ASPE ISSUE BRIEF THE AFFORDABLE CARE ACT: ADVANCING THE HEALTH OF WOMEN AND CHILDREN January 9, 2015 Adelle Simmons, Katherine Warren, and Kellyann McClain The Affordable Care Act has advanced the health of women and children by improving access to care, making coverage more affordable, expanding benefits, and protecting women and children from discrimination based on gender or health status. The law improves coverage for important clinical preventive services and maternity care, requires new Health Insurance Marketplace plans to include benefits for children such as dental and vision, prohibits health insurers from requiring women to pay more than men for the same insurance coverage, and bars insurers from discriminating against individuals with preexisting conditions. Already, millions of women and children have enrolled in health coverage through the new Health Insurance Marketplace or Medicaid since 2013. Medicare's enhanced coverage of preventive services and prescription drugs benefits millions of women. Through improvements in health insurance access and care, the Affordable Care Act will continue to improve the health of women and children from birth into adulthood and old age. Highlights: • Since 2013, the uninsured rate among women ages 18 to 64 declined 5.5 percentage points. • Because of the Affordable Care Act, an estimated 48.5 million women are benefiting from preventive services coverage with no out-of-pocket costs. • Of the total number who have selected a Marketplace Plan during the 2015 Open Enrollment period, more than half (56 percent) are women and nine percent are children ages 0 to 17. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation http://aspe.hhs.gov ASPE Issue Brief Page 2 New Coverage Options for Women and Children in the Health Insurance Marketplaces and Medicaid In October 2013, at the start of the 2014 open enrollment period, more than 4.8 million children ages 0 to 17, and more than 15.9 million women ages 18 to 64 were uninsured. 1 The Affordable Care Act has made health coverage easier to access and afford through the creation of the Health Insurance Marketplace and the expansion of Medicaid. The uninsured rate among women ages 18 to 64 fell 5.5 percentage points by the second quarter of 2014. 2 As of December 15, 2014, more than 4.0 million Americans had selected new coverage or been reenrolled in 2015 health insurance coverage through the Marketplace for coverage beginning January 1. Of the total number who have selected a Marketplace Plan during the 2015 Open Enrollment period, more than half (56 percent) are women and nine percent are children ages 0 to 17. 3 An additional 9.7 million Americans are enrolled in Medicaid and the Children’s Health Insurance Program (CHIP) compared to September 2013, before the initial Marketplace open enrollment period began. 4 New coverage options have allowed millions of women and children to gain access to quality health insurance. Millions more who are currently uninsured stand to benefit from coverage under the Affordable Care Act through the Marketplace or Medicaid. Increasing Access to Preventive Services and Enhancing Benefits for Women and Children Preventive Health Services The Affordable Care Act is increasing access to preventive health services by requiring most private health insurance plans to cover recommended preventive benefits without cost-sharing. For example, since September 23, 2010, plans subject to this rule must cover recommended services including mammograms, screenings for cervical cancer, flu and pneumonia shots, and regular well-baby and well- child visits with no cost-sharing. 5 Eliminating barriers such as copayments, co-insurance, and deductibles has increased access to services that improve the health of women and their children. Beginning August 1, 2012, an Affordable Care Act provision expanded access to additional women’s preventive health services. Under this provision, most insurers are required to also cover the following services with no cost-sharing: • Well-woman visits; • Screening for gestational diabetes; • Human papillomavirus (HPV) DNA testing for women 30 years and older; • Sexually-transmitted infection counseling; • Human immunodeficiency virus (HIV) screening and counseling; 1 Estimates of the “eligible uninsured” are ASPE tabulations of nonelderly (age 0-64) uninsured U.S. citizens and others lawfully present from the 2012 American Community Survey Public Use Microdata Sample, adjusted to exclude estimated undocumented persons based on imputations of immigrant legal status in ASPE's TRIM3 microsimulation model. 2 Sommers, BD, Musco, T, Finegold, K et al. 2014. Health Reform and Changes in Health Insurance Coverage in 2014. N Engl J Med 2014; 371:867-874. Accessed at http://www.nejm.org/doi/full/10.1056/NEJMsr1406753 3 http://aspe.hhs.gov/health/reports/2014/MarketPlaceEnrollment/Dec2014/ib_2014Dec_enrollment.pdf 4 Details about Medicaid and CHIP enrollment through October 2014 are available at http://www.medicaid.gov/medicaid- chip-program-information/program-information/downloads/october-2014-enrollment-report.pdf. 5 U.S. Department of Health and Human Services. Preventive care benefits: Preventive health services for adults. https://www.healthcare.gov/preventive-care-benefits/ ASPE Office of Health Policy ASPE Issue Brief Page 3 • FDA-approved contraception methods and contraceptive counseling; 6 • Breastfeeding support, supplies, and counseling; and • Domestic violence screening and counseling. Because of the Affordable Care Act, an estimated total of 48.5 million women are benefiting from preventive services coverage with no out-of-pocket costs. 