Women spend more out-of-pocket on health care than men do and are more likely to forgo needed care each year because of cost. And millions of women both with and without insurance are missing out on essential preventive care each year.1 A brief I coauthored last spring found that less than half of women ages 19–64 were up to date with a set of recommended preventive care tests in 2010, and we know from other studies that even moderate copayments for preventive services such as Pap smears and mammograms can deter use, particularly among people with low incomes.2
In a move that will likely go a long way toward remedying this problem, the U.S. Health Resources and Services Administration (HRSA) last week issued the first-ever guidelines on preventive services for women. The guidelines are a result of the Women's Preventive Health Care Amendment to the Affordable Care Act, which asked HRSA to supplement the United States Preventive Services Task Force (USPSTF) recommendations with evidence-informed comprehensive guidelines specifically focused on preventive services for women.
The guidelines, along with previous regulations on preventive care, eliminate much of the variation in the preventive services covered by different insurance plans, and in different states (which each have their own requirements for insurers). For example, while all states other than Utah previously required insurers to cover mammography, only 29 required coverage of cervical cancer screens and just three required coverage of Chlamydia screening.3 Private insurers in all states will now be required to cover these services without cost-sharing.
The process of developing the Women’s Preventive Services guidelines started six months ago when the U.S. Department of Health and Human Services (HHS) tasked the Institute of Medicine (IOM) to establish a committee to consider which preventive services not included in the USPSTF recommendations are beneficial for the health and well-being of women and girls ages 10–65. All of the eight recommendations in the IOM Committee’s report, published on July 19, were accepted by HHS, with one adjustment relating to contraceptive services.
The short guideline document gives a list of preventive services for women which all non-grandfathered group and individual market health plans (meaning health plans created since the Affordable Care Act became law) must cover without cost-sharing, copayment, or deductible beginning on August 1, 2012. The August 2012 effective date ensures that college students enrolled in student health plans will have the new benefit in the 2012–2013 school year.
These new guidelines for women are the latest in a series of measures implemented as part of the Affordable Care Act which focus on prevention. Last year, HHS published interim final regulations that require all non-grandfathered group and individual market insurers to cover recommended preventive services without cost-sharing. Covered services include those that the USPSTF rate as either “A” (high certainty that the net benefit is substantial) or “B” (high certainty that the net benefit is moderate); Bright Futures recommendations for adolescents from the American Academy of Pediatrics (in cooperation with HHS); and vaccinations recommended by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices. A full list of covered services is available at http://www.cdc.gov/vaccines/acip/.
The new required services for women, to be covered by all non-grandfathered health plans by next August, include:
- Well-women preventive care visit for obtaining recommended preventive care services including preconception and prenatal care, at least once per year;
- Sexually transmitted infections counseling annually for all sexually active women;
- HIV screening and counseling annually for sexually active women;
- All FDA-approved contraceptive methods, sterilization procedures and patient education and counseling for all women with reproductive capacity—exemptions apply (see below);
- High-risk human papillomavirus (HPV) DNA testing to be added to normal cytology testing for women 30 years or older with normal cytology results, no more than once every three years;
- Gestational diabetes screening for all pregnant women between 24 and 28 weeks gestation and at the first prenatal visit for those identified as at high risk of diabetes;
- Comprehensive lactation support and counseling and the cost of renting breast feeding equipment for pregnant women and new mothers; and
- Domestic and interpersonal violence screening and counseling.
An interim final rule published alongside the guidelines outlines a narrow set of circumstances in which employers may offer health plans which do not cover contraceptive services. Using wording from an exemption in place in California (where, like the majority of the 28 states that require health plans to cover contraception, a religious exemption applies for some organizations), it allows certain nonprofit religious organizations—which have a religious purpose, primarily employ followers of their religion, and primarily serve people with those same religious beliefs—to offer their employees group insurance plans which do not cover contraception. This exemption does not apply in the individual market. The rule is subject to a 60-day comment period.
To aid cost control and efficient care delivery, insurers have some flexibility in how they implement the guidelines. For example, they are permitted to charge beneficiaries for brand-name drugs if a generic version which is as effective is also made available.
The guideline on contraception is perhaps the farthest reaching in terms of the number of Americans who will benefit, particularly financially. Seven of 10 women of reproductive age are sexually active and do not want to become pregnant, but could without contraception.4 It is estimated that nearly half (49%) of pregnancies in the United States were unintended in 2001, and 42 percent of unintended pregnancies ended in abortion.5 Although the IOM committee was asked not to consider cost effectiveness, the IOM did note that contraception is highly cost effective, given that in 2002 the estimated medical cost savings from contraceptive use was $19 billion.
By recognizing the unique health needs of women, these guidelines represent a further important step toward realizing the Affordable Care Act’s commitment to women and the importance of prevention—ensuring screening tests, counseling, and treatments that evidence shows are effective are affordable for all women with insurance. And women have even more to look forward to in 2014: nearly all of the 27 million women who were uninsured in 2010 will gain insurance; gender rating will end, so women will not have to pay more than men for identical insurance in the individual market; women with preexisting conditions will not have them excluded from coverage; and millions of women will gain subsidized comprehensive insurance coverage either through Medicaid or newly established health insurance exchanges, where plans are required to cover maternity care.6
1 R. Robertson and S. R. Collins, Women at Risk: Why Increasing Numbers of Women Are Failing to Get the Health Care They Need and How the Affordable Care Act Will Help (New York: The Commonwealth Fund, May 2011).
2 Institute of Medicine, Clinical Preventive Services for Women: Closing the Gaps (Washington D.C.: National Academies Press, July 2011).
4 Guttmacher Institute, “In Brief: Fact Sheet Facts on Contraceptive Use in the United States” (New York: Guttmacher Institute, June 2010).
5 Institute of Medicine, Clinical Preventive Services for Women: Closing the Gaps (Washington D.C.: National Academies Press, July 2011).
6 R. Robertson and S. R. Collins, Women at Risk: Why Increasing Numbers of Women Are Failing to Get the Health Care They Need and How the Affordable Care Act Will Help (New York: The Commonwealth Fund, May 2011).