The Women’s Health Amendment Is Getting An Update. What Should It Include?
The Affordable Care Act (ACA) requires most private health plans in the United States to cover four sets of recommended preventive services without copayments, deductibles, or other out-of-pocket costs. One of those four sets of services focused on women’s preventive care needs. It was called for under the law’s Women’s Health Amendment, developed by an Institute of Medicine panel, and officially incorporated by the federal government into health plans’ requirements in 2012. Taken as a whole, the ACA’s preventive services provision requires coverage of a wide array of sexual and reproductive health services, from breast and cervical cancer screening to breastfeeding support to counseling for domestic violence.
This year, a formal effort to update the services provided for under the Women’s Health Amendment—a process called the Women’s Preventive Services Initiative—offers a further opportunity to expand and improve coverage of preventive care for women nationwide. This is a five-year effort led by the American College of Obstetricians and Gynecologists (ACOG) under an agreement with the federal Health Resources and Services Administration (HRSA), with representation from about 20 other health professional organizations and consumer advocacy groups. The ACOG panel has reviewed the existing women’s preventive services recommendations and released draft updates to these recommendations on September 1, with a public comment period ending on September 30. The panel is also accepting nominations for new recommendation topics on a rolling basis.
Throughout this process, ACOG and its colleague organizations should address four areas of importance for sexual and reproductive health: expanding the contraceptive coverage guarantee; expanding coverage of services to prevent HIV and other sexually transmitted infections (STIs); covering and ensuring adequate reimbursement for preventive counseling services; and eliminating coverage restrictions related to gender, age, and other patient characteristics.
For contraception, the requirement adopted by HRSA is to cover "all Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity." This requirement had an immediate impact: Between fall 2012 and spring 2014, the proportion of privately insured women paying nothing out of pocket for oral contraceptives increased from 15 percent to 67 percent, with similar changes for injectable contraception, the vaginal ring, and the intrauterine device.
Yet, following reports by organizations such as the Kaiser Family Foundation and the National Women’s Law Center about insurance plans misinterpreting the contraceptive coverage guarantee, the federal government issued multiple rounds of guidance about the specific services and supplies that must be covered, and under what circumstances. The ACOG panel’s draft recommendations build on these important advances in multiple ways.
Incorporate federal guidance
The draft recommendations formally incorporate many pieces of the extensive federal guidance that has been released over the past several years, and provide specific recommendations for implementation by health plans. That includes details about covering each distinct female method, as categorized by the Food and Drug Administration, and all related services, such as device removal, follow-up care, and services needed to initiate a method (which would include necessary anesthesia and ultrasounds, for certain methods).
The final recommendations should further incorporate federal guidance by explicitly including restrictions on medical management techniques for contraception, such as prior authorization, step therapy, generic-only formularies, and inappropriate quantity limits, in addition to clear procedures plans must have in place to allow clinicians to override the plan’s formulary.
As currently written, the contraceptive coverage requirement only applies to methods "as prescribed." This forces women to pay out of pocket for the timeliness and convenience of over-the-counter contraceptive supplies, such as emergency contraception, female condoms, and spermicides. Eliminating this limitation, as Illinois and Maryland did in 2016 and as the draft recommendations would do, will be particularly important if and when oral contraceptive products are approved for over-the-counter sales.
Extended contraceptive supply
The draft recommendations specify that health plans would have to cover a full-year’s supply of contraceptives at one time, as an example of effective family planning practice. This practice has been endorsed by ACOG and other medical professional organizations because of research indicating that many women are unable to obtain monthly refills in a timely manner, and that providing a full year’s supply is "cost effective and improves adherence and continuation rates." Over the past two years, the District of Columbia, Hawaii, Illinois, Maryland, Oregon, and Vermont have all required health plans to cover an extended supply of contraceptives.
Methods used by men
In its draft recommendations, the ACOG panel has taken the opportunity to correct the double standard that requires plans to cover 18 contraceptive methods used by women without cost-sharing, but does not require similar coverage for methods used by men -- currently, vasectomy and male condoms. The federal government has repeatedly asserted that these two methods cannot be recommended as preventive services for women because the woman’s male partner technically uses the method.
That logic is flawed: vasectomy and male condoms each have proven health benefits for women, and for some couples, have distinct advantages over the other contraceptive choices. Vasectomy is less invasive, has lower health risks, and is even less expensive than female sterilization. Male condoms are important as a primary and backup method of contraception with the added benefits of preventing sexually transmitted infections (STIs). Both methods are particularly important options for women who experience side effects from hormonal contraception. Illinois, Maryland, and Vermont all enacted laws in 2016 that will require plans to cover vasectomies without patient cost-sharing.
