Women and Health Care in the Early Years of the ACA: Key Findings from the 2013 Kaiser Women's Health Survey

The passage of the Affordable Care Act (ACA) in 2010 heralded a new era in health care coverage, with major implications for women’s health and access to care. Provisions such as the mandatory inclusion of maternity care, coverage without cost sharing for preventive services such as contraceptives, and a prohibition on charging women more than men for the same plan were all designed to address gaps and inequities in women’s health insurance. Some of these provisions were implemented shortly after the passage of the ACA, including the expansion of dependent coverage and the preventive services coverage rules. The requirement for mandatory insurance coverage and the expansion in Medicaid eligibility and state-based Marketplaces are just getting underway.

Understanding the law’s myriad impacts on women’s health and access to care will take many years, but it is important to have a baseline with which to compare future outcomes. The Kaiser Family Foundation undertook this survey to provide an initial look into the range of women’s health and care experiences, especially those that are not typically addressed by most surveys nor often analyzed through a gender lens. The Kaiser Family Foundation conducted this nationally representative survey in the fall and early winter of 2013, just before the ACA’s major coverage expansion began. The findings presented in this report examine women’s coverage, access, and affordability to care, as well as their connections to health providers and use of preventive care based on an analysis of a nationally representative sample of 2,907 women ages 18 to 64. In addition, a shorter survey of 700 men ages 18 to 64 was also conducted and key findings are included in the text for the purposes of comparison. To provide the data for the analysis of women’s use of reproductive and sexual health services, this report analyzes the responses of a nationally representative sample of 1,403 women ages 15 to 44.

This report addresses a wide range of topics that are at the heart of women’s health care and changes that women may experience as a result of the ACA. It also highlights differences for uninsured, low-income, and minority women–groups of women that have been historically underserved –which is especially important in light of the characteristics of women in the U.S. today. Nearly one in three women ages 18 to 64 live in households that are below 200% of the federal poverty level (FPL) which was $19,530 for a family of three in 2013. One in three women identify as racial and ethnic minorities (13% Black, 14% Hispanic, and 9% Asian or Other) and half are in their childbearing years. A sizable minority of women also report that their health is fair or poor (15%) and over four in ten have a health condition that requires monitoring and treatment (43%). For these women in particular, access to health care is an essential and ongoing concern. Key findings from the survey include:

Coverage, Access and Affordability

The health coverage expansion will fill a major gap in coverage for women.

In the late fall and early winter of 2013, as the ACA’s coverage expansion kicked into gear, approximately one in five women ages 18-64 were uninsured (18%). Employer-sponsored insurance (ESI) covered the majority of women (57%), with nearly half of that group covered as a dependent either through a spouse or parent. Just 7% of women were covered by individual insurance and about one in ten women (9%) had Medicaid, the nation’s health program for low-income individuals. In the coming years, millions of uninsured women could gain access to coverage that includes a wide range of benefits that are important to their care.

Gaps in coverage are experienced by a disproportionately high share of low-income women and women of color.

For low-income women, the gaps in coverage are considerable, with 4 in 10 reporting that they were uninsured at the end of 2013. Nearly a quarter of Black (22%) and over one-third (36%) of Hispanic women were also uninsured. Eligibility for Medicaid and availability of subsidies in the form of tax credits will help many women gain access to coverage. While many may have enrolled in the state Marketplaces or in Medicaid during the open enrollment period, some of the poorest women do not qualify for assistance because they reside in a state that is not expanding Medicaid or are undocumented immigrants that are explicitly excluded from Medicaid and state Marketplace plans.

Coverage under a parent’s plan is now the leading way that women under age 26 get their coverage, but few are aware that parents may get information about their care.

One of the earliest ACA provisions that took effect in September 2010 was the extension of dependent coverage to young people up to age 26, who had the highest uninsured rate of any age group at the time the law was passed. In 2013, over four in ten (45%) women ages 18 to 25 reported that they were covered on a parent’s plan as a dependent. Because they are adult children, the extension of coverage has raised concerns about their ability to maintain privacy regarding the use of sensitive health services such as reproductive and sexual health care and mental health. The survey finds that less than four in ten young women (37%) are aware that private insurers typically send an explanation of benefits (EOB) documenting use of health care services to primary policy holders, often a parent. Yet, the vast majority (71%) of young women state that it is important to them that their use of health services be confidential.

