AOS IST ANT Oe toe H EA LTH PO L | CY
_ - January 11, 2022

od ASPE | Office oF ISSUE BRIEF
Access to Preventive Services without Cost-Sharing:

Evidence from the Affordable Care Act

Research examining the impact of the Affordable Care Act suggests that millions of
individuals have benefitted from increased access to care and coverage of clinical
preventive services without cost-sharing.

 

KEY POINTS

e The Affordable Care Act (ACA) substantially increased access to care and coverage of preventive
services without cost-sharing for millions of Americans.

e Many preventive services including vaccinations, well-child visits, screening for HIV and sexually
transmitted infections, HIV pre-exposure prophylaxis, contraception, and cancer screening are
required to be covered by most group and individual health plans and for many Medicaid
beneficiaries without cost-sharing.

e Expanded access to recommended preventive services resulted from increases in the number of
people covered through private health insurance and Medicaid expansion under the ACA.

e Analysis of recent data indicates that more than 150 million people with private insurance -
including 58 million women and 37 million children - currently can receive preventive services
without cost-sharing under the ACA, along with approximately 20 million Medicaid adult
expansion enrollees and 61 million Medicare beneficiaries that can benefit from the ACA's
preventive services provisions.

e Evidence from studies examining the impact of the ACA indicate increased colon cancer
screening, vaccinations, use of contraception, and chronic disease screening.

 

BACKGROUND

Preventive services canhelp people avoid acute illness, identify and treat chronic conditions, prevent cancer or
lead to earlier detection, and improve health. The Affordable Care Act (ACA) reduced financial barriers to
accessing preventive services by requiring that most private health plans cover certain recommended
preventive services without cost-sharing. This requirement became effective for new health coverage
beginning on or after September 23, 2010, except for a requirement concerning women's preventive services,
which became effective for plan years beginning on or after August 1, 2012.

 

aspe.hhs.gov 1
Under the ACA, in most instances group health plans and individual health coverage plans cannot charge a
patient a copayment, co-insurance, or deductible for these services when they are delivered by an in-network
provider." One exception are so-called "grandfathered" plans, whichare plans that were in existence prior to
2010 and are allowed to continue offering benefit designs other than those generally required by the ACA. By
eliminating cost-sharing for these services, the ACA was designed to increase access and use of preventive
care, especially among individuals for whom affordability was a key barrier.

This issue brief summarizes the ACA's preventive services provisions for private health coverage, Medicare,
and Medicaid; provides updated estimates of the number of people benefiting from these provisions
nationally; and examines evidence on trends in utilization of preventive services and outcomes since the ACA's
preventive services coverage requirements went into effect.

POLICY OVERVIEW

Private Health Coverage

Under the ACA, most private insurance plans are required to cover four categories of preventive services in-
network without cost-sharing, including:

1. evidence-based preventive services that have in effect a rating of A or Bin the current
recommendations of the U.S. Preventive Services Task Force (USPSTF), which indicates moderate to
high certaintythat the net benefits of those services are moderate to substantial;*

2. routine vaccines for adults and children that have in effect a recommendation from the Advisory
Committee on Immunization Practices (ACIP) and which has been adopted by the Director of the
Centers for Disease Control and Prevention (CDC);?

3. evidence-informed preventive services for infants, children, and adolescents provided for in
comprehensive guidelines supported by the Health Resources and Services Administration (HRSA); *
and

4. preventive care and screenings for women, other than those that have in effect a rating of A or B in the
current recommendations of the USPSTF, that are provided for in comprehensive guidelines supported
by HRSA.*

These requirements do not apply to grandfathered plans, which are plans that existed on March 23, 2010,
before the law was enacted, that meet certain requirements, and that are exempt from certain provisions of
the ACA.

