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The Reform Bills And Women’s Health

The inclusion of the Stupak amendment in the House health care bill certainly represented a setback for women’s health. But a provocative article in The Nation suggested that other portions of the bill shortchanged women by not requiring certain basic preventive services for women, or enabling providers to charge extra for them. Sharon Lerner argues that additional women’s health services would not be covered under the reform bills:

None of the bills emerging from the House and Senate require insurers to cover all the elements of a standard gynecological “well visit,” leaving essential care such as pelvic exams, domestic violence screening, counseling about sexually transmitted diseases, and, perhaps most startlingly, the provision of birth control off the list of basic benefits all insurers must cover. Nor are these services protected from “cost sharing,” which means that, depending on what’s in the bill that emerges from the Senate, and, later, the contents of a final bill, women could wind up having to pay for some of these services out of their own pockets. So far, mammograms and Pap tests are covered in every version of the legislation.

However, some experts are calling this reading of the bills misleading, including one who was interviewed for Lerner’s story. This doesn’t mean that the bills, particularly the House bill, don’t fall short in some respects, but it’s not the total disaster that it’s made out to be.

Adam Sonfield, a senior public policy associate at the Guttmacher Institute, who was quoted in Lerner’s Nation story, says that the bill generally does not spell out specific services, be they slanted to men or women, practically anywhere in the designation of the “minimum benefits package” that all insurance plans would be required to cover. “There are broad categories of care in the bills – the narrowest category is maternity care,” Sonfield said. “But just because it’s not specified, that does not equal the assertion that it’s not covered. The Secretary of Health and Human Services and an advisory board will determine the specific coverage assignments at a later date, and we’re talking about thousands of procedures. That’s all in the implementation stage of the bill.”

Because contraception, for example, is almost universally covered currently, it’s reasonable to expect that it will be covered under the minimum benefits package determined by HHS later on in the process.

With respect to preventive services, the bills did get somewhat more specific, because of the provision that eliminated cost sharing for those services. In other words, for all preventive care delineated in the bill, you would not have to provide a co-pay.

Those specific procedures can be found on pages 106-7 of the House bill. Here’s what it says about preventive services:

Preventive services, including those services recommended with a grade of A or B by the Task Force on Clinical Preventive Services and those vaccines recommended for use by the Director of the Centers for Disease Control and Prevention.

The Task Force on Clinical Preventive Services (also known as the US Preventive Services Task Force, or USPSTF) recommendations, which you can see here, are where Lerner got her set of non-covered procedures from, deciding that the bill didn’t cover a “women’s well visit” or birth control. There’s a pretty good reason for that, according to Sonfield. the USPSTF is not entirely comprehensive because a) they have a limited capacity to measure all the procedures, and b) they have a strict methodology requiring lots of proof that a selected preventive service works before adding it to their list.

As Sonfield explains it, it’s far better to use the USPSTF as a guide to what may not be eligible for cost sharing rather than what may not be covered. For example, the USPSTF doesn’t recommend domestic violence counseling in their recommendations because they don’t recommend counseling of any kind – it’s just not under their mandate. Birth control is not on the radar screen for the USPFTF because the rigorous testing the task force would require to determine effectiveness would necessitate a control of a woman not using birth control and a variable of a woman not using it, and you can see how that might get problematic. The USPFTF doesn’t recommend a “women’s well visit” because it doesn’t look at broad categories. Sonfield is confident that all of these things, already covered under most insurance plans, will make it into the minimum benefit package as determined by HHS. “Eventually, those services will be covered and mandated.”

However, Sonfield does agree that the definition of what is exempt from cost sharing is too narrow in the House bill, precisely because of some of the limitations of the USPFTF’s studies. “There is no good rule of thumb for all this, so the House used that task force,” Sonfield said. “It’s not sufficient.” The Senate HELP Committee did pass an amendment, put forward by Sen. Barbara Mikulski (D-MD), that expanded the number of women’s health services that would be exempt from cost sharing. Sonfield prefers that option, and hopes it will live in the merged Senate bill and come out of conference. Obviously reducing costs expands access, particularly for low-income women, and so cost sharing can be as much a barrier as coverage in some respects.

So the final answer is that the picture is mixed – women’s health services are likely to be included in the minimum benefits package, but it will take some work from women’s health advocates and the public to ensure that they get the same treatment with respect to cost sharing in the final bill. And of course, that goes for reproductive choice services as well.

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David Dayen

David Dayen