Many Women Use Preventive Services, but Gaps in Awareness of Insurance Coverage Requirements Persist: Findings from the 2022 KFF Women’s Health Survey

Updated July 19, 2023, to reflect the addition of data on receipt of cervical cancer screenings (Table 1) and STI and HIV tests (Table 2). 

Key Takeaways

• Three in four (76%) women ages 50-64 report that they had a mammogram in the past two years, with higher shares of Black women (86%) and substantially lower shares of uninsured women (45%).
• Forty-four percent of uninsured women ages 50-64 who have not had a mammogram in the past two years say this is because they could not afford one.
• Six in ten (59%) women ages 18-64 report that they had a cervical cancer screening (Pap test) in the past two years, with higher shares among Black women (64%) and women with higher incomes (≥ 200% of the federal poverty level) (62%) or private insurance (64%) and lower shares of uninsured women (42%).
• Thirty-eight percent of women ages 45-64 report having a colon cancer screening (colonoscopy) in the past two years, including slightly higher shares of Black women (44%) and women with Medicaid (44%) and a lower share of uninsured women (16%).
• Many women ages 18-64 went without or delayed health care services they were due for in the past two years, most commonly for dental care (52%).
• Few women ages 18-64 have had an STI test such as for chlamydia or herpes (28%) or an HIV test (25%) in the past two years, with considerably higher shares among women who are Black, LGBT+, or who have Medicaid.
• The Affordable Care Act (ACA) requires most health insurance plans to cover birth control for women without cost sharing; however, more than four in ten (43%) women ages 18-64 are unaware of this coverage requirement. Smaller shares were unaware that an annual check-up for women (19%) and cervical cancer screenings (20%) are also required to be covered.
• Women with higher incomes and those with higher educational attainment are more likely than women with lower incomes and less educational attainment to know that annual check-ups for women and cervical cancer screenings must be covered without cost sharing. Knowledge of no-cost coverage of birth control for women was similar across education levels.

Introduction

Evidence-based preventive services can improve health by identifying illnesses earlier, managing them more effectively, and treating them before they progress into more complicated and debilitating conditions. Since 2010, the Affordable Care Act (ACA) has required most private health insurance plans to cover a range of recommended preventive services for adults without any patient cost-sharing. Over the years, there have been numerous updates and additions to the range of services covered under this policy, and today the slate includes a number of cancer screenings, immunizations, and behavioral health services such as tobacco cessation and weight management services. Some services are specific to women, including annual checkups, prenatal tests, screening for intimate partner violence, and prescription contraceptive services. Despite the policy’s wide reach, there have been several legal challenges over elements of the preventive services requirement since it initially took effect, including in a pending case, Braidwood Management Inc. v. Becerra.

This data note presents findings from the 2022 KFF Women’s Health Survey (WHS) on women’s receipt of cancer screenings and other preventive services and differences between subgroups of women. We also present data on women’s and men’s awareness of federal requirements for private insurance coverage of preventive services. The KFF WHS is a nationally representative survey of 5,145 self-identified women and 1,225 men ages 18 to 64, conducted May 10 – June 7, 2022. See the Methodology section for more details.

Preventive Screenings

Use of preventive services can lead to early identification of conditions when they are more responsive to medical interventions. This is especially true for certain types of cancers and cardiovascular conditions. For example, the USPSTF recommends routine mammograms every two years for women ages 50-74¹  to detect breast cancer, depending on risk factors; cervical cancer screenings for women ages 18-65, though the recommended frequency ranges from every three years to every five years depending on the person’s age and the type of screening test; and colorectal cancer screenings for women ages 45-75, though the recommended frequency ranges from yearly to every ten years depending on the type of screening test. These services are covered in full by most private plans under the ACA’s preventive services coverage requirements and by most state Medicaid programs.

The majority of women ages 50-64 say they have had a mammogram in the past two years, with higher rates among Black women. 

Three-quarters (76%) of women ages 50-64 report having had a mammogram in the past two years (Table 1). A higher share of Black women (86%) report having a mammogram than White women (75%) and Hispanic women (69%). A considerably higher share of insured women (78%) than those who are uninsured (45%) had a mammogram in the past two years. The survey did not find any statistically significant differences in recent mammogram rates by low- vs. higher-income or urbanicity/rurality.

