January 20, 2014
Circumcision Coverage Comes Into FocusRevised Study on Procedure's Benefits Spurs Some States to Reconsider Ending Routine Medicaid Funding for Newborns
by Arian Campo-Flores
Saleem Islam, a pediatric surgeon in Gainesville, Fla., was surprised a few years ago when he started receiving a steady stream of referrals for older boys from low-income families to be circumcised.
"When we ask the parents, 'Why did you not get it done when the child was a baby and when it would have been safer?' they say, 'We couldn't afford it,' " Dr. Islam said recently.
[In other words, these babies never needed it, the parental whim had just overflowed. It is not safer as a newborn.]
Like a dozen other states, Florida ended Medicaid coverage of routine circumcisions for newborns after the American Academy of Pediatrics issued a lukewarm statement on the practice in 1999. While the organization concluded that removing the penis's foreskin has potential benefits, it found the data were insufficient to recommend it as a routine procedure. [If the data are insufficient to recommend it, how can the price make it recommendable?]
So Florida lawmakers justified their decision in part as a way to save money on what the AAP had deemed an unnecessary procedure.
Now, a revised policy statement by the AAP that takes a more favorable stance toward circumcision, along with a series of academic studies examining the impact of reduced coverage of the procedure, has cast a new spotlight on the decision by Florida and other states not to cover it under Medicaid.
In 2012, the AAP concluded that the benefits of circumcision outweigh the risks and justify "access to this procedure for families who choose it." The organization stopped short of recommending routine circumcision, however.
Public funding of routine circumcisions for newborns has been hotly debated in recent years. Supporters of the practice say it helps prevent urinary tract infections in babies and sexually transmitted infections, including HIV, later in life. But groups opposed to circumcision say the procedure is medically unnecessary and an unnatural, antiquated practice. [Also harmful, risky and a human rights violation.] In the case of the older boys referred to Dr. Islam, complaints ranged from inflammation to difficulty with the foreskin.
Ending Medicaid coverage of routine circumcisions may have stuck the state with a bigger bill instead, according to a group of University of Florida Health researchers that includes Dr. Islam. Costs for circumcisions more than doubled in the five years after the 2003 policy change, the study asserts. That was largely because families were opting to have the procedure done when boys were older—a more costly operation that Medicaid still covers if it is deemed medically necessary.
The number of boys ages 1 to 5 who were circumcised each quarter during the study period reached almost 1,000 in the third quarter of 2008, compared with a little over 500 in the fourth quarter of 2003. In every quarter, those figures exceeded the number of circumcisions for newborns.
[But raw numbers explain nothing withut context: birthrate and neonatal circumcision rate. If the neonatal rate is 100% the number of older boys available for circumcision is 0, so the only way it can go us up, whether there is any medical need or not.]
That helps explain why Medicaid costs for circumcisions in Florida climbed to $33.6 million in 2008 from $14.9 million in 2004, according to the study. [But so does inflation.] While the procedure costs as little as $250 for newborns, it can run more than $6,000 for older boys because they require general anesthesia and sometimes an operating room. Older kids also face a higher risk of complications, doctors say. [This is not true.]
"Given the costs to the state, it would make sense for the state to reverse" its decision, Dr. Islam said.
The Florida Agency for Health Care Administration, which administers Medicaid, said in a statement that the study "contains interesting points for discussion, but does not appear to provide conclusive medical evidence to allow for coverage of elective circumcisions."
Using a different database, the agency provided data showing circumcision costs under the traditional "fee-for-service" system in Medicaid dropped to $1.2 million last year from $2.3 million in 2002. But those figures don't include other ways Medicaid money pays for the procedure, such as through managed-care plans, Dr. Islam said.
[And his study doesn't include other costs of circumcision, such as the cost of repairing botches.]
Of the 18 states that no longer cover routine circumcisions, 12 made the decision in the wake of the AAP's 1999 policy statement. When the AAP came out with its revised position in 2012, some states weighed changing their policies. Medicaid officials in Utah recommended restoring circumcision coverage in 2013, but the legislature hasn't acted. Another effort by Colorado lawmakers to reinstate such funding failed last year, though the issue is likely to come up again this year.
Studies show the prevalence of circumcision has declined as more states have stopped paying for it. A 2009 paper published in the American Journal of Public Health found that hospitals in states where Medicaid covered the procedure had circumcision rates 24 percentage points higher than those in states that didn't, leading to potential health disparities.
Overall, newborn circumcision rates in the U.S. have been falling, to 58.3% in 2010 from 64.9% in 1981, according to the Centers for Disease Control and Prevention.
In preparing its 2012 statement, the AAP's task force on circumcision considered the fallout from the 1999 declaration, said Douglas Diekema, one of the members. The previous task force "had not foreseen that their statement would lead to a decrease in insurance coverage," he said.
[Yes, and it's all about the money.]
Around the same time, a team of Johns Hopkins University researchers published a study estimating that a 20-year decline in U.S. circumcision rates had resulted in $2 billion in health care costs to treat sexually transmitted infections and other illnesses in uncircumcised men and their female partners.
Anti-circumcision groups questioned the legitimacy of the Johns Hopkins analysis. And they cited a published response to the AAP statement by a group of mostly European doctors who said it reflected "cultural bias" in favor of the procedure.
[Not just any "group of mostly European doctors" but the heads or spokespeople for most of the paediatric associations of Europe.]
Dr. Islam said his stance on circumcision is neutral. "But if a family wants it done and we're going to fund it," he said, "it makes sense to fund it at the right time."
[Those are two big ifs, and why should they be connected?]