Starting next year, the Affordable Care Act will largely prohibit insurers who sell individual and small-group health policies from charging women higher premiums than men for the same coverage. Long-term-care insurance, however, isn't bound by that law, and the country's largest provider of such coverage has announced it will begin setting its prices based on sex this spring. "Gender pricing is good for insurance companies," said Bonnie Burns, a policy specialist at California Health Advocates, a Medicare advocacy and education organization, "but it’s bad public policy and it's bad for women." Genworth Financial says the new pricing reflects the fact that women receive two of every three claims dollars. The change will affect only women who buy new individual policies, or about 10 percent of all purchasers, according to the company. The new rates won't be applied to existing policyholders or those who apply as a couple with their husbands. More From This Series Insuring Your Health "This change is being made now to reflect our actual claims experience and help stabilize pricing," Genworth Financial spokeman Thomas Topinka said in an e-mail. Women's premiums may increase by 20 to 40 percent under the new pricing policy, said Jesse Slome, executive director of the American Association for Long-Term Care Insurance. The average annual premium for a 55-year-old who qualified for preferred health discounts and bought between $165,000 and $200,000 of coverage was $1,720 last year, according to the association. Experts say they expect other long-term-care insurers will soon follow suit. Long-term-care insurance provides protection for people who need help with basic daily tasks such as bathing and dressing. It typically pays a set amount for a certain number of years -- say, $150 daily for three years -- for care provided in a nursing home, assisted living facility or at home. Never a very popular product with consumers, many of whom found it unaffordable, in recent years the industry has struggled and many carriers have raised premiums by double digits or left the market. Consumer health advocates say they aren't surprised that women's claims for long-term-care insurance are higher than men's. Because women typically live longer than men, they frequently act as caregivers when their husbands need long-term care, advocates say, thus reducing the need for nursing help that insurance might otherwise pay for. Once a woman needs care, however, there may be no one left to provide it. "Women live longer alone than men," Burns said. "If you don't have a live-in caregiver when you start needing this kind of care, you’re in big trouble." LuMarie Polivka-West knows the potential problems all too well. Polivka-West, 64, is the senior director of policy and program development for the Florida Health Care Association, a trade organization for nursing homes and assisted living facilities. (I first spoke with Polivka-West two years ago, when she discussed the financial challenges she and her two brothers faced caring for their aging parents.) About 15 years ago, she bought a long-term-care policy. The company went out of business after five years, and she let her policy lapse rather than switch to another plan with higher premiums and less comprehensive coverage. But she's reconsidering that decision. Polivka-West's husband is four years older than she is. Her mother died of Alzheimer's disease at age 89 after struggling with it for eight years. What if a similar fate awaits her? Polivka-West thinks insurers shouldn't be allowed to charge her more just because she's a woman. "The Affordable Care Act recognized the gender bias in health insurance," she said. "The same [rules] should apply to long-term-care insurance." The federal health overhaul sought to eliminate the coverage and price discrepancies in the larger health insurance market. A 2012 study by the National Women's Law Center found that 92 percent of top-selling health plans in the individual market practiced sex-based pricing in states where the practice was allowed. (Fourteen states banned or limited the practice, according to the report.) Nearly a third of plans charged women at least 30 percent more than men for the same coverage, even plans that did not include maternity benefits, the study found. Insurers that sell individual and small-group health policies on the state-based health insurance exchanges or outside them on the private market in 2014 will be able to vary premiums based only on geography, family size, age and tobacco use. (Plans that have grandfathered status under the law are exempt from these requirements.) Under federal laws against sex discrimination in the workplace, employers are generally prohibited from charging women more than men for the same health insurance coverage. Meanwhile, Genworth Financial says it won't switch to gender-based pricing for long-term care in two states—Colorado and Montana--that prohibit varying premiums based on gender in all health insurance products. As states move to bring their laws into conformance with the gender rating requirements under the Affordable Care Act, some advocates see an opportunity. "Any state with a strong advocacy group could be advocating for a very broad-based prohibition against gender rating" in all insurance products, says Donna Wagner, the associate dean for academic affairs at the College of Health and Social Services at New Mexico State University who also chairs the policy committee for the Older Women’s League, an advocacy group.

In recent years, consumers have increasingly been encouraged by employers and insurers to help control rising health care costs by avoiding unnecessary tests, buying generic drugs and reducing visits to the emergency room, among other things. The hope is that a patient better educated and more engaged in health decisions will choose options that will promote better health and decrease costs.

Such "patient engagement" efforts assume that patients welcome the opportunity--or at least are willing--to get more involved in their own care. But as a study published last month in the journal Health Affairs found, a majority of patients didn’t want to factor costs into their medical decisions, nor did they want their doctors to do so.

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The study investigated the attitudes of 211 focus group participants in Washington, D.C., and Santa Monica, Calif., toward weighing their own out-of-pocket costs as well as the costs borne by their insurer in medical decisions. The participants, researchers said, did not generally understand how insurance works and felt little personal responsibility for helping to solve the problem of rising health care costs. They were unlikely to accept a less expensive treatment option, even if it was nearly as effective as a more expensive choice.

