Washington Watch

Women begin to see impact of health reform

By Adam Sonfield
Senior Public Policy Associate
Guttmacher Institute
Washington, DC

The end of September, marking six months after President Obama signed into law the Patient Protection and Affordable Care Act, was the effective date for numerous provisions intended to expand patients' rights and coverage under private insurance.1 This is the interim period between the law's passage and the 2014 start date for its most expansive changes to Medicaid and the private insurance market. Several provisions should be important in helping women and men meet their reproductive health care needs, although important questions are unanswered, particularly in the wake of the November 2010 elections.

One provision garnering considerable public attention requires all new private health plans to cover a range of preventive health services without any out-of-pocket costs to consumers, such as copayments or deductibles. An initial list of protected services, based on three sets of existing government-supported guidelines, technically took effect on Sept. 23, although in practice, cost-sharing-free coverage of those services will be phased in more gradually. That list includes cervical cancer screening, screening and counseling for HIV and several other sexually transmitted infections (STIs), and vaccination for human papillomavirus, among many others.

In November, a panel convened by the Institute of Medicine began deliberation of more comprehensive recommendations for women's preventive health care that also will receive a guarantee of coverage without cost-sharing, although several factors might conspire so that most women will not benefit until January 2013. This fourth set of guidelines was required under an amendment to the legislation authored by Sen. Barbara Mikulski (D-MD) that was intended by its supporters to include contraceptive counseling, services, and supplies, as well as other key services, such as an annual well-woman exam. The Institute of Medicine was brought in to ensure that the recommendations reflect current, reputable scientific evidence, as well as the legislative history of the amendment and precedents in federal law and policy.2

Patients' rights expand

Several other provisions that went into effect on Sept. 23 were dubbed a "Patient's Bill of Rights" by the law's authors. They include prohibitions on lifetime coverage limits, retroactive coverage rescissions, and exclusions for children's preexisting medical conditions, which is a protection that will be extended to adults in 2014. Of particular relevance for reproductive health, all new private plans must now allow women to visit obstetric or gynecologic care specialists without referral or prior authorization, building on similar "direct access" laws previously enacted in many states.

Another well-publicized provision requires private plans that cover dependent children to extent that coverage to adult children younger than age 26. Previously, plans typically ended dependent coverage at age 19 or upon college graduation. This change should be a boon to young adults, an age group with high levels of uninsurance, unintended pregnancies, and STIs, although reproductive health advocates are concerned that private insurers might end up undermining confidentiality for sensitive services through such practices as sending explanation-of-benefits forms to the policyholder, who might be a parent or spouse.3

Moving toward 2014

A week later, on Oct. 1, the administration rolled out another health reform initiative, the second phase of a nationwide Internet portal for individuals and small businesses to learn about their coverage options in the private and public sectors. Compared with the initial phase introduced in July, the new version includes more detailed information about premiums, cost-sharing, and benefits, although for now, maternity care is the only specific reproductive health service singled out, and only some plans provide information on which contraceptive and other drugs are included in their formulary.

This portal is a precursor and model for one of the central components of health reform, the state-level insurance exchanges that, if all goes as planned, will serve as marketplaces for private coverage starting in 2014. Oct. 4 was the closing date for public comments on a wide range of questions posed by the administration about how these new exchanges should be designed and operated, in preparation for regulations expected in the coming year. Those regulations will influence other aspects of health reform, such as the law's requirement that insurance plans in the exchanges contract with family planning centers and other safety-net providers.

Whether the law ends up meeting Americans' reproductive health care needs is contingent in part on whether it is fully and properly implemented, something that was put further in doubt by the November 2010 elections. The incoming Republican leadership in the House has put its opposition to the health reform law high on its agenda. Democrats in the Senate and President Obama appear capable of blocking a full-fledged repeal of the law. However, the law's opponents in Congress might be able to disrupt the funding needed for the administration to issue regulations and set up new programs, and state governors, legislators, insurance commissioners, and Medicaid officials will have numerous opportunities to limit their states' cooperation with the law.


  1. Public Law 111-148, March 23, 2010.
  2. Sonfield A. Contraception: an integral component of preventive care for women. Guttmacher Policy Rev 2010;13(2):2-7.
  3. Gold RB. Unintended consequences: how insurance processes inadvertently abrogate patient confidentiality. Guttmacher Policy Rev 2009;12(4):12-16.