ASPE ISSUE BRIEF INCREASED COVERAGE OF PREVENTIVE SERVICES WITH ZERO COST SHARING UNDER THE AFFORDABLE CARE ACT June 27, 2014 Amy Burke and Adelle Simmons, ASPE The Affordable Care Act ensures that most insurance plans (so-called ‘non-grandfathered’ plans) provide coverage for certain preventive health services without cost sharing for plan or policy years beginning on or after September 23, 2010. 1 This includes screening for colon cancer for adults over 50, Pap smears and mammograms for women, well-child visits, flu shots for all children and adults, and many more services. 2 Highlights • Seventy six million Americas are estimated to be newly eligible for expanded preventive services coverage under the Affordable Care Act—including 30 million women. Altogether, a total of 48.5 million women are estimated to benefit from free preventive services. • According to data from the IMS Institute for Healthcare Informatics (IMS), between 2012 and 2013, the number of women who filled prescriptions for oral contraceptives with no co-pay more than quadrupled from 1.2 million in 2012 to 5.1 million in 2013 (an increase of 3.9 million). • IMS estimated that the total number of prescriptions for oral contraceptives with no co-pay increased by more than four-fold from 6.8 million in 2012 to 31.1 million in 2013 (an increase of 24.4 million) in part due to the Affordable Care Act’s zero-cost sharing provisions for certain preventive services. • This increase in oral contraceptive prescriptions dispensed with no co-pay contributed to a reduction in out-of-pocket costs estimated by IMS at $483.3 million that would have been spent in 2013 had women bought the same mix of oral contraceptives as those purchased in 2012. 1 Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services Under the Patient Protection and Affordable Care Act, U.S. Departments of Treasury; Labor; and Health and Human Services. Federal Register, Vol. 75, 41726 (July 19, 2010). 2 Preventive Care Benefits. U.S. Department of Health and Human Services, 2014. Accessed at: https://www.healthcare.gov/what-are-my- preventive-care-benefits/#part=1 Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation http://aspe.hhs.gov ASPE Issue Brief Page 2 While some plans already covered the full costs of these services prior to the Affordable Care Act, millions of Americans were enrolled in health plans that did not. According to the Kaiser Family Foundation’s Employer Health Benefits Survey in 2012, 41 percent of all workers were covered by employer-sponsored group health plans that expanded their list of covered preventive services due to the Affordable Care Act. 3 The most recent data from the Census Bureau show that as of 2012, 175 million Americans under age 65 were enrolled in private health coverage. 4 Putting these facts together (0.41*175 million), this gives us approximately 71.8 million privately insured individuals with expanded preventive services coverage. In addition, current enrollment data show that approximately 8 million non-elderly people selected a Marketplace plan since initial open enrollment began. 5 A recent Kaiser survey shows that nearly 6 in 10 people (57 percent or approximately 4.5 million enrollees) enrolled in Marketplace plans were previously uninsured. 6 Based on these data, we estimate that approximately 76 million Americans – and 30 million women – are now eligible to receive expanded coverage of one or more preventive services because of the Affordable Care Act. 7, 8 Using national survey data on children and adults with private insurance and data on enrollment in the Marketplace, we next estimated how those 76 million people are distributed across states, and across age, race, and ethnic groups. We examined the following age/gender groups, and provide here examples of the services now available to them without any cost sharing. Note that this is not an exhaustive list of recommended preventive services required to be covered for people under age 65 and is only meant to highlight illustrative examples. • Children: Coverage includes immunization vaccines for children from birth to age 18; vision screening; hearing screening for newborns; behavioral assessments; obesity screening; and height, weight, and body mass index measurements. • Women: Coverage includes cervical cancer screening, mammograms for women over 40, recommended immunizations, healthy diet counseling for women at higher risk for chronic disease 9 and obesity screening and counseling; cholesterol and blood pressure screening; screening for HIV; depression 3 Kaiser Family Foundation – Health Research and Education Trust. Employer Health Benefits: 2012 Summary of Findings. Exhibit 13.7 shows that 41% of workers were in plans “where the services considered preventive changed because of the ACA.” The same analysis shows that 27% of workers were in plans “where cost sharing changed for preventive services because of the ACA.” We made the conservative assumption that these two groups overlapped completely, meaning that 41% experienced expanded coverage and/or reduced cost sharing, though in fact if some people in the second group were not in the first, the overall percentage of workers affected by expanded coverage or by reduced cost sharing as a result of the ACA could have been even higher than 41% and as high as 68% (41% + 27%). 