By Diana M. Drake, DNP, MSN, APRN, WHNP-BC

From the perspective of women’s healthcare providers (HCPs) in the United States, one of the major shifts in their field over the past decade has been a female patient population that is growing older, with an increasing mix of midlife and senior-life patients.

The following demographic changes have created a need for greater access to affordable preventive healthcare services (PHSs).^1-3:

• The nation’s median age rose from 35.3 years in 2000 to 37.9 years in 2016; in an increasing number of states, the median age is 40 years or older;
• According to U.S. census data, the number of persons aged 65 years or older is increasing rapidly; an estimated 1 in 5 persons will be 65 or older by 2035; and
• Average life expectancy for women is now estimated to be 85 years.

From a global perspective, the World Health Organization (WHO) reports that although men slightly outnumber women, the statistics shift with aging because women tend to outlive men.⁴ And women represent an increasingly higher proportion of older adults as they age: 54% of persons aged 60 or older, almost 60% of those aged 75 or older, and 70% of those aged 90 or older are women.⁴ The rapid increase in the number of older women puts pressure on public health services, on HCPs, and on services that support the aging population (e.g., Meals on Wheels, assisted living housing, transportation assistance), making the role of PHSs ever more important.

Of note, access to PHSs across the lifespan aligns directly with the goals of Healthy People 2020.⁵ This program’s goals, created through a collaborative effort of the Federal Interagency Workgroup and the U.S. Department of Health and Human Services (DHHS), provide the overarching vision of a society where all members live long and healthy lives. These goals are:

• To attain high-quality, longer lives free of preventable disease, disability, injury, and premature death;
• To achieve health equity, eliminate disparities, and improve the health of all groups;
• To create social and physical environments that promote good health for all; and
• To promote quality of life, healthy development, and healthy behaviors across all life stages.

To reach the goal of people attaining long and healthy lives in this country, access to affordable healthcare and PHSs is a necessity. However, this access remains an area of inequity and concern in the women’s healthcare field.⁶ Older women in particular are more financially and medically vulnerable than men, and are at greater risk for developing heart disease, depression, stroke, osteoporosis and subsequent fractures, cancer, and autoimmune disease.¹ The WHO reports that older women also experience more disabilities than do men, reflecting broader determinants of health such as:

• inequities in norms/policies that impede women;
• changing household structures (e.g., more single-parent households are headed by women, who earn less money than men); and higher rates of unpaid or informal sector work (e.g., nannies, housecleaners, and immigrant laborers, who are more likely to be women than men, perform fee-for-service work without benefits, and do not pay into Social Security).

All of these factors combine to increase vulnerabilities among women and reduce their access to care.⁴  Ensuring that women receive a comprehensive set of PHSs that do not require a co-payment, co-insurance, or a deductible can diminish some of the inherent obstacles to their living healthy lives.⁷ 

Closing gaps in women’s healthcare

In light of the current administration’s repeal-and-replace proposals for coverage of PHSs for women under the Affordable Care Act (ACA), a brief summary of the activities that have transpired over the past 7 years regarding these services may be helpful, particularly for women’s HCPs who started their careers after 2011. The ACA requires private health insurers to cover recommended PHSs without any patient cost-sharing such as co-pays or deductibles. Generally recommended PHSs include screening for diabetes, obesity, elevated cholesterol, and various cancers, as well as providing counseling for persons who misuse/abuse drugs or tobacco or who are not following healthful diets.⁸ This ACA requirement took effect for new insurance plans sold or renewed in 2010. Approximately 54 million Americans received expanded coverage of PHSs under the ACA in the first 2 years alone. Although gaps in healthcare coverage persist, the number of uninsured patients has continued to decrease.⁹ 

The DHHS’s Health Resources & Services Administration (HRSA) commissioned the Institute of Medicine (IOM; now known as the National Academies of Science, Engineering, and Medicine) to review services and identify gaps specifically with regard to women’s health. In 2011, the IOM published Clinical Preventive Services for Women: Closing the Gaps.¹⁰ In this report, the Committee on Preventive Services for Women also used the Healthy People 2020  goals to identify gaps in women’s healthcare and defined PHSs to be measures shown to improve well-being and/or decrease the likelihood or delay the onset of a targeted disease or condition. These measures include medications, procedures, devices, tests, education, and counseling. PHSs had to meet the following criteria to be considered for coverage:

• The condition to be prevented affects a broad population.
• The condition to be prevented has a large potential impact on health and well-being.
• The quality and strength of evidence is supportive.

The DHHS charged the IOM with ascertaining which PHSs are important to women’s health and well-being and should therefore be considered in the development of comprehensive guidelines. The IOM convened a committee of experts to identify critical gaps in the PHSs already identified in the ACA, which were based on recommendations developed by the U.S. Preventive Services Task Force, the American Academy of Pediatrics’ Bright Futures, and the CDC’s Advisory Committee on Immunization Practices. Based on the IOM committee findings, the HRSA recommended that eight women’s PHSs be provided with no deductible or co-pay, with an update in recommendations required every 5 years. These eight services include screening for gestational diabetes, testing for human papillomavirus, annual counseling about sexually transmitted infections, annual counseling about and screening for HIV infection, education and counseling regarding the full range of FDA-approved contraceptive methods, lactation support and counseling, screening and counseling for interpersonal violence, and an annual well-woman preventive healthcare visit.¹⁰ 

Additional PHS needs of older adults were addressed in a 2011 CDC report in collaboration with the Administration on Aging, the Agency for Healthcare Research and Quality, and the Centers for Medicare and Medicaid Services. The report, Enhancing Use of Clinical Preventive Services Among Older Adults: Closing the Gap, recommends eight potentially life-saving PHSs for adults aged 65 or older¹¹: influenza vaccination, pneumococcal vaccination, breast cancer screening, colorectal cancer screening, diabetes screening, lipid disorder screening, osteoporosis screening, and smoking cessation counseling. Additional recommendations include alcohol misuse screening and counseling, aspirin use, blood pressure screening, cervical cancer screening, depression screening and counseling, obesity screening and counseling, and zoster vaccination.