The range of preventive services covered without cost-sharing includes services such as alcohol misuse
screening and counseling, blood pressure screening, depression screening, immunizations, and obesity
screening and counseling. Certain covered preventive services recommended by the USPSTF are specific to
people in certain age groups or individuals at increased risk; for example, screening for latent tuberculosis in
populations at increased risk of infection, and colorectal cancer screening for adults aged 45 to 75.557 The
USPSTF defers to the ACIP on recommendations concerning the use of vaccines.§

 

* The guidelines implemented by HRSA are commonly referred to as Bright Futures and the Women's Preventive Services Guidelines.

* These requirements also do not apply to coverage of certain services when a religious exemption applies.

§ The Centers for Disease Controland Prevention (CDC) sets the U.S. adult and childhood immunization schedules based on
recommendations from the ACIP.

 

JANUARY 2022 ISSUE BRIEF 2
Most health plans also generally must cover a set of preventive services for children without cost-sharing (i.e.,
those plans that are not grandfathered as discussed above) including those providing coverage in the group,
individual, and Medicaid markets.® Preventive services benefits for children include, but are not limited to,
alcohol, tobacco, and drug use assessments for adolescents; universal newborn hearing screening;
developmental and autism screening for children at 18 and 24 months; bilirubin concentration screening for
newborns; blood pressure screening for children ages O to 17 years; developmental screening for children
under age 3; and routine immunization for children from birth to age 18 (doses, recommended ages, and
recommended populations vary).

In most instances, non-grandfathered group and individual health coverage plans are required to cover certain
preventive benefits for women, including well-woman visits, screening and counseling for domestic violence,
U.S. Food and Drug Administration (FDA)-approved contraceptive methods, and other services specifiedin the
Women's Preventive Services Guidelines, which initially went into effect August 2012.9 These guidelines are
updated periodically to reflect the latest evidence-based recommendations including, for example, a
recommendation that adolescent and adult women have access tothe full range of FDA-approved
contraceptive products, effective family planning practices, and sterilization procedures for women to prevent
unintended pregnancy and improve health outcomes.

Estimated Population Size with Private Health Coverage Benefitting from ACA Provisions

Previous analyses by the Office of the Assistant Secretary for Planning and Evaluation (ASPE) estimated that
approximately 137 million Americans with private insurance had access to preventive services without cost
sharing in 2015.*° ** Using the same method, ASPE estimates that about 151.6 million had such coverage in
2020. The increase is due in part to growthin the number of people enrolled in private health coverage and a
decrease in the share of such people enrolled in grandfathered plans.

In 2020, the most recent year of data available, 175.9 million people under age 65 had private health coverage,
mainly through an employer, but also including coverage purchased through a state or federal Marketplace. 14
The 2020 Kaiser Family Foundation Employer Health Benefits survey found that 14 percent of individuals with
employer-based health plans were enrolled in grandfathered plans, which are not required to provide
preventive service coverage with zero cost-sharing (we assume that these individuals are subject to some level
of cost sharing for preventive services). Data fromthe 2020 Final Rule on Grandfathered Health Plans and from
the 2020 National Health Expenditures Accounts suggest that at most 12 percent of people with individual
market coverage are enrolled in grandfathered health plans.** Using these statistics, we estimatethat a total
of approximately 151.6 million individuals! currently have private health coverage that covers preventive
services with zero cost-sharing (Figure 1).43 This includes approximately 58 million women, 57 million men,
and 37 million children. Table 1 presents state-level estimates.

 

"* ASPE released a different estimate in 2012 focused on the number of people newly gaining coverage for free preventive services,
based on how many people with private coverage already had access to preventive care vs. how many were gaining it for thefir st time,
with an estimate of 54 million. The morerecent reports, including this report, provide estimates of how many tota/ people have private
coverage without cost-sharing for these services, whether or not some may have had similar coverage prior to the ACA.

tt See Figure 1 sources for more information on this estimate.

