Preventative Services for Women’s Health & Well Being

Francisco R. Velázquez, M.D., S.M., FCAPManaging Director, Quest Diagnostics Nichols Institute

Vice President, Focus Diagnostics

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Agenda

I. Population Changes and Demographics

II. Women and Healthcare

III. Women’s Health Status/Coverage

IV. Health Interview Survey (selected topics)

V. Women’s Health and the 2008 Election

VI. PPACA Publication: Women’s Health Perspective

VII. Preventative Services/Research

VIII. Long-term Issues/Questions

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U.S. Population Distribution and Changes 2000 – 2010 1,2

• Population

–27.3 million more than 2000 (9.7%)

–Approximately 49% male

51% female

• Mean age/sex

–Male 35.4

–Female 38.2

–Population 36.8

1 U.S. Census Bureau, Current Population reports June 2010, http://www.census.gov/popest/nationalasrh/WC-Est2009/NC-Est2009-01.xls >last accessed May 2, 2011

2 U.S. Census Bureau, “2008 National Population Projections,” August 2008, modified: U.S. National Center for Health Statistics, National Vital Statistics Report (NUSR), Vol 58, No. 19, May 2008

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Expectation of Life at Birth 2010 – 2020 3

–2010:

»Male 75.7

»Female80.8

»Population 78.3

–2020:

»Male 77.1

»Female81.9

»Population 79.5

3U.S. National Center for Health Statistics U.S. Census Bureau; The 2011 Statistical Abstract, The National Data Book Table 102; Expectation of Life at Birth and Projections, January 20, 2011 last accessed June 1, 2011

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Life Expectations by Sex, Age and Ethnicity 3

–White»Male 75.8»Female 80.8

–Black»Male 70.0»Female 76.8

–Hispanics»Male 78.4»Female 83.7

3 Ibid

–Asian»Male 76.3»Female 81.1

–American Indian/Native Alaskan»Male 76.6»Female 81.5

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2010 Census Results Key Findings 4,5,6

• Population shift south/west

• From 2007-2009 birth rates for women aged 15-44 declined

• Birth rates declined for all women under age 40

• Fertility rates dropped for all major racial groups and all birth orders

4 2010 Census Data/2010 Census Demographic profile: http://2010.census.gov/2010census/data . Last accessed May 16, 2011

5 Sutton PD. Recent trends in births and fertility rates through June 2010. National Center for Health Statistics Health E-Stat. 2010

6 Sutton PD. Hamilton BE, Matthews TN. Recent decline in births in the United States, 2007-2009. NCHS data brief, No 60. Hyattville, MD: National Center for Health Statistics. 2011

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National Population by Race United States 2010 7,8

% PopulationChange

2000-2011White 72.4 5.7%Black 12.6 12.3%Am Indian/Alaskan 0.9 18.4%Asian 4.8 43.3%Native American 0.2 35.4%Other Race 6.2 24.4%Three of more races 2.9 32.0%

Hispanic or Latino Origin

Hispanic/Latino 16.3 43.0%Non-Hispanic or Latino 83.7 4.9%

7 US Census 2010 Census Data Demographic profiles. http://2010.census-gov/2010census/data last accessed Mary 23, 20118 Sharon R. Ennis, Merarys Rio-Vargas and Nora G. Albert. The Hispanic Population: 2010 2010 Census Brief, May 2011

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Percent Distribution of Number of Visits to Health Care Professionals (National Health Interview Survey) 9

Characteristic None 1 - 3 4 - 9 10 or more

PopulationSex

Male 15.5 46.8 24.8 12.9Female 20.7 47.5 22.2 10

10.8 46.2 27.3 15.8Age

18 - 44 22.7 46.3 19.4 11.745 - 64 14.4 44.5 25.7 15.565 - 74 7 35.7 36.4 20.975 and over 3.9 25.4 39.1 27.6

Race

White 15.4 46.2 25.1 13.3Black 15.4 48.7 24.2 12.2Hispanic 24.3 44 20.6 11.1Asian 18.2 53.7 20.9 7.2Am Indian/Alaskan 15.4 42.8 29.1 12.7

