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The Gaps · Reimbursement
The Reimbursement Gap
Science can be settled and the care can exist, and it still won't reach patients until the payment system carries it. What a procedure code is worth, what a plan is required to cover, and which conditions a new payment model names all decide what actually gets built, staffed, and delivered.
what the effect is
The cost lands on patients first. Deloitte’s analysis of employer-sponsored plans found employed women carry as much as $15.4 billion more in out-of-pocket medical expenses a year than employed men, roughly 20% more per person, and that figure sets maternity aside entirely. The second effect lands on the field building solutions: the Milken Institute’s Coverage and Reimbursement Roadmap for Women’s Health Innovation (August 2026) opens on the observation that promising innovations stall for lack of a clear path to payment rather than for lack of science, and maps nine structural barriers across three routes (self-pay, commercial payer, and public programs). Underneath both sits one connected set of levers: a pricing question (how codes are valued in the first place), a coverage question (what plans are required to pay for, which still varies by state and by payer), and a pathway question (whether new outcomes-based models name women’s-health conditions as they are designed). This page is scoped to those three levers and to who is already moving them.
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Source: Deloitte analysis of employer-sponsored plans; Milken Institute, Coverage and Reimbursement Roadmap for Women’s Health Innovation, August 2026.
What's still missing
The pieces exist; the map between them doesn’t yet. Milken’s roadmap, NASHP’s state trackers, ACOG’s coding win, the reimbursement summit’s policy roadmap, TMaH’s 15-state model and WHA’s congressional asks each cover one piece well. Nothing currently connects them, or organizes them by which lever moves which part of the gap, so a founder, a state advocate and a clinician each start their search from scratch.
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Coverage momentum is concentrated in three conditions. Menopause, fertility and doula care have real, fast-moving legislative machinery behind them, and maternal health now has a dedicated federal model in TMaH. Endometriosis, PMOS (formerly PCOS), autoimmune conditions and cardiovascular presentation differences have strong evidence and far less coverage-specific activity so far, which makes them the natural next front rather than a permanent blind spot.
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The root-cause lever has the fewest hands on it. State mandates are visible, winnable and worth winning. How codes get valued in the first place, through the RUC and CMS, reaches every condition at once and currently draws a much smaller group of advocates. Understanding that process is the highest-leverage thing a new entrant to this space can learn.
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The newest pathways are still being designed, which is the opportunity. TMaH shows a women’s-health condition can get its own federal payment pathway, and ACCESS is actively growing its condition list, with five tracks added for April 2027. That combination means the question is less whether the door opens and more who brings the prepared case for the next round of additions.
where the gap starts
It starts upstream of any single plan or benefit, in how procedure codes are valued. Medicare prices care in relative value units (RVUs), recommended by the AMA/Specialty Society RVS Update Committee (the RUC) and finalized by CMS, and commercial payers largely follow that lead. Comparing 55 anatomically comparable male and female procedure pairs in the 2023 Medicare fee schedule, Penn, Colley, Koirala, King and Fitzgerald (Journal of Women's Health, 2025) found 41 of the 55 female procedures carried lower RVUs, with male-specific procedures averaging about 30% higher, and 25.6% higher facility reimbursement, roughly $76 more per procedure. From 2003 through 2023, that spread held steady at 31% to 34%, and comparing 1997, 2015 and 2023 shows it has barely narrowed, which makes this a structural question about how the code set was built rather than a question about any one payer.
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Source: Penn, Colley, Koirala, King and Fitzgerald, Price and Prejudice, Journal of Women's Health, 2025.
why this is a gap
Coverage arrives condition by condition and state by state, so each advance has to be won on its own. Four states now require insurers to cover menopause care, 25 states and DC have assisted-reproductive-technology mandates, and 26 states plus DC reimburse doula care through Medicaid, each the result of a separate bill with its own champions and its own timeline. Federal payment models show the same condition-by-condition shape. Maternal health has its own dedicated pathway in CMS's Transforming Maternal Health (TMaH) Model, a 10-year model running 2025 through 2034 with 15 state Medicaid agencies selected in January 2025. CMS's ACCESS model, meanwhile, opened in July 2026 with four chronic-condition tracks and is adding four more on April 1, 2027, plus a follow-on for its existing musculoskeletal track, and no women's-health-specific condition appears in either set yet. With tracks actively being added, that is a live and concrete opening rather than a closed door.
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Sources: state menopause law tracker; MultiState on ART mandates; NASHP, March 2026; CMS TMaH and CMS ACCESS model pages.