7 Coverage of women’s preventive services with no cost-sharing improves access to affordable, quality health care for women; helps prevent serious health conditions before they start; and empowers women to obtain better care for their health and the health of their children. Maternity Coverage Previously, many women in the individual market were unable to obtain or afford health coverage that included maternity benefits. In fact, in 2011, 62 percent of individual market enrollees did not include maternity coverage. 8 All private health insurance plans offered in the Marketplace, and most private insurance in the individual and small employer markets outside the Marketplace, must offer a set of Essential Health Benefits, 9 which include maternity and newborn care, preventive benefits, and other benefits such as ambulatory patient services, emergency services, and hospitalization coverage. In the individual market alone, 8.7 million Americans gained maternity coverage because of the Affordable Care Act. 10 Maternity-Related Services In addition to the preventive benefits mentioned above, the Affordable Care Act also requires most plans to cover the following maternity-related preventive services with no cost sharing: • Anemia screening on a routine basis for pregnant women; • Folic acid supplements for women who may become pregnant; • Hepatitis B screening for pregnant women at their first prenatal visit; • Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk; 11 • Syphilis screening for all pregnant women or other women at increased risk; and • Tobacco use screening and interventions for all women, and expanded counseling for pregnant tobacco users. 12 6 In Burwell v. Hobby Lobby Stores, Inc., the Supreme Court held that the requirement for insurers to provide contraceptive coverage, as applied to closely held corporations, violates the Religious Freedom Restoration Act of 1993 (RFRA), 42 U.S.C. 2000bb et seq. 7 U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, 2014. ASPE Issue Brief: Increased Coverage of Preventive Services with Zero Cost Sharing under the Affordable Care Act. http://aspe.hhs.gov/health/reports/2014/PreventiveServices/ib_PreventiveServices.pdf 8 U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, 2011. ASPE Issue Brief: Essential Health Benefits: Individual Market Coverage. Accessed at http://aspe.hhs.gov/health/reports/2011/individualmarket/ib.shtml. 9 All non-grandfathered plans in the individual and small group market, inside and outside the Marketplace, must provide Essential Health Benefits to their beneficiaries. 10 U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, 2011. ASPE Issue Brief: Essential Health Benefits: Individual Market Coverage. Accessed at http://aspe.hhs.gov/health/reports/2011/individualmarket/ib.shtml. 11 Rh incompatibility is a condition that occurs during pregnancy if a woman has Rh-negative blood and her baby has Rh- positive blood. Rh factor is a protein on red blood cells; Rh factor doesn't affect general health, but it can cause problems during pregnancy. http://www.nhlbi.nih.gov/health/health-topics/topics/rh/ ASPE Office of Health Policy ASPE Issue Brief Page 4 Health insurance is not only important for the maternity benefits it covers, but also for the overall financial protection that it provides for childbirth, which is typically expensive. In 2012, six percent of women between the ages of 15 and 44 (3.15 million women) were pregnant and had a normal delivery. A majority of the expenses that these women incurred were for hospital stays, with the average hospital bill amounting to over $23,000 in charges. 13 An analysis of out-of-pocket expenses for hospital stays for childbirth indicate that, on average, women without insurance pay almost three times as much in out- of-pocket expenses per birth as women with private coverage, and more than ten times as much as those with public coverage. 14 The gains in coverage due to the Affordable Care Act will likely help reduce this disparity in out-of-pocket expenses. Pediatric Benefits and Adolescent Health The Affordable Care Act contains several key provisions that aim to improve pediatric and adolescent health and access to health care. All Marketplace health plans and many other plans must cover certain recommended preventive benefits for children without charging a copayment or coinsurance. 15 Most plans in the individual and small employer markets are required to offer services within at least ten categories of Essential Health Benefits, one of which is pediatric services including dental and vision care. These benefits also increase pediatric and adolescent access to preventive services—vaccinations and annual well-child visits are now provided to beneficiaries without cost-sharing. 16 The Affordable Care Act is particularly important for uninsured children and adolescents from low- income families. An estimated 3.9 million uninsured adolescents ages 10 to 19 were eligible to gain health care coverage under the Affordable Care Act beginning in January 1, 2014. 