9 U.S. Census Bureau, Statistical Abstract of the United States: 2011 p 114, Health and Nutrition, Table 162. http://www.census.gov/compenida/statab/2011table/11s0162 last accessed June 3, 2011

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Population Trends

• Population 2015: 325,540,000 (Projected) 10,11,12

– 160,424,000 Male

– 165,116,000 Female

– Numeral difference expected to continue increasing

– Women 65 and above will increase from 14.57% (2010) to 21.79% (2050)

10 U.S. Census Bureau. 2008 National Population Projections”. August 2008, < http://www.census.gov/population/www/projections/2008projections.html/ >. Last Accessed May 7, 201111 Population Division, U.S. Census Bureau; Projections of the Populations by Selected Age Groups and Sex for the U.S.: 2010-2050 (NP 2008-T2), August 14, 2008. Last accessed May 11, 201112 Population Division, U.S. Census Bureau; Percent Distribution of the Projected Populations for the U.S.: 2010-2050 (NP 2008-T3), August 14, 2008. Last accessed May 11, 2011

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Population Characteristics 13

• 12% of women over 18 are head of household

– Non-Hispanic blacks more likely to be head of household (28.1%)

• 40 million Americans below poverty level

– 15% are women age 18 or older

– 13% of adult female population

• 15.5% of women experience household food insecurity

– Female headed households with children make 27.4% of households that rely on food stamps

– Represent 57.7% of food stamps households with children

• 59.5% of women 16 or older participate in the labor force

• 1.8 million are veterans (9% of veteran population)

• Veterans of OEF/OIF are younger than previous veterans (75% 16-40 years)

• 22.7% of women live in rural areas

13 Women’s Health USA 2010: U.S. Department of Health and Human Services. Health Resources and Services Administration. HRSA Information Center 2010 http://mchb.hrsa.gov/whusato/index.html . Last accessed May 21, 2011.

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Women and Healthcare 14-16

– 85% mothers choose their children’s doctor

– 84% take their children to appointments

– 79% ensure follow-up care

– 48% take time off work for sick children

– 45% of low income women have paid sick leave

– 12% of women care for sick or aging relative

– 17% are uninsured

– 35% have a chronic condition that requires on-going medical attention

– 24% of non-elderly women went without or delayed care due to cost

– 51% of women use at least one prescription on a regular basis

– 17 million low income women (18-64 years) covered under Medicaid

– 75% of adult Medicaid population

– 15.1 maternal deaths/100,00 live births

– 40% of uninsured women do not fill their prescriptions

14 Rani, Ushape, Salganicoff, A., PhD. Women’s Healthcare Chart book Key Findings From the Kaiser Women’s Health Survey. The Henry J. Kaiser Family Foundation: pp 1-40, May 2011.15 Ranji, Usha MS, Salganicoff, A., PhD, Stewart, Alexandra JD, Cox, Marisa, MA, MPH and Doamekpor, Lauren: State Medicaid Coverage of Family Planning Services: Summary of State Survey Findings November 2009. The Henry J. Kaiser Family Foundation and The George Washington University School of Public health and Health Services: pp 1-29, 200516 Chaukin, Wendy et al: Women’s Health and Healthcare Reform: The Key Role of Comprehensive Reproductive Healthcare; Columbia University Mailman School of Public Health. November 2007.

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Women’s Health Status 17-21

– 18% of women 18-64 are in fair or poor health

– 35% have chronic conditions requiring ongoing medical attention– 18-44 years 9% arthritis, 11% hytpertension, 9% high cholesterol– 45-64 years rate triple to 39%, 36% and 34% respectively

– Leading seven causes of death• Heart Diseases (25.8%)

• Cancer (22%)

• Stroke (6.7%)

• Chronic Lower Respiratory Diseases (5.3%)

• Alzheimer’s Disease

• Unintentional Injuries

• Diabetes

– 68.4% of women 65 and older report at least one condition that limits their ability to perform common activities

– 15.7% prevalence of “dementia”

– 6.3 million adults over the age of 65 have osteoporosis; approximately 90% are women

– Hospice care discharges 55.1% are women, 65.3% of all hospice care patients 85 and older are women

