Women and Health Care in the Early Years of the ACA: Key Findings from the 2013 Kaiser Women's Health Survey
Conclusions and Implications
The findings of this survey provide new information about the opportunities and ongoing challenges in women’s health care and coverage in the early days of ACA implementation. The ACA includes reforms that could make coverage more affordable, accessible, and stable for many women in the years to come. The bans on pre-existing condition exclusions and gender-rating as well the requirement that plans now include maternity care and contraception could benefit many women, not just those who are uninsured. In the late fall and early winter of 2013 when this survey was conducted, there were still many gaps in coverage and access to care facing women. While the ACA can potentially fill some of these gaps, many challenges related to the law’s implementation and other structural factors remain.
This report documents gaps in women access to care and identifies some of the barriers they experience including the need for affordable care and coverage options. It also highlights some of the distinct health concerns of women, especially the importance of reproductive and sexual health and the need for it to be addressed as part of women’s basic care. Attention to these concerns will need to be part of the larger agenda to improve women’s access to care and coverage, quality of care, and ultimately, their health and well-being.
The health coverage expansion will affect many uninsured women. Gaps in coverage are experienced by a disproportionately high share of low-income women and women of color.
Uninsured women consistently reported barriers to care, lower use, and poorer access to care at much higher rates than women enrolled in Medicaid or private insurance. Millions of uninsured women could gain access to coverage that includes a wide range of benefits. The gaps in coverage are considerable for low-income women, with 4 in 10 reporting that they were uninsured at the end of 2013. The survey finds that Black and Hispanic women also bear a disproportionate burden of being uninsured. Eligibility for Medicaid and the subsidies in the form of tax credits are available to help many low-income women secure coverage under the ACA. While many may have enrolled in the state Marketplaces or in Medicaid during the open enrollment period, some of the poorest women will not qualify for assistance because they reside in a state that is not expanding Medicaid. Additionally, gaps will remain for some immigrant women because federal rules ban Medicaid coverage for new immigrants, and undocumented immigrants are not eligible for Medicaid and do not have access to the Marketplace plans.
Coverage under a parent’s plan is now the leading way that women under age 26 get their coverage, highlighting the importance of confidentiality.
The ACA allows parents to keep their adult children enrolled in their plan until the age of 26. This age group had the highest uninsured rate of any age group before the law was passed. An issue related to this provision that has gotten less attention is confidentiality for this group. This stems from the practice of sending the Explanation of Benefits (EOB) to the principal policy holders, which in these cases is usually a parent of an adult child. The survey finds that most young women are not aware of this policy, but highly value their confidentiality. This is especially important when women see providers for sensitive services such as reproductive health and mental health care. While there are mechanisms available to protect confidentiality and privacy in a health care setting, the receipt of an EOB signaling that an adult child has used services could violate that privacy.
Costs and Access
Many women, not just uninsured women, report they face cost related barriers to health care.
Between one-fifth and one-quarter of women report that they either postponed or went without care they felt they needed because of costs. While health costs are a major barrier to care for many uninsured women, women on Medicaid and privately insured women also report that out-of-pocket costs can limit access on a broad range of indicators. Out-of-pocket spending may still be a barrier to care for newly insured, low-income women despite the availability of subsidies and caps on spending under the ACA. A substantial share of women on Medicaid report that cost is a barrier, which could be attributable to Medicaid policy that permits nominal cost-sharing for some services and in some states limits on the number of visits, prescription drugs, or range of drugs the program will cover.
Medical bills are problems for nearly three in ten women and some are forced to make difficult trade-offs to meet these obligations.
Women report difficulties paying for medical bills at significantly higher rates than men. Not surprisingly, medical debt is a problem for a higher share of women who are low-income, uninsured, and even for women on Medicaid, who may also contend with bills for other family members who are uninsured. A substantial share of women with medical debt report they either used up most of their savings, had difficulty paying for basic necessities, or had to borrow money from friends or relatives to pay for their bills. The issue of medical debt could also be a consideration for women in the selection of a plan’s metal tier available through the Marketplaces. Women choosing bronze plans with low premiums, but higher cost-sharing and deductibles could still face substantial out-of-pocket costs if they have a hospitalization, serious injury, or other medical condition that requires costly medical treatment.
Logistical barriers to care beyond coverage and affordability are challenges for many women.
Lack of flexibility at work, problems with childcare and difficulty securing transportation are reported by a sizable minority of women as a reason that they didn’t get care they felt they needed in the past year. These challenges are more common among low-income women, but are also reported by some with higher incomes. Notably, one-quarter of all women, regardless of income, report that lack of time to go to the doctor is a reason they went without care. The survey suggests that factors such as work place flexibility, sick leave, and child care also could have implications for women’s access to care.
Connections to Care
Expansions in coverage options and system reforms could result in more women having a stronger connection to health providers, but it is important that new models of care be gender sensitive.
While most women report that they have a specific place or provider for their routine care, a substantial share of women who are younger, Hispanic, low-income or uninsured lack this important connection to care. Sizable shares of women also say they have more than one regular provider, typically a family physician/internist along with an Ob/Gyn. The ACA includes incentives to improve primary care and develop new models for patient centered medical homes. It will be important to examine how well these approaches address the diverse needs of women, including reproductive and sexual health care.
