March 2018 | Issue Brief Women’s Sexual and Reproductive Health Services: Key Findings from the 2017 Kaiser Women’s Health Survey INTRODUCTION Reproductive and sexual health is an integral component of women’s general health and well-being. The ACA has afforded more women the opportunity to seek and obtain reproductive health care by expanding access to Medicaid and affordable coverage. In addition, the law requires than plans cover a broad range of recommended preventive services including contraceptive care and STI screening services without cost sharing, critical elements of women’s health care. Plans were required to offer no-cost coverage for prescription contraceptives to women with private insurance starting in August 2012. Coverage for other preventive services, such as counseling and testing for STIs, are also now required benefits in private insurance plans and covered by Medicaid in most states. Women have a choice of providers, and while most seek care at private doctors’ offices, a substantial share go to clinics that are Medicaid participating providers such as community health centers and Planned Parenthood clinics for their reproductive and sexual health care. This brief presents selected findings from the 2017 Kaiser Women’s Health Survey, a nationally representative survey of women conducted in the summer and fall of 2017. The survey also covered a wide range of topics related to women’s coverage, use, access, and experiences with the health care system. This brief presents survey findings on coverage and use of reproductive and sexual health services among women ages 18 to 44 years old. The data presented is from the newest 2017 survey, but some findings presented in this brief include trends from earlier surveys that the Kaiser Family Foundation conducted in 2004, 2008, and 2013. Figure 1 USE OF CONTRACEPTIVES One in five sexually active women report that they are not Nearly one in five sexually using contraception active women of reproductive Among women ages 18-44 age report that they are not who have had sex in past 12 months using contraception, despite reporting that they do not want Not using any to become pregnant. contraception, 18% For women with reproductive Using at least one capacity, but who want to avoid an method of Pregnant or trying contraception, 48% to conceive, 11% unintended pregnancy, contraception Woman or partner is an essential health service. An unable to conceive*, 23% estimated 18% of sexually active women ages 18 to 44, however, are not using contraception and are at high risk for unintended pregnancy NOTES: Among women ages 18-44 who have had sex within the past 12 months. *Includes women who report that they or their partner are sterilized or they have a medical condition that makes it impossible to get pregnant. (Figure 1). Among reproductive-age SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. women who have had sex in the past year, half (48%) report that they or their partners used at least one reversible contraceptive method. One in ten (11%) are pregnant or trying to conceive, and nearly a quarter (23%) of women report that they or their partners have had a sterilization procedure or cannot become pregnant. Women who do not use contraception are more likely to be low-income than women who use contraception. Among sexually active women who are not pregnant or actively trying to conceive, almost half (46%) are low- income, compared to about a third (34%) of women who do use contraception or have had a sterilization (Table 1). However, in some ways, women at risk for unintended pregnancy are similar to women who do use contraception. There are no significant differences in age composition, insurance coverage, or race/ethnicity between the two groups. Table 1: Characteristics of sexually active women who use contraception compared to those who do not use contraception and do not want to be pregnant Use Contraceptives (woman or Do not use contraceptives (at high partner used contraceptives) risk for unintended pregnancy) Characteristics: Age Group 18-24 years 18% 24% 25-44 years 82% 76% Race/Ethnicity White 57% 53% Black 12% 16% Latina 22% 21% Insurance Type Private 65% 62% Medicaid 16% 15% Uninsured 12% 15% Poverty Level <200% FPL 34% 46%* >200% FPL 66% 54%* NOTES: Among women ages 18-44 who were sexually active in past year and say they were not pregnant or trying to get pregnant. Race/Ethnicity and Insurance columns do not sum to 100% because respondents identifying as "Other Non-Hispanic" or stating "Other Public" coverage not shown. The Federal Poverty Level (FPL) was $20,420 for a family of three in 2017. *Indicates a statistically significant difference from Use Contraceptives; p<.05. