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IOM Recommendations on Covered Women’s Preventive Services Likely to Take Effect

By John Reichard, CQ HealthBeat Editor

July 19, 2011 -- Starting in 2013, a growing number of insurance companies are likely to begin 100 percent coverage of comprehensive preventive services for women, including a wide range of contraceptives, because of developments set in motion by a report an Institute of Medicine panel.

The health care law helped set the stage for covering such services by requiring the prestigious institute to issue a report detailing where there are gaps in existing recommendations for covering preventive services without any out-of-pocket charges. The aim was to spur greater use of preventive services that the research community thinks are needed to improve public health.

Health and Human Services is expected to make a decision in early August on whether to accept the recommendations, but with the Institute of Medicine providing cover, it is highly unlikely that federal officials would not follow the suggestions to any significant degree. HHS Secretary Kathleen Sebelius issued a statement praising the report as "historic."

"Before today, guidelines regarding women's health and preventive care did not exist," she said. "These recommendations are based on science and existing literature, and I appreciate the hard work and thoughtful analysis that went into this report."

The recommendations call for full coverage in eight different areas. Perhaps most prominently, they include coverage for a wide range of contraceptives—all of those approved by the Food and Drug Administration. Among them are the so-called morning after contraceptives, Plan B and Ella.

"Access to contraception, counseling for victims of domestic abuse, and preventative screenings for HIV and other diseases will empower women to reduce unintended pregnancies and better protect themselves and their health," said Rep. Louise Slaughter, D-N.Y.

But the panel did not recommend covering the drug RU-486. Its omission may help reduce the intensity of criticism of the IoM recommendations from Americans who oppose abortion because RU-486 is clearly an abortion-inducing drug. Products like Plan B and Ella may be less likely to be viewed that way by many Americans, since they are intended for use right after unprotected sex.

Not surprisingly, leaders of the Catholic church condemned the recommendations, and backers of abortion and contraceptive rights enthusiastically praised them. Surveys show that many U.S. Catholics practice contraception that is opposed by the leaders of the church.

Critics will oppose the recommendations on other grounds, however, such as cost. Robert Zirkelbach, press secretary for America's Health Insurance Plans, said that "current coverage of preventive services is based on the recommendations put forth by independent, expert organizations such as the Advisory Committee on Immunization Practices (ACIP) and the U.S. Preventive Services Task Force (USPTF). Broadening the scope of mandated preventive services that go beyond or conflict with the current evidence-based guidelines will increase the cost of coverage for individuals, families and employers."

Sen. Richard M. Burr of North Carolina, a Republican on the Senate Health, Education, Labor and Pensions Committee, said, "I'm not sure you could point to any area of health care that I believe should be free. All of health care should have some out-of-pocket cost-sharing. One reason why health care spending is at the level it is is because a lot of people perceive it to be free. That's a utilization nightmare."

If HHS or Congress don't go along with the recommendations, it likely will be because insurers and employers kick up a big fuss about the costs. If they strongly argue that it will lead to fewer employers offering coverage and companies holding down wages, the pressure could lead to some narrowing of the scope of the recommendations.

But opposition could be tempered somewhat by the fact that insurers wouldn't be changing coverage right away. Although HHS officials will decide shortly whether to accept the recommendations, they would not go into effect until August 1, 2012, and then only in the first full plan year that begins after that. In addition, plans "grandfathered" from complying with a number of provisions of the health care law (PL 111-148, PL 111-152) would not have to meet the requirements. But many plans will be losing that status over the next few years.

An HHS official said that if the department were to adopt these recommendations on Aug. 1, 2011, "non-grandfathered plans would have to cover them in the first plan year beginning after Aug. 1, 2012. For many plans, this will be Jan. 1, 2013."

The official added that with regard to grandfathered plans, in 2011 "an estimated 31 million people in new employer plans and 10 million people in new individual plans will benefit from the new prevention provisions under the Affordable Care Act. The number of individuals in employer plans who will benefit from the prevention provisions is expected to rise to 78 million by 2013, for a total potential of 88 million Americans whose prevention coverage will improve due to the new policy."

The official added that "many of the 98 million people in group health plans that are expected to be "grandfathered" and thus not subject to these regulations already have preventive services coverage.

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