A network of safety-net clinics, including community health centers and family planning clinics, will still be needed by many women.
Safety-net providers including community health centers, public clinics, and family planning clinics play a significant role serving women, particularly those who are low-income, uninsured, or racial and ethnic minorities. While it is too soon to tell how these providers will fare as more people gain coverage and shift to private or Medicaid plans, many low-income women will remain reliant on these providers for their care.
The ACA private plan coverage requirements may help improve the use of preventive services, yet awareness is still limited.
The new private plan coverage requirements in the ACA for well woman visits and for other preventive services could result in greater numbers of women receiving these services at recommended rates. However, public awareness of these insurance reforms is far from universal. In addition, while most women report a recent checkup or well woman visit, counseling and screening services are often not provided at recommended intervals. Gaps are especially notable among women who are low-income and uninsured.
Medicaid coverage of preventive services is an important benefit for low-income women.
Women with Medicaid coverage, despite their lower incomes and constrained provider options, obtain preventive screening and counseling services at rates that are on par with women with private coverage. The ACA includes a small financial incentive for state Medicaid programs to provide coverage of all services recommended by the USPSTF without cost sharing. In the coming years, we will track how many states take advantage of this option and broaden coverage of preventive care for women under Medicaid.
Sexual and Reproductive Health
There is considerable room for improvement in the rates of counseling on reproductive and sexual health services.
Among women of reproductive age, counseling rates fall far short of recommended levels. Screening rates for sensitive services are particularly low. Although nearly two-thirds of women have received some level of counseling for contraception, counseling on sexual history, HIV, and STIs is only provided to a fraction of reproductive age women. Many women are incorrectly under the impression that HIV and STI tests are routinely included as part of their gynecological exams. Therefore, the actual screening rate is likely lower than the share of women who report being tested. This mistaken assumption has implications for the treatment and prevention of transmission of these infectious diseases, especially given the high rates of STIs among young women and the disproportionate burden of HIV on Black women.
A substantial share of sexually active women is not using any contraception and consequently is at high risk for unintended pregnancy.
While the effectiveness of FDA approved contraceptives in preventing unintended pregnancy is widely known, many women are at very high risk for unintended pregnancy because they are not using any method. Among sexually active women who use reversible contraceptives, condoms are the most frequently reported followed by oral contraceptives, and a sizable share use more than one method. Condoms also offer important protection against certain STIs, but are not among the most effective methods for preventing pregnancy. It has now been 15 years since Plan B® emergency contraceptive (EC) pills were approved by the FDA and nearly 5 years since they became available without a prescription. Today, awareness of emergency contraceptive pills is quite high. However, a fraction of women report that they have used or purchased them to prevent unintended pregnancy in cases of contraceptive failure or as a backup method of contraception.
A sizable minority of women using contraception now rely on long acting reversible contraceptives (LARCs).
Intrauterine devices (IUDs), sub-dermal implants and hormonal injections, considered to be LARCs, are among the most effective methods of birth control. The ACA includes provisions that require new plans to provide no-cost coverage for prescribed FDA-approved contraceptives and services for women (including insertion, removal and follow up care). This provision could expand access to highly effective and long lasting methods by eliminating costs as a barrier. In addition, coverage of family planning services without cost-sharing has long been a mandatory benefit under Medicaid. About half of the states also have special programs that provide coverage for family planning services to low-income women who do not qualify for full Medicaid, which has potentially expanded the pool of low-income women who can obtain LARCs without cost barriers. A recent study demonstrated that when financial barriers were removed, and women were counseled about all contraceptive methods, 75% of women chose LARCs.1
One in three women with private insurance report that their insurance plans covered the full cost of contraceptives.
Almost two years after the ACA contraceptive coverage rule took effect, among women with private insurance, one in three report that their insurance covered the costs of their contraceptive care in full. This provision only applies to “new” or “non-grandfathered” plans and over time it is anticipated that most women with private coverage will be enrolled in plans that offer this coverage. Still, four in ten say their insurance covered part of the costs and 13% reported that their plans did not cover contraceptives. While this provision has received much attention in the media, not all women are aware of this policy, which has the potential to broaden access to the most effective, but sometimes more costly, methods of contraceptives.
Family planning providers and community health centers play an important role providing contraceptive care for uninsured women and women of color.
Community health centers and family planning clinics were established to provide care to individuals regardless of their ability to pay. Title X, the federal planning program, and the Medicaid program are the
leading sources of public funding for family planning services provided by clinics. As care systems under Medicaid increasingly shift to private managed care plans, and growing numbers of uninsured women are enrolled in private plans and Medicaid, it will be important to monitor how care changes for the women who have been relying on these clinics for their reproductive and sexual health care. In addition, there will still be gaps in coverage as many low-income women will either not qualify for coverage or may not be able to afford to enroll. These low-income women will still need affordable sources of care if they are to have access to sexual and reproductive health services.
The findings of this survey provide new information about the opportunities and ongoing challenges in women’s health care and coverage in the early days of ACA implementation. The ACA includes reforms that could make coverage more affordable, accessible, and stable for many women in the years to come. While the ACA can address some of these gaps, many challenges related to the law’s implementation and other structural factors remain. Patient education, affordable care and coverage options, and integrated care systems that encompass the range of women’s health needs, including reproductive and sexual health, will be critical issues to consider moving forward.