Many women report they face cost-related barriers to health care, and many report that medical bills are a problem that force them to make difficult trade-offs.

One in four (26%) women have had to delay or forgo care in the past year due to cost compared to 20% of men. While health costs are a major barrier to care for nearly tw0-thirds (65%) of uninsured women, 16% of women with private insurance and 35% of women with Medicaid also said they delayed or went without care because they could not afford it. Nearly three in ten women have had problems paying medical bills in the past year (28%). Problems are, not surprisingly, more common among uninsured women (52%) and low-income women (44%), who have fewer resources to cover their bills. A substantial share of women with medical debt reported 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.

Logistical barriers to care beyond coverage and affordability are challenges for many women.

Many women report they can’t find the time (23%) or take time off work (19%) to get their care. Childcare (15%) and transportation problems (9%) also prevent some women from getting to care, and are more frequently reported among low-income women (19% and 18%, respectively). One-quarter of all women, regardless of income, reported that lack of time to go to the doctor was a reason they went without care. While the ACA and other reforms have the potential to help offset coverage gaps and assist with the burdens of costs, the survey finds that factors such as work place flexibility, sick leave, and child care also have implications for women’s access to care.

Connections to Care

Coverage and delivery system reforms could result in more women having a stronger connection to health providers, but new models of care need to be gendersensitive.

The vast majority of women say they have a place to go when they need care (86%), have a doctor that they see regularly (81%) and have seen a provider in the past two years (91%). On average, a higher share of women than men report that they have an existing connection to a health care provider or place. Among women, however, those who are uninsured have considerably weaker connections to the health care system, reporting lower rates on all of these indicators. About seven in ten uninsured women (69%) have a regular site of care, but only half (50%) have a regular clinician, and three-quarters (75%) have had a recent provider visit. Women who are younger, Hispanic, low-income or uninsured are also more likely to lack these important connections to care. Women’s care can also be complex because some see Obstetrician/Gynecologists for their reproductive needs and different providers for their other health needs. The ACA includes incentives to improve primary care and develop new models for patient centered medical homes. Given the importance of sexual and reproductive health for women, incorporating these sensitive services into new models of care will be a key consideration.

While most women get their care in a private doctor’s office, community health centers and family planning clinics are sources of care for a sizable minority of women covered by Medicaid or without insurance.

Among women who identify a place where they usually seek care when they are sick or need medical advice, almost three in four (73%) go to a doctor’s office or a health maintenance organization setting (HMO). While eight in ten women with private insurance (82%) go to a doctor’s office for routine care, this share drops to two-thirds of women with Medicaid (66%) and less than half of uninsured women (45%). Medicaid beneficiaries (23%) and uninsured women (28%) have much higher reliance on clinics than privately-insured women (7%). Nearly one in six uninsured women (16%) say they get their routine care from an emergency room. While it is too soon to tell how safety net providers will fare as more people gain coverage and shift to private or Medicaid plans, many women will still rely on these providers for their care.

Preventive Services

The ACA rules that require private plans to cover preventive services without cost sharing may help boost use of preventive services, but awareness of the requirement and use of services are still lagging.

The ACA included new requirements for private plans to cover a wide range of recommended preventive screening and counseling services without cost sharing. Public awareness of these insurance reforms, however, is far from universal. Six in ten women know that plans must now cover well-woman visits and 57% know that mammograms and pap tests are covered without cost sharing. While most women report a recent checkup or well woman visit (82%), rates of specific preventive counseling and screenings are uneven. Most women report that they have discussed diet and nutrition (70%) with a provider in the past 3 years, but fewer than half of women have recently talked to a provider about smoking (44%), alcohol or drug use (31%), and mental health (41%). A deeper focus on the content of well woman visits, along with patient education, may be needed to broaden use of clinical preventive services for women.

Women enrolled in Medicaid use preventive care at rates that are similar or higher than women with private insurance.

Women enrolled in Medicaid, 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. Efforts to expand no-cost coverage under Medicaid to these recommended evidence-based services could further access to screening and counseling services for the millions of low-income women served by the program.

Reproductive and Sexual Health Services

There is considerable room for improvement in the rates of counseling on reproductive and sexual health topics.

