Submitted Testimony of Laura Hessburg
On behalf of
National Partnership for Women & Families
Institute of Medicine Meeting on Women’s Preventive Health Services
November 16-17, 2010
The National Partnership is a non-profit organization with 40 years of experience working to
promote access to quality health care, fairness in the workplace and policies that help women and
men meet the dual demands of work and family. We have long advocated for reforms that ensure
access to comprehensive, affordable health care for all women and their families, with an
emphasis on the needs of low-income women.
As you know, good health is central to women’s well-being. It is a key determinant of our quality
of life, our economic security, and our ability to thrive, prosper and participate in our society. The
failures of the current health care system have been particularly felt by women. Women face
significant barriers to obtaining affordable health care services that meet our needs. Making
preventive care more available and affordable for women is critical. We strongly support Section
2713 of the Affordable Care Act, which requires new health plans to cover a range of preventive
health services without imposing cost-sharing requirements on consumers.
We appreciate the charge of this Committee, which has been convened to make recommendations
to the U.S. Department of Health and Human Service (HHS) regarding requirements for women’s
preventive services that are not addressed by existing guidelines. The National Partnership for
Women & Families urges this Institute of Medicine (IOM) Committee to recommend that the
following services be included in the list of preventive services that health plans should be
required to cover without cost-sharing: family planning counseling and all FDA-approved
prescription contraceptive drugs and devices including permanent contraception; screening for
cervical cancer; screening for intimate partner violence; and needed preventive health care visits.
Family Planning Services and Supplies
No-cost coverage of birth control increases access to health services that prevent poor maternal
and child health outcomes resulting from unintended pregnancies. It also brings enormous costsavings to our health care system. We urge you to recommend that family planning counseling
and all FDA-approved prescription contraceptive drugs and devices, including permanent
contraception, be considered part of preventive care for women and included in the no-cost
coverage requirement for all new health plans.
Birth Control is Basic Preventive Care for Women and Saves Lives: The Centers for
Disease Control and Prevention (CDC) included family planning as one of its “Ten Great Public
Health Achievements in the 20th Century.” Rightfully so – contraceptive use has not only been the
driving force in reducing unintended pregnancies and the need for abortion, but it also leads to
improved health for women and children and reduces maternal and infant mortality.
Regardless of whether or when they have children, women spend much of their reproductive lives
(approximately three decades) trying to avoid pregnancy. For most women, planning their
families and/or appropriately and safely spacing their pregnancies is possible only with consistent
use of reliable, effective contraception. Women whose pregnancies are planned obtain prenatal
care earlier than women with unplanned pregnancies, are less likely to expose the fetus to
harmful substances such as tobacco and alcohol, and are more likely to breastfeed. A child who is
born as a result of an unintended pregnancy is at greater risk for having a low birth weight, dying
in its first year, being abused, and not receiving sufficient resources for healthy development.1
National professional medical societies overwhelming recommend family planning as an integral
component of preventive care. Additionally, the public and private sectors consistently recognize
contraceptive services as basic preventive care.
The federal Healthy People series, released every decade by HHS, has named family planning as a
focus area for improving public health in every edition since 1979. The 2010 edition specifically
calls for preventing unintended pregnancy and improving contraceptive access and use by
increasing the number of health plans that cover contraceptive services and supplies.
In addition, the Medicaid program has historically recognized the importance of making sure lowincome women have access to contraceptive services by mandating that states include no-cost
coverage of these services and by granting several states the ability to expand services and
supplies to more low-income women than previously covered by the program.
From the private sector, the National Business Group on Health recommends that employersponsored health plans provide no-cost coverage of contraceptive services as the minimum set of
preventive health care benefits.2 The National Business Group on Health is a membership
organization that gives guidance to large private and public sector employers on developing
health care policies.
Cost is a Barrier to Contraceptive Access and Use: Even with a strong precedent of
support from the public and private sectors, and despite the common desire by women to avoid
unintended pregnancy, throughout history we’ve seen cost perpetually act as a barrier to
accessing family planning services. Studies show that even minimal co-pays for preventive
services deter consumers from obtaining the care they need.3 In fact, the national family planning
program, Title X, was originally designed to address the cost barrier after research showed that
poor women wanted to limit the size of their families but could not afford preventive health
services.