4 DeNavas-Walt C, Proctor BD, Smith JC. Census Bureau, Current Population Reports, P60-243, Income, Poverty, and Health Insurance Coverage in the United States: 2012, Government Printing Office, Washington, DC, 2013. 5 The Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, May 1, 2014, “Health Insurance Marketplace: Summary Enrollment Report for the Initial Annual Open Enrollment Period,” for the period October 1, 2013 through March 31, 2014, including additional special enrollment period activity reported through 4-19-2014). Accessed at: http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollment.pdf 6 Liz Hamel, Mira Rao, Larry Levitt, Gary Claxton, Cynthia Cox, Karen Pollitz, and Mollyann Brodie, Survey of Non-Group Health Insurance Enrollees: A First Look at People Buying Their Own Health Insurance Following Implementation of the Affordable Care Act, Kaiser Family Foundation, June 2014. 7 We included people with non-group plans in this calculation, since non-group coverage tends to be less generous than employer-provided insurance, suggesting that at least 41 percent of people in the non-group market likely experienced expanded coverage for preventive services due to this provision. We also added in the 4.5 million people who were previously uninsured and selected Marketplace plans during the initial enrollment period October 1, 2013 through March 31, 2014 (including the additional special enrollment period activity reported through 4-19-2014). [(.41 x 175m) + 4.5m = 76 m] This is a conservative estimate since it is possible that those who did have insurance prior to selecting a Marketplace plan might not have had coverage of preventive services without cost-sharing if they had been in one of the “grandfathered” plans exempt from this requirement. 8 This estimate includes only non-elderly Americans with private insurance. In addition, Sections 4103 and 4104 of the Affordable Care Act eliminated cost sharing for Medicare beneficiaries receiving annual wellness visits and certain recommended preventive care including colorectal cancer screening, mammograms, bone mass measurement, and other services. http://www.hhs.gov/healthcare/prevention/seniors/medicare-preventive-services.html 9 Note this service is for patients with high cholesterol and other risk factors for cardiovascular and diet-related chronic disease. ASPE Office of Health Policy June 2014 ASPE Issue Brief Page 3 screening; and tobacco-use screening; well-woman visits, screening for gestational diabetes, domestic violence screening and counseling, and FDA-approved contraception with no cost sharing. 10 • Men: Coverage includes recommended immunizations such as flu shots, colorectal cancer screening for adults over 50, healthy diet counseling for those at higher risk for chronic disease, obesity screening and counseling, cholesterol and blood pressure screening, screening for HIV, depression screening, and tobacco-use screening. Figure 1 presents national totals, including breakdowns by age, gender, race and ethnicity. Table 1 presents totals by state. 11 FIGURE 1: Number of Americans Estimated to be Newly Covered for Expanded Preventive Services Under the Affordable Care Act (in Millions) 12 80 76 70 59.2 60 50 40 29.7 28.1 30 18.6 20 8.8 7.8 10 4.3 0.5 0 Total Children Women Men White Latino Black Asian Native American 10 Certain religious employers are exempt from this requirement with respect to certain contraceptive services that otherwise would be required to be covered without cost sharing. In addition, an accommodation is available to certain other non-profit organizations with religious objections to contraception coverage, such that these eligible organizations are not required to contract, arrange, pay, or refer for contraceptive coverage. See 45 C.F.R. § 147.131. 