Despite the high rates of sexually transmitted infections (STIs) and unintended pregnancy, counseling on these topics is not routine among women of reproductive age (15 to 44 years). While most reproductive age women have had recent conversations with a provider about contraception (60%), the rate is much lower regarding sexual history (50%), HIV (34%), other STIs (30%), and intimate partner violence (IPV) (23%). Furthermore, many women are incorrectly under the impression that HIV and STI tests are routinely included as part of their gynecological exams. While four in ten reproductive age women report that they have had a test for HIV (44%) or other STIs (40%) in the past two years—about half of these women mistakenly assumed this test was a routine part of an examination. Therefore, the actual screening rates are likely lower than the share of women who report being tested. This assumption clearly has implications for the treatment and the prevention of transmission of these infectious diseases.

A substantial share of sexually active women is not using any contraception and is at high risk for unintended pregnancy.

While the effectiveness of FDA approved contraceptives in preventing unintended pregnancy is widely known, an estimated one in five (19%) sexually active women ages 15 to 44 who do not want to get pregnant are at high risk for unintended pregnancy because they and their partner are not using contraceptives and have not had a sterilization procedure. Among women of reproductive age who have had sex in the past year, about half (51%) report that they or their partners used at least one contraceptive method, one in ten (10%) are pregnant or trying to conceive, and one in five (20%) women report that they or their partner have had a sterilization procedure or cannot become pregnant. Among sexually active women who have used contraceptives in the past year, nearly two-thirds (63%) report using male condoms and almost half have used birth control pills (48%).

A sizable minority of women using contraceptives now rely on long acting reversible contraceptives (LARCs).

LARCs, which include IUDs, sub-dermal implants and injections, are among the most effective methods of birth control. While condoms and oral contraceptives are the most common forms of birth control that women use, about one-third of women who have been sexually active in the past year and using a contraceptive say they used a LARC. About one in five (19%) say they have an intrauterine device (IUD), 6% report using an implant, and 7% report using hormonal injections as their contraceptive. LARCs, particularly IUDs, can have significant upfront costs and require provider insertion and follow up care. The ACA contraceptive coverage provision may result in the increased adoption of these highly effective approaches by eliminating potential cost barriers associated with these contraceptives.

While awareness of emergency contraceptive pills is quite high, a small fraction of women say they have actually used or purchased them.

Emergency contraceptive (EC) pills can be taken after unprotected sex or as a backup method to prevent unintended pregnancy in cases of contraceptive failure. In 2009, the EC pills, Plan B®, became available without a prescription and in 2010, a new prescription formulation (ella®), was approved by the FDA. As with other contraceptives, private plans are required to cover prescriptions for EC without cost sharing under the ACA’s preventive services policy. It has now been 15 years since EC pills were approved by the FDA and 86% of women ages 15 to 44 report that they have heard of them. However, a small percentage of women (5%) say they have used or bought EC pills, ranging from 12% of women ages 19 to 24 to 2% of both teens ages 15 to 18 and women ages 35 to 44.

One in three women with private insurance say their insurance covered the full cost of contraception.

The ACA includes provisions that require new plans to provide no-cost coverage for prescription FDA-approved contraceptive services and supplies for women (including insertion, removal and follow up care). While this provision only applies to “new” or “non-grandfathered” plans, over time it is anticipated that most women with private coverage will be enrolled in plans that offer this coverage. Nearly one and half years after the ACA contraceptive coverage rule took effect, insurance covered the full cost for one-third (35%) of women with private insurance. Another 41% reported that insurance covered part of the costs and about one in ten (13%) women with private insurance reported they did not have any coverage for birth control.

Family planning providers and community health centers play a major role in providing contraceptive care for uninsured women and women of color.

Most sexually active women who use birth control state that they receive contraceptives at a doctor’s office or HMO (61%) and 16% obtain contraceptive care at a clinic-based setting. Established to provide care regardless of income, essential community providers finance contraceptive care largely through Title X (the federal planning program) and Medicaid. These clinics provide contraceptive care to substantial shares of uninsured (43%), Hispanic (37%), and Black women (23%). As care systems increasingly shift to private managed care plans, it will be important to monitor how care changes for the women who have been relying on these providers for their reproductive and sexual health care. In addition, because some low-income women will either not qualify for coverage or may not be able to afford to enroll in plans, many will still be reliant on these safety-net providers for their sexual and reproductive health care.


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