US Requires Coverage for Contraceptives, Other Women’s Preventive Health Services

Health insurance plans will be required to fully cover contraception, breastfeeding counseling and supplies, and counseling for domestic violence, among other preventive services by August 2012, under new rules enacted by the US Department of Health and Human Services (DHHS) in August. The agency did, however, include an exception for plans provided by religious institutions that object to contraception.

The new rules add to a growing menu of preventive health services that must be covered by US insurance companies without a co-pay or deductable. This push for greater coverage of preventive care was a key component of the Patient Protection and Affordable Care Act, which outlined a set of preventive services that should be covered. The services required for coverage under the act were based on recommendations from the US Preventive Services Task Force (USPSTF), the American Academy of Pediatrics' Bright Futures initiative for adolescents, and the Advisory Committee on Immunization Practices of the US Centers for Disease Control and Prevention.

To satisfy the requirements of the law, the DHHS established new rules for insurance companies last summer that require full coverage for such recommended services as mammograms, colonoscopies, blood pressure checks, counseling on various health issues (such as obesity), and routine immunizations for children, adolescents, and adults. To build on these rules and close any gaps in the preventive services offered for women specifically, the DHHS commissioned the Institute of Medicine (IOM) to identify other services for women that evidence suggests can improve health outcomes. The IOM released its recommendations in late July.

Linda Rosenstock, MD, MPH, dean of the School of Public Health at the University of California Los Angeles and chair of the IOM committee, explained during a press briefing that the shift toward preventive care outlined in the health reform legislation has the potential to benefit women in particular because they have a separate set of reproductive concerns and because they have traditionally been medically underserved. According to the IOM report, socially disadvantaged women in particular have a higher burden of health conditions, such as more exposure to injury and trauma, depression, asthma, heart disease, and HIV or other sexually transmitted infections.

The report also notes that women's health care needs differ from men’s. For example, diseases may present differently in women than in men, and women may respond differently to treatment.

Potentially preventable gender-specific conditions that affect women can add up to significant out-of-pocket costs. But women are more likely to report cost barriers that prevented them from receiving care or led them to delay undergoing medical tests, filling prescriptions, or receiving other treatments.

“[Out-of-pocket cost] creates a particular challenge to women, who typically earn less than men and who disproportionately have low incomes,” the report notes.

To overcome these cost barriers, the report recommends that insurance companies should provide 100% coverage for several preventive services with no required co-payment.

Paula A. Johnson, executive director of the Connors Center for Women's Health and Gender Biology and chief of the Division of Women's Health at Brigham and Women's Hospital in Boston, noted that removing such cost barriers may also help improve access to care for women of color, who may be disproportionately affected by cost issues.

“We would hope improving the ability to obtain services without a cost barrier will in and of itself improve access,” she said.

The report recommends full coverage for at least 1 annual “well-woman visit.” Such a benefit will provide women with the opportunity to receive a range of preventive health services, although the report acknowledges that some women may require more than one such visit. Alfred O. Berg, MD, MPH, professor of family medicine at the University of Washington School of Medicine in Seattle, explained during the briefing that such visits have shifted away from full physical examinations involving a series of routine procedures toward being opportunities for physicians to provide preventive care and counseling to patients on various health care issues.

Several types of counseling and screening were also recommended for full coverage. For example, the report calls for annual counseling on sexually transmitted infections, including HIV, as well as annual screening for HIV infection. Rosenstock noted that the USPSTF recommends annual screening only for those categorized as high risk, but the committee elected to broaden its recommendation to all women.

“Women may not know their risk factors,” she said. She explained that there is a growing population of heterosexual US women who have become infected because their partner is covertly engaging in risky behavior.

The report also calls for coverage of screening for and counseling about current and past interpersonal and domestic violence for women and adolescents. Such interventions should be delivered in a culturally sensitive way and seek to address both related health concerns and safety.

The requirements that have garnered the most attention and generated the most controversy, however, have been those related to reproductive health.

Under the new rules, health plans will be required to fully cover all contraceptives approved by the US Food Drug Administration, sterilization procedures, and patient counseling on contraceptives. This would include emergency contraceptives as well as insertion of intrauterine devices. However, it would not include abortifacients such as mifepristone, also known as RU-486.

Rosenstock explained that the evidence supports the effectiveness of contraceptives in preventing unintended pregnancy, which can have detrimental effects on the health and well-being of both women and infants. Contraceptive use may also decrease elective abortions. Previously, the USPSTF had also recommended contraceptives as a preventive strategy, Rosenstock noted. However, the USPSTF recommendation was allowed to expire.

Johnson emphasized the importance of women having a range of contraceptive choices available. She explained, “different contraceptives can have adverse effects on different populations of women.”

The committee considered only the medical evidence, and not personal views on contraception, Rosenstock noted.

“We were charged with looking at what works,” she said. However, she noted that the recommendation is for coverage by insurance plans, and would not mandate clinicians to provide such services. The DHHS has established an exemption for religious institutions that provide health insurance but object to covering contraception.

Other recommendations focused on ensuring coverage for evidence-based gynecologic and obstetric care. For example, the report calls for coverage of DNA testing for high-risk strains of human papillomavirus in addition to cytology tests that are currently used for routine cervical cancer screening.

The new rule also calls for screening all pregnant women for gestational diabetes between 24 to 28 weeks of pregnancy. It also says that women at high risk for the condition should be screened at the first prenatal visit.

The IOM also advised full coverage of services to support women in their efforts to breastfeed, including counseling by a trained clinician postpartum and rental of breastfeeding equipment. Rosenstock noted that this recommendation simply clarifies what should be included in the coverage outlined in the health reform bill.

“The Affordable Care Act helps stop many health problems before they start,” said DHHS Secretary Kathleen Sebelius, in a statement announcing the changes. “These historic guidelines are based on science and existing literature and will help ensure women get the preventive health benefits they need.”