Most women ages 18-64 report that they have had a cervical cancer screening/Pap test in the past two years, with higher rates among Black women and those with higher incomes and private insurance.

Six in ten (59%) women ages 18-64 report having had a cervical cancer screening/Pap test in the past two years (Table 1). A higher share of Black women (64%) report having a cervical cancer screening than White women (59%). A higher share of women with private insurance (64%) had a cervical cancer screening than those with Medicaid (56%) or the uninsured (42%). Women with higher incomes (62%) were also more likely to have had a screening than those with lower incomes (< 200% of the federal poverty level) (55%). There were no statistically significant differences in recent cervical cancer screening rates by urbanicity/rurality.

Fewer women ages 45-64 have had a recent colon cancer screening/colonoscopy in the past two years, with lower rates among the uninsured.

Fewer than two in five (38%) women ages 45-64 report having a recent colon cancer screening/colonoscopy in the past two years (Table 1). A higher share of women with Medicaid coverage (44%) and private health insurance (38%) reported having a colon cancer screening in the past two years than uninsured women (16%). There were no statistically significant differences in recent colon cancer screening rates among women of different races/ethnicities, income, or urban/rural residence.

Many women ages 50-64 have not had a mammogram in the past two years because they didn’t think they needed one or that they were not due for one.

Among women ages 50-64 who have not had a mammogram in the past two years, 28% say the main reason was that they didn’t think they needed one or they were not due for one (Figure 1). Fourteen percent say they did not get a mammogram because they were worried about being exposed to COVID-19 and 11% say they couldn’t afford it or that insurance wouldn’t cover it. Smaller shares say they couldn’t get an appointment or didn’t know where to get it (5%). Four in ten (41%) report that they did not get a mammogram in the past two years for some other reason.

The share of women who did have not had a mammogram in the past two years because they couldn’t afford it or because insurance would not cover it is higher among uninsured than insured women (44% vs. 5%) and higher among low-income women than higher-income women (18% vs. 8%) (data not shown).

Many women went without or delayed health care services they were due for in the past two years. 

Most notably, more than half (52%) of women ages 18-64 report that they delayed or went without a dental visit (Figure 2). One-third of women ages 21-64 went without or delayed getting a pap smear. Seventeen percent went without or delayed vaccines other than those for COVID-19. More than one in five (22%) women ages 18-64 with children under 18 say their child went without or delayed a well-visit.

 

Despite clinical recommendations for routine STI and HIV testing, few women have had a recent test.

Routine STI and HIV screenings are important for early detection, treatment, and preventing transmission. STI and HIV tests are covered without cost-sharing in private plans under the ACA’s preventive services coverage requirements and are typically covered by Medicaid programs. However, fewer than three in ten women ages 18-64 have had an STI test such as for chlamydia or herpes (28%), or an HIV test (25%) in the past two years (Table 2). Recent STI and HIV testing rates are higher among women ages 36-49, those who identify as LGBT+² , Black and Hispanic women, lower-income women, and women with Medicaid.

Knowledge of the Affordable Care Act

For ten years, the Affordable Care Act has required most health plans to cover recommended preventive health care services and medications at no cost to the enrollee. Although most people are aware of some of these benefits, over a decade later, a sizeable share is still unaware, particularly about coverage for contraception.

More than two in five (43%) women ages 18-64 did not know that most health insurance plans must cover the full cost of birth control for women, and more than one-third (37%) incorrectly responded that vasectomies must be covered. Although most plans are required to cover contraception for women, and without cost sharing, contraception for men such as male condoms and vasectomies is not required to be covered (Figure 3).

One in five women did not know that an annual check-up for women (19%) or a cervical cancer screening (20%) must be covered without cost sharing, and one-third (32%) incorrectly believed erectile dysfunction medication must be covered.

A higher share of women than men correctly identified that the benefits specifically for women (an annual check-up, cervical cancer screenings, and birth control) are required to be covered without cost sharing. A higher share of men than women correctly responded that vasectomies are not required to be covered. There was no statistically significant difference between the share of women and men who correctly responded that erectile dysfunction medication is also not required to be covered without cost sharing.

