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Policy & practice points


The Patient Protection and Affordable Care Act
By Susan Kendig, JD, MSN, WHNP-BC, FAANP

Since passage of the Patient Protection and Affordable Care Act (PPACA) on March 23, 2010, there has been an ever-present news cycle focused on implementation of various aspects of the law. With passage, implementation, and continuing debate about this sweeping piece of legislation, the key objectives driving the health policy debate—increasing access to care, improving health outcomes and the quality of healthcare service delivery, and decreasing healthcare costs—are sometimes lost in the rhetoric. Yet access to care, quality improvement, patient safety, and cost-effectiveness were at the heart of the healthcare debate long before PPACA’s passage and will most likely remain front and center for the foreseeable future. Whether we as individuals embrace PPACA with all its complexities or favor alternate policy solutions to healthcare challenges, nurse practitioners lend an important voice.
As we prepare this inaugural issue of Women’s Healthcare: A Clinical Journal for NPs, the news is rife with information about another PPACA milestone, implementation of the Health Insurance Marketplaces. These Health Insurance Marketplaces, or Exchanges, are intended to better enable eligible individuals to purchase and enroll in affordable health insurance plans that best meet their needs.


Why is health insurance coverage an important women’s health issue?

On average, women have lower incomes and use more healthcare services than do men. As a result, women are more likely to go without needed healthcare because of cost. In the United States, approximately 18.7 million women were uninsured in 2010, and an additional 16.7 million were underinsured.1 Of those who were insured, some found that their employee premiums increased by up to 63% between 2003 and 2010, and about 25% more individuals faced a deductible payment during the same timeframe. Greater cost-sharing in insurance plans has left women vulnerable to increasing healthcare costs, with the percentage of underinsured women, or women with out-of-pocket costs that were high relative to their income, rising from 12% in 2003 to 18% in 2010.
The failure to provide affordable health insurance has major implications for women’s health. Forty-three percent of U.S. women have reported that they go without recommended healthcare, do not see a healthcare practitioner when ill, or fail to fill prescriptions because of cost, with uninsured women (77%) reporting the highest rates of skipping healthcare because of cost.1 Of women who do seek healthcare,
4 out of 10 report spending $1,000 or more out of pocket, regardless of insured status. Overall, one-fourth of women report having a serious problem paying healthcare bills, with uninsured women (51%) reporting problems with payment or inability to pay.
In addition to the delays in care and economic stress posed by inadequate health insurance coverage, U.S. women are more likely than women in 10 other industrialized countries to have disputes with their insurance company or to discover that their coverage is not what they expected.1 One-third of insured women report having a healthcare claim denied or not having the expected amount paid by their insurance. More than one-fifth of women report spending “a lot of time” on paperwork or disputes related to medical bills. In short, inadequate access to health insurance results in delayed care, additional stress, and lost time, all to the detriment of women’s overall health.

How can improved access to health insurance result in better healthcare for women?

PPACA works to make preventive healthcare more affordable and accessible in several ways.2 First, health insurance issuers that offer coverage through the Health Insurance Marketplace must ensure that coverage includes an “essential benefits package” that includes, among other services, preventive and wellness services, chronic disease management, and maternity and newborn care. In addition, health plans must cover identified preventive services that have strong scientific evidence of benefit without cost-sharing in the form of copays, coinsurance, or deductibles for these services when delivered by a network provider. Preventive services that must be provided without cost-sharing include those with an “A” or a “B” rating in the current U.S. Preventive Services Task Force recommendations; immunizations recommended by the CDC’s Advisory Committee on Immunization Practices; and preventive care and screenings provided in the Health Resource and Services Administration (HRSA)-supported guidelines for infants, children, adolescents, and women. The well-woman visit and the HPV vaccine are on the list of preventive services falling within these recommendations and guidelines.

What do NPs need to know to help women access health insurance coverage?

NPs are in a unique position to assist women in accessing health insurance coverage and preventive health services. First, many women’s health and women’s health-focused NPs practice in settings that provide family planning, prenatal, and well-woman services. Information regarding the Health Insurance Marketplace available at the point of care or provided during outreach efforts can support women in accessing necessary healthcare coverage. In recognition of the important role that NPs in women’s healthcare settings can play in providing information about the Health Insurance Marketplace, on September 12, 2013, NPWH partnered with the HRSA in presenting a webinar regarding the launch of the Health Insurance Marketplace and other PPACA implementation updates. The webinar, featuring Mary Wakefield, PhD, RN, will soon be available on the NPWH website. In the meantime, NPs can access more information about the Health Insurance Marketplaces and links to pertinent government information on the NPWH website. A Provider Marketplace Toolkit, containing state-specific information regarding Health Insurance Marketplace implementation, patient education and handouts, and training for CE credit is available on the HRSA website.
Likewise, inclusion of the well-woman visit as a preventive service without cost-sharing has resulted in renewed interest in identifying the key components of the well-woman visit, and educating women about how the availability of preventive services without cost-sharing affects their ability to increase access to necessary women’s health services. NPWH is participating in a task force, convened by the National Women’s Law Center, that seeks to identify ways to assist women in accessing their preventive benefits without cost-sharing. A toolkit to assist women in understanding their preventive services benefits and tools to use if they encounter problems accessing these services is available from the National Women’s Law Center.


Increasing access to care, improving health outcomes and healthcare service delivery, and decreasing healthcare costs remain priorities for women’s healthcare providers regardless of PPACA implementation. NPs in women’s health have long been identified as part of the solution.
Susan Kendig is a teaching professor and WHNP Emphasis Area Coordinator at the University of Missouri-St. Louis and a consultant at Health Policy Advantage, LLC, in St. Louis, Missouri.
1. Robertson R, Squires D, Garber T, et al. Realizing health reform’s potential. The Commonwealth Fund. 2012. www.commonwealthfund.org/~/media/Files/Publications/

2. The Patient Protection and Affordable Care Act. 2010. www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf
In the Policy & Practice Points department, we seek to provide policy information that is useful, relevant, and timely; and to help NPs understand and address present and emerging health policies that affect our practice and our patients. This department also provides readers with resources to help them play a greater role in using the realities of practice and women’s lives to inform policy. Readers are welcome to send topic suggestions or questions to Beth Kelsey at
bkelsey@healthcommedia.com or Dory Greene at dgreene@healthcommedia.com. We look forward to hearing from you!

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According to the CDC, approximately how many women will develop breast cancer in their life?

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