Eli Y. Adashi, MD, MS, CPE: Hello. I am Eli Adashi, Professor of Medical Science at Brown University and host of Medscape One-on-One.
Joining me today is the Honorable Kathleen Sebelius, US Secretary of Health & Human Services. Our topic: The impact of the Affordable Care Act (ACA) on women's health. Welcome, Madam Secretary.
New Health Services for Women
Kathleen Sebelius, MPA: Thank you, Dr. Adashi. Nice to visit with you again.
Dr. Adashi: It's a pleasure to have you. From the moment of its enactment, even prior to August 1, 2012, the ACA required that health plans cover recommended preventive services for women in the absence of cost sharing. Could you list for our viewers a few of those services that have been available for quite some time?
Secretary Sebelius: There have been 3 different time periods that have introduced new preventive services without cost sharing under the ACA.
The first was in October of 2010. Six months after the law was passed, health plans began incorporating a variety of preventive services, including cancer screenings, flu shots, and well-person visits without copays or coinsurance. This recognizes that it's actually better to keep people healthy in the first place rather than wait until they get ill. So, we're trying to take away the financial barriers to someone getting preventive care.
Then in January of 2011, Medicare added to their services a whole range of preventive services without copays or coinsurance, again available to both men and women, including colon cancer screenings, mammograms, and well-person visits. Under this law, once a year a Medicare beneficiary could actually go talk to their healthcare provider and make a new plan and update their health needs. And all of those benefits, again, are offered without any kind of cost sharing to beneficiaries of Medicare.
The third group was introduced in August of 2012. At the recommendation of the Institute of Medicine (IOM), we adopted a range of specifically preventive services for women, which were often missing from insurance plans. And those included everything from contraception coverage, to lactation assistance and support, to domestic violence screenings. So, there actually have been 3 different times to date that preventive services have been added to health plans with no copays and no coinsurance.
It's a little confusing. But it's good news for recipients who have private health insurance as well as for Medicare beneficiaries.
The Impact of Eliminating Cost-Sharing
Dr. Adashi: It seems that a key feature of these and other services is the elimination of cost-sharing requirements. In your estimation, what has been or will likely be the impact of the elimination of cost sharing on the utilization of preventive services by women and by men?
Secretary Sebelius: What we're hoping is that taking one more barrier away will encourage a higher participation rate. We're already seeing that out of the 47.5 million Medicare beneficiaries, we know that about 19 million have already taken advantage of one or more services without any kind of cost share. We know that there are about 47 million women in private insurance plans, and that they are beginning to access their services. And we hope, as you say, that men are, too.
While there aren't specific numbers at this point, we have heard lots of information from healthcare providers, as well as from patients, who have said, "My patient didn't get the mammogram because she didn't have the copay available," or [the patient] avoided getting a service that might be recommended because they were worried about having the deductible taken out of their paycheck. I think that removing a cost barrier, making it easier and certainly less expensive for people to access preventive care, should actually be a cost saver in the long run.
What we find is that a lot of large corporations who have very good insurance packages for their employees have actually done this for a long time because they find it's very cost-effective. If you don't put up cost barriers to preventive care, you actually have a healthier workforce and lower your healthcare costs in the long run.
Dr. Adashi: In other words, there are precedents which would suggest that this is likely to have a significant impact.
Secretary Sebelius: That's correct. There's been a lot of discussion back and forth asking, "Won't this make insurance more expensive? Won't this add to costs?" And actually, the data indicate that just the opposite happens. We know, for instance, that adding contraception with no copays, no coinsurance to a health plan, actually lowers health costs because there are fewer unintended pregnancies, there are fewer difficulties potentially along the way with a baby that wasn't planned for, or something happening that causes a NICU visit. In the long run, it's a cost saver, not a cost driver.
What's a Well-Woman Visit?
Dr. Adashi: One of the new preventive services that are presently available to women without cost sharing is the so-called well-woman visit. What is the premise of this measure, and what should women be looking for when they visit their provider?
Secretary Sebelius: I think what the well-woman visit is, whether she is a Medicare beneficiary over 65 or someone who is at a younger age, it's really an opportunity to have a conversation with your medical provider about your health needs -- are there any problems? are there any issues? -- rather than waiting until there's a crisis, waiting until there's a serious problem.