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. Condoms and oral contraceptives are the most commonly used forms of contraception. While all forms of FDA approved contraception can reduce the risk of unintended pregnancy when used correctly, they vary in their use and effectiveness. Women are encouraged to consider a range of issues when choosing a contraceptive method in order to find the one that is most effective but also fits best within their beliefs and lifestyle. Condoms can protect against STIs and are widely available through many outlets without a prescription. Oral contraceptives, often referred to as the Pill, require prescriptions and are hormonal, and therefore cannot be used or tolerated by all women. Other methods include injectables, implants, patches, and the vaginal ring, which deliver different doses of hormones. Intrauterine Devices (IUD) are devices that are inserted into a woman’s uterus by a provider and some types also include hormones. They can last up to 5 years or longer and are among the most effective methods of reversible contraception. Under the ACA’s preventive Women’s Sexual and Reproductive Health Services: Key Findings from the 2017 Kaiser Women’s Health Survey 2 services provision, most private plans are required to cover each of the 18 FDA-approved methods of contraception as prescribed for women without cost sharing. Medicaid also prohibits cost-sharing for all family planning services. Among sexually active women who use contraception, just over half (57%) rely on one method and just under half (42%) use more than one method. Women most frequently report that they have used condoms or birth control pills in the past year, a rate that has remained consistent since 2013. Nearly six in ten (59%) sexually active women who have used contraceptives in the past year report using male condoms, four in ten (40%) have used oral contraceptive pills, and about one in five (24%) used an IUD (Table 2). Younger women ages 18-24 rely on the pill (60%) or condoms (79%) at greater rates than those who are 25 and older. Table 2: Types of contraceptives women report they or partners used in past 12 months, by age All Women Age Group Types of contraception used within the past 12 months 18-24 25-34 35-44 Male condoms 59% 79% 56%* 48%* Oral contraceptives 40% 60% 34%* 34%* IUD 24% 16% 27% 25% Injectables 9% 13% 9% 5% Implants 8% 14% 7% 4% Other 10% 13% 11% 8% NOTES: Among women ages 18-44 who were sexually active in past year and used contraceptives in past year. Women may use more than one form of contraception. Oral contraceptives include birth control pills. IUD is an intrauterine device such as Mirena, Skyla, or P aragard. Injectables include Depo-Provera. Implants include Implanon or tubes in arm. Other methods include vaginal ring and the topical patch. *Indicates a st atistically significant difference from 18-24; p<.05. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. Preventing pregnancy is the leading reason for contraceptive use, but more than one-third of women also use them to manage a medical condition. The majority of women ages 18-44 Figure 2 use contraception to prevent Many women use contraception to prevent pregnancy and pregnancy (59%), but 13% use it to manage medical conditions manage a medical condition, and Reasons for contraceptive use among women who were sexually active and used or whose partner used contraception within the past 12 months: 22% use it both to prevent pregnancy Don't and to manage a medical condition know/Refused 6% (Figure 2). Some women use Both prevent hormonal contraceptives to manage pregnancy and manage a medical other conditions, such as acne, condition, 22% irregular menstrual cycle, and Prevent pregnancy endometriosis. This likely affects 59% women’s choices in the types of Manage a medical contraceptives they select. There condition 13% have been a number of efforts to establish new avenues for obtaining prescription contraceptives, such as NOTES: Among women ages 18-44 who have had sex within the past 12 months and have used (or partner has used) contraception in past 12 months. