March 2018 | Issue Brief Women’s Coverage, Access, and Affordability: Key Findings from the 2017 Kaiser Women’s Health Survey INTRODUCTION Since the Affordable Care Act (ACA) went into effect, there has been a sharp drop in the uninsured rate among women, along with major increases in Medicaid and private insurance coverage. In 2013, the Kaiser women’s health survey found nearly one in five non-elderly women were uninsured. By 2017, this had dropped to one in ten. Just as before the ACA, uninsured rates are higher among subgroups of women, particularly those who are low-income and Latina. While coverage is a major factor for women’s access to care, many other factors play a role as well, including insurer practices, out of pocket costs, and provider availability. This brief presents findings from the 2017 Kaiser Women’s Health Survey, a nationally representative survey of women ages 18 to 64 on their coverage, use, and access to health care services. The Kaiser Family Foundation has conducted surveys on women’s health care in 2001, 2004, 2008, and 2013. This brief focuses on findings from the newest 2017 survey and also presents some findings compared to earlier years. COVERAGE The share of women with health coverage has increased since the ACA was implemented; however, approximately one in ten women remain uninsured in 2017. The Kaiser Women’s Health Survey Figure 1 finds that approximately one in ten The uninsured rate among women has dropped sharply (12%) non-elderly adult women since ACA was implemented report being uninsured in 2017, down Percent of women reporting: from 18% in 2013, and consistent 66% 62% 2013 2017 with estimates from other large national surveys (Figure 1). Most women (62%) are covered by a private insurance policy, either through an employer-sponsored plan or one that they purchase on their 18% 14%* own. The ACA’s coverage expansion 9% 12%* also included a large expansion in eligibility for Medicaid, which now Private Insurance Medicaid Uninsured covers 14% of women ages 18 to 64. NOTE: Among women ages 18-64. *Indicates a statistically significant difference from 2013, p<.05. SOURCE: Kaiser Family Foundation, 2013 and 2017 Kaiser Women’s Health Surveys. Approximately one in five women are either currently uninsured or were without coverage at some point in the prior year. In addition to the one in ten (12%) women who remain uninsured in 2017, another 8% are currently insured but report that there was some period in the prior year when they were without any coverage (Table 1). Women can be uninsured for periods as a result of job loss or change, premium prices becoming unaffordable, or in the case of dependent coverage, a spouse’s job loss, divorce, or widowhood. Spells without insurance are more common among low-income women who have lower coverage rates to begin with. Low-income women are more likely to work part-time or part-year, work in a low wage job that lacks health benefits, or live in a household without an attachment to the workplace, all of which can affect coverage stability. Women with poorer self-reported health status are almost twice as likely as those in better health to have gone without insurance at some point in the prior year. Table 1: Share of women 18-64 currently uninsured or uninsured for some period of time in the past 12 months All Insurance Type Race/Ethnicity Poverty Level Health Status <200% >200% Excellent Fair or ESI Individual Medicaid White Black Latina FPL FPL to good poor Currently 12% -- -- -- 8% 12% 28%* 19%* 8% 12% 16% uninsured Time in past 12 8% 6% 10% 15%* 6% 11%* 13%* 14%* 5% 7% 13%* months without insurance NOTES: Among women ages 18-64 with insurance at time of survey. The Federal Poverty Level (FPL) was $20,420 for a family of three in 2017. *Indicates a statistically significant difference from Employer Sponsored Insurance (ESI), White, ≥200% FPL, Excellent to good, p<.05. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. Many women with insurance report their plans would not pay for treatments or did not include doctors they wanted to see as part of their networks. Insurance companies and employers Figure 2 have great discretion over what Women with insurance experience limits with coverage services they cover, the out of pocket Share of women reporting that in past 12 months their plan: costs they charge for covered benefits, and the network of Employer-sponsored insurance Individual insurance Medicaid clinicians their beneficiaries can see. 38% 40% Among women covered by employer- 33% 33% 29%* 29% 26% 26% sponsored insurance, approximately 21% 20% 20%* 21% one in five (21%) reported that their plan would not pay anything for care she or a family member thought was Would not pay anything for Paid less than expected for a Did not cover a particular Would not cover a care she or family member bill from hospital, lab, or doctor she wanted to see prescription drug or covered (Figure 2). Similarly, one in received that she thought doctor required very expensive co- was covered pay for a drug doctor five women reported their plan did prescribed not include a particular doctor she wanted to see in network. Rates were NOTE: Among women ages 18-64 with insurance. *Indicates a statistically significant difference from employer-sponsored insurance, p<.05. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. similar among women who purchased insurance on their own, but were higher among women covered by Medicaid. Approximately four in ten women with ESI (38%) and individual insurance (40%) reported their plan paid less than they expected for Coverage, Access, and Affordability: Key Findings from the 2017 Kaiser Women’s Health Survey 2 a medical bill. This was less common among women with Medicaid, but still a problem for 20%. While co- payments and co-insurance are routine charges in the private insurance market, they are less common in the Medicaid program. Three in ten women with employer-sponsored insurance (29%) and one-third of women with individual policies or Medicaid reported their plan would not cover a particular prescription medicine or they had to pay a very expensive co-pay to obtain it. A sizeable share of women with insurance report paying out of pocket for screening tests, despite the ACA’s requirement for coverage of preventive services without cost sharing. The ACA requires most plans to cover Figure 3 certain preventive services at no cost. A sizeable share of women pay out of pocket for preventive services, These services include cancer but women covered by Medicaid do at significantly lower rates screenings such as Pap tests, Share of women reporting they paid any out of pocket costs for following services: mammograms, and colonoscopies. 28% However, one in five women reported All Women Private Medicaid Uninsured paying out of pocket costs for a 23% 20% recent Pap test, 13% for a 16% mammogram, and 7% for a colon 13% cancer screening (Figure 3). Almost 11% one in four (23%) women with 6%* 7% 8% private insurance paid out of pocket 3%* 4% for a Pap test as did 16% for a 0%* mammogram. Some women are Pap test Mammogram (Ages 40 and older) Colon cancer screening (Ages 50 and older) enrolled in grandfathered plans that NOTE: Among women ages 18-64 who reported they had any of these medical tests in the past two years. *Indicates a statistically significant difference from are not subject to the preventive Private, p<.05. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. services coverage requirement. Furthermore, some women may be seeking care out of network or the primary reason for their visit may not be preventive, both of which are stipulations for no cost coverage. Very few women covered by Medicaid said they had to pay out of pocket for preventive services, but many uninsured women who likely have no coverage for these services report paying for Pap and mammogram screenings. Some uninsured women can get no-cost care for Pap smears or mammograms through the Breast and Cervical Cancer Screening program that is operated by the Centers for Disease Control and Prevention (CDC), but many go without care because of affordability concerns. ACCESS CHALLENGES While coverage plays a large role in access to care, there are many other factors that affect whether or not a woman uses services. These include out of pocket costs, provider availability and capacity, as well as logistical issues such as transportation and finding time to make it to medical appointments. The ACA attempted to alleviate some of the financial barriers through a variety of requirements on insurers, including full cost coverage for preventive services, cost-sharing subsidies for lower income families, and prohibiting insurer lifetime caps on coverage. However, many women report barriers that are related to issues outside of the health care system, such as workplace benefits and flexibility, childcare, and transportation. Coverage, Access, and Affordability: Key Findings from the 2017 Kaiser Women’s Health Survey 3 Out of pocket costs limit access to care for women and men, but more commonly among women. While women and men both feel the Figure 4 impact of health costs, such as A higher share of women forgo health care services due to insurance premiums, co-payments, cost compared to men and deductibles, they can be Percent reporting that in past 12 months they experienced