I think a lot of healthcare providers talk about making a plan for the future. Is weight loss something that an individual wants to look at? Are there any prediabetic signs that could be taken care of with dietary changes? Are there issues in the family history that a woman might want to take a look at where she needs to take some special care, pay more attention? Whether there's a family history of breast cancer or a family history of glaucoma, these are issues that you might not tackle until there is a crisis if you didn't really have an opportunity to have a conversation with your health provider about your health without any added cost.
Dr. Adashi: An ounce of prevention once again.
Secretary Sebelius: You bet.
Dr. Adashi: Another important new service available to women now without cost sharing is, of course, contraception and contraceptive counseling. What range of products is being covered at this time under these benefits?
Secretary Sebelius: The rule was adopted, again, from all of the services that the IOM experts felt were important for women at various stages in their life.
For contraception, the way the rule is written is that all of the FDA-approved methods of contraception would be paid for and included in a health plan. And again, it would be an individual's choice what to access. But it's the range of FDA-approved contraceptive products.
Dr. Adashi: Does this selection include Plan B, or is that considered an exclusion?
Secretary Sebelius: No, it would include Plan B, which is currently an FDA-approved and licensed product that is considered to be contraception. It could be a long-term IUD. It could be a monthly prescription for a pill. Again, I think it raises the question of having an individual conversation with a healthcare provider for women in their reproductive years, understanding what the risks and benefits are, understanding what the opportunity is to either have something that you would take on a regular basis or use less frequently, how quickly you may want to have children, and what the issues are -- really making a very individual choice about how she wants to plan for children.
Dr. Adashi: That's the counseling piece, which I agree is all-important.
Secretary Sebelius: It's the coverage of a range of products and also the opportunity to have a conversation that really can inform the consumer so she can make the best choices for herself and her family.
STI Screening Coverage
Dr. Adashi: Do the expanded preventive services available to women without cost sharing include annual screening for sexually transmitted infections?
Secretary Sebelius: It absolutely does and, again, that's a very important service that often is overlooked by many. Too few women may ask for it and, unfortunately, too few providers may recommend it. But this will hopefully encourage more women and more providers to make that a routine part of a checkup, a routine part of a well-person visit. And again, I think it's important to know you don't have to go back and forth to the doctor to access a different appointment for each service. It's quite possible to do them all at the same time --all that are age appropriate to the individual patient, but making sure that the range of preventive services is taken advantage of and taken care of.
Dr. Adashi: Does this battery normally include, or could it include, a screening for HIV?
Secretary Sebelius: Yes, indeed; it does include an HIV screening. And actually, we have some interesting data available where I think the HIV screenings were often seen as appropriate for a younger age group. There's some new evidence, unfortunately, that some of the newer infections are in the 50-and-over population, folks who may not have initially thought they were susceptible to, or paid a lot of attention to, HIV screening. We're hoping that, again, now that the barrier of cost sharing is gone, this will become a much more routine part of health checkups and health visits, because the goal is to look towards an AIDS-free generation. But that means stopping the new infections, stopping the transmission from an infected person to a noninfected person. And screening is an important part of that puzzle.
Dr. Adashi: Sounds like you're making reference to the perception of invincibility by younger people.
Secretary Sebelius: It's the perception of invincibility, but I think also what we know about HIV and AIDS is that the Centers for Disease Control and Prevention estimate that about 20% of infected persons don't know they're infected, have never been tested.
We're really trying to encourage people to get tested, because then once you get tested, you can not only protect your own health but also protect others who you may be in contact with. You can take steps to make sure that you don't transmit unknowingly the infection to another person.
HPV and Cervical Cancer
Dr. Adashi: Another important concern of women is the role of the human papilloma virus (HPV) in the genesis of cervical cancer. Do the expanded preventive services include testing for HPV DNA?
Secretary Sebelius: Actually, they do, again for age-appropriate patients. That is part of the screening that is done for the population most at risk. And again, identifying the HPV virus early on and taking steps to make sure it doesn't develop into cervical cancer are really important -- not only as health issues, but eventually cost issues. It's a lot more effective to actually identify and treat HPV early on than to allow a case of cancer to develop.