 

JANUARY 2022 ISSUE BRIEF 3
Figure 1.Estimated Number of Individuals with Private Health Coverage, by
Age and Gender, with Preventive Services Coverage without Cost-
Sharing, 2020 (in millions)

160 151.6
140
120

100

58.0 56.5
40 37.1
0

Children 0-18 Women 19-64 Men 19-64 Total

oO
oO

(in millions)

Number of Americans
Oo
oO

Note: ASPE subtracted estimated 14% and 12% of grandfathered plan enrollees from the total
number of individuals with employee sponsored health insurance and the total number of
individuals with nongroup insurance, respectively, to estimate the number of privately covered
individuals with preventive services coverage without cost-sharing.

Sourees: Privately insured individuals, by age and gender: 2020 Kaiser Family Foundation State
Health Facts on Health Coverage and the Uninsured, developed from the 2017-2021 Current
Population Survey (CPS) Annual Social and Economic Supplements: https://www.kff.org/state-
category/health-coverage-uninsured/

Grandfathered plan estimates: 2020 Kaiser Family Foundation Employer Health Benefits Survey:
https://www.kff.org/health-costs/report/2020-employer-health-benefits-surve

Non group estimate calculated from 2020 Final Rule on Grandfathered Health Plans and 2020 National Health
Expenditures Table 22 on coverage:

https://www.govinfo.gov/content/pkg/FR-2020-12-15/pdf/2020-27498. pdf

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics- Trends-and-

Reports/NationalHealthExpendData/NationalHealthAccountsHistorical

 

 

JANUARY 2022

ISSUE BRIEF 4
Table 1. State-level Estimates of Individuals with Private Health
Coverage with Preventive Services Coverage without Cost-Sharing, 2020
(in thousands)

 

 

 

 

 

Children Women Men Total
(<19) (ages 19-64) (ages 19-64)
Oem ks 37,077 58,019 56,483 151,579
Alabama 513 813 757 2,084
Alaska 60 95 91 246
PNapdelaye) 758 1,121 1,163 3,042
Arkansas 274 480 460 1,214
California 4,411 6,718 6,860 17,988
Colorado 625 1,032 1,055 2,712
Connecticut 341 615 587 1,543
Delaware 92 174 153 420
District of Columbia 53 157 156 367
Florida 1,872 3,606 3,566 9,045
er-Yolg-if-) 1,081 1,871 1,706 4,658
Hawaii 134 229 236 599
Idaho 227 315 320 862
Illinois 1,656 2,429 2,433 6,518
Indiana 946 1,241 1,220 3,407
lowa 406 588 593 1,587
Kansas 402 523 517 1,441
Cava AU Lol a7 414 712 713 1,840
Louisiana 417 663 644 1,724
Maine 105 248 220 573
Maryland 800 1,195 1,118 3,113
Massachusetts 767 1,326 1,249 3,343 Note: ASPE subtracted the estimated 14% and
WV TrealFex-10) 1,203 1,759 1,697 4,659 12% of grandfathered plan enrollees from the
Minnesota 817 1,145 1,135 3,097 total number of individuals with employee
Mississippi 294 513 445 1,252 sponsored health insurance and the total number
Missouri 741 1,152 1,070 2,964 of individuals with nongroup insurance,
Montana 116 171 166 453 respectively, to estimate the number of privately
Nebraska 278 364 388 1,030 covered individuals with preventive services
Nevada 316 524 529 1,369 coverage without cost-sharing. Numbers of
New Hampshire 162 261 279 702 individual children, women, and men may not
New Jersey 1,143 1,673 1,693 4,509 sum to total due to rounding.
New Mexico 131 257 251 640 Sources: Privately insured individuals, by age and
New York 2,073 3,452 3,067 8,592 gender: 2020 Kaiser Family Foundation State Health
North Carolina 959 1,908 1,783 4,650 Facts on Health Coverage and the Uninsured,
North Dakota 114 141 156 411 developed from the 2017-2021 Current Population
Ohio 1,302 1,983 1,950 5,235 Survey (CPS) Annual Social and Economic
Oklahoma 379 578 579 1,537 Supplements: https://www.kff.org/state-
Oregon 510 803 740 2,053 category/health-coverage-uninsured/
Pennsylvania 1,432 2,441 2,348 6,220 Grandfathered plan estimates: 2020 Kaiser Family
Rhode Island 127 206 191 524 Foundation Employer Health Benefits Survey:
South Carolina 483 887 905 2,275 https://www.kff.org/health-costs/report/2020-
South Dakota 113 163 174 450 employer-health-benefits-survey/
ATalatets-X-) 685 1,118 1,093 2,895 Non group adjustment calculated from 2020 Final
abel 3,472 4,884 4,583 12,939 Rule on Grandfathered Health Plans and 2020
Utah 617 620 591 1,829 National Health Expenditures Table 22 on coverage:
Vermont 64 114 115 292 https://www.govinfo.gov/content/pkg/FR-2020-12-
Virginia 1,115 1,680 1,596 4,392 15/pdf/2020-27498.pdf
Washington 896 1,502 1,477 3,875 https://www.cms.gov/Research-Statistics-Data-and-
West Virginia 172 277 294 743 Systems/Statistics-Trends-and-
Wisconsin 704 1,191 1,276 3,171 Reports/NationalHealthExpendData/NationalHealthA
62 101 93 256 ccountsHistorical