This long-time public health challenge is illustrated by the staggering rates of unintended
pregnancy in the United States. Nearly half of pregnancies in our nation, including more than 80
percent of teen pregnancies, are unintended. By age 45 almost one-third of American women will
have had an abortion. In the U.S. 36 million women of reproductive age (13-44) need
contraceptive services; that is, they are sexually active and do not want to become pregnant.4
Almost half of them, an estimated 17.4 million, need subsidized contraceptive services and
supplies because they are unable to access or purchase them on their own.5
Low-income women and young women continue to be disproportionately affected. Among the
17.4 million women in need of publicly funded contraceptive care, 71 percent (12.4 million) were
poor or low-income adults, and 29 percent (5.1 million) were younger than 20. Four in 10 poor
women of reproductive age have no insurance coverage whatsoever.6 The number of women
needing subsidized services increased by more than one million (six percent) between 2000 and
2008.7 Between 1994 and 2001, unintended pregnancy among low-income women increased by
29 percent, while unintended pregnancy decreased by 20 percent among women with higher
incomes.8
Birth Control Improves Public Health and is Cost-Effective: Contraceptive services
have improved maternal and child health while also reducing unintended pregnancies and the
need for abortion –all the while saving public dollars. Without publicly funded family planning
services, the number of unintended pregnancies and abortions occurring in the United States
would be nearly two-thirds higher among women and teens overall and the number of unintended
pregnancies among poor women would nearly double.9 In addition, services provided at publicly
funded clinics saved federal and state governments an estimated $5.1 billion in 2008. Put another
way, nationally, every $1 invested in helping women avoid unintended pregnancies saved $3.74 in
Medicaid expenditures that would have otherwise been needed.10
2
Most recently, the recession highlighted the extent to which cost can act as a deterrent for women
who want and need contraceptive services. An analysis of the Census data this year by the
National Women’s Law Center showed that the poverty rate among women rose to 13.9 percent in
2009, the highest rate in 15 years. This translates to more than 16.4 million women living in
poverty with close to 7 million of them living in extreme poverty with incomes of less than half of
the federal poverty line.11 A Guttmacher Institute survey found that even as the recession made
families more determined to avoid unintended pregnancy, they were finding it more difficult to
afford prescription contraceptives. Eighteen percent of women surveyed reported inconsistent
contraceptive use as a way to save money.12 This is an abysmal circumstance for our nation’s
families. Just as their economic security is being threatened, the very tools they need to preserve
their futures, like the basic health care required to plan their families, are becoming more out of
reach.
While the cost-effectiveness of a particular intervention is not generally taken into account when
making scientific recommendations about what works, cost factors into the behaviors and
decisions made by almost all other stakeholders. And when it comes to birth control, the
overwhelming evidence about its cost-effectiveness is compelling. Scientific evidence supports
considering birth control a preventive service AND providing no-cost coverage both provides a
powerful incentive for consumers to use it and results in significant savings to consumers and the
public health system.
Health Reform Shouldn’t Decrease Access to Birth Control; Covering Basic
Preventive Care Must be Mandatory: Many women currently served by publicly-funded
programs will be transitioning to the private insurance market. Requiring plans to provide nocost coverage ensures that low-income women and young people – the two groups who are most
at risk for unintended pregnancy and who currently obtain birth control through public programs
– continue to have affordable access to these essential preventive health services. In addition, a
number of low-income women are expected to regularly switch back and forth between Medicaid
and subsidized private insurance offered in the health insurance exchanges as their income
fluctuates. If the scope of benefits between these different sources of coverage does not align,
individuals will face confusion and uncertainty and may lose previously covered benefits. It
would be an unnecessary and cruel irony if health reform resulted in less access to contraceptive
services and supplies for the nation’s women.
Screening for Cervical Cancer
The National Partnership for Women & Families also urges the panel to consider relevant
professional guidelines on cervical cancer screening. The American Cancer Society estimates
there were 11,270 cases of cervical cancer in the US in 2009, and about 4,070 deaths.13 No one
should die of cervical cancer in this country. Early detection through routine cervical cancer
screening with follow-up of abnormal results can prevent most cases of cervical cancer. Cervical
cancer screening guidelines recommended by the United States Preventive Services Task Force
(USPSTF) have not been updated to reflect recent guidelines by major medical societies. We
recommend that this panel review relevant cervical cancer screening guidelines in order to ensure
that women have access to screening services based on the most current evidence-based
guidelines.