Domestic Violence Services
Dr. Adashi: Moving now for a moment to the social arena: What does the ACA offer women with respect to the critical challenge of interpersonal and domestic violence?
Secretary Sebelius: This is an area where, again, far too many women are susceptible.
In fact, I used to do a lot of domestic violence work with victims, and one of the most alarming statistics that still is sharply etched in my brain is that often the most dangerous place for a woman is in her own home. Domestic violence is a very real and very persistent problem. This provides an opportunity for a health provider to actually choose from a battery of known tools: a questionnaire, which includes a series of questions he or she may just want to ask, using either the information experts have put together or using their own intuition, which really adds to a visit from a patient. If there's any reason to suspect a violent situation, if there's any reason to spot trauma, then hopefully following up on that and then referring that individual to additional counseling, help, and support is a critical step forward.
We've done very well as a society in terms of child abuse and more clearly identifying the possible signs, having a higher alert level. But I think that same kind of attention needs to be paid to women in domestic violence situations or the potential of domestic violence situations.
Dr. Adashi: This must be especially gratifying to you, considering your previous involvement in this area.
Secretary Sebelius: It is. I think this whole discussion has come a long way. It's a lot more into the light than it was before. But I think it needs to be something that's on healthcare providers' radar screen, that they need to pay some additional attention to it. And now there'll be some tools and additional help and support that they can give to their patients if they have reason to suspect that she might be a victim.
New Benefits for Pregnant Women and New Mothers
Dr. Adashi: Are pregnant women also included in the expanded benefits that went into effect in August of this year?
Secretary Sebelius: They are. Gestational diabetes is an issue that is able to be identified but unfortunately is too often missed during the course of a pregnancy. So that is one of the specifically called-out prevention services that is part of the new health plan's package. The fact that maternity coverage will be part of health plans is one of the features in the essential health benefits. A lot of plans right now don't even include maternity care, and those days are coming to an end, which is good news for women. They will not only have maternity coverage, but gestational diabetes screening, and then lactation help and support.
I am a new grandmother. Our son and daughter-in-law had a baby recently, so I'm very attuned to watching pregnancies develop. I watch my daughter-in-law get a lot of help and support around how best to breast-feed her baby. If she had any questions or issues, she had somebody to follow up with. She could have that dialogue. Breast-feeding is very good for the baby, provides a lot of immunities that are not available any other way. It actually is a great, frankly, postpregnancy diet for new moms. And it is a wonderful bonding experience. So it's a win-win-win situation. But often, I think moms who don't have somebody to turn to for help, they're afraid that they're really harming their baby if he or she isn't eating well at first, if they don't have some kind of support, and if they don't have access to a breast pump or an available space. That's all been part of the recommended services that will now be included in health plans.
Dr. Adashi: Finally, and looking ahead a bit, as the ACA unfolds, are there additional women-specific benefits that have yet to be implemented?
Secretary Sebelius: Once the rules and regulations are out about essential health benefits, which are the 10 categories of services that every health plan will now include, there will be an outline on the different services, like maternity care, that will be part of every health plan.
But I think in terms of preventive services for women, we now know the full range. Some services went into effect, as I said, in October of 2010, 6 months after the ACA was passed. This included services for men and women, like cancer screenings and flu shots. Starting in January of 2011, a range of new services for Medicare beneficiaries were added.
And now, the final group, which was specifically for women, was added. And they were added because what we found is that insurance plans didn't take into account the special services that women might need, like domestic violence screening, like gestational diabetes screening, and like contraception. And for plans on or after August 1 of this year, when the plan year renews, those services will automatically be part of an insurance package. And that's very good news for women. That's a lot of not only additional health benefits, but a lot less out-of-pocket costs.
Dr. Adashi: Madam Secretary, thank you for making the time to speak with us and for being so informative.
Secretary Sebelius: It's great to visit with you again. I look forward to our continued conversation.
Dr. Adashi: On that note, sincere thanks to Secretary Sebelius and to you, our viewers, for joining Medscape One-on-One. Until next time, I am Eli Adashi.