When Insurance Policies Harm Women

Written by Cheryl B. Iglesia, MD

SHE+ Medical Advisory Board Member

My name is Dr. Cheryl Iglesia, and I am on the Medical Advisory Board for the SHE+ Foundation. 

I have been the Director of the Section of Urogynecology and Pelvic Reconstructive Surgery for MedStar Health since 1999. I am a professor in the Departments of Obstetrics & Gynecology and Urology at Georgetown University School of Medicine, and am also the founding director of the Urogynecology fellowship program and the National Center for Advanced Pelvic Surgery. 

As a double board-certified ObGyn and urogynecologist, I use my medical knowledge and surgical skills to make significant improvements in my patients’ quality of life, pelvic floor and bladder and bowel function, and sexual health.

We know that the economic impact of Medicaid coverage in the U.S.  is immense. For every $1 spent on Medicaid by individual states, the federal government contributes up to $9 in return (MACPAC). Hospitals in non-expansion states - meaning, hospitals in states where the Affordable Care Act Expansion has not been implemented, have lost an estimated $6.8 billion in Medicaid reimbursement between 2013 and 2020 (Urban Institute) 

While the operating room is often a symbol of advanced care, many gynecologic and pelvic reconstructive surgeries are among the hardest to access—not because of a lack of need, but because of how the surgeries are reimbursed.

These policies aren’t just inefficient—they are unjust, and they disproportionately harm women of color, low-income patients, and people on public insurance.

Insurance—particularly how much hospitals are reimbursed—can impact available OR block time and care decisions in several subtle but significant ways:

• Hospitals are often reimbursed based on procedure type and diagnosis-related groups (DRGs). More complex or higher-reimbursed procedures may be prioritized for OR access or scheduled more efficiently.

• Private insurance typically reimburses more than Medicare or Medicaid, leading some systems to schedule insured patients during peak times or assign more experienced surgical teams. 

• Shorter OR times may be financially incentivized if hospitals are reimbursed a flat amount (bundled payment or DRG), encouraging efficiency to reduce costs per procedure.

• Hospitals may be less likely to invest in advanced technology due to tighter margins.

Inadequate reimbursements - especially on stigmatized procedures like those in women’s health - can lead to fewer OR staff and limited dedicated resources. Data confirm real disparities in surgical care based on insurance status with Medicaid and uninsured patients experiencing longer wait times for elective surgeries and worse post-op outcomes (Source: Annals of Surgery, 2016)

But, how does this impact women’s health? 

Endometriosis Excision Surgery

• Excision surgery is often coded under generic laparoscopy codes that don't distinguish between excision and ablation, even though excision is more complex, time-consuming, and is associated with improved clinical outcomes.

• Excision is often under-reimbursed relative to OR time, discouraging hospitals from prioritizing it.

• According to the Endometriosis Foundation of America, many excision specialists operate out-of-network due to poor reimbursement rates.

Pelvic Organ Prolapse Surgeries (i.e. uterosacral ligament suspension, sacrocolpopexy) 

• Pelvic Organ Prolapse Surgeries are often considered“quality-of-life” surgeries, not life-saving, so insurers may deny or delay coverage.

• Complex pelvic reconstructive surgeries are longer in duration, but reimbursement is bundled at a flat rate, possibly discouraging full repair techniques.

Hysterectomy for Chronic Pain or Bleeding 

• Insurers often require documentation of multiple failed treatments before approving surgery for conditions like adenomyosis or fibroids.

• Medicaid may only reimburse for hysterectomy if it's deemed medically necessary (e.g., cancer risk), not for quality-of-life indications.

• Surgeons face delays or denials, and reimbursement doesn't always match surgical complexity (e.g., laparoscopic vs. abdominal hysterectomy).

Reconstructive Surgery Post Cancer (i.e. vulvectomy, labiaplasty for radiation scarring) 

• Additional procedures on external genitalia are often excluded from standard oncologic packages, despite being critical for sexual function and quality of life.

• Labiaplasty and clitoral reconstruction post-radical surgery are considered cosmetic, even after cancer treatment.

The barriers are systemic. From flat-rate DRG reimbursements that discourage time-intensive gynecologic surgeries, to deprioritization of sexual and reconstructive pelvic surgeries compared to surgeries with higher margins, the barriers to sexual healthcare are tremendous. 

Medicaid reimbursement rates for gynecologic surgery average 30–40% less than private insurance, leading to provider drop-off in participation. Recent legislation negatively impacting Medicaid coverage, particularly for the most vulnerable populations, will make access even harder as the numbers of uninsured patients increase in the United States.

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For more information, check out the SHE+ Foundation Resource Hub at www.sheplusfoundation.com/resourcehub