Claire Brindis: ACA's Impact on Women and Young Adults

Claire Brindis, DrPH, director of the UCSF Philip R. Lee Institute for Health Policy Studies, is an expert on women’s health services, including the role of preventive health care, such as elimination of out-of-pocket cost sharing for preventive health services under the Affordable Care Act (ACA).

In addition, she has conducted research focused on the role of the ACA in expanding health care coverage for young adults up to age 26 as part of their parents’ health plans. Here, Brindis discusses the changes to health coverage under the Affordable Care Act for women and young adults.

Q. How does implementation of the ACA specifically impact women?  

Traditionally, women have played a central role in navigating the health care system not only for themselves, but in their roles as mothers and caregivers, particularly for elders and disabled family members. Thus, at the core of the potential impact of the ACA on women is the great promise of expanding overall access to health insurance coverage for a large proportion of the 40 to 45 million Americans who have been living without secure health insurance coverage.

The architects of the ACA made major commitments to coverage of preventive health services, many of which disproportionately impact women. There are also financial incentives, but not requirements, for Medicaid to cover these services without cost-sharing.

Coverage of specific services will likely have a greater impact on women’s health, and in turn, the health of their children. These include prenatal visits, screening and access to family planning counseling and all FDA-approved contraceptive methods – one of the most widely used services among women – as well as an annual “well women” visit, screening for domestic violence and pregnancy-related services. These preventive services will also cover women over their life course, including colorectal cancer screening, breast and cervical cancer, osteoporosis, and cardiovascular health (e.g., hypertension, lipid disorders).

The law also includes a provision that permits women in group health plans to have direct access to participating ob-gyns, without needing a primary care provider referral. This access is noteworthy as childbirth and pregnancy-related conditions are leading causes of hospitalizations in the U.S., accounting for nearly 25 percent of hospital stays.

Q. Are there downsides of the health insurance exchanges for women in particular?

Affordability of care is a key issue for women, who are disproportionately low income. In the past, women have been far more likely to report cost-barriers to care for their families and themselves, including that they skipped needed care or didn’t pick up their prescription medicines due to out-of-pocket costs.

Having access to health insurance plan premiums and coverage options that respond to the needs of women and their families will be a key factor in the success of the exchanges.

Secondly, while the federal law specifies the minimum package of services that must be offered, the specifics of this package of services will be left to each state. Assuring that women and their families truly have access to the full range of preventive services, as well as the other components of the minimum package, will be important to monitor. 

While the federal Department of Health and Human Services has deferred to each state to choose a “benchmark plan” to serve as a guide for what must be covered, there is a risk of incomplete or inadequate coverage in some states.

Q. You recently participated in a webinar about the practical considerations of implementing the Affordable Care Act for adolescents and young adults. Would you give us a summary of your key points?   

Young adults represent about a third of those without any health insurance. Thus, the ACA has tremendous promise for filling substantial health care delivery gaps. A clear initial success of the ACA has been the enrollment of between 3 million to 6 million young adults up to age 26 on their parents’ health plans; the financial effect of extending coverage to this newly eligible group has been documented as negligible, a mere 0.2 percent increase in overall plan spending.

As a society, we need to recognize that we have often failed to incorporate true preventive services in the delivery of health care. The lack of insurance, combined with risk-taking behaviors, has often resulted in young adults having high rates of emergency room visits – only the very young and the elderly have higher rates.

The major health problems of late adolescence and early adulthood are largely preventable, and many negative health outcomes are linked directly to behavioral decisions. This time period represents a unique opportunity for early intervention with emerging mental health issues, alcohol and tobacco dependence, and obesity, which contribute to chronic health conditions, such as diabetes, heart disease and cancer.

Q. What about the health access of undocumented and legal immigrants?

It is important to note that a substantial proportion of those without health insurance will remain so under the Accountable Care Act, either because they represent undocumented immigrants, or because they are legal immigrants who have lived in the U.S. less than five years.

We are currently conducting a study of a special sub-group of immigrants, known as the Dreamers or DACAs (Deferred Action Childhood Arrivals), to better understand their health care needs, experiences with the health care system and attitudes to health insurance. DACAs have lived in the U.S. at least 5 years, arrived in the U.S. before the age of 16 and who are no older than age 30, and are currently enrolled in school, military or are employed. Initial results point to the need for both physical and mental health services among this population, as well as greater information on how to successfully navigate the health care system. Recently, California’s Medicaid program has been expanded to provide full-scope benefits to eligible, low-income populations, but at this point in time, it is not clear, how many DACAs are aware of their eligibility and whether there have been any barriers in their signing up for these benefits.

In the meantime, immigration law reforms are being debated in Congress and if successful, will have clear implications for the eventual enrollment of these populations in health insurance programs.

Q. How will UCSF health policy experts monitor the impact of the ACA or Covered California?

We are fortunate to have the opportunity to live in California, where many of the ACA elements will be implemented ahead of the country. It is clear that this “road-test” will have many bumps and potentially “near misses,” given the incredible complexity of going to scale with such a multi-pronged policy, with so many moving components.

While initially the focus of policymakers may be on the numbers of covered lives, our UCSF health policy experts will have the opportunity to monitor and evaluate the ACA’s implementation in several key areas.

UCSF researchers will be working with the state to ascertain implementation for the Medicaid population, as well as studying other ramifications, such as workforce issues, meaningful use of electronic health care records in the provision of medical care, the integration of primary care and other systems of care (hospitals, behavioral health, specialty care, etc.) and the conversion of family planning services from a state plan to Medicaid beneficiaries.