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. from online apps or pharmacists who are now able to prescribe certain contraceptives in some states. However, when asked how they obtained oral Women’s Sexual and Reproductive Health Services: Key Findings from the 2017 Kaiser Women’s Health Survey 3 contraceptives and the patch, almost all women (95%) stated they obtained these methods from a doctor or clinic prescription rather than directly from pharmacy or from an online app. Contraceptive Coverage Three-fourths of privately insured women who used contraception in the past year say they had full contraceptive coverage, a sharp rise since 2013. In 2012, the Affordable Care Act Figure 3 (ACA) required all new private plans The share of privately insured women reporting that their insurance to cover, without cost sharing, the covered the full costs of their prescription contraception rose sharply full range of contraceptives and How was the bill for your birth control paid for during your most services approved by the Food and recent visit? Drug Administration (FDA) as 19% prescribed for women. In 2017, approximately three-fourths (75%) of 48%* privately insured women ages 18-44 Insurance covered part of the cost who use contraception reported that Insurance covered the full cost 75% their insurance fully covered the cost of contraceptives (Figure 3). 45%* Another 19% said their insurance paid for part of the costs. Partial 2013 2017 coverage could represent women who NOTES: Among privately insured women ages 18-44 who reported they used a prescription contraceptive in the past 12 months. Total may not add to 100% are enrolled in an older private plan due to missing data. *Indicates a statistically significant difference from 2017; p<.05. SOURCE: Kaiser Family Foundation, 2013 and 2017 Kaiser Women’s Health Surveys. that is still “grandfathered” from the ACA requirements, who used a Figure 4 Most women receive a 3 months supply of oral contraceptive pills, particular contraceptive that is not but one in five receive a longer term supply covered by the requirement (such as Months supply of pills covered by insurance plans or clinics: a brand name drug), or who obtained Plan does not care outside of the plan’s network. cover pills Don't know 6% Most (92%) women with private 3% insurance stated they did not have >6 months any trouble getting insurance to pay 15% for prescribed contraceptives. Only 4-6 months 5% reported that they had problems 5% 3 months or less getting their insurance to pay. 70% The share of privately insured women with full contraceptive coverage has sharply increased since NOTES: Among women ages 18-44 have used contraception within the past 12 months. 2013 when 45% of insured women SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. who used prescription contraception reported their insurance paid the full cost and almost half had only partial coverage. Women’s Sexual and Reproductive Health Services: Key Findings from the 2017 Kaiser Women’s Health Survey 4 Among women who use oral contraceptives, most typically receive 3 months’ supply at a time. Women who use oral contraceptives must take a pill every day; therefore having an adequate supply is important for consistent and effective use. One quarter (25%) of women reported that they have missed a pill because they were not able to get their next pack in time. Among women who have used oral contraceptives in the past year, most (70%) report their insurance plan or clinic allows them only to receive three months or less at a time (Figure 4). However, 15% of women reported their plan allows them to get a supply that lasts six months or longer. This has been an area of public policy activity in recent years, with several states now requiring private plans and Medicaid to provide women up to 12 months’ supply. The vast majority of women support making oral contraceptives available over the counter (OTC). Research suggests that OTC access to Figure 5 Three in four women support making oral contraceptive pills oral contraceptives would increase available over the counter the use of contraception and facilitate Would you support making birth control pills available over the counter if the continuity of use; however currently, Food and Drug Administration said it was safe and effective? oral contraceptives are only available by prescription, usually from a No doctor’s office. Among women of 24% reproductive age, three-fourths (74%) support making oral contraceptives available over the counter if the FDA said it was safe and effective (Figure 5). Support Yes remains at this level across age, race, 74% income, and insurance type subgroups. NOTES: Among women ages 18-44. May not add to 100% due to missing data. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. Because the federal contraceptive Figure 6 coverage requirement applies only to Awareness of emergency contraception has increased over prescription methods, new federal the years legislation or administrative changes Have you ever heard of emergency contraceptive pills, sometimes called morning- to the ACA’s preventive services after pills,Plan B or ella*? policy would be needed to include 88%* 93% over the counter contraceptives as a 75%* 74%* no cost benefit. Awareness about emergency contraception has been rising over the past decade. Emergency contraception (EC), which is contraception that can be used after sex to prevent pregnancy, 2004 2008 2013 2017 has been available in the U.S. since NOTE: Among women ages 18-44. The phrase “ella” was added in 2017. *Indicates a statistically significant difference from 2017; p<.05. SOURCE: Kaiser Family Foundation, 2004, 2008, 2013, and 2017 Kaiser Women’s Health Survey. Women’s Sexual and Reproductive Health Services: Key Findings from the 2017 Kaiser Women’s Health Survey 5 1999. There are multiple forms, including the copper IUD, Plan B® pills (levonorgestrel), and another pill, known by the brand name ella® (ulipristal acetate). Copper IUDs and ella® both require a prescription, but Plan B® is available over the counter and has generic equivalents. As with other contraceptives, most private plans are required to cover prescriptions for EC without cost sharing under the ACA’s preventive services policy. There has been growing awareness about EC pills over the past decade (Figure 6). In 2004, three-quarters of reproductive-age women reported they had heard of EC pills, and that share has now climbed to more than nine in ten women (93%). Among this group, about one in ten (8%) report they bought or used EC pills in the prior year. Use is highest among women in their late teens or early twenties, Latina women, and women living in urban areas (Table 3). Table 3: Emergency contraception, use and awareness All Age Group Race/Ethnicity Location Poverty Level Women 35- <200% ≥200% 18-24 25-34 White Black Latina Urban Rural 44 FPL FPL Have heard of emergency contraception 93% 92% 93% 94% 97% 94% 91%* 94% 93% 90%* 97% (EC) Have taken or bought 8% 14%* 10%* 2% 5% 5% 12%* 11% 4%* 7% 8% EC in the past year^ NOTES: ^Among women ages 18-44 who had heard of emergency contraception. Emergency contraception, sometimes called morning-after pills, include Plan B or Ella. The Federal Poverty Level (FPL) was $20,420 for a family of three in 2017. *Indicates a statistically significant difference from 35-44, White, urban, ≥200% FPL; p<.05 SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. A small share of women with employer-sponsored insurance are in plans sponsored by faith- based organizations. The ACA requires that all private plans, including employer-sponsored plans, cover the full cost of prescription contraceptives for women. This policy has been challenged in the courts since it was put in place as some employers with religious or moral objections to contraception claim that the policy violates their religious rights. In October 2017 the Trump Administration greatly broadened the exemption from this requirement that was available for any employer that objects to contraceptive coverage for religious or moral reasons. While currently blocked from implementation, if this policy is ultimately adopted, it has the potential for very large impact, given that employer-based plans cover the majority of women. In the Kaiser Women’s Health Survey, 6% of women with employer-sponsored insurance say that the employer is faith-based or affiliated with a faith- based organization. These employers and other employers who object to contraception for other reasons could qualify for an exemption if the October 2017 regulations are implemented. Women’s Sexual and Reproductive Health Services: Key Findings from the 2017 Kaiser Women’s Health Survey 6 SITE OF CARE FOR SEXUAL HEALTH SERVICES Six in ten reproductive-age Figure 7 women have had a gynecologic Over half of women have had a gynecologic or obstetric or obstetric visit in the past year. exam in the past year except for women who are uninsured Last time a woman saw a doctor or nurse for a gynecologic or obstetric Most women ages 18-44 (58%) report exam: seeing a provider for a gynecologic or obstetric visit in the past year 5% 9% 7% 8% (Figure 7). This rate is higher 8% 7% 22%* Have not seen a doctor 22% among women with private insurance 24% 25% 14%* or nurse for an exam (66%) and Medicaid (58%) and far More than three years ago 27% lower among uninsured women More than one year (36%). One in seven (14%) uninsured 58% 66% 58% ago, but within three years women reported that their last visit 36%* Within 12 months was more than 3 years ago, twice the rate of women with private insurance All women Private insurance Medicaid Uninsured (7%) and Medicaid (7%). Just 9% of NOTES: Among women ages 18-44. *Indicates a statistically significant difference from Private insurance; p<.05. women ages 18-44 reported they had SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. never