Certain Preventive Services Under the Affordable Care Act

Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
Attention: CMS-9968-ANPRM
P.O. Box 8016
Baltimore, MD 21244-1850
Certain Preventive Services Under the Affordable Care Act
Dear Sir/Madam:
The National Health Law Program (?NHeLP?) is pleased to offer these comments on the Advanced Notice of Proposed Rulemaking for Certain Preventive Services Under the Affordable Care Act from the Department of the Treasury, Department of Labor, and Department of Health and Human Services (?ANPRM?) published in the Federal Register on March 21, 2012.1 NHeLP protects and advances the health rights of low income and underserved individuals. The oldest non-profit of its kind, NHeLP advocates, educates and litigates at the federal and state levels.
Consistent with this mission, NHeLP works to ensure that all people in the United States? including women?have access to preventive health services. The Patient Protection and Affordable Care Act (?ACA?) similarly recognizes that preventive health services are critical to individual and community health, and that cost is often a barrier to accessing needed preventive services. By explicitly requiring that health insurance plans cover women?s preventive health services without cost-sharing, the ACA further acknowledges both the critical role that a woman?s health plays in the health and well-being of her family and her community, as well as her disproportionately lower earnings.2
NHeLP strongly supports the Department of Health and Human Services? (?HHS?) requirement that most new health insurance plans cover women?s preventive health services? including contraception?without cost-sharing.3 HHS? decision is a significant triumph for millions of women who are currently insured or who will obtain health insurance through the ACA. Adherence to the HHS guidelines will ensure that most women have access to contraception without expensive co-pays, saving some women up to $600 per year. We are very concerned that the Department of the Treasury, Department of Labor, and HHS? (?Departments?) ANPRM is considering ?accommodations? for compliance with § 2713 of the Public Health Services Act (?PHS Act?) for certain religiously-affiliated non-profit organizations.4 Any such accommodation would create delays and erect barriers to contraceptive access. It will, moreover, not only undermine the intent of the ACA, but the health and autonomy of affected women as well. We therefore urge the Departments to reject this approach.
The Departments? healthcare coverage decisions should be based on accepted standards of medical care recognized by the various professional medical academies. This evidence-based approach is the framework on which the independent Institute of Medicine of the National Academies (?IOM?) based its recommendations to HHS regarding the women?s preventive health services that most health plans must cover without cost-sharing pursuant to § 2713 of the PHS Act.5 The IOM?s recommendations, which were adopted by HHS in its ?Women?s Preventive Services: Required Health Plan Coverage Guidelines,? include coverage of all forms of Food and Drug Administration (?FDA?)-approved contraceptive drugs and devices.6 Guaranteeing women coverage of contraception is critical to protecting their health. A recent NHeLP report, Health Care Refusals: Undermining Quality Care for Women, a copy of which is attached to these comments, provides an extensive analysis of the adverse medical consequences for women when health care decisions are based on ideological beliefs instead of medical standards of care.7
The importance of a woman?s ability to prevent pregnancy for many reasons is well established within medical guidelines across a range of practice areas. Women consider a number of factors in determining whether to become pregnant, including age, educational goals, economic situation, the presence of a partner and/or other children, medical condition, mental health, and whether they are taking medications that are contra-indicated for pregnancy. Further, millions of women live with chronic conditions such as cardiovascular disease, diabetes, lupus, and epilepsy, which if not properly controlled, can lead to health risks to the pregnant woman or even death during pregnancy. Denying these women access to contraceptive information and services does not comport with medical standards that recommend pregnancy prevention for these medical conditions. For example, according to the guidelines of the American Diabetes Association, planned pregnancies greatly facilitate diabetes care.8 Their recommendations for women with diabetes of childbearing potential include (1) use of effective contraception at all times, unless the patient is in good metabolic control and actively trying to conceive; (2) counseling about the risk of fetal impairment associated with unplanned pregnancies and poor metabolic control; and (3) maintenance of blood glucose levels as close to normal as possible for at least two to three months prior to conception.9
Notwithstanding the near universal agreement in medical practice guidelines that women should be given information about and access to contraceptives to prevent pregnancy, women face many barriers to contraceptive use, including cost. Unintended pregnancy rates are highest among low-income women, women aged 18-24, cohabiting women, and women of color.10 Low- income women have higher rates of unintended pregnancy, as compared to higher-income women.11 While low-income women are the least likely to have the resources to obtain reliable methods of family planning, they are the most likely to be impacted negatively by unintended pregnancy.12 It is therefore not surprising that poor women?s higher rate of unintended pregnancy results in their having higher rates of abortions and unplanned births.13 Further, unintended pregnancy disproportionally impacts women of color: 67 percent of pregnancies among African American women, 53 percent of pregnancies among Latina women, and 40 percent of pregnancies among white women are unintended.14
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