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Testimony by Judy Waxman, Before the Institute of Medicine Committee on Preventive Services for Women

Introduction
Thank you for inviting me to testify on behalf of the National Women’s Law Center.  The Center is a non-profit organization dedicated to expanding the possibilities for women and girls.  Since its founding in 1972, the Center has sought to address the discrimination and barriers women experience in the health care system.  We appreciate the important role this panel will play in rectifying some of these long-standing challenges and are grateful for the opportunity to provide our recommendations. 

Women Face Key Barriers to Obtaining Affordable Care
Women face significant barriers to obtaining affordable health care.  Women generally have less income than men.  On average, women earn only 78 cents for every dollar that men earn, and the median earnings of female workers working full time, year round, were $35,549 in 2009, compared to $45,485 for men.  [1]

In addition, health insurance is often more expensive for women than it is for men and meets fewer of their needs.  Before the Affordable Care Act, insurance companies could refuse to sell a woman coverage due to her history of health problems or could charge a woman a higher premium on the basis of her sex.  Research by the National Women’s Law Center found that the majority of plans available to women in the individual market do not cover pregnancy, and the limited number of supplemental riders that are available are often prohibitively expensive. [2]  Though women who get health insurance from their employer are partially protected by both federal and state employment discrimination laws, cost and coverage challenges exist for women in other insurance markets as well.

These Barriers Create Hardships for Their Health and Lives
The barriers women face to obtaining affordable health care jeopardize their financial stability.  Millions of women—and more women than men—have experienced significant financial hardship due to their health care needs.  In 2007, for example, one-third of women, compared to one-quarter of men, were either unable to pay for food, heat or rent, had used up all of their savings, had taken out a mortgage or loan against their home, or had taken on credit card debt because of medical bills. [3]

The barriers women face also jeopardize their health. Women are more likely than men to avoid needed health care, including preventive care, because of cost.  In 2007, for example, 52% of all nonelderly women reported a cost-related access barrier—not filling a prescription, skipping a recommended test or treatment, not getting needed basic or specialist care because of cost—compared to 39% of all nonelderly men. [4]  Preventive services are among those that women forgo because of cost; nearly half (45%) of women report delaying or not receiving a cancer screening or dental exam because of its cost, as compared to 36 percent of men. [5]  Evidence suggests that even moderate co-payments can cause individuals to forgo needed preventive care, particularly those with low and moderate incomes. [6]

Women’s Health Amendment:  Purpose and Promise
The National Women’s Law Center was proud to support the Affordable Care Act because of its promise to address many of these challenges.  One of the law’s key protections is the guarantee that all new insurance plans will cover preventive services, including counseling, screenings, and interventions that have received either “A” or “B” recommendations from the United States Preventive Services Task Force. [7]  The guarantee that all USPSTF A and B recommended interventions, including folic acid, blood pressure screening, breast feeding counseling, and many others, will be covered and provided without cost-sharing is an enormous benefit to women.

However, the Women’s Health Amendment, which gives rise to this panel’s charge, was enacted because USPSTF recommendations leave some important gaps in preventive care for women.  The National Women’s Law Center urges this panel to recommend the following additional services to be included in the list of all preventive services that must be covered and provided without cost-sharing: 

Family Planning Counseling and All FDA-Approved Prescription Contraceptive Drugs and Devices
Family planning counseling and all FDA-approved prescription contraceptive drugs and devices should be considered part of preventive care for women and included in all new health insurance plans without cost-sharing.  This should include both reversible and permanent contraception, as well any related physician visits. 