11 Data come from the Census Bureau’s Current Population Survey, for the years 2010-2012. We use three pooled years to allow for state- level estimates. We analyzed the proportion of all non-elderly individuals (0-64 years old) with private insurance in each category and state listed in Figure 1 and Table 1, and scaled the survey-weighted percentages to total 71.6 million individuals in aggregate (the number of those with private coverage from the Census data alone), to match the projected number of people affected by this policy. Note that this overall approach is only a rough approximation and does not reflect any potential uneven distribution of individuals by age, race/ethnicity, or state of residence in private plans affected by the preventive coverage provisions of the Affordable Care Act. We then added the state breakouts from the enrollment data to the Census state breakouts to get national totals and state totals that reflect the estimates of those with expanded preventive service coverage from both data sources. 12 The Census Bureau records race and ethnicity separately, which means that totals combining racial and ethnic groups sum to more than 100%. The source of these data are: ASPE calculations using Census Bureau’s Current Population Survey, for the years 2010-2012 and enrollment data from the Marketplace Summary Enrollment Report (for more information see: http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollment.pdf). Age data for women and men were not available for the State-based Marketplace (SBM); gender estimates include the elderly in the enrollment data for the SBMs. Enrollment data for race and ethnicity were not available for the SBMs. The estimates presented here by race and ethnicity do not include enrollment data for the State-Based Marketplaces. Age breakouts by race and ethnicity also were not available for any of the states. Enrollment data by race and ethnicity include the elderly. The elderly are 0.5% of the total enrollment for the country (eight million). ASPE Office of Health Policy June 2014 ASPE Issue Brief Page 4 TABLE 1: Americans Estimated to be Newly Covered for Expanded Preventive Services Under the Affordable Care Act, by State 13 State Total Children Women Men Alabama 1,170,000 280,000 467,000 424,000 Alaska 172,000 45,000 64,000 65,000 Arizona 1,486,000 398,000 557,000 546,000 Arkansas 598,000 142,000 237,000 221,000 California 9,050,000 2,177,000 3,514,000 3,407,000 Colorado 1,382,000 368,000 520,000 502,000 Connecticut 991,000 246,000 386,000 362,000 Delaware 225,000 56,000 88,000 82,000 District of Columbia 152,000 24,000 68,000 61,000 Florida 4,349,000 935,000 1,801,000 1,638,000 Georgia 2,358,000 579,000 933,000 854,000 Hawaii 333,000 79,000 128,000 127,000 Idaho 407,000 114,000 149,000 149,000 Illinois 3,183,000 774,000 1,233,000 1,184,000 Indiana 1,592,000 415,000 609,000 573,000 Iowa 813,000 209,000 305,000 299,000 Kansas 714,000 186,000 273,000 257,000 Kentucky 1,027,000 243,000 401,000 388,000 Louisiana 965,000 233,000 382,000 351,000 Maine 331,000 71,000 138,000 125,000 Maryland 1,575,000 379,000 623,000 575,000 Massachusetts 1,786,000 428,000 692,000 650,000 Michigan 2,518,000 634,000 983,000 910,000 Minnesota 1,465,000 396,000 536,000 532,000 Mississippi 639,000 159,000 251,000 230,000 Missouri 1,532,000 382,000 585,000 571,000 Montana 230,000 54,000 90,000 87,000 Nebraska 505,000 131,000 189,000 188,000 Nevada 633,000 169,000 222,000 219,000 New Hampshire 382,000 88,000 152,000 143,000 New Jersey 2,282,000 591,000 869,000 828,000 New Mexico 401,000 98,000 160,000 144,000 New York 4,695,000 1,085,000 1,871,000 1,745,000 North Carolina 2,266,000 537,000 917,000 827,000 North Dakota 193,000 49,000 72,000 73,000 Ohio 2,814,000 698,000 1,079,000 1,045,000 Oklahoma 849,000 213,000 330,000 310,000 Oregon 943,000 220,000 380,000 345,000 Pennsylvania 3,368,000 759,000 1,338,000 1,277,000 Rhode Island 268,000 62,000 107,000 100,000 South Carolina 1,084,000 260,000 443,000 386,000 South Dakota 211,000 55,000 79,000 78,000 Tennessee 1,514,000 356,000 597,000 566,000 Texas 5,762,000 1,456,000 2,211,000 2,130,000 Utah 833,000 281,000 283,000 278,000 Vermont 171,000 33,000 72,000 67,000 Virginia 2,153,000 549,000 849,000 766,000 Washington 1,694,000 389,000 675,000 635,000 West Virginia 413,000 100,000 162,000 152,000 Wisconsin 1,539,000 382,000 587,000 573,000 Wyoming 146,000 39,000 53,000 55,000 TOTAL 76,162,000 18,606,000 29,710,000 28,100,000 13 The source of these data are: ASPE calculations using Census Bureau’s Current Population Survey, for the years 2010-2012 and enrollment data from the Marketplace Summary Enrollment Report (for more information see: http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollment.pdf). The age range for these estimates are ages 0 to 17 for children and 18 to 64 for both men and women. Age data for women and men were not available for the State-based Marketplace (SBM); gender estimates include the elderly in the enrollment data for the SBMs. ASPE Office of Health Policy June 2014 ASPE Issue Brief Page 5 The numbers in Table 1 represent people who had a change in coverage related to the Affordable Care Act. Of course, the total number of people who benefit from coverage of preventive services with no out-of-pocket cost is higher once you take into account those who already had that benefit at baseline. Using 2013 Kaiser Survey data of the number of people covered by non-grandfathered plans, we estimate that a total of 48.5 million women ages are able to benefit from free preventive services (see Table 2 for totals by state). 