1. 1 WOMEN AND HEALTH REFORM: LESSONS FROM MASSACHUSETTS November 9, 2010 American Public Health Association Annual Meeting Tracey Hyams, JD, MPH, Director Laura Cohen, Policy Analyst Women’s Health Policy and Advocacy Program Connors Center for Women’s Health and Gender Biology Brigham and Women’s Hospital, Boston Connors Center for Women’s Health and Gender Biology

2. PRESENTER DISCLOSURES Tracey Hyams The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose Funded in part by the U.S. Department of Health and Human Services Region 1 Office of Women’s Health Connors Center for Women’s Health and Gender Biology

3. GOALS FOR TODAY’S PRESENTATION 1)Present our findings on women’s experience with health reform in Massachusetts Coverage Access to care Affordability 2)Discuss implications for state and federal policymakers Connors Center for Women’s Health and Gender Biology

4. BACKGROUND Connors Center for Women’s Health and Gender Biology Women have a vulnerable relationship with the health care system: Use more health services throughout their lives Live longer, higher rates of chronic disease Spend more out-of-pocket on health care More likely to work in part-time jobs or for small employers that don’t offer health coverage More likely to be covered as a dependent

5. LIMITED DATA ON MASSACHUSETTS HEALTH REFORM AND WOMEN Connors Center for Women’s Health and Gender Biology (1) Urban Institute / Blue Cross Blue Shield Foundation of Massachusetts The Impacts of Health Reform on Health Insurance Coverage and Health Care Access, Use and Affordability for Women in Massachusetts, June 2010 [1] (2) Ibis Reproductive Health / Massachusetts Department of Public Health Family Planning Program Low-income Women’s Access to Contraception after Massachusetts Health Care Reform, September 2009 [2] [2] (3) Suffolk University Center for Women’s Health and Human Rights Women and Health Care Reform in Massachusetts, Spring 2008 [3] [3] (4) Connors Center for Women’s Health and Gender Biology, Brigham and Women’s Hospital Massachusetts Health Reform: Impact on Women’s Health, June 2010 [4] [4] [1] http://bluecrossfoundation.org/~/media/Files/Publications/Policy%20Publications/060210ImpactsonWomenFINAL.pdf [2] http://www.ibisreproductivehealth.org/publications/documents/IbisMDPH_womencontracepMAHCR10-09.pdf [3] [3] http://www.suffolk.edu/files/cwhhr/HealthBrief_V3.pdfhttp://www.suffolk.edu/files/cwhhr/HealthBrief_V3.pdf [4] http://masshealthpolicyforum.brandeis.edu/forums/Documents/Issue%20Brief_ConnorCenter.pdf

6. COMPARING MASSACHUSETTS WITH NATIONAL HEALTH REFORM Massachusetts 2006 Connors Center for Women’s Health and Gender Biology Affordable Care Act 2010 Goal: coverage and costs Individual mandate Medicaid expansion Premium subsidies Employer responsibility Exchange Insurance market reforms Other provisions Goal: coverage Individual mandate Medicaid expansion Premium subsidies Employer responsibility Connector Insurance market reforms Source: London, K. National Healthcare Reform: Implications for Nursing Education and Practice

7. 7 COVERAGE Connors Center for Women’s Health and Gender Biology

8. 8 Source: Current Population Survey 2003 - 2009

9. 9 OVERALL, COVERAGE HAS IMPROVED Women experienced significant coverage gains, including 1 –Low-income women –Racial and ethnic minorities –Women age 50 – 64 –Women without dependent children Most gains are in publicly-subsidized coverage Women have comprehensive benefits Connors Center for Women’s Health and Gender Biology 1 Source: Sharon Long, The Impacts of Health Reform on Health Insurance Coverage and Health Care Access, Use and Affordability for Women in Massachusetts. BCBS of MA Foundation, 2010.

