Thanks to blogger spork_incident for bringing this to my attention. According to a press release for SEIU, 9 states allow insurance companies to consider domestic violence a pre-existing condition, and use that to deny insurance claims. Eight of the 16 major insurance companies have used this right to deny coverage to victims of domestic violence.

Perversely, if you understand domestic violence, it's easier for you to see why insurance companies would do this than it might be for someone who doesn't realize that it's about more than just hitting, but that it involves the abuser pulling his victim into a cycle of dependence and stalking in order to control her. Once a man has hit a woman, the odds of him doing it again are astronomical, and the odds are that he will escalate the level of violence as well, because part of being an abuser is testing your boundaries and seeing how much you can get away with before she leaves. For those of us in the humane world, the fact that a woman who has been slapped today is in grave danger of receiving a massive beatdown in the next few months or years is a tragedy that we should seek to prevent. From the insurance company's perspective, however, a woman who is slapped today is likely someone who will incur a massive hospital bill in the future, and that's all they need to know.

Indeed, from the report I linked, which is a federal report on domestic violence in rural (and therefore geographically isolated) communities:

Domestic violence is one of the most powerful predictors of increased health care utilization.

Besides the immediately obvious bad effects of this---particularly since a woman who has been abused before is in serious danger of getting severely hurt by the abuser, especially if she tries to leave---there are a number of unintended consequences. Obviously, the major one is that the fear of losing insurance coverage might drive victims to avoid reaching out for help, and it may even mean that they don't get treatment for their injuries after an abusive incident. And of course, the less a woman reaches out for help, the less likely she is to get out of the situation. In addition, one form of control that abusers use over their victims is financial dependence, and impoverishing a woman by denying her health care coverage will only make her more dependent on the abuser. I wouldn't even be remotely surprised to find out if abusers often use health insurance as leverage over their victims, especially since a much higher percentage of women than men are covered through a spouse's employer-provided insurance.

The report I link is heavy on screening recommendations, which is already a point of tension between people who look at these issues from a public health perspective and individual providers. After all, it's both true that screening for domestic violence at the doctor's office would help lower the overall incidence of it and that having those individual conversations is a miserable event for everyone involved. But obviously, providers can be convinced to set aside their reservations and do the screening if there's an overall benefit to their patients. The problem, though, is if you include screening questions about domestic violence, you're helping put your patient in danger of losing her insurance coverage or being accused of defrauding the insurance company if it comes out that she has been victimized, but declined to admit that in the screening process. More than anyone, doctors are sensitive to the importance of not provoking insurance companies to deny coverage, and I doubt they'll eagerly sign up for further screening programs that could create financial problems for their patients.

I've seen a lot of skepticism from the right on the idea that preventive medicine could save money, or that insurance companies discourage basic prevention. But here's a classic example of how that works. You have a common, expensive, and preventable health care issue with domestic violence, and we know that abusive relationships are easiest to bring to a halt early in. But here the system is actively working to make it harder for women to report their problems before they spiral out of control, which means that a lot of relationships that could have been stopped at bruises are going to escalate to broken bones, internal bleeding, choking, and even fatal injuries. And of course, extensive mental health care concerns. Simple, inexpensive prevention is easy to implement in this situation. Sure, a whole lot of women that are screened for domestic violence won't be open to leaving, but every one that we get out of a relationship in the early stages of abuse is a woman who won't be, to put it in financial terms, incurring huge hospital bills down the road when the abuse escalates past the point of hiding it. Contrast the cost of giving someone aspirin for a bruise and a referral to mental health and crime experts who can get her out of the relationship with expense of repairing broken bones and other severe injuries incurred later in a relationship, when the abuser is emboldened by previous successes, and you can see how much cheaper prevention is.