Contraception use is nearly universal among women of reproductive age in the United States and is a key part of preventive health care for women.  Most women have the biological potential for pregnancy for over 30 years of their lives, and for approximately three-quarters of her reproductive life, the average woman is trying to postpone or avoid pregnancy.  Yet, for decades, insurance plans typically did not cover contraceptives.  A 1993 survey, for example, found that half of indemnity plans for large groups did not cover any nonpermanent contraception, and only 39% of HMOs routinely covered all methods of reversible contraception. [8]

Contraceptive care and counseling allows women to control the timing, number, and spacing of births, leading to improved health and mortality outcomes for themselves and their children.  Planned pregnancies—which for most women require contraception—improve women’s health.  The ability to determine the timing of a pregnancy can prevent a range of pregnancy complications that can endanger a woman’s health, including gestational diabetes, high blood pressure, and placental problems, among others. [9]   In addition, an unintended pregnancy may have significant implications for a woman’s health.  A preexisting health condition such as diabetes, hypertension, or coronary artery disease may be worsened by a pregnancy. [10]  A planned pregnancy allows a woman to take steps so she is sufficiently healthy to undergo pregnancy and childbirth. [11]

Planned pregnancies not only improve women’s health, but improve the health of their children.  Women who wait for some time after delivery before conceiving their next child lower their risk of adverse perinatal outcomes, including low birth weight, preterm birth, and small-for-size gestational age. [12]  And a planned pregnancy affords women an opportunity to make behavioral changes that lead to better birth outcomes. [13]
 
This panel will have a substantial weight of authority to draw upon in its deliberations.  A consensus study panel convened by the Institute of Medicine in 1995 to address unintended pregnancy recommended that financial barriers to contraception be reduced by “increasing the proportion of all health insurance policies that cover contraceptive services and supplies … with no copayments or other cost-sharing requirements, as for other selected preventive health services.” [14]  The Centers for Disease Control and Prevention named family planning one of the ten most important public health achievements of the 20th century because of its contribution to “the better health of infants, children, and women.”  [15] Contraceptive use is already one of the cornerstones of Healthy People 2010, the nation’s agenda for promoting health and preventing disease. [16]  The National Business Group on Health, a non-profit organization representing large employers' perspectives on national health policy issues, conducted a comprehensive review of available evidence and recommends a clinical preventive service benefit design that includes all FDA-approved prescription contraceptive methods at no cost-sharing. [17]

Including contraceptive counseling and all FDA-approved contraceptive products among this panel’s recommendations would build on key federal protections already in place for millions women.  For nearly four decades, Medicaid has covered family planning services and supplies without co-payments.  And a number of existing federal laws and regulations, including those governing HMOs and those allowing states to design alternative Medicaid benefit packages, already consider “family planning services” among the “preventive services” that are required to be covered. [18]

In addition to the preventive health benefits of contraception, we urge the panel to take into account its unique opportunity to rectify a long-standing inequity for women.  Pregnancy is a condition unique to women.  The only forms of FDA-approved prescription contraceptives available today are for women.  The failure to cover contraceptives forces women to bear higher out-of-pocket health costs, totaling approximately $9,000 over a woman’s lifetime. [19]  And the failure to cover contraceptives exposes women to the unique physical, economic, and emotional consequences of unintended pregnancy.  That is why ten years ago next month, the Equal Employment Opportunity Commission issued an interpretation of the federal civil rights law that prohibits discrimination in employment, ruling that it is sex discrimination for employer-sponsored health insurance plans to provide coverage of other prescription drugs and preventive services but fail to provide coverage of contraceptives. [20]

Screening for Intimate Partner Violence
A well-established body of evidence exists in support of routine behavioral assessment for intimate partner violence.  At a time when three women are murdered each day by their husbands or boyfriends and the Centers for Disease Control and Prevention reports that women in the United States experience two million injuries from domestic violence each year, [21] we should be using every tool at our disposal to identify and help victims of intimate partner violence. 

Screening for Cervical Cancer
The National Women’s Law Center urges the panel to review the relevant evidence for routine cervical cancer screening.  Though cervical cancer was once the leading cause of cancer death for women in the United States, screening and early intervention has dramatically reduced the number of deaths from cervical cancer each year. [22]  We understand that it has been several years since USPSTF last updated its recommendations.  We urge the panel to review recommendations from relevant professional societies in order to ensure that women are receiving the appropriate care. 

