Utah's Medicaid program doesn't pay for the routine circumcisions of infant boys, a money-saving move taken in 2003 as policymakers and others began questioning whether there was any medical reason for the procedure.
But that decision may be putting Utah boys at higher risk for HIV and other sexually transmitted diseases, and exaggerating health disparities among socioeconomic lines, a new University of California Los Angeles analysis suggests.
The study and other research are fueling renewed debate over circumcision for American newborns.
Circumcision rates for infant boys, on average, are 24 percentage points lower at hospitals in Utah and in 15 other states where Medicaid programs do not cover the procedure, the UCLA researchers found.
And that's important, they point out, because a recent round of clinical trials in South Africa, Kenya and Uganda found that male circumcision reduces a man's risk of becoming infected with HIV by his female partner by 55 percent to 76 percent.
A lack of Medicaid coverage for circumcision, they say, could translate into future health disparities for children born into poor families covered by the public health program. The transmission rate of HIV and other STDs, they note, is highest among low-income populations.
Likewise, they contend, Utah and other states' refusal to cover circumcision could result in higher long-term medical costs.
"If you could save your child the trauma of all kinds of infectious diseases later in life for $350 or $300, wouldn't you think that's worthwhile?" asked Arleen Leibowitz, a professor of economics at UCLA, whose study was recently published in the American Journal of Public Health .
Parents, she said, get their children inoculated against diseases -- some of which have been nearly eradicated -- in case they're ever exposed. Circumcision should be seen in the same vein, she believes.
"We have all of these parents who are vaccinating their girls against the human papillomavirus (HPV) now, also at a fairly high price," Leibowitz said. "Shouldn't we also be thinking about the boys?"
Critics: Benefit unclear
Not everyone sees it that way. Opponents of circumcision argue that, unlike a shot, the procedure is painful, invasive and offers questionable benefits at considerable risks.
Angela Chaudhari, an assistant professor in the University of Utah School of Medicine's Department of Obstetrics and Gynecology, gave birth to twin boys Ashym and Aryan Patel last week. She decided against circumcision, which she considers a traumatic procedure not supported by a lot of data.
Chaudhari, who also has performed circumcisions, said, "it's just pretty tearful. They cry a lot and you need to strap them down." For her and her husband, who is also a physician, "we really felt like we're not interested in putting our kids through elective surgery on day two of life."
Most Utah parents elect to have the procedure performed. Chuck Norlin, a U. professor of pediatrics and chief of the Division of General Pediatrics, estimates that only a quarter of his patients don't get their sons circumcised.
"I try to present a balanced view of the data," he said.
Circumcision, for example, does reduce a male's chance of getting urinary tract infections -- and contracting STDs, he said. But by having safe sex, an uncircumcised male could just as easily minimize his risk.
The American Academy of Pediatrics (AAP) has long taken a neutral stance, concluding "parents should determine what is in the best interest of the child."
In the U.S., the AAP estimates, 1.2 million newborn males are circumcised annually at a cost of between $150 million and $270 million, though the UCLA study notes that since the 1980s circumcision rates have been declining.
The academy is re-evaluating its position, in part due to the African studies and others published during the past decade. In 2007, it formed a circumcision committee of 10 physicians to scrutinize the data.
"We're not there yet in terms of making a firm recommendation, or even having formulated tentative ones," said committee member Douglas Diekema, a professor of pediatrics at the University of Washington.
The problem, he said, is figuring out how the African studies translate into actual risk reduction in the U.S., where HIV is most commonly spread among men having sex with men, and among intravenous drug users. So far, research on how much circumcision reduces transmission in these populations is ambiguous.
While research shows "more medical support for circumcision than there was 10 years ago," Diekema said he would be surprised it is "strong enough to make a firm recommendation that all children should be circumcised."
Still, the academy's position statement may be more nuanced, he said, with perhaps greater emphasis on the medical benefits. Either way, its stance shouldn't set insurance policy, he said.
"Just because the academy makes a recommendation," Diekema said, "doesn't mean it shouldn't be paid for."
Utah officials cut routine circumcision from Medicaid coverage in 2003 "because of the elective, non-therapeutic nature of the procedure rather than medical necessity," according to a Medicaid Information Bulletin published that year. The program also stood to save $100,000 it spent annually covering circumcision, said Utah Department of Health spokeswoman Kolbi Young. In the last year it covered the procedure, Medicaid paid for 4,635 circumcisions in Utah.