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On August 1, the Department of Health and Human Services (HHS) released new guidelines on women’s preventive health services, and announced the services for women that insurance plans must cover without co-payments under the Affordable Care Act (ACA).

The HHS guidelines ensure that women across the country will be able to access important services they need without a co-payment — removing a significant barrier to women living healthier lives.

The guidelines follow the release of an Institute of Medicine (IOM) report that outlined eight recommendations for HHS. The IOM was asked to recommend which women’s health services should be added to the list of preventive services that are already exempt from insurance co-pays and deductibles under the ACA.

“For thousands of direct-care workers, the inclusion of women’s preventive health services without co-pays will mean the elimination of cost barriers to seeking important health services,” said Carol Regan, PHI director of government affairs.

Nearly 90 percent of the direct-care workforce is female (pdf).

Co-Pay–Exempt Services

The services that women will have access to without co-pays include:

• well-woman visits
• screening for gestational diabetes
• human papillomavirus (HPV) DNA testing for women age 30 and older
• sexually transmitted infection counseling
• HIV screening and counseling
• Federal Drug Administration–approved contraception methods and contraceptive counseling
• breastfeeding support, supplies, and counseling
• domestic violence screening and counseling

In an attempt to handle objections to the inclusion of contraception, HHS included an exemption for religious institutions.

The exemption of co-pays for these women’s preventive health services will take effect for non-grandfathered private insurance policies beginning August 1, 2012.

According to a recent PHI analysis (pdf), one in four direct-care workers lack health care coverage. Of all direct-care workers, just 47 percent report having employer-sponsored coverage.

Once fully implemented, the ACA will result in 900,000 direct-care workers gaining insurance coverage through Medicaid, and thousands more getting subsidies to make private health coverage more affordable, the analysis shows.

– by the PHI Policy team

The American Health Care Association, a leading long-term care industry group, has announced it will not seek an exemption from the Affordable Care Act‘s requirement that employers with 50 or more full-time employees provide their workers with health coverage.

In a reversal of its initial position, Beth Martino, the AHCA senior director of public affairs, told McKnight’s Long-Term Care News on June 20 that her organization is “not seeking a waiver or change” that would exempt its members from the health reform law’s coverage requirements.

Additionally, LeadingAge, a nonprofit organization that represents nonprofit long-term care providers, has reiterated its support for the coverage provision.

Hidden Costs of Uninsured Workers

In May, the New York Times reported that many nursing homes and home care agencies were seeking an exemption from the law’s requirement to provide health coverage.

The provision in the law, which mandates that employers with 50 or more full-time employees provide coverage or risk paying a penalty, takes effect in 2014. Administrators of some long-term care organizations told the Times they simply could not afford to give their workers affordable coverage.

However, employers who fail to take that step face certain hidden costs, according to LeadingAge President and CEO Larry Minnix.

“These costs include absenteeism and productivity loss,” he told McKnight’s. “In addition, nursing homes that do not offer health insurance are hampered in their ability to recruit and retain highly-qualified staff. This not only affects the bottom line, but also can impact quality of care.”

In a letter to the Times, PHI Government Affairs Director Carol Regan wrote:

Our nation will not be able to build a stable eldercare workforce without adequate public resources to ensure that direct-care workers receive a living wage and health coverage. Simply maintaining the status quo by exempting nursing homes from the requirements of the Affordable Care Act is not a solution.

According to a PHI analysis (pdf), which was reported in the Times:

• 37 percent of direct-care workers employed by home health agencies lack health care coverage, and
• 26 percent of direct-care staff employed in nursing and residential care facilities lack insurance.

– by Matthew Ozga

In recent weeks, numerous media outlets have taken note of the fact that many direct-care workers — who provide the majority of paid hands-on care to elders and people with disabilities — lack health coverage themselves.

Much of the coverage stemmed from the March release of the PHI fact sheet Facts 4: Health Care Coverage for Direct-Care Workers, which found that nearly 1 million direct-care workers — or 28 percent of the total workforce — lacked health coverage at some point in 2009.

Other coverage that cited PHI’s findings includes an article by veteran health reporter Robert Pear in The New York Times about how nursing homes and home care agencies are seeking exemptions from a health-reform provision requiring them to offer health coverage to their employees.

