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The American Academy of Nursing on policy proposed healthcare policy changes threaten women's health

Published:September 18, 2018DOI:https://doi.org/10.1016/j.outlook.2018.09.005

      Executive Summary

      The Patient Protection and Affordable Care Act (

      Patient Protection and Affordable Care Act (PPACA), Public Law 111-148, enacted March 23, 2010 (2010).

      ), further referred to in this policy brief as the Affordable Care Act (ACA), provides women and girls access to affordable sexual and reproductive healthcare services that were not otherwise provided prior to the ACA becoming law in 2010. The change in political Administration in January 2017 brought about many accompanying policy changes, including measures to repeal or disassemble, in whole or in part, the Affordable Care Act. Access to many healthcare services provided to women and girls under the ACA is now in jeopardy due to these proposed measures. If women and girls cannot access care, their overall health and the health of the nation will suffer (
      • MacDorman M.F.
      • Declercq E.
      The failure of United States maternal mortality reporting and its impact on women's lives.
      ). Policies and practice protocols following enactment of the ACA are facing reduced funding, dismantlement, and restrictions (
      • Olshansky E.
      • Taylor D.
      • Johnson-Mallard V.
      • Halloway S.
      • Stokes L.
      Sexual and reproductive health rights, access and justice: Where nursing stands.
      ). A number of sexual and reproductive health services are negatively targeted by changes in legislation and regulations. These include services funded by Title X, Private, Medicaid, and marketplace options that provide coverage for sexual and reproductive health, such as the human papilloma virus (HPV) vaccinations to prevent cancer, cervical cancer screening, family planning, abortion care, and preventive services for women. Policy decisions, funding, and clinical care must be guided by evidenced-based data, which clearly demonstrate the need for continued access to this care by women and girls. Consumers of health care look to the American Academy of Nursing (Academy) to address current shifts in policies that affect the health of the nation.

      Background

      The ACA provided access to healthcare benefits and preventive services for girls, women, families, and society as a whole, with no or little cost sharing (
      • Snyder A.
      • Weisman C.
      • Liu G.
      • Leslie D.
      • Chuang C.
      The impact of the Affordable Care Act on contraceptive use and costs among privately insured women.
      ). The ACA drastically improved access to sexual and reproductive healthcare services for millions of girls and women (
      • Finer L.B.
      • Zolna M.R.
      Shifts in intended and unintended pregnancies in the United States,2001–2008.
      ). Specifically, for adolescent girls and vulnerable women, improved access to primary care services resulted in fewer mistimed/unintended pregnancies, lower abortion rates, increased use of long acting reversible contraceptives (LARCs), and increased cancer screening services (
      • Sommers B.D.
      • Gunja M.Z.
      • Finegold K.
      • Musco T.
      Changes in self-reported insurance coverage, access to care, and health under the Affordable Care Act.
      ). Additionally, the ACA led to increased HPV vaccine rates in tandem with innovative cancer screening methods such as DNA testing for high risk strains of HPV, increased access to primary healthcare providers, and improved access to care for women, girls, and racial/ethnic minorities (
      • Finer L.B.
      • Zolna M.R.
      Shifts in intended and unintended pregnancies in the United States,2001–2008.
      ,

      Patient Protection and Affordable Care Act (PPACA), Public Law 111-148, enacted March 23, 2010 (2010).

      ).
      In 1993, only half of insurance companies covered contraception (
      Guttmacher Institute
      State policies in brief: Insurance coverage of contraceptives.
      ). Despite the Institute of Medicine's (IOM) 1995 report recommending access to affordable contraception to reduce unwanted pregnancies and their 2011 report recommending access to contraception without a copay for all women, most states did not mandate coverage for sexual and reproductive healthcare needs such as contraception (
      ,
      Institute of Medicine (IOM)
      Clinical preventive services for women: Closing the gaps.
      ). Thus, prior to the ACA's enactment, many women and girls encountered barriers to accessing sexual and reproductive healthcare services, often due to lack of insurance or funding ().
      The current Administration's healthcare reforms threaten access to sexual and reproductive benefits currently provided to women and girls under the ACA (
      • Brindis C.D.
      • Freund K.M.
      • Baecher-Lind L.
      • Merz C.N.B.
      • Carnes M.
      • Gulati M.
      • Regensteiner J.G.
      The risk of remaining silent: Addressing the current threats to women's health.
      ). Section 1557 of the ACA was written to prohibit discrimination based on religion, race, and/or gender. The ACA's provision for contraceptive coverage challenges is based on the Moral Exemption Rule by religious organizations, non-profit or for-profit organizations that are not publicly traded (). Repeated attempts to limit access to sexual and reproductive healthcare services based on moral exemptions continue. As an example, in May 2018, Iowa introduced legislation to restrict abortion once a fetal heartbeat has been identified. Another example is a provision restricting sexual and reproductive health information, even if evidence based, under a threat of withdrawal of federal funds if such information is provided–known as the Gag Rule ().
      The ACA provides key aspects of care by mandating no cost sharing for Food and Drug Administration approved, evidence-based, contraceptive methods, abortion care, and tubal ligations (

      Patient Protection and Affordable Care Act (PPACA), Public Law 111-148, enacted March 23, 2010 (2010).