Knowledge about the ACA’s no-cost preventive services coverage requirements varies by sociodemographic characteristics.

A smaller share of younger women than older women know that most health plans are required to cover annual check-ups and cervical cancer screenings without cost sharing, but a higher share of younger women than older women know that vasectomies are not required to be covered without cost sharing (Table 3). In addition, a smaller share of women with less education and lower incomes are aware of the coverage requirements for check-ups and cervical cancer screenings than their counterparts. Awareness of birth control coverage requirements was similar across education levels.

Conclusion

Coverage for preventive services is an established part of health plan benefits for most people in the United States today. However, this survey finds that not all women are aware of the no-cost coverage requirements for some preventive services, notably contraception. Lack of awareness of these coverage requirements means that some people may be less likely to obtain these services due to concerns about cost sharing. The outcome of a pending legal case could jeopardize the federal government’s authority to require plans to cover preventive services. Should the court ultimately rule in favor of the plaintiffs, millions of people who now have guaranteed coverage of preventive services without cost sharing could see this benefit eroded in the future.

Overview

The 2022 KFF Women’s Health Survey is a nationally representative survey of 6,442 people ages 18 to 64, including 5,201 females (self-reported sex at birth) and 1,241 males, conducted from May 10, 2022, to June 7, 2022. The objective of the survey is to help better understand respondents’ experiences with contraception, potential barriers to health care access, and other issues related to reproductive health. The survey was designed and analyzed by researchers at KFF (Kaiser Family Foundation) and fielded online and by telephone by SSRS using its Opinion Panel, supplemented with sample from IPSOS’s KnowledgePanel.

Questionnaire design

KFF developed the survey instrument with SSRS feedback regarding question wording, order, clarity, and other issues pertaining to questionnaire quality. The survey was conducted in English and Spanish. The survey instrument is available upon request.

Sample design

The majority of respondents completed the survey using the SSRS Opinion Panel (n=5,202), a nationally representative probability-based panel where panel members are recruited in one of two ways: (1) through invitations mailed to respondents randomly sampled from an Address-Based Sample (ABS) provided by Marketing Systems Group through the U.S. Postal Service’s Computerized Delivery Sequence. (2) from a dual-framed random digit dial (RDD) sample provided by Marketing Systems Group.

In order to have large enough sample sizes for certain subgroups (females ages 18 to 35, particularly females in the following subgroups: lesbian/gay/bisexual; Asian; Black; Hispanic; Medicaid enrollees; low-income; and rural), an additional 1,240 surveys were conducted using the IPSOS KnowledgePanel, a nationally representative probability-based panel recruited using a stratified ABS design. (Note that due to small sample sizes, data for Asians are combined with data for Pacific Islanders for this survey.)

Data collection

Web Administration Procedures

The majority of surveys completed using the SSRS Opinion Panel (n=5,056) and all of the surveys completed using the KnowledgePanel (n=1,240) were self-administered web surveys. Panelists were emailed an invitation, which included a unique passcode-embedded link, to complete the survey online. In appreciation for their participation, panelists received a modest incentive in the form of a $5 or $10 electronic gift card. All respondents who did not respond to their first invitation received up to five reminder emails and panelists who had opted into receiving text messages from the SSRS Opinion Panel received text message reminders.

Overall, the median length of the web surveys was 13 minutes.

Phone Administration Procedures

In addition to the self-administered web survey, n=146 surveys were completed by telephone with SSRS Opinion Panelists who are web reluctant. Overall, the median length of the phone surveys was 28 minutes.

Data processing and integration

SSRS implemented several quality assurance procedures in data file preparation and processing. Prior to launching data collection, extensive testing of the survey was completed to ensure it was working as anticipated. After the soft launch, survey data were carefully checked for accuracy, completeness, and non-response to specific questions so that any issues could be identified and resolved prior to the full launch.