PHI Letter in NY Times Says Maintaining Status Quo Is Not a Solution

Later in the week, the Times also published a letter from PHI in response to the article.

“Our nation will not be able to build a stable elder-care work force without adequate public resources to ensure that direct-care workers receive a living wage and health coverage,” the letter, written by PHI Government Affairs Director Carol Regan, states.

“Simply maintaining the status quo by exempting nursing homes from the requirements of the Affordable Care Act is not a solution,” Regan continues.

Other Media Reports

Pear’s article has continued to receive attention throughout both the trade-industry media and the mainstream media.

For example, McKnight’s Long Term Care News took note of Pear’s front-page piece on its website on May 17.

Some of the other outlets that recently reported on direct-care workers’ lack of coverage include:

• Annals of Long-Term Care: The website of the American Geriatric Society”s medical journal posted a notice to its “LTC Bulletin Board” highlighting PHI’s analysis of insurance rates among direct-care workers.
• Healthcare Finance News: In an article entitled “Workers on the Edge,” HFN associate editor Stephanie Bouchard explains that many direct-care employers encourage their workers to work fewer hours in order to disqualify them from costly employer-provided coverage. Additionally, Regan notes that the Affordable Care Act, which will extend Medicaid coverage to households earning less than 133 percent of the federal poverty level, will have a “huge” effect on direct-care workers.
• Concord Monitor: The editorial board at the New Hampshire capitol’s daily newspaper argues that “nursing home workers and home health care aides are critical societal employees who need and deserve access to quality health care.” The editorial was written in response to Pear’s recent New York Times article.

– by Matthew Ozga

Many nursing homes and home care agencies are lobbying for an exemption from a health-reform mandate requiring employers to offer health coverage to employees beginning in 2014, according to an article published in The New York Times on May 15.

The article by Robert Pear cites PHI research stating that 26 percent of direct-care workers in nursing homes and 37 percent of home care workers lack health coverage.

Under the terms of the Affordable Care Act, employers with 50 or more full-time employees would be required to offer affordable, comprehensive health coverage, or risk facing a penalty.

Long-term care industry groups say that many nursing home and home care agencies cannot afford to pay for their employees’ coverage unless Medicaid and Medicare reimbursement rates are increased, Pear reports.

Others, however, say that the uniquely dangerous work done by direct-care workers is a strong argument in favor of mandatory coverage.

“It’s scandalous to have nursing home employees taking care of people when they themselves lack coverage and go without care,” said Charlene Harrington, a professor at the School of Nursing at the University of California, San Francisco.

Defending the Affordable Care Act in the article, PHI Director of Policy Research Dorie Seavey says, “This assistance could significantly increase coverage among direct-care workers.”

The Times‘s piece has since been cited in these and other articles:

• Connie Schultz, a columnist for the Cleveland Plain Dealer, trails a local direct-care worker, who says she is anxious about what will happen to her job if Medicaid is cut.
• New America Media commentator Paul Kleyman takes a deeper look at The New York Times‘s article.

– by Matthew Ozga

A survey conducted by The Commonwealth Fund found that 27 million working-age women were uninsured for some or all of 2010, and women with low and moderate incomes were much more likely to lack health coverage (pdf) and less likely to get the medical care they need.

These and other survey findings are reported in Women at Risk: Why Increasing Numbers of Women Are Failing to Get the Health Care They Need and How the Affordable Care Act Will Help, The Commonwealth Fund’s May 2011 report based on its Biennial Health Insurance Survey of 2010.

The report explains how the Affordable Care Act (ACA) is “already bringing dramatic change for women and their families” and that greater relief is on the horizon in 2014 when health reform is fully implemented.

Survey Findings

The survey also found that in 2010:

• Half (51 percent) of women with incomes below 133 percent of the federal poverty level were uninsured.
• Women who try to buy coverage in the individual insurance market can pay premiums that are 84 percent higher than men for identical coverage because of gender rating, which is permitted in 42 states.
• Problems paying medical bills and paying off medical debt have increased over the past five years, particularly for women with low and moderate incomes. Two-thirds (64 percent) of women who were uninsured for a time experienced a bill or debt problem in the past year, compared with one-third (36%) of those insured all year.
• More than three of five women with incomes below 200 percent of poverty reported avoiding or delaying timely care — such as filling a prescription or skipping a test, treatment, or follow up — up from just under half in 2001. More than three-quarters (76 percent) of uninsured women went without care because of cost in the past year.
• Less than half (46 percent) of women were up to date on recommended preventive care such as mammograms and cervical cancer screenings, and those with low incomes or without health insurance were far less likely to have had all recommended preventive tests.