 

 

 

JANUARY 2022 ISSUE BRIEF 5
Medicaid and Children's Health Insurance Program

In addition to the 151.6 million individuals with non-grandfathered group health plans and non-grandfathered
group and individual health coverage who benefit from preventive services coverage under the ACA, the ACA
provisions also address coverage of preventive services in both Medicare and Medicaid. Medicaid coverage
offered by states (and the District of Columbia) that have expanded Medicaid eligibility to non-elderly adults
with family incomes at or below 133 percent of the federal poverty level must cover the full range of
preventive services required by the essential health benefits (EHB) regulations, which includes recommended
preventive services coverage without cost-sharing.

In Medicaid, the ACA requirement for coverage of preventive services without cost-sharing applies only to
Medicaid expansion enrollees and other Medicaid enrollees in Alternative Benefit Plans. As of October 2021,
38 states andthe District of Columbia have expanded Medicaid.1* Under Medicaid expansion, approximately
20 million adults had coverage for preventive services without cost-sharing as of September 2021.15

Unrelatedto the ACA, all children in Medicaid (31 million in December 2020)* are covered without cost-
sharing for Early and Periodic Screening, Diagnostics and Treatment (EPSDT), created in 1967, which includes
well-child visits and ACIP-recommended vaccines,' and other essential preventive health benefits for children.

Medicaid coverage of preventive services for adults in states that have not expanded Medicaid is a state
option, but most states provided some level of coverage of these services before the ACA.12 Tobacco cessation
for pregnant women is the only preventive service listed under mandatory Medicaid benefits.19 Optional
benefits include "other diagnostic, screening, preventive and rehabilitative services." Intraditional Medicaid,
states that opt to cover all USPSTF Grade "A" or "B" recommended preventive services and ACIP-
recommended vaccines and their administration without cost-sharing receive a one percentage point increase
in the federal medical assistance percentage (FMAP) for those services.2° State Medicaid Agencies are
encouraged to consider this option to ensure access to preventive services without cost-sharing to additional
Medicaid beneficiaries without mandatory coverage.