following due to costs: particularly burdensome for women 33% who on average earn lower wages, Women Men 26% 27% have fewer financial assets, 25% accumulate less wealth, and have 19%* 19% 20% 16% 17% 17% higher rates of poverty than men. 15% 12%* Roughly one in four (26%) women and one in five (19%) men have had to delay or forego care in the past year due to cost (Figure 4). Because Delayed or went Put off or Skipped Didn't fill Rx or Problems paying Currently paying off without care postponed recommended cut/skipped doses medical bills medical bills of costs, approximately one in five preventive services medical test or of medicines treatment women have postponed preventive care (19%), skipped a recommended NOTE: Among women and men ages 18-64. *Indicates a statistically significant difference from Women, p<.05. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey and 2017 Kaiser Men’s Health Survey. test or treatment (20%), or made medication tradeoffs such as not filling a prescription or cutting dosages (17%). One in four women report that they have had problems paying medical bills (25%) in the prior year and one in three are currently paying off medical bills (33%). Costs are particularly burdensome for uninsured and low-income women and those in fair or poor health. For uninsured women in particular, Figure 5 health costs are a sizeable barrier to Costs impede care for uninsured women and women with care. Half (49%) of uninsured women coverage went without or delayed care because of the costs (Figure 5). Almost as Percent reporting that in past 12 months they experienced following due to costs: many postponed preventive services Private insurance Medicaid Uninsured 49%* (47%) and 42% skipped a 47%* 42%* recommended medical test or 33%* treatment. One in three uninsured 25% 21% women did not fill a prescription 18%19% 17% 15%16% 14% 16%* 8% 9% and/or skipped or cut pills, and roughly one in six (16%) reported Delayed or went Put off or postponed Skipped Not filled prescription, Experienced trouble they experienced problems obtaining without care preventive health recommended cut pills or skipped getting mental health services medical test or doses of medications care mental health care because of cost. treatment NOTE: Among women ages 18-64. *Indicates a statistically significant difference from Private insurance, p<.05. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. Coverage, Access, and Affordability: Key Findings from the 2017 Kaiser Women’s Health Survey 4 However, many women with coverage also experience affordability challenges that limit their access to care. For example, nearly one in five women with private insurance (18%) or Medicaid (19%) skipped a test or treatment because of the costs and many experienced other cost barriers as well. State Medicaid programs are permitted to charge nominal cost sharing amounts, which can be an obstacle since women on the program have very low incomes by definition, and even a few dollars can pose a barrier to receiving care. Low-income women and those in poorer health who generally have greater health needs experience some cost-related barriers at twice the rate of their counterparts with higher incomes and better health status. Rates of cost barriers are similar across racial/ethnic groups (Table 2). Table 2: Cost barriers to health care for women, by selected characteristics Health Status Poverty Level Race/Ethnicity Share of women reporting that in Excellent to Fair or past 12 months they experienced <200% FPL >200% FPL White Black Latina good Poor following due to costs: Delayed or went without care 22% 43%* 39%* 19% 25% 25% 27% Postponed preventive services 17% 29%* 28%* 15% 19% 16% 18% Skipped a recommended medical 18% 34%* 29%* 16% 22% 22% 19% test or treatment Didn’t fill a prescription or skipped 13% 35%* 25%* 14% 17% 18% 16% or cut pills Had problems getting mental health 8% 17%* 14%* 8% 10% 9% 7% care NOTES: Among women ages 18-64. The Federal Poverty Level (FPL) was $20,420 for a family of three in 2017. *Indicates a statistically significant difference from Excellent to Good, >200% FPL, White, p<.05. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. Fewer low-income women report cost Figure 6 to be a barrier to care, but it is still a Cost barriers have declined modestly among low-income challenge for many. In 2017, women approximately a quarter of low- Percent of low-income women reporting that in prior 12 months they experienced income women reported that costs following due to costs: was a reason that they postponed 45% 2013 2017 preventive services (28%) or skipped 39% 35% 35% 33% medication doses (25%), but this is a 28%* 29% 25%* drop from 2013 when approximately 15% 14% one-third of women reported these barriers (Figure 6). Since 2013, millions of low-income women have Delayed or went Put off or postponed Skipped Not filled prescription, Experienced trouble gained coverage, both through without care preventive health recommended cut pills or skipped getting mental health services medical test or doses of medications care Medicaid expansion as well as private treatment plans in ACA Marketplaces, which NOTE: Among women ages 18-64 with incomes <200% FPL. The Federal Poverty Level (FPL) was $20,420 for a family of three in 2017. *Indicates a may explain part of this decline. statistically significant difference from 2013, p<.05. SOURCE: Kaiser Family Foundation, 2013 and 2017 Kaiser Women’s Health Surveys. Coverage, Access, and Affordability: Key Findings from the 2017 Kaiser Women’s Health Survey 5 Women face logistical barriers to obtaining health care related to their roles as mothers and employees. Costs and affordability are not the Figure 7 only barriers to health care for Logistical problems such as time and transportation pose women. Lack of time and flexibility barriers to care, particularly for low-income women with work can pose a challenge in Share of women reporting they delayed or went without care in past 12 months because: getting care for a sizeable fraction of All women Less than 200% FPL 200% FPL or greater women. Nearly one in four women 34%* report that they did not obtain care 27% they needed because they did not 24% 23% 23% have time (24%) and because they 19% 19%* 17%* could not take time off work (23%) 14% 11% (Figure 7). Transportation and 9% childcare also present as barriers to 3% care but to a lesser degree. These Couldn't find time to go to Couldn't take time off work Had problems getting child Had transportation problems barriers affect women of all income doctor care + levels, but low-income women more NOTE: Among women ages 18-64. Among women employed full- or part-time. +Among women with children. The Federal Poverty Level (FPL) was $20,420 for commonly experience childcare and a family of three in 2017. *Indicates a statistically significant difference from 200% FPL or greater; p<.05. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. transportation problems. One-third of low-income women (34%) also reported they missed or delayed care because they could not take time off work, compared to one in five higher income women (19%). Consistent with the disparities by poverty level, some barriers are reported more frequently among women of color, and those in fair or poor health (Table 3). Table 3: Logistical barriers to care for women, by race/ethnicity and health status Race/Ethnicity Health Status Share of women reporting they delayed or went Fair or Excellent White Black Latina without care in past 12 months because they: Poor to Good Couldn’t find time to go to doctor 24% 23% 21% 23% 25% Couldn’t take time off work 21% 25% 25% 34%* 21% Had problems getting child care 14% 10% 20% 11% 14% Had transportation problems 6% 15%* 12%* 21%* 6% NOTES: Among women ages 18-64. *Indicates a statistically significant difference from White, Excellent to good, p<.05. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. IMPACT OF MEDICAL BILLS Women and their family members can face problems paying medical bills for a variety of reasons. Some women incur significant medical expenses because of an unexpected health event such as cancer, or an illness or injury that limits a woman’s ability to work and earn income to pay off bills. Women who are uninsured do not have coverage to offset the charges and may even be charged higher rates than insured women are. However, women with Medicaid and with private insurance may also have difficulties paying medical bills, which can include charges for out of network care and coverage limits or exclusions. Coverage, Access, and Affordability: Key Findings from the 2017 Kaiser Women’s Health Survey 6 One in three women reported that they have unpaid medical bills. There are several reasons women might report they have outstanding bills including they have not yet received the bill, their insurer has yet to approve the claim, or they cannot afford to pay what they owe. Outstanding medical bills are more common among those with greater health needs as well as those with lower incomes to pay the bills. This includes roughly four in ten Black women (44%), those in poorer health (45%), those who live in rural areas (39%), and four in ten low-income women (40%) (Table 4). Table 4: Rates of unpaid medical bills, by selected characteristics All Race/Ethnicity Location Poverty Level Health Status Women Share of Excellent Fair or women White Black Latina Urban Rural <200% FPL >200% FPL to good Poor reporting: Currently have unpaid medical bills 33% 32% 44%* 26% 29% 39%* 40%* 31% 30% 45%* or bills being paid off NOTE: Among women ages 18-64. The Federal Poverty Level (FPL) was $20,420 for a family of three in 2017. *Indicates a statistically significant difference from White, Urban, >200% FPL, Excellent to good, p<.05. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. One in four women say they or a family member had problems paying medical bills in the past year. One in four women stated that they or a member of their family had trouble paying medical bills in the past year (Table 5). This share rises to 28% of women ages 26 to 34 and nearly a third (32%) of women ages 45 to 54. It is not surprising that more uninsured (37%) and low-income (34%) women report problems paying bills, given that they do not have coverage or as many financial resources to cover their bills. Table 5: Share of women who have had trouble paying medical bills in past year, by selected characteristics All Age Group Insurance Type Poverty Level Women Uninsured Medicaid Share of Private <200% >200% 18-25 26-34 35-44 45-54 55-64 FPL FPL women reporting: They or family member had trouble paying 25% 18% 28%* 23% 32%* 24% 24% 21% 37%* 34%* 22% medical bills in past 12 months NOTES: Among women ages 18-64. The Federal Poverty Level (FPL) was $20,420 for a family of three in 2017. *Indicates a statistically significant difference from Ages 18-25, Private, ≥200% FPL; p<.05. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. Coverage, Access, and Affordability: Key Findings from the 2017 Kaiser Women’s Health Survey 7 Medical bills can force women to make tradeoffs in paying for other basic necessities such as food or financial ones such as borrowing money and lowering credit standing. Medical bills can have tangible Figure 8 consequences on other aspects of Medical bills affect many aspects of women’s financial women’s lives. Among those who stability reported trouble paying bills, more Among women reporting they had trouble with medical bills in past 12 months, the share reporting they experienced following due to those bills: than half said they used up most of All Less than 200% FPL 200% FPL or greater their savings or had been contacted by a collection agency as a result 59% 58%* 58%* 56% 61% 53% 55% (Figure 8). A little over four in ten 48% 42% 44% reported they had difficulty paying 35% 30% for other necessities such as food (42%) or that they borrowed money to pay off bills (44%). Most of these consequences were more common Used up most of savings Difficulty paying for basic Borrowed money from Been contacted by a necessities (food,heat, family or friends or got a collection agency among low-income women, who have housing) loan fewer resources to pay off bills. NOTE: Among women ages 18-64 who reported trouble paying medical bills in prior 12 months. The Federal Poverty Level (FPL) was $20,420 for a family of three in 2017. *Indicates a statistically significant difference from 200% FPL or greater, p<.05. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. USE OF PRESCRIPTION MEDICINES Over half (55%) of women take at least one prescription medicine on a regular basis. Fewer women of color rely on prescription medications to manage a medical condition. Prescription drugs help many women treat and manage chronic conditions and acute illnesses. Prescription medicines can also play an important role in prevention for women, particularly contraception. More than half (55%) of women report they take at least one prescription medicine on an ongoing basis (Table 6). This includes women who take oral contraceptives. However, 45% of women report that they do not take any prescription medicines. Over half of Black, Latina, and urban women report that they do not take any prescription medications on a regular basis. Almost three in ten women (28%) report taking one or two prescription medications, 15% report taking three to five medications, and one in ten women (11%) report they take at least six medications on an ongoing basis. Almost four in ten (38%) women who rate their health status as fair or poor take at least six medications. Women covered by Medicaid (18%), low-income women (17%), and those who live in rural areas (15%) are also more likely than their counterparts to take at least six medications on a routine basis. Coverage, Access, and Affordability: Key Findings from the 2017 Kaiser Women’s Health Survey 8 Table 6: Prescription medication use among women, by selected characteristics All Poverty Health Race/Ethnicity Location