Women and the ACA: Coverage, contraception, and disparities

Last week was National Women’s Health Week, and the Kaiser Family Foundation used the occasion to release the report Women and Health Care in the Early Years of the ACA: Key Findings from the 2013 Kaiser Women’s Health Survey, by Alina Salganicoff, Usha Ranji, Adara Beamesderfer, and Nisha Kurani. The telephone survey of 3,015 women ages 15 – 64 was conducted before the launch of the health-insurance exchanges and several states’ Medicaid expansions, but after several other key provisions of the Affordable Care Act took effect. Starting with plan years beginning after September 22, 2010, insurers with non-grandfathered plans now have to cover preventive services without cost-sharing and allow adult children up to age 26 to remain on their parents’ insurance policies (see the Kaiser Family Foundation implementation timeline for details). The Kaiser Women’s Health Survey results demonstrate that these provisions are especially important for women’s health, but it also offers a reminder that coverage doesn’t always translate into receiving healthcare services or having good health outcomes.

“Preventive services” covered by this ACA provision include those getting top ratings (A or B) from the US Preventive Services Task Force, immunizations recommended by the Advisory Committee on Immunization Practices, and services specified in guidelines from the Health Resources and Services Administration (HRSA). For these services, insurers may not require enrollees to pay co-payments or other cost-sharing. In 2012, the Department of Health and Human Services calculated that 47 million women would be eligible to receive a range of co-pay-free services, including “well-woman visits, screening for gestational diabetes, HPV DNA testing, domestic violence screening and counseling, HIV screening and counseling for sexually transmitted infections, breastfeeding supplies, contraceptive methods and family planning counseling.”

Guidelines developed by the Institute of Medicine and supported by HRSA specify that the “contraceptive services” category includes “all Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity.”  The Center for Consumer Information & Insurance Oversight provides more detail in an FAQ:

The HRSA Guidelines ensure women’s access to the full range of FDA-approved contraceptive methods including, but not limited to, barrier methods, hormonal methods, and implanted devices, as well as patient education and counseling, as prescribed by a health care provider. Consistent with PHS Act section 2713 and its implementing regulations, plans and issuers may use reasonable medical management techniques to control costs and promote efficient delivery of care. For example, plans may cover a generic drug without cost-sharing and impose cost-sharing for equivalent branded drugs. However, in these instances, a plan or issuer must accommodate any individual for whom the generic drug (or a brand name drug) would be medically inappropriate, as determined by the individual’s health care provider, by having a mechanism for waiving the otherwise applicable cost-sharing for the branded or non-preferred brand version. This generic substitution approach is permissible for other pharmacy products, as long as the accommodation described above exists.

Certain religious employers have received an exemption for contraceptive coverage requirement (see this National Health Law Program timeline for more details), and the Supreme Court will soon decide whether private employers can also refuse to cover healthcare services to which they object.

For younger women, the possibility of remaining on a parent’s insurance plan until age 26 can be important not only for accessing healthcare, but for exploring new job opportunities. During a panel discussion at the Kaiser event, Amy Allina of the National Women’s Health Network and Raising Women’s Voices noted that first jobs these days often lack employer-sponsored insurance, and that young women’s earnings may be higher if they’re not experiencing job lock – that is, if having a parent’s insurance coverage enables them to change jobs rather than staying in less-than-ideal positions in order to keep health benefits.

Incomplete awareness of contraceptive coverage and confidentiality
Key findings from the 2013 Kaiser Women’s Health Survey include the following:

  • 57% of women had employer-sponsored insurance in 2013, while 18% were uninsured (the remaining figures: 9% Medicaid, 7% individual policies, 6% other government program).
  • Uninsurance rates were higher among Hispanic and Black women – 36% and 22%, respectively – than among White women (13%).
  • 26% of women delayed or went without healthcare due to cost over the past 12 months, and 28% report problems paying medical bills.

As far as preventive services, many women were either unaware of ACA provisions on cost-sharing or did not receive contraceptive services free of charge – and perhaps partly as a result, nearly one in five women are at risk of an unintended pregnancy:

  • 57% of women knew the ACA requires most private plans to cover the full cost of many preventive services.
  • Among women with private insurance, only 35% reported their insurers covered the full cost of contraceptives.
  • Among sexually active women not trying to become pregnant, 19% were not using any form of contraception.