      ). Removing cost as a barrier to family planning services has resulted in fewer mistimed/unintended pregnancies and decreased abortion rates (
      • Brindis C.D.
      • Freund K.M.
      • Baecher-Lind L.
      • Merz C.N.B.
      • Carnes M.
      • Gulati M.
      • Regensteiner J.G.
      The risk of remaining silent: Addressing the current threats to women's health.
      ). Repeated attempts to repeal or dismantle the ACA continue without a viable replacement. If successful, this would severely limit access to sexual and reproductive health care for women and girls who most need access to these services.

       Response and Policy Options

      Creating barriers to health care is a consequence of the political battles inherent in this current political climate (
      • Jost T.S.
      Active December caps historic year for reform.
      ). Access to sexual and reproductive healthcare services has many evidence-based benefits beyond preventing unintended/mistimed pregnancies (
      • Fullman N.
      • Lozano R.
      Towards a meaningful measure of universal health coverage for the next billion.
      ). Some health issues specific to women require management by providers trained to care for them, such as very heavy menses resulting in anemia that may require treatment with hormonal contraception (
      • Schindler A.S.
      Non-contraceptive benefits of hormonal contraceptives.
      ). Another example of a gender-specific condition in need of care by an expert in sexual and reproductive health is endometriosis, a painful condition with a potential sequela of infertility if left untreated. Moreover, women with a personal or family history of reproductive cancer may be at risk of late diagnosis and higher mortality risk (
      • King J.K.
      Noncontraceptive uses of hormonal contraception.
      ). The year 2019 portends further changes in access to sexual and reproductive healthcare services as the Administration continues to promote policies that dismantle the ACA without offering a valid replacement.
      As of 2019, the penalty for consumers having shared responsibility for healthcare cost will disappear, predicting ∼13 million consumers losing health coverage by 2027 (
      • Jost T.S.
      Active December caps historic year for reform.
      ). The United States has the highest rate of adolescent pregnancy among developed countries (). Coverage for adolescent pregnancy prevention services is key because of the risk of maternal and neonatal morbidity and mortality as well as the risk for poor educational, economic, and social outcomes for both the adolescent mother and her offspring (
      • Fullman N.
      • Lozano R.
      Towards a meaningful measure of universal health coverage for the next billion.
      ). Increased access to contraception has not been associated with any change in the rate of adolescent sexual activity; however, it has been associated with decreased adolescent pregnancy rates (
      • Lindberg L.
      • Santelli J.
      • Desai S.
      Understanding the decline in adolescent fertility in the United States, 2007–2012.
      ).
      For women approaching midlife, an unintended pregnancy may carry significant morbidity and mortality risks for both the woman and the fetus. Access to reliable birth control also removes the need for a midlife woman to face abortion (
      • Johnson-Mallard V.
      • Kostas-Polston E.A.
      • Woods N.F.
      • Simmonds K.E.
      • Alexander I.M.
      • Taylor D.
      Unintended pregnancy: A framework for prevention and options for midlife women in the US.
      ). Additionally, access to woman-focused primary care is critical for women approaching midlife and beyond.
      For every 1 million women of an age cohort, removal of insurance coverage for contraception would result in over 33,000 additional unintended pregnancies, a portion of which would result in abortion, all due to limitations in access to highly effective contraception (
      • Canestaro W.
      • Vodicka E.
      • Downing D.
      • Trussell J.
      Implications of employer coverage of contraception: Cost‐effectiveness analysis of contraception coverage under an employer mandate.
      ). In short, reverting to prior barriers to access sexual and reproductive health care for women and girls will result in more unintended pregnancies, more medically induced abortions, decreased access to primary care services, and significantly increased total costs from both the societal and employer/payor perspectives.
      Evidence reflects that the health of women and girls improved under the ACA (
      • Brindis C.D.
      • Freund K.M.
      • Baecher-Lind L.
      • Merz C.N.B.
      • Carnes M.
      • Gulati M.
      • Regensteiner J.G.
      The risk of remaining silent: Addressing the current threats to women's health.
      ). Access to sexual and reproductive health services offers females an opportunity to discuss their questions and concerns with healthcare providers, who in turn play a key role in prevention of sexually transmitted infections (STIs) and sexual risk reduction, including screening for intimate partner violence, as well as health enhancements such as vaccination, cancer screenings, and healthy lifestyle recommendations.