Insurance Type Women Level Status Share of Excellent to Fair to Poor ≥200% FPL Uninsured <200%FPL women 18-64 Medicaid Private Latina Urban White Good Rural Black reporting that on a regular basis they take: No prescription 45% 40% 53%* 57%* 47% 43% 53% 37%* 43% 46% 62%* 24% 50%* medication 1 or 2 prescription 27% 28% 30% 19%* 26% 19%* 33% 24% 34% 20%* 17%* 15% 31%* medications 3 to 5 prescription 15% 17% 14% 11%* 16% 16% 11% 22%* 15% 15% 11% 14% 16% medications 6 or more prescription 8% 11% 12% 14% 5%* 17%* 8% 15%* 6% 18%* 10% 38% 5%* medications NOTES: Among women ages 18-64. Totals may not add 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 White, ≥200% FPL, Urban, Private, Excellent to good p<.05. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. One in four women report they had to pay higher cost sharing than they expected or that insurance stopped covering a drug they take. The cost of prescription drugs is one Figure 9 of the top health care concerns Some women with face unexpected out of pocket costs for among the American public. medicines they take on a regular basis Insurance companies have great Among privately insured women who take a leverage over the drug benefits they prescription drug on a regular basis, share reporting in prior 12 months: include in their policies. They can raise out of pocket costs, change the drugs they cover, and drop drugs No change in coverage or cost from policies at any time and without in past 12 months, 72% No prescription Take at least one notifying beneficiaries. Among medicines prescription medicine 43% on a regular basis privately insured women who say 56% they take a prescription drug on a Had to pay a higher co- insurance or copay or regular basis, about one in four insurance stopped covering a drug she takes, 26% (26%) reported that in the prior year their cost for the prescriptions rose or that their insurer dropped NOTE: Among privately insured women ages 18-64. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. coverage for a drug they were taking (Figure 9). This was more commonly experienced by women ages 45-54 (31%) and 55-64 (32%) than women ages 18-44 (23%). It is also more common among White (30%) and Black (29%) women than Latinas (13%). Coverage, Access, and Affordability: Key Findings from the 2017 Kaiser Women’s Health Survey 9 The share of women who take Figure 10 six or more prescription medications has increased over Among women who take prescription medications, there the past decade. has been a rise in the share who take at least six medicines The proportion of women who report Among women who take at least one prescription drug on a regular basis, share reporting they take: taking any prescription medicines has remained relatively steady from 51% in 2008 to 55% in 2017 (data not 14%* 16%* 21% shown). Among that group, the share 6 or more 32% 28% 28% medicines who take at least six medicines has 3-5 medicines risen from 14% in 2008 to 21% in 2017 (Figure 10). Almost two-thirds 54% 56% 1 or 2 medicines 51% (63%) of this group rate their health as fair or poor, but over one-third (37%) rate their health positively 2008 2013 2017 (Figure 11). NOTE: Among women ages 18-64 who take at least one medication on a regular basis. Percentages may not add to 100% due to rounding. *Indicates a statistically significant difference from 2017, p<0.05. SOURCE: Kaiser Family Foundation, 2008, 2013, 2017 Kaiser Women’s Health Survey. CONCLUSION Figure 11 Women who take at least six different medicines are more Seven years after the passage of the likely to be older and in poorer health ACA, nine in ten women have health coverage, more than ever before. On many measures, women with insurance have better access to care, but some still face barriers such as Fair/Poor 45-64 years services that are not covered, 63% 76% expensive cost sharing, and providers that do not accept their coverage. Excellent/Very Affordability continues to be a good/Good 18-44 years challenge, with many women 24% 37% reporting they could not afford to Age Group Health Status obtain preventive care, treatments, or prescription medicines because of the NOTE: Among women ages 18-64 who take at least six medications on a regular basis. SOURCE: Kaiser Family Foundation, 2017 Kaiser Women’s Health Survey. out of pocket costs. In addition, some barriers are outside the health care system and result because women do not have time to seek care or do not have workplaces that support them taking time off to go for appointments. This brief was prepared by Usha Ranji, Caroline Rosenzweig, 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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