By Judy Waxman,
Vice President for Health and Reproductive Rights, National Women's Law Center

The process of implementing the new health care law continues this week as a panel of independent experts meet to begin to develop evidence-based preventive health guidelines for women that will be used to determine what preventive services will be covered in all new health insurance plans and provided with no cost-sharing.

Under a part of the new health care law that went into effect in September, all new insurance plans are required to cover certain preventive measures like mammograms, pap smears, smoking cessation therapy and folic acid and provide them to patients at no cost. To supplement these new rules, the Institute of Medicine has been tasked with addressing serious gaps in the definition of preventive care for women and ensuring that this landmark protection meets the full range of women’s health needs. This week the Institute of Medicine’s panel of women’s health experts is holding its first meeting to begin the process of making preventive care more accessible and affordable for women.

As a part of this meeting, I testified before the panel and discussed general barriers to care that women face and recommended five services that the panel should be sure to include in their final recommendations to Department of Health and Human Services (HHS).

Women seeking affordable health care face significant and unique barriers. Women generally make less than men. With women making on average just 78 cents for every dollar a man earns, women have less money to spend on their health care. It is then not hard to imagine why more women than men have faced economic hardship due to health care needs. Women are also more likely to delay or avoid seeking care, including preventive care, due to cost. Evidence also suggests that even moderate co-pays can cause individuals, especially those with low and moderate incomes, to forgo needed preventive care.

As NWLC has shown, before the Affordable Care Act, the individual insurance market routinely failed women, making access to affordable health care even more challenging. Women obtaining identical plans to men oftentimes pay higher premiums. To add insult to injury, maternity care is rarely included in basic individual plans, and as a result women must purchase a supplemental policy to cover pregnancy. These riders can be prohibitively expensive. Women who obtain coverage through an employer are partially protected from these barriers due to federal and state employment discrimination laws, but cost and coverage challenges continue to exist.

The National Women’s Law Center also proposed five additional services to be included in the final list:

• Family Planning Counseling and All FDA- Approved Prescription Contraceptives — Nearly all American women use contraceptives during their reproductive years. Family planning counseling and supplies allow women to control the spacing, timing and number of births, which leads to improved health and mortality outcomes for women and their children. The ability to plan a pregnancy can prevent a range of pregnancy related complications that can endanger a woman’s health, and allows women to the take the necessary steps to ensure her own health is adequate to undergo pregnancy and childbirth.

A wealth of information supports the recommendation that reversible and permanent forms of contraception be covered by health insurance:

• A consensus study by a panel convened by the IOM in 1995 to address unintended pregnancy recommended that financial barriers to contraception be reduced by “increasing the proportion of all health insurance policies that cover contraceptive services and supplies…with no copayments or other cost-sharing requirements, as for other selected preventive health services.”
• The Centers for Disease Control and Prevention named family planning one of the ten most important public health achievements of the 20th century because of its contribution to “the better health of infants, children, and women.”
• Contraceptive use is one of the cornerstones of Healthy People 2010, the nation’s agenda for promoting health and preventing disease.
• The National Business Group on Health, a non-profit organization representing large employers’ perspectives on national health policy issues, conducted a comprehensive review of available evidence and recommends a clinical preventive service benefit design that includes all FDA-approved prescription contraceptive methods at no cost-sharing.

Including family planning counseling and supplies in the final recommendations would also build on key federal protections in place for millions of women. For almost 40 years, Medicaid has covered family planning services and supplies and provided them without co-payments for millions of low-income women.

Because the only FDA-approved prescription contraceptives available today are for women, and pregnancy is a condition unique to women, the panel has the opportunity to rectify a long-standing inequity for women. Failure to cover contraceptives forces women to bear higher out-of-pocket health costs, totaling approximately $9,000 over her lifetime.  Nearly ten years ago, the Equal Employment Opportunity Commission issued an interpretation of the federal civil rights law that prohibits discrimination in employment, stating that it is sex discrimination for employer-sponsored health insurance plans to provide coverage of other prescription drugs and preventive services, but fail to provide coverage of contraception.

• Screening for Intimate Partner Violence — Three women are murdered each day by their husbands or boyfriends, and two million injuries result from domestic violence each year. We should be using every tool at our disposal to identify and help victims of intimate partner violence and we believe routine behavioral assessment for intimate partner violence could help reduce these numbers.
• Screening for Cervical Cancer — Cervical cancer was once the leading cause of cancer death for American women, but screening and early intervention has greatly reduced the number of deaths each year. It has been a several years since the United States Preventive Service Task Force (USPSTF) has updated its recommendations. We urge the panel to review relevant evidence to ensure women are receiving the appropriate care.
• Breast Pump Equipment — Studies have shown that breastfeeding provides important long-term health benefits for mothers. Lactation supplies, including breast pumps, are critical for mothers to sustain breastfeeding and receive the preventive health benefits that lactation affords.
• Physician-Recommended Preventive Services — Many of the services that are provided in a routine preventive visit are included among USPSTF recommendations, yet the Task Force does not recommend the actual visit itself, and women are often charged co-payments at the time of service. We urge the panel to consider covering all well-woman and preconception care visits.  When a doctor recommends a preventive health visit, a woman’s decision about whether to comply should not turn on her ability to afford the care.

A number of organizations, including the U.S. Conference of Catholic Bishops, decried the possibility that contraception may be included among the preventive health services covered, but this extreme position is without merit and harmful to women. Sound science should trump ideology, and we’re confident that the Institute of Medicine panelists will not let the religious views of some interfere with their expert review of the scientific and medical evidence and the needs of American women. 

The IOM is expected to submit its final recommendations to HHS in June 2011.

Cross-posted on Womenstake.