14 14 To estimate the total number of women guaranteed preventive services coverage with no cost sharing, we used the proportion of covered workers in non-grandfathered plans from the Kaiser Family Foundation’s 2013 Employer Health Benefits Survey together with the number of women enrolled through the Marketplace. ASPE Office of Health Policy June 2014 ASPE Issue Brief Page 6 TABLE 2: Americans Estimated to Covered in Non-Grandfathered Plans for Expanded Preventive Services Under the Affordable Care Act, by State 15 State Total Children Women Men Alabama 1,836,000 346,000 791,000 728,000 Alaska 264,000 54,000 106,000 107,000 Arizona 2,282,000 501,000 915,000 919,000 Arkansas 920,000 184,000 382,000 368,000 California 13,681,000 2,764,000 5,640,000 5,515,000 Colorado 2,117,000 460,000 858,000 841,000 Connecticut 1,522,000 299,000 641,000 610,000 Delaware 347,000 69,000 146,000 137,000 District of Columbia 234,000 32,000 107,000 96,000 Florida 6,476,000 1,181,000 2,806,000 2,603,000 Georgia 3,580,000 726,000 1,513,000 1,405,000 Hawaii 517,000 98,000 214,000 213,000 Idaho 611,000 145,000 240,000 241,000 Illinois 4,901,000 973,000 2,032,000 1,973,000 Indiana 2,443,000 515,000 1,010,000 961,000 Iowa 1,259,000 262,000 509,000 507,000 Kansas 1,096,000 238,000 450,000 427,000 Kentucky 1,577,000 312,000 653,000 636,000 Louisiana 1,473,000 293,000 623,000 580,000 Maine 503,000 89,000 221,000 201,000 Maryland 2,437,000 474,000 1,035,000 970,000 Massachusetts 2,778,000 533,000 1,164,000 1,101,000 Michigan 3,844,000 786,000 1,610,000 1,516,000 Minnesota 2,270,000 497,000 898,000 905,000 Mississippi 977,000 198,000 407,000 389,000 Missouri 2,343,000 490,000 957,000 937,000 Montana 347,000 69,000 143,000 140,000 Nebraska 775,000 166,000 312,000 311,000 Nevada 974,000 215,000 378,000 376,000 New Hampshire 584,000 108,000 248,000 237,000 New Jersey 3,510,000 726,000 1,457,000 1,389,000 New Mexico 615,000 124,000 262,000 239,000 New York 7,210,000 1,359,000 3,069,000 2,893,000 North Carolina 3,424,000 674,000 1,462,000 1,353,000 North Dakota 298,000 63,000 120,000 120,000 Ohio 4,343,000 878,000 1,805,000 1,736,000 Oklahoma 1,303,000 271,000 538,000 514,000 Oregon 1,449,000 283,000 619,000 569,000 Pennsylvania 5,156,000 956,000 2,167,000 2,107,000 Rhode Island 409,000 74,000 175,000 166,000 South Carolina 1,655,000 334,000 715,000 630,000 South Dakota 326,000 70,000 131,000 130,000 Tennessee 2,315,000 450,000 976,000 927,000 Texas 8,762,000 1,868,000 3,562,000 3,493,000 Utah 1,274,000 359,000 476,000 472,000 Vermont 254,000 40,000 112,000 106,000 Virginia 3,292,000 698,000 1,380,000 1,269,000 Washington 2,593,000 488,000 1,094,000 1,048,000 West Virginia 639,000 124,000 267,000 257,000 Wisconsin 2,357,000 469,000 971,000 954,000 Wyoming 224,000 48,000 87,000 92,000 TOTAL 116,376,000 23,433,000 48,454,000 46,414,000 15 The source of these data are: ASPE calculations using Census Bureau’s Current Population Survey, for the years 2010-2012 and enrollment data from the Marketplace Summary Enrollment Report (for more information see: http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Apr2014/ib_2014Apr_enrollment.pdf). The age range for these estimates are ages 0 to 14 for children and 15 to 64 for both men and women. Age data for women and men were not available for the State-based Marketplace (SBM); gender estimates include the elderly in the enrollment data for the SBMs. ASPE Office of Health Policy June 2014 ASPE Issue Brief Page 7 Women’s Preventive Services Under the preventive services provisions in the Affordable Care Act, non-grandfathered health insurance plans and policies are required to cover 100 percent of the costs of certain recommended preventive services for women—that is, without charging a co-pay, co-insurance, deductible, or other cost sharing. The Women’s Preventive Services Guidelines supported by the Health Resources and Services Administration (Guidelines), which specify these services, were designed to address health needs that are specific to women and fill gaps in other existing preventive care recommendations.16 The Guidelines include annual well-woman visits; screening for gestational diabetes; human papillomavirus DNA testing; counseling for sexually transmitted infections; HIV counseling and screening; FDA-approved contraceptive methods and counseling; breastfeeding support, supplies, and counseling; and screening and counseling for interpersonal and domestic violence.17 These coverage requirements took effect for plan or policy years starting on or after August 1, 2012, so the impact may have started in 2012 (but for most consumers, they took effect with the new plan or policy year on or after January 1, 2013). A recent report from the IMS Institute for Healthcare Informatics (IMS), in 2013, found that oral contraceptives accounted for the largest increases in prescriptions dispensed with no cost sharing. 