Authored by Rhea Manohar, MPH, Meghan Etsey, Ariela Marshall, MD —- on behalf of AMWA Gender Equity Task Force
From higher insurance premiums to increased out-of-pocket costs for medications and procedures, women routinely pay more than men for healthcare services (Sommers et al., 2022). Over the past decade, many consumers have become aware of this phenomenon, often referred to as the “Pink Tax” as a term used for the additional cost of products marketed to female consumers with slight modifications to the coloring and design from the male marketed product. However, the Pink Tax goes beyond the cost of products marketed to women, such as razors and shampoo. The definition has expanded to refer to the higher costs women incur simply for being women (Feingold, 2022). The impact of the Pink Tax is embedded deep within the healthcare system impacting not only the financial cost of healthcare for women, but also their access to care, illness experiences, and the navigation within the healthcare system (Feingold, 2022). A 2022 analysis found that women between the ages of 19 and 64 spend an average of 18% more out-of-pocket on healthcare than men in the same age range. This difference in healthcare spending costs persisted even when maternity-related care was excluded. This analysis found that the additional spending was attributed to greater use of services, more frequent prescriptions, and higher cost-sharing for comparable services (Sommers et al., 2022). While some of this disparity may be due to the increased frequency of care visits for reproductive healthcare, preventative screenings, and management of chronic diseases more prevalent in women, the disparity far outweighs these differences.
One key difference seen is in the impact of adverse effects of prescription drugs on women versus their male counterparts. Historically, women have been excluded from clinical trials citing the impact on fertility and reproductive health. This has led to downstream effects of dosing guidelines and side effect profiles based on male physiology that may not reflect the impact on the women using the drug. One study found that women are 1.5 to 2 times more likely than men to experience an adverse drug reaction (Zucker & Prendergast, 2020). While some of this can be attributed to pharmacokinetic differences, including higher fat-to-muscle ratios and variations in enzymatic activity, it only offers a partial explanation. This was seen in the FDA’s modification of the recommended dose of Zolpidem, otherwise known as Ambien, in 2013. Despite Zolpidem having already been on the market for years, it was not until further clinical evaluation and case studies years later that the dosage was lowered by 50% due to higher blood levels in women the morning after taking the drug; thereby increasing the risk of drowsiness and accidents (Zucker & Prendergast, 2020). Suboptimal dosing recommendations for women has led to a pattern of adverse drug reactions being more common in women has been developed, which in turn requires additional interventions and expenses (U.S. GAO, 2001).
With the passing of the Affordable Care Act (ACA), gender rating in insurance premiums was banned, preventing insurers from charging women more than men for the same plan (U.S. Department of Health and Human Services, 2015). Despite this step, unequal coverage continues to persist, specifically in the realm of fertility and reproductive healthcare coverage, areas that are often not covered by private insurance plans unless mandated by a state’s laws (KFF, 2022). As of 2022, only 20 states mandated coverage for infertility diagnosis and treatment and fewer required coverage for assisted reproductive technologies, such as IVF (KFF, 2022). Even within ACA requirements for coverage of FDA-approved contraceptives without cost sharing, many employer-sponsored and religiously affiliated plans have yet to close the gap in coverage (Daniels & Abma, 2020). In other cases, the coverage of these costs has been done with undue financial and logistical burden to women with steep copays and prior authorizations to receive coverage. This can often discourage women from seeking or remaining compliant with care.
Beyond the financial impact of the pink tax, it exacerbates the lack of support and dismissal that women often face in healthcare settings. Studies have shown that women are more likely to have their symptoms dismissed or misdiagnosed, especially when it comes to pain. A 2019 study found that women reporting the same pain intensity as men were less likely to receive opioid analgesics and more likely to be referred to mental health services; thereby incurring additional costs and treatment delays (Hoffmann & Tarzian, 2001). When faced with this, many women choose to seek multiple opinions or undergo unnecessary tests, in turn, further inflating their costs and eroding their trust in the system. Stuck between a rock and a hard place dilemma of unaffordability and untrustworthiness, women are twice as likely to choose to delay or avoid critical care compared to men (KFF, 2022)
Given the systemic inequities faced by women within the healthcare system, one way to address such inequities is to try and abolish the Pink Tax in an attempt to combat the persistent undervaluation and overcharging of women’s healthcare needs. By strengthening federal mandates and standardizing state-wide requirements for equitable insurance coverage, specifically for reproductive and prescriptions, care services are more likely to become equitable. Additionally, standardization of state-wide requirements and transparency in insurance coverage will provide a foundation for more equitable insurance coverage. This will lead to a reduction in the penalties women face for utilization of services that directly affect their care and well-being.
It is also critical to address the persisting effects of the historical lack of women’s inclusion in clinical trials to better understand drug dosing, side effects, and efficacy. We advocate for funding for gender-specific health research on existing pharmaceuticals available in the marketplace as well as for the inclusion of women in future trials on drugs in development. Funding should additionally be allocated to focus on conditions that disproportionately affect women such as endometriosis, postpartum depression, and autoimmune conditions. Coupling this with provider education on diagnostic differences between gender in symptoms as well as management may provide a more comprehensive and supportive healthcare experience for women. Greater awareness of The Pink Tax in healthcare will spark meaningful discourse and advocacy to decrease the inequities in logistical, financial, and quality of care burden faced by women in healthcare settings.
