Affordable Care Act

Reena Aggarwal: What does the failure of AHCA mean for women’s healthcare? 

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Despite the AHCA failing, plans to defund Planned Parenthood in the US will damage women’s healthcare choices, says Reena Aggarwal

reena_aggarwalThe Affordable Care Act (ACA) was a game changer for women’s health. Prior to the ACA, 1 in 6 Americans were uninsured—non pregnant women were twice as likely to be uninsured compared to pregnant women, and 25% of women of reproductive age were uninsured at some point over the course of one year. [1,2] The ACA expanded federal funding to increase Medicaid eligibility which  resulted in 20 million previously uninsured individuals gaining coverage, and women of reproductive age who did not have health insurance dropping by a third. [3]

During the Republican Party’s recent failed attempt to “repeal and replace” the ACA, women’s healthcare came under fire. One element of the ACA was the requirement that all insurers cover an array of ten “essential health benefits” which spanned maternity care and preventive services (vaccinations, screening, and contraceptive coverage) at no extra cost. In order to make the American Health Care Act (AHCA) more palatable to the House Freedom Caucus (a group of strict fiscal Conservatives in the Republican Party), these essential benefits were taken away to allow individual states to decide what counted as “essential.” It is worth remembering that prior to ACA, the majority of insurers either had no maternity benefit, or it was prohibitively expensive (high deductibles and co-pays). If a woman became unexpectedly pregnant and discovered her plan did not cover maternity, and then tried to change plans, pregnancy would be a considered a pre-existing condition and she could therefore be denied coverage. Adding a maternity benefit to all health insurance policies prevented discrimination and also prevented women paying more for health insurance. Without health insurance, childbirth can cost anything up to $20,000 in the USA, but whilst the maternity benefit has raised premiums overall, it made childbirth affordable for millions of families. However, now that President Trump has said he will allow “Obamacare to explode” due to the instability of insurance markets, there is legitimate concern that with no federal oversight private insurers may remove essential benefits from their plans, which could leave millions of women without maternity coverage.

Additionally, in an effort to appease the pro-life agenda of more Conservative Republicans, the AHCA had proposed defunding Planned Parenthood by removing federal funding. From the creation of Margaret Sanger’s birth control organization in 1916, Planned Parenthood has grown into a global not for profit organization providing comprehensive family planning and related reproductive health services. It has received federal funding since 1970 when President Nixon wrote that, “no American woman should be denied access to family planning assistance because of her economic condition” and brought into being the Title X Family Planning Program with broad bipartisan support. The purpose was to ensure all people, not just the wealthy, could plan their families. The 1976 Hyde Amendment banned federal funding for abortions, so despite receiving Title X funding and being reimbursed by Medicaid for providing services, Planned Parenthood cannot use these funds to pay for abortions. Opponents of abortion attest that by allocating money to Planned Parenthood for the provision of other medical services allows other funds from philanthropic organizations to be re-allocated for abortions.

The Congressional Budget Office (CBO) predicted that by removing federal funding from Planned Parenthood about 15% of women in low income areas would lose care by affecting “services that help women avert pregnancies” and the additional births “stemming from the reduced access” would add to federal Medicaid spending. This is because Planned Parenthood is the sole source of publicly funded contraceptive care in the United States offering comprehensive methods including more expensive (but reliable) long acting reversible contraception (LARCs), alongside STI testing, mammograms and cancer screening. Abortion care accounts for only 3% of services. Many of their clients are young, immigrant, low income women whose only source of care are their services as clinics often operate medically underserved areas making it the “safety net” for marginalized women. [4]

President Trump blamed the House Freedom Caucus (vehemently pro-life) for helping to save Planned Parenthood by opposing the AHCA. At the end of April, the US government faces an expiration of their spending bill to fund federal government and in order to pass a new resolution, calls to deny federal funding to Planned Parenthood may become a non-negotiable condition. President Trump needs the funding bill to pass as many of his policies hinge upon this—for example, increasing defence spending and funds to build a border wall between Mexico and the United States. Despite failing to pass AHCA, last week, Vice President Pence cast a tie-breaking senate vote to pass legislation allowing states to withhold federal funds from Planned Parenthood and other providers performing abortions.