18 IMS estimated that the number of prescriptions for oral contraceptives with no co-pay rose 24.4 million from 2012 to 2013 in part due to the Affordable Care Act’s zero-cost sharing provisions for certain preventive services. Figure 2 displays the proportion of prescriptions for oral contraceptives dispensed with and without co-pay among women with private insurance. The number of prescriptions with no co-pay increased more than four-fold from 6.8 million in 2012 to 31.1 million in 2013. 19 This contributed to a reduction in out-of-pocket costs of $483.3 million that would have been spent in 2013 had women purchased the same mix of brand, generic, branded generic, and other types of oral contraceptives as those purchased in 2012. 20 According to data from IMS, 9.1 million women filled prescriptions for oral contraceptives in 2013. 21, 22 IMS reports that the share of women with no out-of-pocket costs for oral contraceptives increased from 14 percent in 2012 (1.2 million women) to 56 percent in 2013 (5.1 million women). 23 That is, according to data from IMS, the number of women filling prescriptions for oral contraceptives with no co-pay increased by 3.9 million from 2012 to 2013 (see Table 3). By making preventive services more affordable and accessible, this is one way the Affordable Care Act is helping women. 16 “If a recommendation or guideline does not specify the frequency, method, treatment, or setting for the provision of that service, the plan or issuer can use reasonable medical management techniques to determine any coverage limitations.” Accessed online: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs12.html 17 U.S. Department of Health and Human Services, August 2011. Women's Preventive Services Guidelines: Affordable Care Act Expands Prevention Coverage for Women’s Health and Well-Being. http://www.hrsa.gov/womensguidelines/ 18 IMS Institute for Healthcare Informatics, April 2014. Medicine Use and Shifting Costs of Healthcare. Parsippany, NJ. 19 IMS Institute for Healthcare Informatics, April 2014. Medicine Use and Shifting Costs of Healthcare. Parsippany, NJ. 20 IMS Institute for Healthcare Informatics, April 2014. Medicine Use and Shifting Costs of Healthcare. Parsippany, NJ. The savings are calculated by taking the increased number of oral contraceptive prescriptions in 2013 (versus 2012) received without co-pay and estimating the money saved by multiplying the number of prescriptions times the average patient cost for a prescription in 2012 when the patient paid a co-pay. 21 Based on personal communication with IMS we also report in Table 3 the estimated number of women who filled prescriptions for oral contraceptives in 2012. 22 We recognize that there are different estimates for the number of women using oral contraceptives. For example see: Jo Jones, William Mosher, and Kimberly Daniels, Current contraceptive use in the United States, 2006-2010, and changes in patterns of use since 1995, National Health Statistics Reports, 2012, No. 60. Estimate based on data from 2006-10 National Survey of Family Growth for women ages 15 to 44. 23 IMS Institute for Healthcare Informatics, April 2014. Medicine Use and Shifting Costs of Healthcare. Parsippany, NJ. ASPE Office of Health Policy June 2014 ASPE Issue Brief Page 8 TABLE 3: Number of Women Who Filled Prescriptions for Oral Contraceptives, Total and With No Co-Pay, 2012 and 2013 24 Year Total number of woman with Share of women who filled Number of women who filled oral contraceptive prescriptions for oral prescriptions for oral contraceptives prescriptions contraceptives with no co-pay with no co-pay 2013 9.1 million 56% 5.1 million 2012 8.3 million 14% 1.2 million Increase in the number of women who filled prescriptions 3.9 million for oral contraceptives with no co-pay 2012 to 2013: FIGURE 2: Dispensed Prescriptions for Oral Contraceptives, Privately Insured Women 25 60 55.9 50.0 50 Total OCs Growth 24.8 Prescriptions (Million) 40 +11% Co-Pay 30 43.2 Co-Pay 20 31.1 No Co-Pay 10 6.8 No Co-Pay 0 2012 2013 24 Numbers of women based on personal communication with IMS Institute for Healthcare Informatics, June 2014. 25 Data based on information from IMS Institute for Healthcare Informatics, April 2014. Medicine Use and Shifting Costs of Healthcare. Parsippany, NJ and on personal communication with IMS Institute for Healthcare Informatics, June 2014. Exact numbers of prescriptions without co-pay are 6.76 million and 31.15 million. ASPE Office of Health Policy June 2014