Breast Pump Equipment
We urge the panel to include lactation supplies, including breast pump equipment, as part of preventive care for women and included in all new health insurance plans without cost-sharing.  Studies have demonstrated that breastfeeding provides important long-term benefits for mothers, including reduced risk of developing Type 2 diabetes, [23] breast cancer, [24] ovarian cancer [25] and postpartum depression,[26]  and reduced risk factors for cardiovascular disease [27] and metabolic syndrome. [28] Lactation supplies, including breast pumps, allow women to maintain their milk supply when their child is unable to breastfeed directly or when they are away from their child.  These supplies are critical for mothers to sustain breastfeeding and receive the preventive health benefits that lactation affords. 

Physician-Recommended Preventive Visits
Finally, we urge the panel to consider the available evidence for well-woman and preconception care visits to be covered by all new health insurance plans with no cost-sharing.  Though many of the services that are provided in a routine preventive visit are included among USPSTF recommendations, the Task Force does not recommend the actual visit itself, and women are often charged copayments at the time of service.  In circumstances where a doctor recommends a preventive health visit, a woman’s decision about whether to comply with the recommendation should not turn on her ability to afford the care. 

Methodological Issues
Finally, this panel has been asked to identify the full range of preventive care necessary for women's health and well-being.  This broad charge allows the panel to take into account factors that other bodies, including the USPSTF, have not considered.  I urge this panel to take into account the various forms of discrimination women have long faced in the private health insurance market and to consider, as part of its charge, recommendations to rectify these long-standing inequities.

Thank you again for the opportunity to address the panel.  I am happy to answer any questions I can. 

 

