Benefits for Women and Children of New Affordable Care Act Rules on Expanding Prevention Coverage
Too many Americans don’t get the preventive health care they need to stay healthy, avoid or delay the onset of disease, lead productive lives, and reduce health care costs. Often because of cost, Americans use preventive services at about half the recommended rate. Yet chronic diseases, such as heart disease, cancer, and diabetes – which are responsible for 7 of 10 deaths among Americans each year and account for 75% of the nation’s health spending – often are preventable. Cost sharing (including deductibles, co-insurance, or copayments) reduces the likelihood that preventive services will be used. One study found that the rate of women getting a mammogram went up as much as 9% when cost sharing was removed.1
The Affordable Care Act – the health insurance reform legislation passed by Congress and signed into law by President Obama on March 23, 2010 – helps make prevention affordable and accessible for all Americans by requiring health plans to cover preventive services and by eliminating cost sharing. According to regulations released by the U.S. Departments of Health and Human Services (HHS), Labor, and the Treasury, if an individual or family enrolls in a new health plan on or after September 23, 2010, then that plan will be required to cover recommended preventive services without charging a deductible, copayment or co-insurance.2 Expanding access to preventive care can improve health outcomes for women and children.
Keeping Your Children Healthy
Many children don’t get the preventive care they need: 12% of children have not had a doctor’s visit in the past year, and a recent study found that children receive recommended care less than half of the time. Nearly one-third of kids are overweight or obese, putting them at risk for conditions such as diabetes and heart disease. While approximately 12 percent to 16 percent of children experience developmental problems, only one-third of those children are identified in pediatric practices prior to school entry. Early identification helps kids get the developmental services they need.3
The Affordable Care Act and new regulations ensure that a comprehensive set of preventive services are available in new health plans for children with no cost sharing. This includes:
- Well-baby and well-child visits: This includes a doctor visit every few months when your baby is young, and a visit every year until your child is age 21. These visits will cover a comprehensive array of preventive health services:
- Physical exam and measurements
- Vision and hearing screening
- Oral health risk assessments
- Developmental assessments to identify any development problems
- Screenings for hemoglobin level, lead, tuberculin, and other tests
- Counseling and guidance from your doctor about your child’s health development
- Screenings and counseling to prevent, detect, and treat common childhood problems like:
- obesity to help children maintain a healthy weight
- depression among adolescent children
- dental cavities (caries) and anemia
- Immunizations like an annual flu vaccine, and many other childhood vaccinations and boosters, from the measles to polio.
For more information on what preventive services must be covered by health plans, please visit www.HealthCare.gov/center/regulations/prevention.html.
Promoting Healthy Pregnancy
The U.S. infant mortality rate is a troublingly high 6.8 deaths for every 1,000 live births, and 8.2% of babies have a low birth weight, up 17% since 1990.4 At least 13% of American women smoke during pregnancy,5 and 1% of women drink alcohol during pregnancy.6
The new law and regulations make sure that more mothers have access to services they need to ensure a healthy pregnancy, such as:
- Screening for conditions that can harm pregnant women or their babies, including iron deficiency, hepatitis B, a pregnancy related immune condition called Rh incompatibility, and a bacterial infection called bacteriuria
- Special, pregnancy-tailored counseling from a doctor that will help pregnant women quit smoking and avoid alcohol use
- Counseling to support breast-feeding and help nursing mothers
Preventing Heart Disease and Obesity Among Women
Keeping your family healthy means keeping yourself healthy, too. Heart disease is the number one cause of death for women. More women than men have weight problems; 36% of women are obese, significantly increasing their risk of cardiovascular disease.
Because of the Affordable Care Act and the new regulations, new health plans must offer coverage without cost sharing for services that will prevent and control these diseases, like:
- Screening for obesity, and counseling to promote sustained weight loss
- Blood pressure screening
- Counseling on the use of daily aspirin to reduce the risk of a stroke
- Tests to screen for high cholesterol and diabetes
Preventing and Controlling Breast and Other Types of Cancer
Despite our progress in controlling cancer, breast cancer, cervical cancer, colon cancer, and lung cancer continue to cause thousands of preventable deaths in the U.S each year. About 210,000 new cases of invasive breast cancer will occur among women in the United States during 2010, and an estimated 40,000 women are expected to die from breast cancer this year. African American women are about one-third more likely to die from breast cancer compared to others. In 2006, 12,000 women in the U.S. were told that they had cervical cancer, and nearly 4,000 women died from the disease. More than 16% of women in the U.S. smoke,7 significantly increasing their risk of lung cancer and other tobacco related illness.