The data file programmer implemented a “data cleaning” procedure in which web survey skip patterns were created in order to ensure that all questions had the appropriate numbers of cases. This procedure involved a check of raw data by a program that consisted of instructions derived from the skip patterns designated on the questionnaire. The program confirmed that data were consistent with the definitions of codes and ranges and matched the appropriate bases of all questions. The SSRS team also reviewed preliminary SPSS files and conducted an independent check of all created variables to ensure that all variables were accurately constructed.

As a standard practice, quality checks were incorporated into the survey. Quality control checks for this study included a review of “speeders,” reviewing the internal response rate (number of questions answered divided by the number of questions asked) and open-ended questions. Among all respondents, the vast majority (97%) answered 96% or more of the survey questions they received, with no one completing less than 91% of the administered survey (respondents were informed at the start of the survey that they could skip any question).

Weighting

The data were weighted to represent U.S. adults ages 18 to 64. The data include oversamples of females ages 18 to 35 and females ages 36 to 64. Due to this oversampling, the data were classified into three subgroups: females 18 to 35, females 36 to 64, and males 18 to 64. The weighting consisted of two stages: 1) application of base weights and 2) calibration to population parameters. Each subgroup was calibrated separately, then the groups were put into their proper proportions relative to their size in the population.

Calibration to Population Benchmarks

The sample was balanced to match estimates of each of the three subgroups (females ages 18 to 35, females ages 36 to 64, and males ages 18 to 64) along the following dimensions: age; education (less than a high school graduate, high school graduate, some college, four-year college or more); region (Northeast, Midwest, South, West); and race/ethnicity (White non-Hispanic, Black non-Hispanic, Hispanic-born in U.S., Hispanic-born Outside the U.S., Asian non-Hispanic, Other non-Hispanic). The sample was weighted within race (White, non-Hispanic; Black, non-Hispanic; Hispanic; and Asian) to match population estimates. Benchmark distributions were derived from 2021 Current Population Survey (CPS) data.

Weighting summaries for females ages 18 to 35, females ages 36 to 64, and males ages 18 to 64 are available upon request.

Finally, the three weights were combined, and a final adjustment was made to match the groups to their proper proportions relative to their size in the population (Table 1).

Margin of Sampling Error

The margin of sampling error, including the design effect for subgroups, is presented in Table 2 below. It is important to remember that the sampling fluctuations captured in the margin of error are only one possible source of error in a survey estimate and there may be other unmeasured error in this or any other survey.

KFF Analysis

Researchers at KFF conducted further data analysis using the R survey package, including creating constructed variables, running additional testing for statistical significance, and coding responses to open-ended questions. The survey instrument is available upon request.

Rounding and sample size

Some figures in the report do not sum to totals due to rounding. Although overall totals are statistically valid, some breakdowns may not be available due to limited sample sizes or cell sizes. Where the unweighted sample size is less than 100 or where observations are less than 10, figures include the notation “NSD” (Not Sufficient Data).

Statistical significance

All statistical tests are performed at the .05 confidence level. Statistical tests for a given subgroup are tested against the reference group (Ref.) unless otherwise indicated. For example, White is the standard reference for race/ethnicity comparisons and private insurance is the standard reference for types of insurance coverage. Some breakouts by subsets have a large standard error, meaning that sometimes even large differences between estimates are not statistically different.

A note about sex and gender language

Our survey asked respondents which sex they were assigned at birth, on their original birth certificate (male or female). They were then asked what their current gender is (man, woman, transgender, non-binary, or other). Those who identified as transgender men are coded as men and transgender women are coded as women. While we attempted to be as inclusive as possible and recognize the importance of better understanding the health of non-cisgendered people, as is common in many nationally representative surveys, we did not have a sufficient sample size (n >= 100) to report gender breakouts other than men and women with confidence that they reflect the larger non-cisgender population as a whole. The data in our reproductive health reports use the respondent’s sex assigned at birth (inclusive of all genders) to account for reproductive health needs/capacity (e.g., ever been pregnant) while the data in our other survey reports use the respondent’s gender.

1. The Women’s Preventive Service Initiatives (WPSI) recommends that average-risk women initiate mammography screening no earlier than age 40 and no later than age 50. ↩︎
2. For more information, see our brief LGBT+ People’s Health Status and Access to Care. ↩︎