A total of 33 states covered well-adult exams in FFS and in managed care, and five states covered well-adult
exams in managed care in 2012.21 Halfthe states charged co-pays in 2012. Three states did not cover
screening mammograms at all, and two states did not cover Pap testing while some states covered Pap testing
only as part of family planning visits. A 2018-19 study showed that only 24 out of 49 Medicaid state programs
responding to a survey covered all 13 ACIP-recommended adult vaccines.22 Atotal of 48 Medicaid state FFS
programs covered hepatitis B and meningococcal ACWY** vaccines and 47 Medicaid state FFS programs
covered influenza; tetanus, diphtheria, and pertussis (Tdap); measles, mumps, and rubella (MMR); varicella;
and pneumococcal vaccines. A total of 29 states out of 34 states responding to the survey required their
Medicaid managed care plans to cover Tdap, hepatitis B, and meningococcal ACWY vaccines, and 28 states
required their Medicaid Managed plans to cover influenza, MMR, varicella, pneumococcal conjugate, and
meningococcal B vaccines.

The Children's Health Insurance Program (CHIP) is a program funded by the Federal government and states to
cover children up to age 19 in households with income too high to qualify for Medicaid. Ten states and the
District of Columbia cover all of their CHIP beneficiaries under Medicaid and provide them with the same
Medicaid benefits, including EPSDT.22 Thirty-eight states cover some CHIP beneficiaries under Medicaid and
some under a separate CHIP program. Twostates only have separate CHIP programs. All CHIP programs are
required to cover well-child visits without cost-sharing.24 CHIP programs are also required to cover vaccines

 

+# Meningococcal ACWY vaccine can help protect against meningococcal disease caused by serogroups A, C, W, and Y.

 

JANUARY 2022 ISSUE BRIEF 6
and vaccine administration for children without cost-sharing. Fifteenstates cover pregnant women under
CHIP.25 The American Rescue Plan Act (ARP) requires CHIP programs to cover COVID-19 vaccines for children
and pregnant women without cost-sharing through the last day of the quarter of the end of the public health
emergency.2® Other preventive services may be covered with or without cost-sharing by separate state CHIP
programs, but there are no studies on this. All children enrolled in CHIP (6.7 million in December 2020)?' are
covered for vaccines and well-child visits without cost-sharing and may be covered for other preventive
services withor without cost-sharing.

Medicare

Under the ACA, services recommended by the USPSTF with a Grade "A" or "B" must be covered by Medicare
without cost-sharing if the Secretary of the U.S. Department of Health and Human Services (HHS) determines
through the national coverage determination process that they are reasonable and necessary for the
prevention or early detection of anillness or disability, and appropriate for individuals entitled to the
program's Part A benefits or who are enrolled in Part B.28 There are approximately 61.5 million individuals
enrolled in Medicare, all of whom potentially benefit from this provision of the ACA.29

After the ACA was enacted, HHSissued new rules on November 29, 2010, to eliminate Medicare cost-sharing
for USPSTF recommended preventive services and to provide Medicare coverage for an annual wellness visit
that includes a comprehensive health risk assessment anda 5- to 10-year personalized prevention plan.
Medicare Part B provides coverage without cost-sharing for certain USPSTF-recommended services and four
vaccinations: COVID-19, influenza, hepatitis B, and pneumococcus. Medicare Part B does not currently cover
preventive shingles and tetanus, diphtheria, and pertussis (Tdap) vaccinations.2° Optional Medicare Part D
plans generally cover these other vaccinations, though they mayinclude cost-sharing.$*3! The Build Back
Better Act (BBB), being considered in the Congress, proposes covering these vaccinations without cost-sharing
in Medicare Part D.

EVIDENCE ON CHANGES IN UTILIZATION AND OUTCOMES

Research shows that the ACA reduced health coverage disparities across racial groups and expanded access to
a range of clinical services including preventive services.223 Gains inaccess toservices were due in large part
to uninsured individuals obtaining health coverage. For example, people who became newly covered under
Medicaid and the Marketplace through the ACA in 2014 were much less likely than uninsured people to report
being unable to get care or delaying needed care because of cost.34 There have been fewer studies specifically
examining the effects of eliminating cost-sharing for preventive services among individuals who already had
health coverage. Inthis section, we describe the effects of the ACA on utilization of several types of preventive
services; these effects are likely a combined result of the provisions expanding coverage tothe uninsured and
the provisions increasing access to preventive services without cost-sharing.