By resuscitating these measures, women covered by Medicaid will no longer be able to choose Planned Parenthood clinics for their care. Unless alternative services are provided, this would be catastrophic for women’s reproductive choices and health needs. The US abortion rate has declined 14% between 2011-14 and in 2014 was at the lowest rate since 1973 when abortion was legalized. This is attributed to education and contraception coverage. [5] Without publicly funded family planning care, it is predicted that US teen pregnancies could be 73% higher than they are now. [6] Some commentators have suggested that women look for other providers or even move states. Lest we forget restriction of contraception and abortion services in Romania led to one of the highest maternal mortality rates in Europe.

Removing federal funding from Planned Parenthood doesn’t prevent abortions—it hurts women’s choices by denying them access to affordable contraception or screening services. Removing maternity care from the essential health benefits in insurance policies means it will cost women more to have coverage. Both of these are unconscionable. Sean Spicer, suggested “men and women beyond maternity age and young people paying for end of life care” did not make “sense.” This exposes a lack of understanding about health insurance and the role of essential health benefits. Despite AHCA failing, there is a very real danger that the hostility toward abortion will roll the clock back to the discriminatory policies before the ACA was implemented, and make it harder for women to prevent an unintended pregnancy (already 1 in 2 pregnancies is unplanned), have care throughout their pregnancy, and maintain their health needs. President Trump once espoused that his healthcare plans would cover “everyone”—let’s hope he remembers to do just that for the 50.8% of the American population who are women.

Reena Aggarwal is a specialist registrar in Obstetrics and Gynaecology and a research fellow at Ariadne Labs in Boston. Twitter @drraggarwal

Competing interests: None declared. 

  1. Institute of Medicine. America’s Uninsured Crisis: Consequences for Health and Health Care. Washington DC; 2009.
  2. Kozhimannil KB, Abraham JM, Virnig BA. National Trends in Health Insurance Coverage of Pregnant and Reproductive-Age Women, 2000 to 2009. Women’s Heal Issues. 2012;22(2):e135-e141. doi:10.1016/j.whi.2011.12.002.
  3. Gold RB, Starrs AM. US reproductive health and rights: beyond the global gag rule. Lancet Public Heal. 2017;2(3):e122-e123. doi:10.1016/S2468-2667(17)30035-X.
  4. Understanding Planned Parenthood’s Critical Role in the Nation’s Family Planning Safety Net | Guttmacher Institute.
  5. Behind the Declines. Guttmacher Policy Rev. 2017;20.
  6. Teen Pregnancy | Guttmacher Institute. https://www.guttmacher.org/united-states/teens/teen-pregnancy. Accessed March 31, 2017.

Source:http://blogs.bmj.com

For Some, Another Costly Delay in Implementing Part of the Affordable Care Act.

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The Obama administration has deferred for a year putting into place a provision of the Affordable Care Act that limits an individual’s annual out-of-pocket expenditures to $6350.

Some patients will have to pay up to $6350 for physician and hospital services, plus another $6350 for prescription drugs — and possibly more, according to the New York Times.

Why the delay? The Times explains that separate computer billing systems for drugs and services within some organizations cannot communicate. One unnamed administration source told the newspaper: “We had to balance the interests of consumers with the concerns of health plan sponsors and carriers, which told us that their computer systems were not set up to aggregate all of a person’s out-of-pocket costs. They asked for more time to comply.”

In addition, last month the administration announced a delay in the requirement that large employers offer health insurance to full-time employees.

Source: New York Times

What’s the point in restaurant calorie counts?.

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There are a lot of fat people in America. More than a third of US adults are obese according to data from the Centers for Disease Control and Prevention. In 2008, medical costs associated with obesity were estimated at $147bn (£97bn; 113bn); the medical costs for people who are obese were $1429 higher than those of normal weight. Between 1988-94 and 2007-8 the prevalence of obesity increased in adults at all income and education levels. It’s a big problem, no pun intended.

So it’s no surprise that measures are progressing to reverse this problem, and one of the more recent campaigns has been a push to require chain restaurants to list calorie counts on their menus. In the Patient Protection and Affordable Care Act, the US Food and Drug Administration (FDA) began the process of requiring calorie labeling for “restaurants and similar retail food establishments that are part of a chain with 20 or more locations doing business under the same name and offering for sale substantially the same menu items.” The guidelines have been a source of controversy ever since.

The evidence over the efficacy of such moves is mixed and an understandable reluctance from various quarters of the food industry probably doesn’t greatly help the cause.