Many young women seem to be taking advantage of the ability to stay on parent’s private health plans; however, a significant portion of them are unaware that these plans can send Explanation of Benefit (EOB) statements that may alert their parents to the services the young women receive:

  • 45% of women ages 18 -25 have employer-sponsored insurance through a parent, while only 8% are insured by their own employers.
  • Among women ages 18 – 25, 71% rate confidentiality as important, but only 37% know private plans can send EOBs to policyholders.

Panelist Francisco Garcia, Director and Chief Medical Officer of the Pima County Health Department in Arizona, warned that insufficient privacy protections can have a chilling impact on women’s use of reproductive-health services – but, he noted, safety-net providers like community health centers and family-planning clinics offer a high level of confidentiality. (See Kim Krisberg’s recent post about Title X-funded clinics in Massachusetts for more on this issue.)

Barriers and disparities persist
The Affordable Care Act aimed to slash uninsurance rates nationwide, but the Supreme Court’s decision that states could choose whether or not to accept the ACA’s Medicaid expansion has left many of the poorest residents of Florida, Texas, and several other states without health insurance. At the Kaiser event, panelist Cara James, Director of the Office of Minority Health at the Centers for Medicare and Medicaid Services, noted that state decisions not to expand Medicaid have had a disproportionate impact on Black and Latina women. There’s hope that more states will accept the expansion in the coming years, or develop HHS-approved plans (waivers) to devote federal dollars to other mechanisms for covering residents with incomes near or below the federal poverty level. (For instance, Arkansas is using federal funds that would have gone to a Medicaid expansion to instead buy private insurance coverage for adult residents with income up to 138% FPL).

As I’ve written before, insurance coverage is not synonymous with access to healthcare or with improved health outcomes. As the 2013 Kaiser Women’s Health Survey found, many women didn't get all the healthcare recommended, and not everyone knows that private insurers are supposed to pay the full cost of preventive services like well-woman visits and contraceptive services. Some insurers may drag their heels on adding coverage for certain forms of contraception, for instance. Panelist Vanessa Cullins of Planned Parenthood Federation of America noted that it will take “enforcement and diligence” to ensure that women are able to get what they’re entitled to under the Affordable Care Act.

Even when women have insurance coverage and know that they can get preventive services without cost-sharing, other barriers can persist. The Kaiser survey found the following about reasons women gave for delaying or going without care:

  • 23% of women couldn’t find time to go to the doctor.
  • 19% of all women, and 26% of those with incomes under 200% FPL, couldn’t take time off work.
  • 15% had problems getting childcare (19% for those under 200% FPL).
  • 9% of all women, and 18% of those with incomes under 200% FPL, had transportation problems.

All the panelists emphasized that difficulties with time, transportation, and childcare – as well as money for cost-sharing – can be significant barriers to care, especially, but not solely, for lower-income women. Cullins stressed that these are among the determinants of health "that the ACA cannot address, but need to be addressed through our political process – such things as income inequity, such things as paid leave, personal days that are paid, sick time that is paid.” (The good news here is that several cities and states have already passed laws for paid medical and/or family leave and paid sick days, and several more jurisdictions are considering paid-leave bills and ballot measures. A bill for a national social-insurance system for paid medical and family leave has also been introduced in the US Congress.)

Garcia pointed out that safety-net providers – including community health centers, family-planning clinics, and public-health departments that provide healthcare services – will continue to be a key source of care for many people, especially black women and women of color. These providers are accustomed to meeting the needs of low-income clients, and are already a trusted source of care for millions of people with and without insurance. However, Garcia warned that some public officials assume that such safety-net providers will be less needed as the ACA is implemented, when in fact they are still essential and should keep receiving funding. Practitioners and advocates will need to communicate about the crucial role of safety-net providers to those who make resource-allocation decisions.

In her remarks at the beginning of the panel discussion, the Kaiser Family Foundation’s Alina Salganicoff (one of the authors of the new report) noted that the 2013 survey was conducted shortly before much of the ACA’s coverage expansion took effect – so, it will serve as a baseline to which to compare future findings. Usha Ranji, also of the Kaiser Family Foundation and an author of the report, expressed the hope that the insurance marketplaces won’t just allow more women to get coverage, but will also help them understand what different plans cover and compare their options. Panelists agreed that improving health literacy and insurance literacy will be important to help people make the best use of their benefits and achieve better health outcomes, and several efforts are underway, including one being pilot-tested by the Office of Minority Health. The next survey, scheduled for 2017, should give some indication of women’s awareness of and ability to use the benefits they’re entitled to under the ACA.


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