Only about 67% of women aged 40 or older have had a mammogram in the last two years. The rate of women getting mammography screening has not improved since 2002. If 90% of women 40 and older received breast cancer screening, 3,700 lives would be saved annually.8 More than 17% of women in the U.S. have never had a Pap smear.
The new regulations ensure that new health plans offer coverage without cost-sharing for a variety of important cancer prevention tools, such as:
- Preventing breast cancer: Annual mammograms for women over 40. Other services to prevent breast cancer will also be covered, including a referral to genetic counseling and a discussion of chemoprevention for certain women at increased risk.
- Preventing cervical cancer: Regular Pap smears to screen for cervical cancer and coverage for the HPV vaccine that can prevent cases of cervical cancer.
- Tobacco cessation interventions – like counseling or medication to help individuals quit.
- Preventing colon cancer: Screening tests for colon cancer for adults over 50.
New Comprehensive Coverage for Women’s Preventive Care
Under the Affordable Care Act, women’s preventive health care – such as mammograms, screenings for cervical cancer, pre-natal care, and other services – is covered with no cost sharing starting on September 23, 2010 for new health plans. For the first time ever, the Department of Health and Human Services has also begun the process for developing women’s prevention guidelines, which do not exist in a comprehensive format today. These guidelines will be released by August 2011. As it has done with all other scientific prevention guidelines, HHS is relying on independent doctors, scientists, and experts to make these determinations based on scientific evidence.
Preventive Care Means New Cost Savings for all Americans
While the elimination of copays, deductibles and other cost sharing under the Affordable Care Act will mean cost savings for all Americans, it will provide significant savings for Americans in greatest need of important, potentially life-saving preventive services. For instance, if a 58-year old woman who is at risk for heart disease should receive a mammogram, a colon cancer screening, a Pap test, a diabetes test, a cholesterol test, and an annual flu shot. Under a typical insurance plan, these tests could cost the consumer more than $300 out of her own pocket.
The proven benefits of preventive services also include additional cost savings for the nation from improved health and productivity of the nation’s workforce, and reduced national health care spending.
- If just five preventive services –colorectal and breast cancer screening, flu vaccines, and counseling on smoking cessation and regular aspirin use – were utilized effectively, 100,000 deaths could be averted each year. In addition, effective cancer screening and early and sustained treatment could reduce the cancer death rate by 29%.
- 69 million workers reporting missed days due to illness each year, and reducing economic output by $260 billion per year.
- Obese individuals have health care costs 39% above average, and reducing obesity and the diseases related to it could lower premiums overall by 0.05 to 0.1 %.
- Every dollar spent on immunizations could save $5.30 on direct health care costs and $16.50 on total societal costs of disease.
1 Solanki G., Halpin Schauffler, H., Miller, L.S. “The Direct and Indirect Effects of Cost-Sharing on the Use of Preventive Services,” Health Services Research, vol. 34, no. 6, February 2000, pp. 1331-1350.
2 To help individuals who like the coverage they have keep it, some plans that were in effect on March 23, 2010 and that were not significantly modified thereafter will be “grandfathered”. Grandfathered health plans are not subject to this policy. Many of the 98 million people in group health plans that are expected to be grandfathered and thus not subject to these regulations already have preventive services coverage. For more information about the definition of a grandfathered plan, see http://www.healthreform.gov/newsroom/keeping_the_health_plan_you_have.html
4 Centers for Disease Control and Prevention, Health United States 2009.
5 Centers for Disease Control and Prevention. “Tobacco Use and Pregnancy”: http://www.cdc.gov/reproductivehealth/tobaccousepregnancy/index.htm
7 Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System Survey Data (BRFSS), 2008, unpublished data. Information about the BRFSS is available at http://www.cdc.gov/brfss/index.htm.
8 Partnership for Prevention, A National Profile on Use, Disparities, and Health Benefits, 2007
HHS will not enforce these rules against issuers of stand-alone retiree-only plans in the private health insurance market.
Posted: July 14, 2010