Cancer Screening

Overall, Americans utilize recommended clinical preventive services at low rates, and utilization of preventive
services suchas cancer screening differs across racial and ethnic populations. 253637 ACA provisions to
eliminate cost-sharing for recommended clinical preventive services, suchas cancer screenings, presented an
opportunity to increase early diagnosis of cancer. Studies examining changes in cancer screening among
privately insured individuals after the ACA eliminated cost-sharing show an overall increase in colorectal
cancer screening tests, while breast cancer screening rates were stable; rates of Pap testing decreased, though

 

§§ Generally, Medicare prescription drug plans (Part D) cover all commercially available vaccines (e.g., shingles) needed to prevent illness.

 

JANUARY 2022 ISSUE BRIEF 7
this time period coincided with revised cervical cancer screening recommendations that include less frequent
testing for many patients .32°° An analysis of 2013-2016 national survey data indicated utilization rates among
newly insured immigrants increased for colon cancer screenings but did not change for Pap testing or
mammography.*° Some research also shows that patient navigation interventions have helped increase
cervical cancer screening rates among Latinas and Chinese-American women.*! While the studies reviewed
show some evidence of improved use of cancer screening since enactment of the ACA, disparities remain.4244

The USPSTF announced a new recommendation in May 2021 that colon cancer screening start at age 45
instead of 50.44 We estimate that this means an additional 15.0 million to 17.5 million individuals will be able
to benefit from the ACA's provisions for preventive services without cost-sharing for colon cancer screening .*°
An analysis of data from 2009 and 2014 suggest that the elimination of cost-sharing under the ACA positively
affected colorectal cancer screening among men and women with private health coverage, and among men
and Hispanic beneficiaries with Medicare coverage.*® While data show that colon cancer mortality among men
and women was decreasing prior to the ACA, colon cancer remains one of the leading causes of cancer deaths,
and increased screening - which can result in identification and removal of precancerous growths - has
resulted in a decrease in colorectal cancer incidence.*"

Health coverage is important for individuals with cancer because access tocare can affect health outcomes.
Annual out-of-pocket costs among recently diagnosed survivors of cancers like breast, prostate, colorectal, and
lung cancers average more than $1,000 for medical care costs, depending on age.*8 Some research suggests
that increased access to preventive services and increased affordability of care since the ACA has helped
cancer survivors obtain the care they needed.*9°° However, decreases incancer screenings during 2020 as a
result of the COVID-19 pandemic indicate the need to monitor post-pandemic changes in cancer incidence,
later-stage cancer diagnosis, and cancer mortality. 51-2

Vaccinations

One ACA provision with particular relevance for young adults is the dependent coverage provision, which
generally allows young adults to stayon their parents' healthcare plans until age 26. With the ACA dependent
coverage provision and the provision for preventive services without cost-sharing, an estimated 854,000 young
women completed the human papillomavirus (HPV) vaccine series from 2010 to 2012, an increase of 5.8
percentage points compared to a control group of women who were not eligible for dependent coverage.*5?
Coverage without cost-sharing was associated witha 4.3 percentage point increase in HPV vaccine completion
for females aged 9 to 26 who were privately insured and a5.7 percentage point increase for Medicaid
enrollees in three states (Massachusetts, New Hampshire, and Maine) in a study of 2009-2015 claims.>4

Influenza vaccinations showeda small but significant increase from 2009 to 2011/2012 after the elimination of
cost-sharing among adults with private health coverage.*> National survey data from 2016 showed that among
adults 65 and older, 70.4 percent received an influenza vaccine and 66.9 percent had been vaccinated against
pneumococcal disease; Tdap vaccination of adults 19 years and older was just 26.6 percent. °° Thus, many
adults do not receive all of the recommended vaccinations, sometimes for reasons other than cost, andthere
is still potential for greater uptake and utilization of routine vaccination among adults who have private health
coverage, Medicare, and Medicaid.°"