The report details the many ways in which the ACA is already making a difference for women, and the ways in which the law will improve coverage when it is fully implemented — especially for women with low incomes, such as direct-care workers (pdf). Among these provisions are:

• Tax credits (pdf) for small business to reduce their health insurance costs (implemented in 2010)
• New coverage of preventive health services with no cost sharing (2010)
• Insurance market reforms such as prohibiting gender rating (2014)
• Coverage can no longer be denied to people with a pre-existing condition (pdf) (2014)
• Medicaid eligibility expansion for all legal residents with incomes up to 133 percent of the federal poverty level (2014)
• Establishment of health insurance exchanges (pdf) (2014)

For more information on health care reform and how it will impact the direct-care workforce and its employers, visit the PHI Health Reform Resource Center and Health Care for Health Care Workers websites.

– by Deane Beebe

A new PHI analysis (pdf) on health care coverage for direct-care workers found that occupation, industry/setting of employment, and geographic region were key indicators of whether these frontline caregivers had coverage.

The new analysis, published in PHI Facts 4, Health Care Coverage for Direct Care Workers: 2009 Data Update (pdf), found that in 2009, of all the nation’s direct-care workers — nursing assistants, home health aides, and personal care aides:

• nearly 1 million (28 percent) were uninsured;
• nearly 20 percent received health coverage through Medicaid or other public insurance at some point during the year; and
• only 47 percent had employer-sponsored coverage — compared to 68 percent of U.S. workers generally.

Home Care Workers More Likely to Be Uninsured

While home care is the fastest-growing long-term care industry, home care aides employed by agencies are more likely to be uninsured and far less likely to have employer-sponsored coverage than direct-care workers who work in other eldercare and disability employment settings.

In 2009, of home care workers employed by agencies:

• 37 percent lacked health coverage, and
• only one-third had employer-sponsored insurance at some point during the year.

“Home care workers support the health and well-being of our rapidly growing aging population, yet these health care jobs are notorious for their lack of adequate health insurance despite very high rates of on-the-job injury,” said Dorie Seavey, Ph.D., PHI director of policy research.

“Without better health coverage for home care workers,” Seavey said, “our nation will have considerable difficulty attracting a stable, qualified workforce to support elders and people with disabilities who want to remain in their homes and communities.”

Coverage Varies by Regions

Health coverage for direct-care workers also varies considerably by region of the country.

In New England, for example, 13 percent of direct-care workers lacked coverage compared to 45 percent of direct-care workers in the West South Central region. These variations are largely due to state differences in Medicaid eligibility and the existence of collective bargaining agreements that secure health insurance for workers, PHI Facts 4 explains.

Health Reform: A Remedy

The new PHI analysis also provides the first assessment available of the likely impact of the Affordable Care Act on the direct-care workforce. When fully implemented in 2014, the act opens up the Medicaid program to all adults who earn less than 133 percent of the federal poverty level.

PHI finds that over 900,000 direct-care workers lived in households under 133 percent of the federal poverty level in 2009. As many as 40 percent of these workers were uninsured while 30 percent relied on public insurance, and another 30 percent had some kind of private insurance.

“The Affordable Care Act’s expansion of Medicaid eligibility to 133 percent will significantly reduce the number of uninsured direct-care workers,” said Carol Regan, PHI government affairs director.

“Since employer-sponsored insurance is either not available or not affordable for most direct-care workers, the importance of a strong, responsive public insurance system could not be more essential to determining the future of the eldercare/disabilities workforce.”

The complete analysis is available in PHI Facts 4, Health Care Coverage for Direct Care Workers: 2009 Data Update (pdf), which was made possible with support from The SCAN Foundation.

More information on health coverage and the direct-care workforce can also be found at PHI Health Care for Health Care Workers and in the PHI Chart Gallery.

– by Deane Beebe