I talked about the findings with study co-author Susan Dorr Goold, a professor of internal medicine and health management and policy at the Center for Bioethics and Social Sciences in Medicine at the University of Michigan. This is an edited transcript of that conversation.

Q. What if anything about the findings surprised you?

A. We as a team were surprised at how firmly and frequently people talked about not wanting cost considerations to factor into decision-making at all. It surprised us as we were analyzing the data that there weren't some people speaking out and saying, "Wait, we're all going to pay more if we don't consider the costs." We heard it, but not very often and not very much. If patients think we shouldn't consider costs at all, doctors are put in a difficult position.

Q. But isn't it true that doctors don't generally like discussing the cost of care with patients?

A. What other research has shown is that doctors feel some responsibility to help contain health care costs. However, they feel even more responsibility to patients.

Q. In the study, you asked patients to consider how cost might influence their thinking if, for example, someone had a headache for three months and discussed getting an MRI versus a CT scan with his doctor. In this scenario, the doctor explained that a CT scan would identify nearly all the problems that were serious enough to need treatment for a fraction of the cost of an MRI. In general, people were unwilling to consider the cheaper test. How do you interpret that?

A. As a research team, we talked about what might have happened if we had chosen a different example. When you talk about headache, you’re talking about your brain. What if we’d talked about toenail fungus instead? Is getting rid of it worth a treatment that’s nearly a thousand times more expensive? There’s a whole spectrum of medical problems, from life threatening to living with ugly toes.

Although we know from other research patients certainly consider their out of pocket costs, they're not very good at deciding what's worth spending extra money on. Doctors have to be part of the discussion about the value of different options.

Q. One of the beliefs people expressed was that you get what you pay for, that more expensive care is by definition better. That seems like a very "American" attitude, doesn't it?

A. The idea that you get what you pay for is a very American, market-oriented point of view. I often talk to patients about generic versus brand-name medications, for example, and how for the most part there’s no difference in value. If you're trying to get your blood pressure down or treat a rash, using a generic medication is fine. But you'd be surprised at how many people resist something just because it's cheaper, even if it is just as good.

Q. Participants seemed to feel that since they're paying health insurance premiums they should be entitled to unlimited care whenever they need it. How do health insurance claims differ from auto insurance or homeowners’ insurance claims?

A. Health insurance is different because we're not talking only about a rare, catastrophic event. We’re talking about all kinds of events. The fact that you've been paying into the insurance plan gives you a just claim to resources needed to care for your needs. But paying into insurance doesn't mean that you can ask them to pay for anything and everything you ask for. It should be a real health need, a legitimate service and at a reasonable price.

With car repairs, insurers would say that you have to get a couple of estimates, and they want to make sure the price is reasonable, and they're not going to give you a sun roof if you didn't have one before. You get a replacement for what you lost. But with health care it's not necessarily a rare and expensive event. It could be an ongoing event for a particular person. If you have diabetes and heart disease, you may have doctor visits every couple of months. So it's a little bit different than car insurance.

Q. People talked about not being willing to make any tradeoffs between health and money, no matter how expensive the treatment. Isn't it ironic that people who seem to place such value on their health are often unwilling to invest in inexpensive, life-prolonging activities like exercise and eating right?

A. Some of it is the episodic versus cumulative effect. If you're facing an event—a headache or chest pain--that is a different kind of scenario than, "What am I going to eat today?" Of course people do not always make choices that are the absolute healthiest, whether it's exercise, diet or wearing a seatbelt. Healthy choices in life and much of what we do in health care (like treating high blood pressure) try to decrease your risk of a bad event. But nothing decreases your risk to zero.

Q. People expressed concern that they don't want physicians to factor in patient resources when they make treatment decisions. Care should be the same, they said, whether someone is penniless or just flew in on a private jet. To what extent do patient resources influence care?

A. No matter if you flew in on your private jet or came in penniless off the street, for the most part I'm going to recommend the same treatment. That doesn't mean you'll be able to afford it.

Lots of places have looked at what care we should pay for, and frankly the insurance companies are making those decisions now. They're deciding what’s covered and what’s not, what's medically necessary and what’s not. That's a judgment. No matter what kind of system you have, somebody has to decide what's going to be paid for.

Q. In the study, you found that some participants seemed motivated to choose expensive care "out of spite," because they were antagonistic toward their insurance company. What's going on there?

A. There was an almost vengeful attitude toward insurance companies, the idea that "I've been paying in and now I'm going to get what I'm owed," or "I'm going to get them back for all the money I've paid in all these years."

The motivation that "I'm sick and I don’t want to think about the money," that's understandable. But "I want to hurt the insurance company?" Why? Those health care payments come from money all of us have paid to insurers. It's an interesting finding that requires more looking into.