References:
- Daniels, K., & Abma, J. C. (2020). Current contraceptive status among women aged 15–49: United States, 2017–2019(NCHS Data Brief No. 388). National Center for Health Statistics. https://www.cdc.gov/nchs/products/databriefs/db388.htm
- Feingold, S. (2022, July 14). What is the “pink tax” and how does it hinder women? World Economic Forum. https://www.weforum.org/stories/2022/07/what-is-the-pink-tax-and-how-does-it-hinder-women/
- Hoffmann, D. E., & Tarzian, A. J. (2001). The girl who cried pain: A bias against women in the treatment of pain. The Journal of Law, Medicine & Ethics, 29(1), 13–27. https://doi.org/10.1111/j.1748-720X.2001.tb00037.x
- Kaiser Family Foundation (KFF). (2022). State requirements for insurance coverage of infertility treatment. https://www.kff.org/womens-health-policy/state-indicator/infertility-treatment-coverage/
- KFF (Kaiser Family Foundation). (2022). Women’s health care utilization and costs in the United States. https://www.kff.org/womens-health-policy/issue-brief/womens-health-care-utilization-and-costs-in-the-united-states/
- Sommers, B. D., Blendon, R. J., & Orav, E. J. (2022). Gender differences in healthcare spending and use among adults with private insurance. Health Affairs, 41(2), 101–110. https://www.healthaffairs.org/doi/10.1377/hlthaff.2021.01201
- Zucker, I., & Prendergast, B. J. (2020). Sex differences in pharmacokinetics predict adverse drug reactions in women. Biology of Sex Differences, 11(1), 32. https://doi.org/10.1186/s13293-020-00308-5
- U.S. Department of Health and Human Services (HHS). (2015). How the Affordable Care Act is working to improve access to preventive services for women. https://aspe.hhs.gov/reports/how-affordable-care-act-working-improve-access-preventive-services-women-0
- U.S. Government Accountability Office. (2001). Drug safety: Most drugs withdrawn in recent years had greater health risks for women (GAO-01-286R). https://www.gao.gov/products/gao-01-286r
About the Authors
Rhea Manohar, MPH, MS2
Rhea Manohar is a second year medical student from St. George’s University. She has a Masters in Public Health with a concentration in Maternal and Child Health from George Washington University Milken Institute of Public Health and a Bachelors of Science in Microbiology, Immunology, and Public Health from the University of Miami. She served as Co-VP of OB/GYN Education for St. George’s University’s Women in Medicine chapter in St. George, Grenada where she developed and implemented hands-on workshops to further reproductive health issues and bolstered medical students’ abilities to navigate physician-patient communication. Prior to medical school, she was a research associate for Fors Marsh Group, where she led qualitative and quantitative public health research and campaign development for federal agencies (e.g., CDC, NIH, DHHS, CPSC). She is also a member of the Gender Equity Task Force and Reproductive Health Coalition within the American Medical Women’s Association. When she is not pursuing medicine, you can find her reading, exploring artistic passions, and spending time connecting with friends and family.
Meghan Etsey, MS3
Meghan Etsey is a third year medical student from St. George’s University. She has a Bachelors of Arts in Biology and a Bachelors of Arts in Nutrition and Dietetics from Bluffton University in Bluffton, Ohio. She served as the President of the St. George’s University’s Women in Medicine chapter in St. George, Grenada where she expanded relationships with the community and worked towards educating women and helping the youth. She is also a member of the Gender Equity Task Force and Sex and Gender Health Collaborative Committees within the American Medical Women’s Association. When she is not pursuing medicine, you can find her with her friends and family on different road trips and adventures exploring the world.
Dr. Ariela Marshall, MD
Dr. Ariela Marshall is a Harvard-trained physician and an internationally renowned advocate, career development advisor, and mentor. Dr. Marshall specializes in bleeding and clotting disorders, especially as they relate to women’s health. She has worked at Mayo Clinic and the University of Pennsylvania and currently practices part-time as a consultative hematologist at the University of Minnesota. In addition to her clinical work, Dr. Marshall is a highly respected leader, mentor, and speaker. She is an active leader with the American Society of Hematology (where she led efforts to found the Women in Hematology Working Group and currently holds seats on the Women in Heme Working Group, Committee on Communications and Media Experts Subcommittee) and American Medical Women’s Association (leading the Infertility Working Group and holding seats on the Gender Equity Task Force). She is the Chief Innovation Officer at Women in Medicine and the Curriculum Chair at IGNITEMed, which are both 501(c)(3) nonprofit organizations dedicated to promoting career development for women in medicine. She speaks regularly on a national and international scope to discuss her efforts to advance career development and mentorship for physicians, gender equity, fertility/infertility awareness, parental health and wellbeing, reproductive health and rights, and work-life integration.