WASHINGTON – A just-released survey conducted last fall shows that low-income women with private insurance or Medicaid were often foregoing preventive care and use of contraceptives, in part due to cost, but also because of a lack of awareness of benefits that were already available under the Affordable Care Act.
The Kaiser Family Foundation conducted the survey of some 3,000 women aged 15-64 years by telephone – in English and Spanish – from September to November 2013. The goal was to get a baseline picture of women’s health care before the ACA was fully implemented in January.
Alicia Ault/Frontline Medical News
Survey authors Usha Ranji and Alina Salganicoff
"It’s important to know where we are today, to have a baseline" with which to compare outcomes in the future, after more women have insurance and broader access to benefits, Alina Salganicoff, vice president and director of women’s health policy for the Kaiser Family Foundation, said at a briefing*.
At the time of the survey, many preventive benefits had already been available to a large number of women since 2012. Under the ACA, health plans that had changed since the law went into effect in 2010 were required to cover services such as mammograms, Pap smears, counseling on domestic and interpersonal violence and sexually transmitted infections (STIs), and contraception. Medicaid also has been covering those preventive benefits.
Among the women surveyed, 51% had employer-provided insurance, 9% were on Medicaid, 7% had individual coverage, 6% were on a parent’s policy, 6% were covered by another government program, and 18% were uninsured. When stratified by income, women who were under 200% of the poverty line were more likely to be uninsured (40%) or on Medicaid (21%).
More than a quarter overall (26%) said they’d delayed care in the past year because of cost, and about 20% said they had skipped recommended tests or treatments, or not filled prescriptions. Twenty-eight percent said they had trouble paying medical bills. All of these rates are higher than in a comparable sample of men surveyed by Kaiser.
When it came to knowledge about preventive services, 60% said they knew insurers were required to cover the cost of at least one preventive visit a year with no out-of-pocket costs, and a slightly smaller number were aware that the plans were also required to provide preventive services free of copays, deductibles, or other charges.
About 88% of women with private insurance said they’d had a recent checkup with a doctor, compared with 81% of those with Medicaid. Not surprisingly, fewer uninsured women had a recent checkup – only about 60%. Only about 40% of women said they’d talked with a health provider about a mental health issue. Mental health services are considered an essential benefit under the ACA, but it’s not clear yet what exactly will be covered.
Most women (73%) reported that their usual source of care was a doctor or an HMO; 13% received care in a clinic, but 3% reported the emergency room as their usual source of care.
For screening tests that are covered, rates of use were high for hypertension (92%) but extremely low for colonoscopy – only 39% of all women reported having had the exam at the appropriate interval, with rates dipping to 35% for blacks and 34% for Hispanics.
Women with private insurance were more likely to have visited an ob.gyn. in the past year – at about 70%, compared with 58% of those on Medicaid, and 43% of the uninsured.
Physician counseling varied by insurance status and ethnicity. Clinicians were more likely to discuss sexual history, HIV, and STIs with women on Medicaid, and black and Hispanic women. Of women on Medicaid, 52% said their provider had talked about HIV, compared with only 29% of those with private insurance. The uninsured had the lowest rate of counseling on any of those topics.
Only about 40% of women were tested for an STI, and among those women, half assumed that the test was a routine part of an ob.gyn. exam. It is not, so rates of testing are probably even lower than those being reported by the survey respondents, said Usha Ranji, associate director for women’s health policy at Kaiser, who was also an author of the survey.
Even though contraceptives are required to be covered by most health plans, 20% of those surveyed said they were not using any contraception. In part, that may be because condoms were reported as the primary method for all women, but especially for those under age 25, and for black women. Condoms are not reimbursed by any plan.