seen a provider for gynecologic or obstetric care. However, 22% of uninsured women reported they had never seen one, almost three times the rate of women with Medicaid (8%) and more than four times the rate of women with private insurance (5%). The majority of women get their gynecologic care in private doctors’ offices or HMOs, but clinics play an important role for certain groups of women. Most women (83%) report that their Figure 8 last reproductive health visit was for Most women obtained gynecologic exams at a doctor’s office, but a fair gynecologic care or a check-up and share went to clinics Site of most recent gynecological exam among women 16% report it was for prenatal or who have had one in past three years: pregnancy care. Among the women School/ college Unspecified location, who report they have had a based clinic or 8% urgent care center/ gynecologic exam in the past three walk-in facility, 4% Planned Parenthood years, 72% report that their most or other family planning clinic, 4% recent exam took place at a doctor's office or HMO. Roughly one in ten Community health center or public (12%) women report that they went clinic, 12% Doctor's office or to a public health clinic or HMO, 72% community health center (Figure 8). However, this rate is higher among some groups - 30% of Latinas, 23% of rural women, 34% of NOTES: Among women ages 18-44 who had a gynecological exam within the past three years. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. uninsured women, and 19% of women who have Medicaid reported going to these clinics for their most recent exam (Table 4). Women’s Sexual and Reproductive Health Services: Key Findings from the 2017 Kaiser Women’s Health Survey 7 Table 4: Site of most recent gynecologic exam among women, by selected characteristics Poverty Age Group Insurance Type Race/Ethnicity Location Level <200% FPL ≥200% FPL Uninsured Medicaid Private Latina Urban 18-44 18-24 25-44 White Black Rural Site of most recent visit Doctor’s office or 72% 59% 75%* 81% 59%* 46%* 81% 71% 53%* 73% 64% 58%* 82% HMO Community health center or public 12% 14% 12% 8% 19%* 34%* 5% 13%* 30%* 13% 23%* 23%* 5% clinic Other place 15% 27% 13%* 12% 22%* 21% 13% 16% 17% 15% 13% 19% 13% NOTES: Among women ages 18-44 who have had an exam in the past three years. Other place includes other types of clinics such as Planned Parenthood centers, school-based clinics, and other locations such as emergency departments. Columns may not sum to 100% due to rounding. The Federal Poverty Level (FPL) was $20,420 for a family of three in 2017. *Indicates a statistically significant difference from ages 18-24; Private, White, Urban, ≥200% FPL; p<.05. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. There are differences in the patient populations that seek gynecologic care at doctors’ offices compared to clinics. Community health centers and other publicly funded clinics have a commitment to delivering care to underserved communities, and this is reflected in their patient population. More than half (56%) of women who obtained gynecologic exams at community health centers are low-income, compared to about a quarter (28%) of women at private doctors’ offices (Table 5). Latina and Black women accounted for 48% of clinic patients, while making up less than a third (31%) at doctors’ offices. Coverage patterns also differ. Private insurance is the leading payer at both sites, but less than half of women at clinics (46%) are privately insured compared to 72% of women at doctors’ offices. Medicaid covers nearly a quarter (24%) of women at clinics, and one in five are uninsured (19%). Table 5: Characteristics of women who obtained a gynecologic exam in prior three years Characteristics: Doctor’s Office Clinic or Health Center Age Group 18-24 15% 29%* 25-34 40% 40% 35-44 45% 31%* Race/Ethnicity White 61% 36%* Black 16% 16% Latina 15% 32%* Other 8% 16%* Poverty Level <200% FPL 28% 56%* ≥200% FPL 72% 44%* Insurance Type Private 72% 46%* Medicaid 14% 24%* Uninsured 6% 19%* NOTES: Among women ages 18-44 who have had a gynecologic exam in the past three years. The Federal Poverty Level (FPL) was $20,420 for a family of three in 2017. *Indicates a statistically significant difference from doctor’s office; p<.05. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. Women’s Sexual and Reproductive Health Services: Key Findings from the 2017 Kaiser Women’s Health Survey 8 Most women go to a doctor’s office or HMO for contraception care; however, among low- income women, over one-third get their contraceptives from a clinic-based provider. As with gynecologic care, most Figure 9 women obtain contraception at Low-income women more likely to get contraception from private doctors’ offices but there are a clinic-based provider differences between subgroups. Share of women reporting that their site of care for contraception in the past 12 months is: Overall, more than half (60%) of women got their birth control care from a doctor or HMO, 21% from a 19% 17% 21% Other place clinic-based provider such as a 13% 21% community health center, Planned 36%* Parenthood clinic or other family Clinic-based planning clinic. A large share of 66% women (19%) also report going to 60% 47%* Doctor's office or HMO some other place for their contraception, which includes drugstores and clinics in retail All women 18-44 <200% FPL ≥200% FPL NOTES: Among sexually active women ages 18-44 who had used any birth control within the past 12 months. The Federal Poverty Level (FPL) was $20,420 for a outlets. Among low-income women family of three in 2017. “Clinic-based” includes community health centers, Planned Parenthood and other family planning clinics, and school-based clinics. “Other place” includes drugstores and other unspecified sites. *Indicates a statistically significant difference from ≥200% FPL; p<.05. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. however, roughly one in three (36%) get contraception at a clinic based-provider. Comparatively, among women who are at or above 200% FPL, only 13% get their contraceptives from a clinic-based provider (Figure 9). The outcome of current debates about the future of federal financing of family planning services, including Medicaid reimbursements to Planned Parenthood clinics, will have a disproportionate impact on low-income women’s access to contraception. A third of reproductive-age Figure 10 women report that they have One-third of women report having ever visited a Planned ever visited a Planned Parenthood clinic for health Parenthood for health care services care services. 45%* One in three women ages 18-44 39% 40% report having ever visited a Planned 33% 35% 32% 34% 33% Parenthood clinic for health care 26% services (Figure 10). This is higher among women in fair or poor health, with almost one half (45%) reporting they have ever visited a Planned Parenthood clinic, compared to 32% of women in good, very good or excellent health. Rates do not differ significantly by race/ethnicity or type NOTES: Among women ages 18-44. *Indicates a statistically significant difference from White; Private insurance; Excellent/Very Good/Good; p<.05. of insurance. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. Women’s Sexual and Reproductive Health Services: Key Findings from the 2017 Kaiser Women’s Health Survey 9 COUNSELING AND SCREENING A higher share of women report provider counseling for contraception than for sexual history, sexually transmitted infections (STIs), and HIV. An important element of reproductive and sexual health care is the counseling and education that health care clinicians can offer patients. Counseling allows clinicians to provide patient education, screen for high-risk behaviors, social determinants that could affect health outcomes, and identify the need for additional testing or treatment. Some factors that are associated with poor reproductive and sexual health outcomes are preventable or avoidable. It is estimated that nearly half of all pregnancies in the U.S. are unintended. In addition, there are approximately 20 million new cases annually of STIs, such as chlamydia, gonorrhea, and HPV, and many reached record-breaking levels in 2016. Most Medicaid programs and private plans include coverage for provider counseling on a wide range of sexual health topics, including STIs, contraception use, and partner violence. Despite these public health Figure 11 challenges and the recommendations Counseling rates for STIs and HIV are higher among Black and Latina of professional groups, counseling on women compared to White women many of these topics is not routine Share of women who said their physician discussed these reproductive health issues with them in past 3 years among women of reproductive age. All Women, ages 18-44 White Black Latina While most reproductive-age women 76%* 72%* 71%* report having had a recent 65%62% 61%59% 60% conversation with a provider about 53%* 55%* 51%* 50%* contraception (65%) and sexual 36% 37% history (61%), fewer report having 26% 24% discussed HIV (36%) and other STIs (37%). Overall, counseling rates are higher among Black and Latina Contraception or birth Sexual history or HIV Another STI women (Figure 11). While women control relationships who have private insurance report the highest rates of counseling on NOTE: Among women ages 18-44. *Indicates a statistically significant difference from White, p<.05. