IOM Recommends Free Health Coverage for Contraceptives

Pauline Anderson

July 20, 2011

July 20, 2011 — Birth control for women of reproductive age, gestational diabetes screening for pregnant women, and DNA testing for cervical cancer are among the preventive services that are recommended for coverage without patient copay in a new report, Clinical Preventive Services for Women: Closing the Gap, released July 19 by a committee of the Institute of Medicine of the National Academies. The committee recommends that these and 5 other women-specific preventive services be added to the landmark Patient Protection and Affordable Care Act (ACA) of 2010.

The ACA "holds much promise" for millions of Americans, and not just for the expansion of healthcare coverage, said Linda Rosenstock, MD, MPH, dean of the School of Public Health, University of California–Los Angeles, who chaired the committee, which was charged with finding gaps in existing coverage pertaining to women and with recommending additional preventive services.

Approved preventive services already include such things as blood pressure measurements, diabetes and cholesterol tests, immunizations, and mammography and colonoscopy screening.

The list of 8 additional preventive services necessary for women's health and well-being that the committee is recommending for inclusion under the ACA appears in the institute's new recommendations, discussed during a press briefing held yesterday.

To develop its recommendations for further coverage, the 16-member Institute of Medicine committee, which included specialists in disease prevention, women's health, adolescent health, and evidence-based guidelines, reviewed the current list of preventive services for women, examined evidence for additional services, and obtained input from stakeholders, advocacy groups, and the general public

For the purposes of the report, preventive health services were defined as measures, including medications, procedures, devices, tests, education, and counseling, that have been shown to improve women's well-being and/or decrease the likelihood or delay the onset of a targeted disease or condition.

The committees' recommendations are aimed at women and girls aged 10 to 65 years and include the following:

  • Screening for gestational diabetes in pregnant women between 24 and 28 weeks' gestation and at the first prenatal visit for pregnant women at high risk for diabetes.

  • Human papillomavirus DNA testing, in addition to conventional cytology testing, in women with normal cytology results every 3 years, beginning at age 30 years. "Coupling this new technology of DNA testing with conventional [Papanicolaou] smears has the opportunity to do a much better job in screening for cervical cancer," said Dr. Rosenstock during the briefing. "Doing this after 30 years of age should result in the ability to actually screen women less often, by dual testing every 3 years."

  • Annual counseling on sexually transmitted infections for all sexually active women.

  • Annual counseling and screening for HIV infection for sexually active women. It is often not the women themselves who undertake risky behavior, but their male partners, and women do not always know about this behavior, said Dr. Rosenstock. "It has been shown that screening these women may have important health benefits for them," she said.

  • All US Food and Drug Administration–approved contraceptive methods, sterilization procedures, and patient education and counseling for women of childbearing age. Contraceptive methods would include emergency contraception such as ulipristal acetate (ella, Watson Pharma) tablets, but not mifepristone (sometimes referred to the "abortion pill"), according to another committee member, Alina Salganicoff, PhD, vice president and director, Women's Health Policy, Henry J. Kaiser Family Foundation, Menlo Park, California. About half of all pregnancies in the United States are unintended, noted Dr. Rosenstock.

  • Breastfeeding equipment rental costs and counseling from a trained provider for all pregnant women and new mothers, to ensure a positive breastfeeding experience.

  • Screening and counseling for interpersonal and domestic violence in a culturally sensitive and supportive manner.

  • An annual well-woman preventive care visit to obtain such services as preconception care and prenatal care. "We recommended this once a year, but we acknowledge that for some women in some situations, it will take more such visits," said Dr. Rosenstock.

In general, these health services met the following 2 criteria: the condition to be prevented affects a broad population and has a large potential effect on health and well-being, and the quality and strength of the evidence is supportive. Some health insurance plans already cover many of these preventive services, noted Dr. Rosenstock.

The committee did not consider costs. However, said Dr. Rosenstock, "if you're successful at prevention, that's a very cost-effective tool for avoiding conditions, or delaying their onset, and certainly for improving health."

She added that preventive services can be beneficial outside the primary care setting; for example, in schools and in the workforce.

The ACA's focus on preventive services is a profound shift from a previous system that responded primarily to acute problems, the committee members write in their report. Women stand to benefit from this shift more than men, given their longer life expectancies, reproductive and gender-specific conditions, and greater burden of chronic disease and disability

However, the committee said that it would "make the most sense" to consider a parallel approach for determining covered preventive services for men, children, and male adolescents.

Dr. Rosenstock said that the 15 of the 16 members, who represent a broad range of perspectives and backgrounds, came to a strong consensus about the evidence supporting the recommendations. One member of the committee dissented after the committee's final meeting.

The report also outlines a process for the Department of Health and Human Services to coordinate regular updates to the list of preventive screenings and services. Among other things, the committee recommends that the process for updating the preventive services for women be independent, free of conflict of interest, evidence based, and gender specific, said Dr. Rosenstock.

The secretary of the Department of Health and Human Services will now consider the recommendations and identify which ones will be followed. Committee members said they expect a prompt response, perhaps as early as August 1.

Asked to comment, Ruth Lesnewski, MD, attending physician, Beth Israel Residency program in Urban Family Practice, and medical director, East 13th Street Family Practice, New York City, said the report is "fabulous," especially as it addresses comprehensive contraction coverage.

"The contraception coverage was the piece I was waiting anxiously for, because the coverage of that is so spotty right now," Dr. Lesnewski said.

The United States has a "huge epidemic" of unintended pregnancies, with a rate that is much higher than in other developed countries, added Dr. Lesnewski, who is also a consultant at the Center for Reproductive Health Education in Family Medicine, Montefiore Medical Center, New York City. "The really poor job we're doing is not due to lack of knowledge, it's due to lack of will, really, and this provides some direction that we need in order to get this coverage for everyone."

She especially welcomed the elimination of the copayment, pointing out that even though New York State insurance plans are required to cover contraception, to keep costs down managers make the copay equal to about 90% of the retail cost of the product. "The copay is so high that it's a serious barrier for women," said Dr. Lesnewski. "Women are neglecting their health in this important area because they can't afford it."

Clinical Preventive Services for Women: Closing the Gap . Released July 19, 2011.


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