Screening for Intimate Partner Violence
The National Partnership for Women & Families urges this panel to reconsider the evidence
around assessment and counseling for intimate partner violence (IPV) as a behavioral health
practice and recommend that it be considered part of preventive care for women and included in
the no-cost coverage requirement for all new health plans. According to the Family Violence
Prevention Fund, nearly one-third of women in the United States report being physically or
sexually abused by a husband or boyfriend at some point in their lives. And clinical studies have
shown that as many as 50 percent of patients seen have been exposed to abuse. Health care
3
providers continue to say that lack of coverage and other system supports prevent them from
doing this critical screening. Requiring plans to provide no-cost coverage of IPV screening would
address a significant social determinant of health for women and girls.
Preventive Health Visits
The National Partnership for Women & Families urges this panel to consider available evidence
for physician-recommended preventive health visits and recommends that well-woman and preconception care visits be covered without cost-sharing by all new health plans. While many
services provided in a routine preventive health visit are included in USPSTF recommendations,
the Task Force guidelines do not address the actual visit itself so women are often charged
additional co-payments for routine preventive health services. Including the preventive visits in
the no-cost coverage requirements would ensure that cost is not a barrier to women’s access to
critical preventive health services.
Conclusion
Health care reform provides an opportunity to dramatically improve public health and make a
real difference in the lives of millions of women and families by improving access to basic
preventive care.
Making sure women and families have access to basic preventive care without cost-sharing must
be a national priority.
The National Partnership urges that your recommendations to HHS for no-cost coverage of
women’s preventive services include: family planning counseling and all FDA-approved
prescription contraceptive drugs and devices including permanent contraception; screening for
cervical cancer; screening for intimate partner violence; and needed preventive health care visits.
November 2010
The National Partnership for Women & Families is a non-profit, non-partisan advocacy group dedicated to
promoting fairness in the workplace, access to quality health care and policies that help women and men
meet the dual demands of work and family. More information is available at www.nationalpartnership.org.
© 2010 National Partnership for Women & Families
All rights reserved.
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1
Healthy People 2010
Jones RK et al., Repeat abortion in the United States, Occasional Report, New York: Guttmacher Institute,
2006, No. 29 and Finer LB and Henshaw SK, Disparities in rates of unintended pregnancy in the United
States, 1994 and 2001, Perspectives on Sexual and Reproductive Health, 2006, 38(2):90-96.
3
Solanki G and Schauffler HH, Cost-sharing and the utilization of clinical preventive services, Am J Prev
Medicine 17, no.2 (Aug 1999) 127-133.
4
Guttmacher Institute, Facts on Publicly Funded Contraceptive Services in the United States, In Brief, May
2010.
5
Guttmacher Institute, Facts on Publicly Funded Contraceptive Services in the United States, In Brief, May
2010.
6
Gold RB, Sonfield A, Richards C and Frost JJ, Next Steps for America’s Family Planning Program:
Leveraging the Potential of Medicaid and Title X in an Evolving Health Care System, New York: Guttmacher
Institute, 2009.
7
Guttmacher Institute, Facts on Publicly Funded Contraceptive Services in the United States, In Brief, May
2010.
8
Finer LB and Henshaw SK, Disparities in rates of unintended pregnancy in the United States, 1994 and
2001, Perspectives on Sexual and Reproductive Health, 2006, 38(2):90-96.
9
Gold RB, Sonfield A, Richards CL and Frost JJ, Next Steps for America’s Family Planning Program:
Leveraging the Potential of Medicaid and Title X in an Evolving Health Care System, New York: Guttmacher
Institute, 2009.
10
Frost JJ, Finer LB and Tapales A, The impact of publicly funded family planning clinic services on
unintended pregnancies and government cost savings, Journal of Health Care for the Poor and
Underserved, 2008, 19(3): 778-796.
11
National Women’s Law Center, Poverty Among Women and Families, 2000-2009: Great Recession
Brings Highest Rate In 15 Years, September 2009
12
Guttmacher Institute, A Real-Time Look at the Impact of the Recession on Women’s Family Planning and
Pregnancy Decisions, September 2009.
13
American Cancer Society, “What Are the Key Statistics About Cervical Cancer?” Available at
http://www.cancer.org/docroot/cri/content/cri_2_4_1x_what_are_the_key_statistics_for_cervical_cancer_8.a
sp. Updated January 2010, accessed online April 26, 2010.
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