This week the BMJ publishes research that will probably only add to the uneven picture rather than solve the conundrum. Investigators researching estimations of calorie content in consumers’ meals from fast food restaurants found a routine and sizable underestimation—so far so positive for calorie labeling (doi:10.1136/bmj.f2907). But despite the conclusion that labeling “might” reduce the underestimation it was hard for them to be more concrete as they also found that “noticing calorie information in the restaurant had no effect on the accuracy of calorie estimations.”

There’s no doubt that on an anecdotal level some people do find calorie labeling helpful, but if we’re tackling a public health problem and the population level data show questionable benefit, is this part of the Affordable Care Act worth the continuing controversy?

The implementation of the Affordable Care Act is one of the big ongoing topics of 2013 and this week we also publish an international view on it from four visiting academics, currently researching in the US (doi:10.1136/bmj.f3261). Their conclusions on the challenges facing Medicaid expansion hardly make for a walk in the park either, but then, if health reform were straightforward, it would have been done already.

Source: BMJ

Changing Social Norms about Tobacco Use, One Campus at a Time

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As the Assistant Secretary for Health, I have the honor of advancing a broad portfolio of public health issues on behalf of the Department of Health and Human Services (HHS). An overriding priority is reinvigorating our national commitment to tobacco control. The first-ever HHS Strategic Action Plan for Tobacco Control, entitled Ending the Tobacco Epidemic: A Tobacco Control Strategic Action Plan, commits the department to mobilizing leadership to encourage proven, pragmatic, and achievable interventions at the federal, state, and community levels.

Among other things, the action plan commits to reducing the initiation of tobacco use among young adults, a topic with special relevance to institutions of higher learning. Furthermore, the 31st Surgeon General’s Report on Tobacco, released in March, highlighted some startling statistics pertinent to this goal. Preventing Tobacco Use among Youth and Young Adults notes that 90 percent of all smokers start before age 18, and 99 percent start before age 26. Of concern, progression from occasional to daily smoking frequently occurs during the initial years following high school. Indeed, the number of smokers who initiated smoking after age 18 has increased substantially over the past decade—from 600,000 in 2002 to 1 million in 2010.

The report cites reasons for these disturbing trends. Tobacco industry expenditures related to marketing, promotion, and advertising of tobacco products exceed $1 million per hour—totaling more than $27 million a day. Targeted messages and images portray tobacco use as a desirable and appealing activity. As a result, smoking represents the current social norm in many movies, video games, websites, and communities, thereby promoting a culture that fosters tobacco dependence and disease.

Restoring the social norm to one that, instead, promotes wellness and health requires a commitment to smoke-free and tobacco-free environments.

The Affordable Care Act, the health care law of 2010, is also part of our comprehensive approach toward turning this goal into reality. Most health plans must now cover—without cost-sharing—tobacco-use screening and interventions for tobacco users. The law also makes it easier and more affordable for young adults to get health insurance coverage, by allowing them to stay on their parents’ employer-sponsored or individually purchased health plans.

Smokefree Teen, a website specifically developed to help teen smokers quit, offers several social media pages to connect teens with cessation tools.

In particular, colleges and universities can take the next step in protecting the health of their students and inspiring change through the adoption of smoke-free and tobacco-free campuses.

To launch a new chapter in ending the epidemic of smoking, I was honored to participate last week in the announcement of the Tobacco-Free College Campus Initiative(TFCCI). The University of Michigan School of Public Health in Ann Arbor hosted the September 12 event, which was webcast to nearly 500 attendees across the country. The TFCCI represents a public/private partnership involving key leaders from universities, colleges, and the public health community to promote the adoption of tobacco-free policies at institutions of higher learning. This landmark public health initiative will protect students, staff, and faculty against involuntary exposure to secondhand smoke while encouraging a change in social norms that can help reduce tobacco use.

To date, more than 700 colleges and universities, representing an estimated 17 percent of institutions of higher learning nationwide, have committed to smoke-free or tobacco-free campus policies.

HHS is pleased to recognize the leadership of institutions that promote public health in this way. Such actions exemplify a key pillar of the tobacco control action plan—“leading by example.” In fact, by adopting a tobacco-free campus policy on July 1, 2011, HHS has already joined the ranks of such institutions leading by example. This action now protects the health of our 80,000 employees who work in dozens of buildings, grounds, and facilities across the country.

It is my hope that the launch of the TFCCI will encourage all institutions of higher learning to take action. It is time for us to end the epidemic leading to the single most preventable cause of death in this nation.

Together we can make smoking history.

Dr. Howard K. Koh
Assistant Secretary for Health
U.S. Department of Health and Human Services

Source: NCI.