The decision about whether to circumcise a newborn boy requires ticking through an age-old roster of questions: Is it medically necessary? Will the baby feel much pain? Now there's another question to add to the list: how much will it cost?
Following a 1999 report from the American Academy of Pediatrics, which said that the health benefits of circumcision were not significant enough to make the procedure mandatory, Medicaid programs began dropping coverage. Ever since, new parents in 16 states have been discovering that getting it done anyway will run about $300. According to a January report by researchers at UCLA, the cost has had a serious impact: the circumcision rate in states offering coverage for it is, on average, 24 percent higher than in the states that don't. And that's based on data only through 2004, the most current year available; with unemployment rising and more Americans turning to public insurance, the disparity can be expected to grow. "The $300 is a luxury," says Dr. Andrew Freedman, director of pediatric urology at L.A.'s Cedars-Sinai Medical Center. "For many people [it] is an insurmountable barrier."
The decline isn't across the board. Religious traditions still tend to hold sway: if the parents are Jewish or Muslim, they won't let Medicaid get in their way. What the neighbors do has a lingering impact as well. In the Midwest, "we whack 'em all," says Dr. Renee Stein, whose clinic at St. John's Mercy Medical Center in St. Louis offers payment plans for families on Medicaid. Elsewhere, though, more parents are opting to pass. "You have families that had a child six years ago who was circumcised, and then had a child three years ago who was not, because they couldn't afford it," says Dr. Anthony Atala, director of urology at Wake Forest University's medical center.
A new AAP task force has been reexamining the 1999 report for more than a year. According to two members of the panel, though, while the oft-delayed review is likely to feature a stronger endorsement of circumcision—chiefly owing to recent studies showing benefits in reducing the spread of HIV—it will again stop short of a mandate. Panelists are aware, and worried, that anything less may cause more states—or even HMOs—to drop coverage. The fate of a million foreskins is in their hands.