The ACA’s preventive services requirement already includes coverage for at least some women of several important services to protect against HIV and other STIs: screening for chlamydia, gonorrhea, hepatitis B and C, HIV, and syphilis; vaccinations for hepatitis B and HPV; and counseling about STI prevention. Yet, several other proven STI prevention services are currently omitted. None of these services are addressed in the ACOG panel’s draft recommendations, but they should be considered when the panel looks at future recommendation topics.
Condoms to prevent STIs
Future recommendations should require coverage of male and female condoms as methods of HIV/STI prevention. As with contraception, it should not matter whether the woman or the man technically uses the condom; either way, the condom provides substantial preventive health benefits for women, who face more severe potential health risks from many STIs than do men. Male and female condoms have long been recommended for HIV/STI prevention by the Centers for Disease Control and Prevention (CDC) and numerous other government agencies and health professional organizations.
Expedited partner therapy
The ACOG panel should also recommend expedited partner therapy (EPT), in which a woman’s clinician provides a supply of, or prescription for, antibiotics to the woman’s partner without an actual diagnosis for the partner. This helps break the cycle of reinfection that commonly occurs if only one partner in a couple is treated, and has been promoted by the CDC and other medical experts specifically for chlamydia and gonorrhea, where effective single-dose therapies minimize the chance of improper or incomplete treatment.
As of mid-2016, 35 states and the District of Columbia explicitly allow clinicians to provide EPT in at least some circumstances. Including EPT in future recommendations would ensure coverage under the woman’s insurance plan, even if that plan does not cover her partner.
Home testing kits
Another addition to the recommendations should be to explicitly endorse the use and coverage of home-testing kits for HIV and other STIs. Home testing provides significant benefits for many women in terms of convenience, timeliness, and confidentiality. But as with most over-the-counter products, health insurance plans do not typically provide coverage for them, creating a financial barrier for low-income women.
One final HIV prevention service the ACOG panel should consider is pre-exposure prophylaxis (PrEP), in which individuals at very high risk for HIV take a daily dose of HIV medications to reduce their risk of infection. Federal guidelines currently recommend PrEP for "people who are HIV-negative and in an ongoing sexual relationship with an HIV-positive partner," along with other groups at high risk. This describes numerous U.S. women. PrEP is already covered by many insurance plans, but is not necessarily free of cost-sharing.
The current preventive services requirements include several important recommendations for counseling related to sexual and reproductive health, including contraceptive counseling, STI prevention counseling, and extensive counseling recommendations for adolescents. They also include periodic well-women visits, of which counseling is a central component. Nevertheless, more extensive and detailed recommendations for counseling would be valuable.
Reproductive life planning
The CDC and the U.S. Office of Population Affairs, along with many other expert bodies, have highlighted the importance of talking to patients about whether and when they would like to have children. Engaging with patients about their thoughts and goals around childbearing enables clinicians to tailor a visit to a patient’s specific needs around contraception, pregnancy testing, services to help achieve pregnancy, and preconception care. The ACOG panel should explicitly include this type of counseling when it finalizes its recommendation on well-woman preventive visits.
Reimbursement for counseling
The ACOG process is also an opportunity to address a shortcoming of the ACA’s preventive services requirement: Although health plans must cover a range of preventive counseling services without patient cost-sharing, they are not explicitly required to reimburse clinicians for the time they spend providing this counseling. Rather, counseling is more commonly included as part of a patient visit, and reimbursement does not always account for the extensive counseling many patients need around contraception, STIs, intimate partner violence, and more.
Moreover, health plans might not cover counseling and other services provided by non-clinicians, such as the time a pharmacist spends counseling a patient about over-the-counter products, or the time a lactation consultant spends helping a new mother with breastfeeding. The ACOG panel’s draft recommendations address the latter example about breastfeeding counseling, but the final recommendations should address this issue more comprehensively.
Restrictions Based on Patient Characteristics
Finally, the ACOG process may also be an avenue for addressing a variety of persistent coverage restrictions based on a patient’s gender, age, or other characteristics. For example, the National Women’s Law Center has received frequent reports through its consumer hotlines that insurers are denying contraceptive coverage to women in their 50s, even though the current recommendations are for all women with reproductive capacity (which differs across individual women).
Moreover, many preventive services recommendations account for gender, age, and other characteristics that affect a patient’s risk for a particular health problem. For instance, federal guidelines recommend that sexually active women aged 24 or younger and older women at increased risk be routinely screened for chlamydia and gonorrhea. Yet, clinicians assess each patient individually and might sometimes need to provide services to patients who do not match up with a recommendation’s patient profile.
Moreover, clinical recommendations rarely reflect the particular needs of transgender people and may unintentionally exclude them. A particular patient characteristic highlighted in clinical recommendations should never translate to exclusions or other restrictions in insurance coverage. As the ACOG panel finalizes this round of updated recommendations and considers new topics, it should make it clear that if a service is recommended for some patients, then health plans must cover that service for all patients when a clinician deems it appropriate.
This article was originally published in Health Affairs Blog.