17 Ibid18 Centers for Disease Control and Prevention; FASTSTATS Women’s Health http://www.cdc.gov/nchs/faststats/womens_health.htm . Last accessed April 29, 2011.19 Nicholas, Carol, MSTC; May, Rick, MD: The Seventh Annual Health Grades Women’s health in America Hospitals Study: 1-47, April 201020 Cancer Facts and Figures 2010. American Cancer Society. http://www.cancer.org/acs/groups/content/epidemiologysurveillance/documents/document/acspc-026238.pdf Accessed June 5, 201121 Hartker, M. MD and Reed, K: The Twelfth Annual Healthgrades Hospital Quality in America Study. Healthgrades, Inc. October 2009

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Women’s Health Insurance Coverage 22-26

– 32% Employer sponsored primary

– 29% Employer sponsored dependant

– 17% Uninsured

– 10% Medicaid

– 6% Individually purchased

– 4% Medicare

– 2% Other

– 40% of uninsured women work

– 7% of women were uninsured at some point during prior year

– 24% of women 18-64 are currently without health insurance or have been uninsured in the past year

– 35% of women under poverty level

– 29% of near poor women (100% to 199% of poverty lack coverage)

– 42% of non elderly Latina women are uninsured

22 Ibid23 Glied S, Jack K, Rachin, J: Women’s Health Insurance Coverage 1980-2005, Women’s Health Issues: 2008 Jan-Feb; 18(1) 7-1624 Salganicoff, A, Cubanski J, Ranjiu, Newman, T: Health Coverage and Expenses: Impact on Older Women’s Economic Well-Being: Journal of Women, Politics and Policy, 30: 222-247, 200925 Angel J.L., Karas Montez J, Angel RJ: A Window of Vulnerability Health Insurance Coverage Among Women 55 to 64 Years of Age. Women’s Health Issues, Volume 21 (1) pp 6-11 (January 2011)26 Gold, R.B., Alrick, C: role of Medicaid Family Planning Waivers and Title X in Enhancing Access to Preconception Care. Women’s Health Issues. 2008 Nov-Dec; 18 (6 Suppl): 547-51.

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Obtaining Needed Medical Care 27

27 Centers for Disease Control, Early Release of Selected Estimates Based on Data From the 2010 National Health Interview Survey http://www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201106.pdf

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Current Smoking

27Ibid

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Alcohol Consumption

27Ibid

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Leisure-time Physical Activity

27Ibid

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Personal Care Needs

27Ibid

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Women’s Health and the 2008 Election

• Top Issues for women 28

– Coverage/Affordability

– Preventive Services & Primary Care

– Long-term Care/Medicare

– Reproductive Health

28 Kaiser Health Tracking Poll: Election 2008 (conducted April 3-13, 2008) http://www.kff.org/womenshealth/h08_7822.cpm . Last accessed June 1, 2011

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Election 2008 Tracking Poll 29

29 Kaiser Health Tracking Poll: Election 2008 (conducted April 3-13, 2008)

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PPACA Public Law: Women’s Health Perspective 30-34

• Coverage/affordability

• Preventative Services/Primary Care

• Long-Term Care/Medicare

• Reproductive Health

• Gender Ratings

• Imbalance

• Workplace “Reasonable Accommodations”

• Health Policy/Health Research

30 Ibid31 Kosiak B, Sangl J, Correa-de-Arraujo R: Quality of health Care for Older Women: What Do We Know. Women’s Health Issues, 2006 Mar-Apri; 16 (2) 18-9932 Rochman B: What Healthcare Reform Means for You. Forbes.com Sept 11, 2009. http://www.forbes.com/2009/09/11/healthcare-reform-insurance-forbes-woman-well-being-maternity.html Accessed April 29, 201133 Proskauer: Healthcare Reform Has Arrived: “Benefits for Women and Responsibilities for Employers” Client Alert April 6, 2010. http://www.proskauer.com/publications/client-alerts/health-care-reform-has-arrived-benefits-for-women-and-responsiblitieis-for-employers . Accessed April 29, 201134 Wood, S.F, Blehar M.C., Marvery D.R.: Policy Implications of a New National Institutes of Health Agency for Women’s Health Research 2010-2020 . Women’s Health Issues 21-2 (2011) 99-103