Translating policy to practice

Patients and HCPs alike witness regular accounts in the news of threats to repeal PHS coverage established through the ACA, Medicaid, and Medicare. Several fundamental women’s PHSs mandated through the ACA are at risk of being diminished or discontinued. Patients have growing concerns about being able to afford these fundamental services, which include cancer screenings, contraception, adult immunizations, and regular preventive healthcare visits. HCPs are being challenged to respond to their female patients in an uncertain practice environment regarding coverage of these PHSs. Although women’s HCPs have trained their focus on their patients’ healthcare needs during the reproductive years, they also need to realize that, as these patients age, they face an increased need for PHSs. Rather than thinking of the field of women’s health as a series of episodic or fragmented events (e.g., pregnancy, menopause), HCPs should consider it a lifelong and inclusive continuum; this approach can optimize and sustain women’s good health for a lifetime.¹² 

From policy to action

In its continuing policy efforts to support PHSs for women, the National Association of Nurse Practitioners in Women’s Health (NPWH) has been an integral member of the multidisciplinary leadership committee that developed the national statement on PHS guidelines for women. The American College of Obstetricians and Gynecologists (ACOG) received a grant from HRSA to update the PHS guidelines for women 5 years after the initial guidelines were developed. NPWH was one of three organizations (the other two were the American Academy of Family Physicians and the American College of Physicians) chosen to work with ACOG as part of the Women’s Preventive Services Initiative (WPSI) Advisory Committee. In December 2016, ACOG published a Consensus of Health Experts statement on the PHSs that women need. HRSA supported the new recommendations and updates that address the unique healthcare needs of women. Gay Johnson, Chief Executive Officer of NPWH, made this announcement: The National Association of Nurse Practitioners in Women’s Health is pleased to endorse the Women’s Preventive Services Initiative (WPSI) recommendations and fully supports the consensus process used by the WPSI advisory panel and steering committee in reaching the final recommendations. This document will provide helpful guidelines and valuable information to all healthcare providers in the care of their patients.

Women’s HCPs are well poised to lead a call to action that will protect, promote, and expand PHSs for women throughout their lifespan. They can do so by:

• Advocating for preservation of access to PHSs for women through the ACA, Medicare, and Medicaid;
• Tracking the current trends, debates, and analysis of national health policies that shape women’s access to care and coverage throughout the lifespan and promoting awareness to colleagues and patients;
• Becoming active members of professional organizations and community action groups to address social determinants of health and health disparities and improve population health by reducing social inequality;
• Working collaboratively with women in health promotion through lifestyle counseling and provision of appropriate PHSs;
• Promoting PHSs in their practices and communities by utilizing currently recommended evidence-based women’s health guidelines. These PHS benefits for patients under the ACA are provided without requiring a co-payment or co-insurance;¹⁴ and
• Promoting PHSs in their practices and in communities for older women by utilizing the currently recommended general PHS guidelines for older adults. These PHS benefits for patients under the ACA are provided without requiring a co-payment or co-insurance.

Changing demographics, along with uncertainties in policy and practice, affect patients and HCPs alike. The percentage of women living longer, productive lives is growing, as is the need for care that optimizes and sustains good health and well-being. Protecting access to PHSs across all of life’s stages helps women make the major shift toward attaining the Healthy People 2020 vision of…high-quality, longer lives free of preventable disease, disability, injury, and premature death.⁵ 

Diana M. Drake is Clinical Associate Professor and Specialty Coordinator of the WHNP Program at the University of Minnesota School of Nursing and Program Director for Integrative Women’s Health at the Women’s Health Specialists Clinic, both in Minneapolis. She serves on the NPWH Board of Directors, Great Lakes Region, and is Chair of the NPWH Policy Committee.

 References

1. Advisory Board, Service Line Strategy Advisor. Women’s Health Market Trends. June 6, 2017.
2. U.S. Census Bureau. United States Census Report. 2017.
3. U.S. Census Bureau. United States Census 2010.
4. World Health Organization. 10 Facts on Health Inequities and Their Causes. April 2017.
5. Healthy People 2020. Framework.
6. National Women’s Law Center. Health Care and Reproductive Rights.
7. Health Resources & Services Administration. Women’s Preventive Services Guidelines. Last reviewed October 2017.
8. Healthcare.gov. Health Benefits & Coverage. Preventive Health Services.
9. Kaiser Family Foundation.
10. 10. Institute of Medicine, Clinical Preventive Services for Women: Closing the Gaps. 2011.
11. CDC. Enhancing Use of Clinical Preventive Services Among Older Adults: Closing the Gap. 2011.
12. Drake D, Torkelson C. Twenty-first century women’s health care. Minn Med. 2012;95(3):34-35.
13. American Congress of Obstetricians and Gynecologists. Consensus of Health Experts Ensure that Women Receive the Preventive Care They Need. December 20, 2016.
14. Healthcare.gov. Preventive Care Benefits for Women.
15. U.S. Preventive Services Task Force. USPSTF A and B Recommendations. September 2017.