17 Under the law, states must now cover children up to age 19 with family incomes below 133 percent of the Federal Poverty Level through the Medicaid program. 18 This applies in all states, regardless of whether the state chooses to expand Medicaid. Preventive care, health education, and access to health care during these young ages have a major impact on health and healthy lifestyles in the future. 19 20 Medicare The Affordable Care Act also enhanced Medicare coverage of recommended preventive services, including screening mammograms, by waiving any cost-sharing (coinsurance or deductible) that would 12 Men are also eligible for some of these preventive services (e.g., smoking cessation counseling). 13 2012 Medical Expenditure Panel Survey (MEPS) data. These charges account for the full, established charges for a room and board, before any adjustments or discounts. 14 ASPE computation using 2012 Medical Expenditure Panel Survey (MEPS) data. 15 U.S. Department of Health and Human Services. Preventive care benefits: Preventive health services for children. https://www.healthcare.gov/preventive-care-benefits/children/ 16 All non-grandfathered plans in the individual and small group market, inside and outside the Marketplace, must provide Essential Health Benefits to their beneficiaries. 17 ASPE tabulations from the CY 2012 ACS Public Use Microdata Sample were adjusted to exclude estimated undocumented persons based on imputations of immigrant legal status in ASPE's TRIM3 microsimulation model. Includes currently eligible but not enrolled and those newly eligible in 2014. 18 Section 2002 of the Affordable Care Act provides for an income disregard of 5 percent of Federal Poverty Guidelines, raising the effective income limit to 138 percent. 19 U.S. Department of Health and Human Services. HealthyPeople 2020 Topics and Objectives: Adolescent Health, Overview. Accessed at http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=2 20 U.S. Department of Health and Human Services. ASPE Issue Brief: The Affordable Care Act and Adolescents. Accessed at http://aspe.hhs.gov/health/reports/2013/Adolescents/rb_adolescent.cfm ASPE Office of Health Policy ASPE Issue Brief Page 5 otherwise apply. In addition, Medicare beneficiaries can now get a free Annual Wellness Visit. Medicare Part D prescription drug coverage helps beneficiaries save money on brand-name drugs. Beneficiaries with Medicare prescription drug coverage have saved more than $11.5 billion on prescription drugs since 2010. 21 This includes prescription drug savings of $6.5 billion for more than 4.6 million women with Medicare. 22 Because of the Affordable Care Act, the donut hole will be closed completely by 2020. Ending Gender Discrimination in Coverage Prior to 2014, most insurance companies in the individual market could charge men and women different premiums for comparable coverage, and maternity benefits were routinely excluded from policies. 23 In addition, a 2012 study found that 56 percent of best-selling plans in the capital cities of states that permit gender rating charged 40-year-old non-smoking women higher rates than 40-year-old male smokers in the same plan. 24 As of January 1, 2014, the Affordable Care Act prohibits insurance companies in the individual and small-group health insurance markets from charging higher rates due to gender or health status. Premium rates can vary only based on age, tobacco use, family size, and geographic location. Prohibiting Pre-Existing Conditions Exclusions As many as 129 million non-elderly Americans have some type of pre-existing health condition, including 17 million children. 25 The Affordable Care Act prohibits insurers from denying coverage because of a pre-existing condition. Prior to this Affordable Care Act provision, women could have been denied coverage for pre-existing conditions, ranging from pregnancy, to C-section deliveries, to diabetes, to breast cancer. Women and children now have guaranteed access to health coverage, regardless of their health status. Other Important Affordable Care Act Programs Benefiting Women and Children In addition to the programs and benefits outlined above, the following are examples of other ways the Affordable Care Act supports women’s and children’s health: Maternal, Infant, and Early Childhood Home Visiting (MIECHV) The Affordable Care Act created the MIECHV program to support families and improve outcomes for children through home visiting programs. Administered by the Maternal and Child Health Bureau at the Health Resources and Services Administration in collaboration with the Administration for Children and 21 http://downloads.cms.gov/files/Medicare-Part-D-Donut-Hole-Savings-Summary-2010-June-2014.pdf 22 ASPE’s estimates of beneficiaries are based on Medicare Part D claims in 2012; savings estimates are based on Medicare Part D claims from 2010 to 2012. 23 Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, 2011. ASPE Issue Brief: Essential Health Benefits: Individual Market Coverage. Accessed at http://aspe.hhs.gov/health/reports/2011/individualmarket/ib.shtml 24 National Women’s Law Center. “Turning to Fairness.” 