Medicare Wellness Visits

The percentage of Medicare beneficiaries utilizing annual wellness visits increased 14.9 percentage points
between 2011 (the first year when such visits were covered) and 2016, rising from 8.1 percent to 23.0
percent.>® This trend suggests that it may take time for beneficiaries and providers to use a new service when
it becomes available. However, the utilization of this new service was characterized by disparities, with

 

JANUARY 2022 ISSUE BRIEF 8
utilization 10.2 percentage points lower for non-Hispanic Black Medicare beneficiaries and 11.6 percentage
points lower for Hispanic beneficiaries than non-Hispanic White beneficiaries in 2016.

Women's Health and Contraception

Provisions in the ACA addressed a range of women's health needs by increasing health coverage - which
increased access to medical and mental health care- and by establishing HRSA-supported Women's
Preventive Services Guidelines specifying certain services that must be covered without cost-sharing by non-
grandfathered group and individual health coverage. Services included in the Women's Preventive Services
Guidelines are: screening for anxiety, breast cancer screening for average-risk women, breastfeeding services
and supplies, screening for cervical cancer, contraception (including contraceptive counseling), screening for
gestational diabetes mellitus, screening for diabetes after pregnancy, screening for human immunodeficiency
virus infection, screening for interpersonal and domestic violence, counseling for sexually transmitted
infections, well-woman preventive visits, and screening for urinary incontinence.

Most recently in January 2022, the Guidelines incorporated new, updated evidence-based recommendations
for breastfeeding services and supplies, contraception, screening for human immunodeficiency virus (HIV)
infection, counseling for sexually transmitted infections, and well-woman preventive visits, and added a new
recommendation for preventing obesity in midlife women.

Access to contraceptives has been shown to improve a variety of women's healthand economic outcomes,
including reduced rates of entryinto poverty, increased rates of entry into professional school, or the labor
force, and increases inwages.°? Accesshas alsohad intergenerational effects. Children of women who have
access tocontraceptives have been shown to achieve higher rates of college graduation and higher incomes
than children of women who did not have access tocontraceptives.®! Contraceptives include a wide array of
products. Long-acting reversible contraceptives (LARCs) - which include intrauterine devices (IUDs),
intrauterine systems (IUSs), and subdermal implants - are among the most effective methods of
contraception, while the birth control pill is among the most popular. Other types of contraception include the
hormone patch, the vaginal ring, and emergency contraceptive medication. The ACA provision requiring
coverage of contraceptives without cost-sharing mitigated a major barrier to contraceptive use: cost. High
cost-sharing has been shown to be associated with contraceptive nonacherence and discontinuation, as well
as lower use of LARCs, which often have high one-time costs even though they can be less expensive over time
than methods that must be purchased periodically such as the birth control pill.62.63-64.65

A comparison of out-of-pocket costs for contraception before and after the implementation of the ACA found
that average costs for every category of contraception decreased. The mean out-of-pocket cost for an IUD fell
from $262.38 in the first half of 2012 to $84.30 in the first half of 2013. The ACA provision saved an average of
$255 annually per user of birth control pills between 2012 and 2013.® After the implementation of the ACA's
preventive service zero-cost sharing requirements, the median out-of-pocket spending for all categories except
the vaginal ring and the subdermal patch was SO. The estimated out-of-pocket savings to women totaled
approximately $1.4 billion in 2013.