      Academy Position

      The Academy has long supported unfettered access to non-discriminatory sexual and reproductive health care (
      American Academy of Nursing
      Engaging the voice of women in HIV prevention, care, and treatment.
      ,
      • Olshansky E.
      • Taylor D.
      • Johnson-Mallard V.
      • Halloway S.
      • Stokes L.
      Sexual and reproductive health rights, access and justice: Where nursing stands.
      ). On September 25, 2017, the Academy joined the Leadership Conference on Civil and Human Rights, the National Health Law Program, the National Partnership for Women & Families, and 233 other organizations urging the Senate to oppose the Graham–Cassidy proposal that would have severely cut Medicaid health coverage for millions of Americans, ended Medicaid expansion, and defunded Planned Parenthood (). Similarly, in a separate statement, on May 12, 2018, the Academy publicly denounced the Gag Rule, citing unethical muzzling of providers who, under this rule, are not allowed to tell their patients about all legal options to prevent unwanted pregnancies and address problem pregnancies (). The Academy continues to support unconstrained access to sexual and reproductive health care and opposes federal and state regulations that elevate religious and moral beliefs over evidence-based policies and discriminatory practices.

      Recommendations

      Women's health, particularly sexual and reproductive health, continues to be marginalized within the dominant society (e.g., women's health is often the “bartering” point in legislative decisions about healthcare policy in general). The politicization of sexual and reproductive health care, especially contraception and abortion, creates burdens for all women, especially those on the margins of society. The following recommendations build on the existing policies promoted by the Academy and other nursing organizations to engage national, state, and local coalitions for SRH care access and reproductive justice: Policies, guidelines, and clinical practice protocols must be evidence-based and not limited by religious, philosophical, or moral beliefs of an individual healthcare provider, institution, or employer.
      • (1)
        Professional organizations such as the American College of Obstetricians and Gynecologists (ACOG), Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), Society for Adolescent Health and Medicine (SAHM), American Academy of Pediatrics (AAP), National Association of Pediatric Nurse Practitioners (NAPNAP), and others are strongly encouraged to disseminate evidence-based guidelines and clinical practice protocols for the sexual and reproductive health of women and girls.
      • (2)
        Nursing advocates join forces with national groups such as the National Women's Law Center, National Partnership for Women & Families, Center for Reproductive Rights, National Institute for Reproductive Health, Center for Adolescent Health & the Law, and others to speak out and educate federal and state legislators, policy makers, and research funding sources on the broad and significant negative health consequences to women and girls caused by limiting the access to and affordability of sexual and reproductive health care.
      • (3)
        The Department of Health and Human Services’ future rules for Title X assure coverage for full-scope evidence-based health care for women.
        • (a)
          The Department of Health and Human Services (HHS) policies and activities be firmly based on scientifically valid and appropriate evidence. We urge HHS to remain religiously and morally neutral in its funding, policies, and activities to ensure individualsdo not receive an inappropriately limited scope of service and that the ethical obligations of healthcare providers are not compromised.
        • (b)
          The Academy opposes the Administration and DHHS effort to undermine the ACA and Title X programs and any policy proposals that interfere with the patient–provider relationship, violate professional ethics, and limit access to high-quality, affordable family planning care under the Affordable Care Act and the Title X program.
        • (c)
          Federal and state legislators protect women and girl's health by enacting policies that maintain and increase access to full-scope sexual and reproductive health care, including requiring full disclosure by employers about the insurance coverage that they provide for their female employees.

      Acknowledgment

      Our thanks to Ellen Olshansky for her beneficial help with this brief.

      References

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        Engaging the voice of women in HIV prevention, care, and treatment.
        Nursing Outlook. 2016; 64: 103-105
        • American Academy of Nursing
        American Academy of Nursing statement on Trump–Pence Administration's Gag Rule on Title X.
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        • Gulati M.
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        The risk of remaining silent: Addressing the current threats to women's health.
        Women's Health Issues. 2017; 27: 621-624
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        Towards a meaningful measure of universal health coverage for the next billion.
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        Sexual and reproductive health rights, access and justice: Where nursing stands.
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