10. 10 Connors Center for Women’s Health and Gender Biology SOME COVERAGE GAPS REMAIN Low-income residents are frequently transitioning between coverage programs (women and men) –19,000 residents transition each month –1 in 5 had coverage gap Many reasons for transitions are related to gender –Variable employment status –Inconsistent income –Part-time jobs –Life events (marriage, pregnancy, divorce) Complex administrative requirements create gaps –3/4 of denied applications due to paperwork, not finances

11. 11 WHO REMAINS UNINSURED AFTER HEALTH REFORM? Nearly 60,000 women were uninsured in 2009 Uninsured women are disproportionately –Young –Single –Hispanic Over half are employed (often in smaller firms) Over 3/4 of have income under 300% FPL and appear to be eligible for a subsidized health plan Connors Center for Women’s Health and Gender Biology Source: Sharon Long, The Impacts of Health Reform on Health Insurance Coverage and Health Care Access, Use and Affordability for Women in Massachusetts. BCBS of MA Foundation, 2010.

12. 12 ACCESS TO CARE Connors Center for Women’s Health and Gender Biology

13. 13 Connors Center for Women’s Health and Gender Biology Source: Sharon Long. The Impacts of Health Reform on Health Insurance Coverage and Health Care Access, Use, and Affordability for Women in Massachusetts. The BCBS of MA Foundation, 2010. Between Fall 2006 and Fall 2009, percent of women with* Usual source of care+2.5 Any doctor visit+5.8 Preventive care visit+4.6 Any dental visit+6.4 *in past 12 months OVERALL, ACCESS TO CARE AMONG WOMEN IMPROVED

14. 14 Connors Center for Women’s Health and Gender Biology Low-income women report improved access to contraceptives Insurers continue to cover abortion However, new challenges emerged : - No Rx coverage in some young adult plans - Insurance transitions affect continuity of contraceptive use - Women have difficulty understanding covered benefits Source: Ibis Reproductive Health and Massachusetts Department of Public Health (MDPH) Family Planning Program. Low-income women’s access to contraception after Massachusetts health care reform. MA: Ibis Reproductive Health and MDPH Family Planning Program, September 2009. ACCESS TO REPRODUCTIVE HEALTH SERVICES ALSO IMPROVED

15. 15 CHALLENGES HAVE DEVELOPED IN ACCESS TO PRIMARY CARE Connors Center for Women’s Health and Gender Biology At least 1 in 5 women had difficulty finding a provider in 2009 Massachusetts has “Severe Labor Market Conditions” in internal medicine, family medicine and ob/gyn Long wait times for internal medicine, family medicine and Ob/Gyn (about 45 days; higher in Boston) → Health reform exacerbated existing problems; didn’t create shortages → Massachusetts trends mirror national trends

16. 16 AFFORDABILITY Connors Center for Women’s Health and Gender Biology

17. AFFORDABILITY REMAINS A CHALLENGE FOR MANY WOMEN From 2006 – 2009, there was no significant change in the: –Share of women spending >5% of income on out-of-pocket health costs –Share of women with problems paying medical bills –Share of medical debt being paid off over time –BUT the share of women with unmet need for medical care due to cost decreased Findings seem contradictory; possible explanation is women are accessing care but assuming increasing financial burden Connors Center for Women’s Health and Gender Biology Source: Sharon Long. The Impacts of Health Reform on Health Insurance Coverage and Health Care Access, Use, and Affordability for Women in Massachusetts. The BCBS of MA Foundation, 2010.

18. ADDITIONAL AFFORDABILITY CONCERNS Age rating, which disproportionately impacts “women in their prime” Higher premiums charged by exchange plans vs. employer-sponsored insurance Substantial / unpredictable out-of-pocket costs, especially for women in low-premium, high cost-sharing plans Setting an appropriate affordability standard Connors Center for Women’s Health and Gender Biology

19. 19 Connors Center for Women’s Health and Gender Biology POLICY OPPORTUNITIES

20. 20 POLICY OPPORTUNITIES 1)Simplify Administrative Procedures to Remove Barriers to Enrollment 2)Ensure Comprehensive Benefits 3)Address Physician Shortages 4)Monitor Affordability / Reduce Costs 5)Collect and Stratify Data on Women Connors Center for Women’s Health and Gender Biology

21. 21 Issue Brief: http://www.brighamandwomens.org/ConnorsCent er/images/ConnorsCenter.pdf http://www.brighamandwomens.org/ConnorsCent er/images/ConnorsCenter.pdf Contact Information: Tracey Hyams, JD, MPH Director, Women’s Health Policy and Advocacy Program Connors Center for Women’s Health and Gender Biology Brigham and Women’s Hospital Boston, MA thyams@partners.org www.brighamandwomens.org/womenspolicy Connors Center for Women’s Health and Gender Biology