2012. Accessed at http://www.nwlc.org/sites/default/files/pdfs/nwlc_2012_turningtofairness_report.pdf 25 U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, 2011. At Risk: Pre-Existing Conditions Could Affect 1 in 2 Americans. Accessed at http://aspe.hhs.gov/health/reports/2012/pre- existing/index.shtml ASPE Office of Health Policy ASPE Issue Brief Page 6 Families (ACF), the program facilitates coordination of services at the federal, state, and community levels to improve health and development outcomes for at-risk children through evidence-based home visiting programs. Families voluntarily choose to participate in the program, which was established to improve maternal and child health, child health and development, parenting skills, school readiness, family economic self-sufficiency, and coordinated referrals for other community resources and supports. The program has provided nearly 670,000 visits to parents and children in 774 at-risk communities across the country. Home visiting services are now available in three-fourths of urban areas that have populations over 500,000. The Strong Start for Mothers and Newborns Initiative The Strong Start for Mothers and Newborns initiative is a collaborative effort by the Centers for Medicare & Medicaid Services (CMS), the Health Resources and Services Administration, and the Administration on Children and Families, to reduce preterm births and improve outcomes for newborns and pregnant women. The initiative’s main strategies include a public-private partnership and an awareness campaign to reduce early elective deliveries prior to 39 weeks, testing ways to encourage best practices, and testing evidence-based maternity care approaches that enhance prenatal care delivery. There are 182 participating sites involved in this four-year initiative, which is funded by the Affordable Care Act through the CMS Innovation Center with the ultimate purpose of achieving better care, improved health, and reduced costs by improving outcomes for high-risk pregnant women enrolled in Medicaid or CHIP. 26 Break Time for Nursing Mothers Under the Affordable Care Act, employers must provide reasonable break time for an employee to express breast milk for her nursing child for one year after the child’s birth. Employers must also provide a place other than a restroom for an employee to express breast milk, shielded from view and free from intrusion from coworkers and the public. This applies to all employers covered by the Fair Labor Standards Act. 27 Childhood Obesity Demonstration Project Childhood obesity has both immediate and long term effects, including increased incidence of diabetes, heart disease risk, and obesity as an adult. 28 Based on 2007-2008 data, an estimated 10 percent of children ages 2 to 5 were obese and about 20 percent of children ages 6 to 11 were obese. Though child obesity rates among children aged 2 to 5 have decreased since 2003-2004, much work remains to be done. 29 The Affordable Care Act aimed to address this public health problem with the Childhood Obesity Demonstration Project. This four-year program, administered by the Centers for Disease Control and Prevention, targets children ages 2 to 12 and children covered by the Children’s Health Insurance Program (CHIP). It builds upon existing community work to identify innovative strategies, focusing on successful approaches used by community health workers, physicians, child care providers, and other community members to address childhood obesity. 26 Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services. Strong Start for Mothers and Newborns Initiative: General Information. Accessed at http://innovation.cms.gov/initiatives/strong-start/ 27 U.S. Department of Labor. Wage and Hour Division (WHD) Frequently Asked Questions – Break Time for Nursing Mothers. Accessed at http://www.dol.gov/whd/nursingmothers/ 28 Adolescent Health. U.S. Department of Health and Human Services, 2013. Accessed at http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=2 29 Childhood Obesity Facts. CDC. Accessed at http://www.cdc.gov/obesity/data/childhood.html ASPE Office of Health Policy ASPE Issue Brief Page 7 School-Based Health Centers School-based health centers provide services like medical care, mental health services, oral health care, and preventive services through nearly 2,000 schools nationally. 30 The Affordable Care Act appropriated funds for award to school-based health centers to address capital needs. Through this grant program, the Department of Health and Human Services provided $200 million in 2010-2013 for construction, renovation, and equipment. By December 2012, a cumulative total of 520 awards had been made to school-based health centers in 47 states, the District of Columbia, and Puerto Rico. Conclusion Through an emphasis on innovative approaches to prevention, insurance coverage, and health care delivery, the Affordable Care Act provides significant new opportunities to improve the health of women and children in the United States in the coming years. In addition to the progress to date, additional women and children will benefit from these improvements to health care access and outcomes now that open enrollment for 2015 is underway. 30 Health Resources and Services Administration, U.S. Department of Health and Human Services. School-Based Health Centers. Accessed at http://www.hrsa.gov/ourstories/schoolhealthcenters/ ASPE Office of Health Policy