Research also demonstrates that the reduction in cost-sharing led to increased use of LARCs. One study found
that the reduction in cost-sharing was associated with increases in prescription contraceptive usage, witha
shift toward longer-term methods (including non-reversible options such as sterilization).°" Alater study found
that women enrolled in high deductible health plans (HDHPs) initiated LARC use at rates more than twice as
high than women in non-high deductible health plans (non-HDHPs) beginning after the implementation of the
ACA. This study is consistent with the idea that women in HDHPs were hesitant to access IUDs/LARCs because
they would have had higher cost-sharing due to their high deductibles, until the ACA provision removed that
barrier.®

 

JANUARY 2022 ISSUE BRIEF 9
Ananalysis of data through 2018 showed that ACA Medicaid expansion was associated with greater
preconception health counseling and postpartum use of effective birth control methods among low-income
women, and another study found that expanded Medicaid coverage under the ACA was associated with
decreases inthe proportion of pregnancies that were unintended among individuals with a high-school degree
or less, but was not associated with any significant change in the overall birth rate.6?-" The overall national
rate of intended pregnancy decreased from 67 percent of births to 62 percent of births between 2011 and
2019,"**.71

Chronic Conditions

Gaining access to health coverage and preventive services can allow earlier detection and treatment of chronic
health conditions such as hypertension and diabetes. Several studies have found that the ACA resulted in
improvements in affordability of care, regular care for chronic conditions, medication adherence, and self-
reported health.72:73 During 2012-2015, the percentage of adults aged 18 to 64 with two or more chronic
health conditions who delayed or did not obtain needed medical care due to cost decreased. 74

More adults with private insurance received blood pressure and cholesterol screening in 2011-12, compared to
pre-ACA screening rates in 2009.75 An analysis of 2012-2018 data showed that ACA Medicaid expansion was
associated with sustained increases in improvements in blood pressure and glucose control over a five-year
period among individuals receiving care at Federally Qualified Health Centers, especially Black and Hispanic
patients.7° Preventive services and chronic disease management contribute to improvements in cardiovascular
health, blood pressure control,'" and both the incidence and care for diabetes; increasing access tosuch
services is an important factor in improving health outcomes over time and addressing healthdisparities. ACA
implementation has also contributed to improved health outcomes among people living with HIV in terms of
viral suppression and retention in care."®

CONCLUSIONS

The implementation of the ACA increased health coverage, especially among Black Americans, Latinos, Asian
Americans and Pacific Islanders, American Indians/Alaska Natives, and individuals living in states that
expanded Medicaid. 79*°8182 We estimate that more than 150 million people with private health coverage are
now benefitting from the ACA's coverage of preventive services without cost-sharing, across a range of
services and conditions. Inaddition, tens of millions of Medicare and Medicaid beneficiaries are also
benefitting from the ACA provisions regarding preventive services without cost-sharing. Studies demonstrate
increases in access to preventive services, including colon cancer screening, HPV vaccination, Medicare annual
wellness visits, and contraceptive use. Investments in prevention in the early and middle decades of life, when
people are more likely to be covered by private health coverage including Marketplace insurance and
Medicaid, may also help people enter the Medicare program at age 65 in better health. Ongoing research can
help monitor the impact of the ACA on access tocare, use of preventive services, health disparities, and long -
term health outcomes.

 

ee

Intendedness of births as reported by women, 2011-2015 and 2017-2019 National Survey of Family Growth data

 

JANUARY 2022 ISSUE BRIEF 10
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81. ASPE. Health Insurance Coverage and Access to Care for American Indians and Alaska Natives: Current
Trends and Key Challenges. https://aspe.hhs.gov/reports/health-insurance-coverage-changes-aian
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JANUARY 2022 ISSUE BRIEF 15
 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

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200 Independence Avenue SW, Mailstop 447D
Washington, D.C. 20201

For more ASPE briefs and other publications, visit:
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SUGGESTED CITATION

Access to Preventive Services without Cost-sharing:

Evidence from the Affordable Care Act (Issue Brief No. HP-2022-
01). Office of the Assistant Secretary for Planning and Evaluation,
U.S. Department of Health and Human Services. January 2022.

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