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. contraception and sexual history, women covered by Medicaid report significantly higher rates of counseling on HIV and other STIs (Table 6). Lower-income women and those who live in urban settings report higher rates of discussion on HIV and STIs. Only one-third of women between the ages of 40-64 said a clinician had discussed symptoms of menopause with them in the past three years. Women’s Sexual and Reproductive Health Services: Key Findings from the 2017 Kaiser Women’s Health Survey 10 Table 6: Share of women who said their physician discussed these reproductive health issues with them in past three years, by selected characteristics All Women Insurance Type Poverty Level Age Group Location Uninsured Medicaid Reported having Private ≥200% <200% Urban 18-24 25-34 35-44 Rural FPL FPL discussed in past 3 years Contraception or birth 65% 70% 61% 55%* 69% 62% 69%* 74%* 54% 66% 60% control Sexual history or 61% 63% 60% 50%* 61% 63% 70%* 68%* 48% 62% 55% relationships HIV 36% 29% 50%* 38% 30% 43%* 42%* 37% 30% 41% 27%* Another STI 37% 34% 48%* 36% 32% 46%* 48%* 40%* 28% 43% 32%* Menopause^ 34% 33% 37% 34% 33% 37% - - 34% 32% 46% NOTES: ^All topics are among women ages 18-44, except Menopause, which is among women, ages 40-64. The Federal Poverty Level (FPL) was $20,420 for a family of three in 2017. *Indicates a statistically significant difference from Private, ≥200% FPL, Ages 35-44, Urban; p<.05. – indicates data not available. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. Despite the high rate of sexual violence on women in the U.S., few women report they have talked with a provider about intimate partner violence. More than 1 in 3 adult women in the United States (36%) have experienced rape, physical violence, and/or stalking by an intimate partner in their lifetime. Intimate partner violence (IPV), also called domestic or dating violence, can affect women at any point in their lives, but rates are highest among women in their reproductive years. It has long been recognized that Figure 12 clinicians can play an important role Approximately one quarter of women have discussed domestic in the identification and treatment of violence with their provider recently, but rates are higher among women who have suffered from Black and Latina women and those with Medicaid Age Group Race/Ethnicity Insurance Status Poverty Location violence, and one of the preventive 38%* 36%* services that the ACA covers without All women 33%* 34%* cost sharing is provider counseling 27% 30% on IPV. While there have been 26% 26% 26% 23% 23% 23% 23% 23% advances in the health care system’s handling of IPV and newly developed screening tools for providers to use, it is still far from routine for providers to raise the issue of violence with women. A little more than a quarter (27%) of women say they have NOTE: Among women ages 18-44. The Federal Poverty Level (FPL) was $20,420 for a family of three in 2017. *Indicates a statistically significant difference from discussed domestic or dating violence White; Private insurance; ≥200% FPL, Urban; p<.05. Health Survey. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s in the past three years with their provider (Figure 12). Counseling rates are higher among women of color, low-income women, and those covered by Medicaid. Women’s Sexual and Reproductive Health Services: Key Findings from the 2017 Kaiser Women’s Health Survey 11 Provider counseling rates on Figure 13 many sexual health topics are Counseling rates for some sexual health topics has increased over on the rise. the past decade There has been a rise in counseling Share of women 18-44 who said their provider discussed these rates on some sexual health topics reproductive health issues with them in past 3 years over the past decade, particularly Sexual history HIV STIs Intimate Partner Violence sexual history and intimate partner 61% violence (Figure 13). In 2004, less 50%* than a third of women reported recently speaking with a provider 37%* 37% 34% 31%* 28%* 36% about their sexual history, but this 31% 30%* 28%* 28%* 27% has risen sharply to six in ten women 24% (61%) in 2017. Provider counseling 12%* 15%* on violence remains relatively low at 2004 2008 2013 2017 27%, but this is up from 12% in 2004. Counseling rates on HIV and STIs NOTE: Among women ages 18-44. *Indicates a statistically significant difference from 2017; p<.05. