"Many of the Patient Protection and Affordable Care Act's sweeping reforms have special implications for the health and healthcare of women across the life course."

The Patient Protection and Affordable Care Act (ACA) of 2010 is a catalyst for sweeping reforms to the US health insurance industry and healthcare system. The ACA, through extensions of and revisions to myriad existing laws, establishes a "near-universal guarantee of access to affordable health insurance coverage, from birth through retirement".[1] Overall, there are ten separate legislative titles in the ACA that, taken together, propel major changes in critical components of the US healthcare system, including health insurance markets and affordable coverage; the large public programs of Medicaid and Medicare; healthcare quality and efficiency; the healthcare work force; and prevention and public health.[2,101]

Many of the ACA's sweeping reforms have special implications for the health and healthcare of women across the life course. In the year the law was passed, approximately one in five women aged 19–64 years (19 million) did not have health insurance.[102] By 2016, the individual and employer health insurance requirements and state-based insurance exchanges/subsidies will go into effect, and approximately 13.5 million women are expected to gain coverage.[103] In states that implement Medicaid eligibility expansions (which the Supreme Court determined must be optional rather than mandated by the ACA), the number of insured women will rise even more.

Several reports and articles provide a general summary of the implications of the ACA for women's health in the USA.[3,103] In this article, I will focus on one key set of provisions under 'Title IV: Prevention of Chronic Disease and Improving Public Health, Subtitle B: Increasing Access to Clinical Preventive Services'.[4] These provisions require insurance coverage without cost sharing for proven clinical preventive services, including important services for women such as immunizations, cancer screenings including Papanicolaou tests and mammograms, bone density tests, iron deficiency and anemia screening, hypertension and lipid screening, depression screening, folic acid supplements and behavioral counseling regarding obesity, alcohol use and smoking cessation. This provision means that the majority of insurance plans in the USA must cover evidence-based clinical preventive services without copays, deductibles or other economic burdens to the consumer.

Starting in January 2011, all Medicare, newly expanded Medicaid and nongrandfathered private insurance plans (including individual, small-group, large-group and self-insured plans) were required to provide benefits without cost sharing for: all items or services with an A or B rating from the US Preventive Services Task Force (USPSTF); immunizations recommended by the CDC Advisory Committee on Immunization Practices; and guidelines issued by Bright Futures for Children and the Advisory Committee on Heritable Disorders. In addition, in a display of the ongoing politics regarding breast cancer screening, the ACA mandates coverage for mammography screening for women in their 40s, contrary to the most recent USPSTF recommendation that gives breast cancer screening in this age group a C rating.[5]

Furthermore, the ACA stipulated that because women have "unique healthcare needs" and because the USPSTF has not reviewed all relevant and important preventive health services for women (including family planning), other covered services should be identified through an evidence-based process implemented by the Department of Health and Human Services (DHSS).[101] As such, in the fall of 2010, DHHS contracted with the Institute of Medicine (IOM; Washington, DC, USA) to conduct a review of additional clinical preventive services for women and to make recommendations based on the existing scientific evidence. The IOM is an independent, nonprofit and nongovernmental organization that provides expert, science-based and unbiased advice to policy-makers and the public.

The IOM convened a committee of women's health experts who worked for 6 months to craft a report entitled 'Closing the Gaps'. This report, released in July 2012, recommended that eight additional preventive services for women be considered by the DHSS for coverage without cost sharing:[6]

Diabetes screening at 24–28 weeks gestation;

Human papillomavirus DNA testing for high-risk women;

Sexually transmitted infection counseling;

Annual HIV screening and counseling for sexually active women;

Contraception counseling for women with reproductive capacity, and all US FDA-approved methods of contraception and sterilization;

Breastfeeding counseling, consultation and equipment rental;

Interpersonal and domestic violence screening and counseling.

On 1 August 2011, the major recommendations of the report were accepted by DHSS Secretary Kathleen Sebelius. Plans covered by the ACA provisions were instructed to cover this additional range of clinical preventive services for women without cost sharing in the first 'plan year' beginning after 2 August 2012 (most likely 1 January 2013).

Although this expanded coverage of clinical preventive services for women should be celebrated, these provisions are not without some controversy. First, certain religious employers, such as churches and other nonprofit organizations whose primary mission is the inculcation of a specific faith, are notably exempt from covering contraceptives.[7] As of early January 2013, 40 federal lawsuits had been filed challenging the perceived narrowness of this exemption clause, primarily by organizations that do not meet the definition of a religious employer and for-profit businesses whose owners have personal/moral objections to contraception.[8]

A second concern is that without cost sharing, expanded coverage will bring forth a broad range of services (many of which are quite expensive), which will lead to overutilization and drive up the price of insurance premiums. North Carolina Senator Richard Burr articulated this concern: "All of healthcare should have some out-of-pocket cost sharing. One reason why healthcare spending is at the level it is is because a lot of people perceive it to be free. That is a utilization nightmare".[104]

Third, in a twist of gender inequality, coverage without cost sharing for some services became required for women through this process but not for men, even though the state of the evidence regarding effectiveness is the same (e.g., HIV testing and sexually transmitted infection counseling).

"As the provisions in the Patient Protection and Affordable Care Act continue to be implemented over the next several years, American women will enjoy increased health insurance coverage…"

Fourth, the IOM committee recommendations were accompanied by a minority report from one of the members. Economist Anthony LoSosso wrote that: "The committee process for evaluation of the evidence lacked transparency and was largely subject to the preferences of the committee's composition. Troubling, the process tended to result in a mix of objective and subjective determinations filtered through a lens of advocacy".[6] This, in turn, has fueled concerns about the process and whether the committee reached beyond standards for what constitutes evidence-based guidelines. This accompanies lingering concerns in the scientific community about Congress rejecting the most recent USPSTF evidence-based guidelines for mammography screening for ages 40–49 years in the language of ACA law.[5]

In summary, the ACA of 2010 represents a watershed moment in women's health law and advocacy in the USA. Although the ACA's historic focus on financial access to clinical preventive services is a great achievement for women's health, it is not without controversy. Concerns about costs are justified by basic microeconomic moral hazard theory. Concerns about the strength of the evidence base for some of the covered services are justified given the criteria the IOM committee used as 'evidence' and the review of the existing literature provided in the report.[6] It is my opinion that, at the time this report was produced, a conclusive scientific evidence base was lacking for the recommendations for gestational diabetes screening, domestic violence screening and breastfeeding counseling and equipment rental in the US context. These services were included in the recommendations primarily because the committee included not only scientific studies, but also the presence of existing federal, state or international practices and professional guidelines in the assessment of the 'strength and quality' of the supporting evidence.[6]

As the provisions in the ACA continue to be implemented over the next several years, American women will enjoy increased health insurance coverage, improved healthcare quality and an increased focus on prevention and wellness for themselves and their families. An obvious caveat, however, is that the impact of this large expansion in healthcare coverage and associated insurance industry reforms could very well increase the cost of health insurance premiums for many individuals, families and employers. In addition, there are a few lingering question marks in the evidence base for some of the clinical preventive services now mandated for coverage without cost sharing.