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Key Milestones 35-40

• “Patient Protection and Affordable Care Act”35

(Patient Protection and Affordable Care Act (P.L. 111-148) as amended by the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152)

• Interim Final Rules for Group Health Plans and Health Insurance Issues Relating to Coverage of Preventative Services under the Patient Protection and Affordable Care Act36

• Institute of Medicine: Women’s Health Research: progress, pitfalls and promise37,38

• Institute of Medicine: Clinical Preventive Services for Women: Closing the Gaps39

• Health Resources and Services Administration – Supported Women’s Preventive Services: Required Health Plan Coverage Guidelines40

35 Ppaca & Hcera; Public Laws 111-148 & 111-152, One Hundred Eleventh Congress Second Session, January 5, 201036 Preventative Regulations: Department of the Treasury 26 CFR 54, Department of Labor 29 CFR part 2590, Department of Health and Human Services OCIIO-9992-IFC, 45 CFR part 14737 Women’s Health Research: Progress, Pitfalls and Promise, Institute of Medicine, The National Academy of Sciences Press. Consensus Report pp1-14, September 23, 201038 Consolidated Appropriations Act of 2008: 110th Congress, Public Law 110-161 H.R. 2764, December 26, 200739 Clinical Preventive Services for Women: Closing the Gaps, The National Academy of Sciences Press, Consensus Report, July 20, 201140 The Health Resources and Services Administration (August 1, 2011), http://www.healthcare.gov/news/factsheets/womenprevention08012ulla.html

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Covered Preventive Services for Women, Including Pregnant Women

• Anemia

• Bacteriuria

• BRCA

• Breast Cancer Mammography

• Breast Cancer Chemoprevention

• Breastfeeding*

• Cervical Cancer

• Chlamydia Infection

• Contraception*

• Domestic and interpersonal violence*

• Folic Acid

• Gestational diabetes*

• Gonorrhea

• Hepatitis B

• Human Immunodeficiency Virus (HIV)*

• Human Papillomavirus (HPV) DNA Test*

• Osteoporosis

• Rh Incompatibility

• Tobacco Use

• Sexually Transmitted Infections (STI)*

• Syphilis

• Well-woman visits*

35IbidServices marked with an asterisk (*) must be covered with no cost sharing in plan years starting on or after August 1, 2012

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Conditions Discussed by Committee, Categorized by Extent of Progress

• Conditions on Which Research Has Contributed to Major Progress

– Breast Cancer

– Cardiovascular Disease

– Cervical Cancer

• Conditions on Which Research Has Contributed to Some Progress

– Depression

– HIV/AIDS

– Osteoporosis

• Conditions on Which There Has Been Little Progress

– Unintended Pregnancy – Lung Cancer

– Maternal Morbidity and Mortality – Gynecological Cancers Other than Cervical Cancer

– Autoimmunne Diseases – Non-Malignant Gynecological Disorders

– Alcohol and Drug Addiction – Alzheimer’s Disease

37,38Ibid

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Health Resources and Services Administration-Supported Women’s Preventive Services: Required Health-Plan Guidelines

36,40Ibid

Type of Preventive Service

Frequency

Well-woman visits Annual, although HHS recognizes that several visits may be needed to obtain all necessary recommended preventive services, depending on a woman’s health status, health needs, and other risk factors

Screening for gestational diabetes

In pregnant women between 24 and 28 weeks of gestation and at the first prenatal visit for pregnant women identified to be at high risk for diabetes

Human papillomavirus testing

Screening should begin at 30 years of age and should occur no more frequently than every 3 years

Counseling for sexually transmitted infections

Annual

Counseling and screening for human immune-deficiency virus

Annual

Contraceptive methods and counseling **

As prescribed

Breastfeeding support, supplies, and counseling

In conjunction with each birth

Screening and counseling for interpersonal and domestic violence

Annual

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Key Issues Long-Term

• Implementation

• Affordability and Scope of Coverage

• Primary Care and Prevention

• Long-Term Care

• Research / Policy

• Excluded Populations

• Economic Recovery

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Questions…

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