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. have risen more modestly. Approximately four in ten women report recent screenings for HIV and other STIs, but many incorrectly assume they are being tested. Along with counseling, several Figure 14 professional groups and government Many women incorrectly believe that STI tests are a agencies, including the USPSTF, the routine part of an examination Institute of Medicine, and the Share of women reporting Among women who received an STI test, that in past two years they: Centers for Disease Control and who initiated the test? Prevention, recommend that women in their reproductive years be tested Asked to be tested for STIs such as chlamydia, 41% gonorrhea and HIV. Knowing one’s Did not have an Had an STI test Doctor recommended status is important to receive early STI test 42% test, 11% 57% treatment and prevent transmission to sexual partners. STI and HIV tests Impression test was routine part of exam are covered without cost sharing in 48% new private plans under the ACA’s preventive services coverage requirements and are typically NOTE: Among women ages 18-44. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. covered by most Medicaid programs. Approximately four in ten women report that they have had a test for HIV (42%) or other STIs (42%) in the past two years; however, roughly half (49%) of these women assumed this test was a routine part of an examination—which is often not the case (Figure 14). Therefore, the actual screening rate is likely lower than the share of women who report being tested. This may cause women to believe they do not have an STI when in fact they have not actually been tested. Women’s Sexual and Reproductive Health Services: Key Findings from the 2017 Kaiser Women’s Health Survey 12 Screening rates for HIV and other STIs were higher among women of color, women covered by Medicaid, and women living in urban areas (Table 7). Black women reported asking to be tested for HIV and other STIs at higher rates, whereas Latina and White women were more likely to have the impression it was a routine part of the exam. Table 7: Receipt of sexual health screening tests, by race/ethnicity, insurance status, poverty level All Race/Ethnicity Insurance Type Poverty Level Women Reported having test in past <200% ≥200% White Black Latina Private Medicaid Uninsured 2 years FPL FPL HIV Test 42% 33% 66%* 51%* 38% 58%* 39% 54%* 36% Thought test was routine part 49% 52% 35%* 60%* 50% 47% 48% 47% 49% of exam Doctor recommended test 11% 9% 11% 10% 12% 6% 12% 11% 11% Asked to be tested 40% 38% 54%* 29% 38% 47% 40% 42% 39% STI Tests 42% 37% 63%* 45% 41% 54%* 31% 50%* 39% Thought test was routine part 48% 50% 31%* 66%* 47% 48% 59% 42% 52% of exam Doctor recommended test 11% 9% 12% 8% 10% 9% 6% 10% 11% Asked to be tested 41% 41% 57%* 26%* 42% 43% 34% 47% 37% NOTES: Among women ages 18-44. The Federal Poverty Level (FPL) was $20,420 for a family of three in 2017. *Indicates a statistically significant difference from White; Private insurance; ≥200% FPL, p<.05. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. CONCLUSION This survey finds that a sizeable share of sexually active women are not using any contraception and are at greater risk for unintended pregnancy. Provider counseling rates on many topics such as a woman’s sexual history and STIs, have increased over time, but many women still report that their provider has not spoken with them about important issues, such as intimate partner violence. Publicly supported clinics, including community health centers and Planned Parenthood sites, play an important role in providing reproductive and family planning care for uninsured women and women of color. The ACA’s requirement for contraceptive coverage without cost sharing has reached a large swath of women, who now do not pay any out of pocket costs for contraception. However, the Trump Administration’s health policy agenda proposes many changes that would affect women’s access to reproductive health care. The Administration has proposed new regulations that would extend the number of employers who may be exempted from the contraceptive coverage requirement because of religious or moral objections. The Administration has also expressed support for withdrawing federal reimbursements for services that Planned Parenthood provides to low-income women including Medicaid and Title X family planning funds. These policies would cripple the ability of Planned Parenthood to continue to provide care that women need and use, and would disproportionately limit access to low-income and minority women. This brief was prepared by Caroline Rosenzweig, Usha Ranji, and Alina Salganicoff of the Kaiser Family Foundation. The authors would like to thank Anthony Damico, an independent consultant, for his assistance with survey analysis. The Henry J. 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