescriptions in general, three-fourths of which are covered. But it also means that, just five weeks after it became available, Viagra is covered nearly as often as are birth control pills, and far more often than diaphragms and intrauterine devices, according to IMS.

Typically, health plans are paying for Viagra as long as they cover treatment for sexual dysfunction in general. Since the 9 million-patient federal health insurance system excludes such treatment, it does not cover the drug. Most health plans require a physician's proof that the prescription is sought to address impotence, and not simply to enhance a patient's sexual performance.

Blue Cross and Blue Shield of Maryland and the National Capital Area is one of many plans that decided to cover Viagra, even though it generally does not cover birth control unless employers are willing to pay extra for it. "The analogy is ... elective surgery versus removal of a gallbladder," said Winston Wong, Blue Cross's director of pharmacy management. "There's always that question of medical necessity."

But because it is hard for insurers to determine why patients are seeking the drug, Blue Cross has sidestepped the issue of medical necessity by agreeing to pay for a limited number of Viagra pills per month to any patient with a prescription. Blue Cross is paying for six pills, which cost $10 each.

Some doctors and women's advocates dispute the idea that contraceptives are not medically necessary. "People say pregnancy is natural, but what woman wants 21 or 25 pregnancies" over her reproductive years, said Luella Klein, a professor of obstetrics and gynecology at Emory University in Atlanta who is director of women's health issues for the American College of Obstetricians and Gynecologists.

Even before the advent of Viagra, the question of whether insurance should pay for contraception had begun quietly to attract legislative attention. Maryland and Virginia are two of a half-dozen states that have passed recent legislation to require at least some level of contraceptive coverage. A year ago, Sen. Olympia J. Snowe (R-Maine) introduced a bill, similar to Maryland's new law, that would require any health plan that has prescription benefits to pay for birth control.

Now, Snowe is seizing on anger over the drug for men in hopes of galvanizing interest in her bill. "Viagra has simply highlighted the problem," she said.