[1]  David M. Getz, U.S. Census Bureau, U.S. Dep’t of Commerce, Men’s and Women’s Earnings for States and Metropolitan Statistical Areas: 2009 1 (2010), available at http://www.census.gov/prod/2010pubs/acsbr09-3.pdf.
 [2] Lisa Codispoti, Brigette Courtot & Jen Swedish, Nat’l Women’s Law Ctr, Nowhere to Turn: How the Individual Market Fails Women 4 (2008), available at http://www.nwlc.org/sites/default/files/pdfs/NWLCReport-NowhereToTurn-81309w.pdf.  Maternity riders in Kansas and New Hampshire, for example, cost upwards of $1,100 per month.  Id. at 11.
 [3] Sheila D. Rustgi, Michelle M. Doty, & Sara R. Collins, The Commonwealth Fund, Women at Risk: Why Many Women are Forgoing Needed Health Care 5 (2009), available at http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2009/May/Women%20at%20Risk/PDF_1262_Rustgi_women_at_risk_issue_brief_Final.pdf
 [4] Id at 3.
 [5] Id at 3-4.
 [6] Geetesh Solanki  &  Helen Halpin Schauffler, Cost-sharing and the utilization of clinical preventive services, 17 Am. J .Preventive Med. 127 (1999); Amal N. Trivedi et al., Effect of Cost Sharing on Screening Mammography in Medicare Health Plans, 358 New Eng. J. Med. 375 (2008).
 [7] Patient Protection and Affordable Care Act, Pub. L. No. 111-148, § 1001, 124 Stat. 119, 131 (2010) (codified at 42 U.S.C. § 300gg-13).
 [8] Rachel Benson Gold & D. Daley, Alan Guttmacher Inst., Uneven & Unequal: Insurance Coverage and Reproductive Health Services (1994).
 [9] March of Dimes, Pregnancy After 35 (May 2009), http://www.marchofdimes.com/Pregnancy/trying_after35.html
 [10] Rowena Bonoan & Julianna S. Gonen, Washington Bus. Group on Health, Promoting Healthy Pregnancies: Counseling and Contraception as the First Step, Fam. Health in Brief, Aug. 2000, at 2. 
 [11] Id.
 [12] U.S. Dep’t of Health and Human Servs., Healthy People 2010  9-32 (2nd ed. 2000), available at http://www.healthypeople.gov/Document/pdf/Volume1/09Family.pdf
 [13] For example, a woman whose pregnancy is unplanned is less likely to seek prenatal care in the first trimester and more likely not to obtain prenatal care at all, less likely to breastfeed, and more likely to expose the fetus to harmful substances, such as tobacco or alcohol.   Id. at 9-5.
 [14] Cmte. On Unintended Pregnancy, Inst. of Med., The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families (Sarah S. Brown & Leon Eisenberg, eds. 1995).
 [15] See Ctrs. for Disease Control and Prevention, Achievements in Public Health, 1900-1999: Family Planning, 48 Morbidity and Mortality Wkly. Rep. 1073 (1999), available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4847a1.htm
[16]  See, e.g. U.S. Dep’t of Health and Human Servs., Public Comment: Healthy People 2020, http://www.healthypeople.gov/hp2020/Objectives/TopicArea.aspx?id=21&TopicArea=Family+Planning (last visited Nov. 15, 2010).
[17] Nat’l Bus. Group on Health, Investing in Maternal and Child Health: An Employer’s Toolkit 41 (K.P. Campbell ed., 2007), available at http://www.businessgrouphealth.org/healthtopics/maternalchild/investing/docs/mch_toolkit.pdf
 [18] E.g. 42 U.S.C. § 300e-1 (1)(H) (2010) (statute governing HMOs); 42 C.F.R. § 417.101 (2010) (regulation governing HMOs under Medicare); 42 C.F.R. § 440.335 (2010) (regulation governing benchmark-equivalent benefits coverage).
[19]  The National Business Group on Health estimates that the average cost for one year’s worth of birth control pills (the most popular form of contraception) is $240 to $300.  Campbell, supra note xvii at 5 (cost of birth control pills in 2005 dollars); William D. Mosher & Jo Jones, Nat’l Ctr. for Health Statistics, U.S. Dep’t of Health and Human Servs., Use of Contraception in the United States: 1982-2008, Vital Health Stat., Aug. 2010, at 9-10, available at  http://www.cdc.gov/NCHS/data/series/sr_23/sr23_029.pdf (the pill is used by a higher percentage of contraceptors than any other method).  Since the typical woman spends 30 years of her life trying to prevent pregnancy, a conservative estimate of the lifetime cost of contraception is approximately $9,000.  See Michelle Andrews, Preventing Pregnancy: Should Patients Get Contraceptives from Health Plans at No Cost?, Kaiser Health News, Jul. 6, 2010, http://www.kaiserhealthnews.org/Features/Insuring-Your-Health/cost-of-birth-control.aspx (time spent avoiding pregnancy).
 [20] Coverage of Contraception, E.E.O.C. Dec. (2000), available at http://www.eeoc.gov/policy/docs/decision-contraception.html
 [21] See Ctrs. for Disease Control and Prevention, Adverse Health Conditions and Health Risk Behaviors Associated with Intimate Partner Violence—United States, 2005, 57 Morbidity and Mortality Wkly. Rep. 113 (2008), available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5705a1.htm
 [22] Ctrs. for Disease Control and Prevention, CDC—Cervical Cancer Statistics, http://www.cdc.gov/cancer/cervical/statistics/index.htm (last visited Nov. 16, 2010).
 [23] E.B. Schwarz et al., Lactation and Maternal Risk of Type 2 Diabetes:  A  Population-based Study, 123 American Journal of  Medicine 863, 863 (2010).
 [24] Stanley Ip et al., Agency for Healthcare Research & Quality, AHRQ Publication No. 07-E007, Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries 138 (2007).
 [25] Id. at 146.
 [26] Id. at 131.
 [27] E.B. Schwarz et al., Lactation and Maternal Measures of Subclinical Cardiovascular Disease, 115 Obstetrical Gynecology 41, 41 (2010); E.B. Schwarz et al., Duration of Lactation and Risk Factors for Maternal Cardiovascular Disease, 113 Obstetrical Gynecology 974, 974 (2009).
 [28] E.P. Gunderson et al., Lactation and Changes in Maternal Metabolic Risk Factors, 109 Obstetrical Gynecology 729, 729 (2007); E.P. Gunderson et al., Duration of Lactation and Incidence of the Metabolic Syndrome in Women of Reproductive Age According to Gestational Diabetes Mellitus Status:  A 20-Year Prospective Study in CARDIA (Coronary Artery Risk Development in Young Adults), 59 Diabetes 495, 495 (2010).