Access to healthcare is critical for women to benefit from the preventive service coverage with no out-of-pocket cost provision in the ACA. Having sufficient access means consumers have the ability to afford health care services, access a health care location where needed services are provided in a timely manner, and find a health care provider with whom the patient can communicate and trust.²³ Gaining entry into the health care system in the United States generally begins with having health insurance. Accessing a health care location to receive preventive services requires consumers to find a primary care provider who will accept them as a patient. And, in order to benefit from coverage without out-of-pocket costs for preventive services, this provider must be within the patient’s insurance network of providers. Successfully navigating all of these steps can be difficult given a shortage of primary care providers and family physicians who serve women.^{24, 25} This may also be a challenge for women newly enrolled in a health insurance plan and not familiar with using health insurance to access primary care services. Assuming a consumer is able to secure a primary care provider and schedule a timely appointment, she must still make it to her appointment—a task that may be challenging for women who work, care for children, provide eldercare, or do both. Making scheduled appointments becomes more difficult if women encounter barriers to transportation, a factor that continues to adversely affect access to healthcare in the United States.²⁶ In the end, preventive service coverage alone is not sufficient for women to access preventive care.

Fortunately, there are a number of ACA provisions that aim to improve patient access to primary care. Patients’ access to preventive care is primarily expanding as more Americans gain entry into the health system by obtaining health insurance coverage through the Health Insurance Marketplace. To date, an estimated 16.4 million previously uninsured people have gained health insurance coverage since the implementation of the ACA coverage provisions.²⁷ As the number of insured Americans continues to rise, the ACA expands the capacity to provide primary care services by funding efforts to support the operation, expansion and construction of community health centers throughout the country over five years (§5313).²⁸ This funding is expected to increase the number of patients served by community health centers by 4.5 million – from 19.5 million in 2010 to a projected 24 million in 2014.²⁸ In turn, these clinics are supported by HRSA to receive recognition as patient centered medical homes (PCMHs), a designation reserved for clinics that achieve quality standards such as ensuring patient-centered access to care by expanding operating hours and offering alternative types of clinical encounters.^{29, 30} In parallel, the ACA is expanding the primary care workforce by increasing investments in the National Health Service Corps, a program that funds 9,200 Corps clinicians to serve in medically underserved communities, and increasing investments in primary care residency positions and programs.^{31, 32} Collectively, these ACA provisions are perceived to be improving consumers’ access to preventive care.^{7, 33}

The ACA’s preventive service coverage requirement has been in effect for certain plans for up to five years for the USPSTF and ACIP services and for up to two years for the HRSA-endorsed women’s preventive services. A poll conducted in March of 2014 found that fewer than half of Americans were aware that the ACA eliminates out-of-pocket costs for select preventive care.³⁴ Addressing this knowledge gap is critical to optimizing preventive care receipt, especially among women given the tendency for women to forgo care due to cost or perceived cost. A recent survey found that 20% of women aged 18–64 report they postponed preventive services in the past year due to cost, including 13% of insured and 52% of uninsured women.³⁵ Knowing that some preventive care is available at no out-of-pocket cost may help mobilize consumers to seek out these services. Increased efforts by health care and public health professionals to make more women and their providers aware of this special coverage could help increase uptake of preventive services.

The U.S. Department of Health and Human Services is making strides to increase the public’s knowledge about preventive service coverage and other health insurance benefits. There are a number of resources and tools available to help consumers learn about their preventive service coverage benefit. The Centers for Medicare and Medicaid Services (CMS) leads an initiative called “Coverage to Care,” a campaign to help people use their health care coverage to access primary care.³⁶ Consumers can access the Coverage to Care Roadmap online at http://www.hhs.gov/healthcare/prevention/index.html. Healthcare professionals can also download or order free Coverage to Care materials online at http://marketplace.cms.gov/c2c. CMS also houses the Center for Consumer Information and Insurance Oversight (CCIIO), a government resource center that provides information and technical support through the Consumer Assistance Program to help consumers understand their health insurance coverage and, if appropriate, appeal coverage decisions.³⁷

Consumer education about the value of clinical preventive services can be a contributing factor to the receipt of services.³⁸ If women are aware of the health benefits that preventive services may offer, they may be more inclined to receive recommended care.³⁹ For example, data suggest lack of knowledge is the main reason why parents of girls allow their child to go without receiving the ACIP-recommended vaccine that protects against HPV infection.^{21, 40} If more unvaccinated young women were informed about the benefits of the HPV vaccine – and its potential for being covered with no out-of-pocket costs – HPV vaccination coverage could rise.

Addressing knowledge deficits about recommended preventive care and the health benefits of these services is a key step to increase receipt of preventive care. Recently a wealth of consumer-facing information about recommended preventive services has been made publicly available online. One new consumer-facing tool is CDC’s Prevention Checklist, an interactive tool, also available as a mobile application, that produces a list of recommended preventive services specific to the user based on sex, age and, if appropriate, pregnancy status.⁴¹ Each service in the list also has a link to valid information about the preventive services for consumers. This tool is available online at http://www.cdc.gov/prevention/. Medicare also provides information about Part B preventive services coverage at http://www.medicare.gov/coverage/preventive-and-screening-services.html. Despite the public availability of this information, it remains critical for patients to speak with their providers about the preventive services that are recommended for them. This patient-provider dialogue is fundamental to the delivery of preventive services.^42–44 Given their knowledge of their patients’ medical history and family health history and their extensive knowledge about the risks and benefits associated with preventive services, primary care providers are uniquely situated to champion the delivery of recommended preventive services.

Receipt of clinical preventive services may also face barriers from the supply side. One key factor is the limited amount of time a provider has to provide preventive services. Yarnall et al. estimated that it would take a primary care provider in a standard-sized practice 7.4 hours of every working day to implement all of the USPSTF recommendations in every case that warranted a preventive service.⁴⁵ The authors also found that it would take two hours of every working day just providing the services recommended with an “A” grade by the USPSTF.⁴⁶ These time constraints may limit the degree to which primary care providers prioritize the delivery of preventive services during patient visits.

An emerging body of evidence suggests leveraging the workforce of other State-qualified non-licensed providers, like community health workers, can be an effective way to improve uptake of appropriate preventive services and help alleviate the limitations that come with health care provider time constraints.^47–51 With appropriate training and supervision, community health workers may be used to provide services like one-on-one counseling services.⁵² These counseling services may address women’s health issues such as breastfeeding, contraceptives, intimate partner violence, prevention of sexually transmitted infections and HIV, or diet and nutrition—all of which are services made available without out-of-pocket costs through the preventive services coverage requirement. Studies have also shown that community health worker interventions can increase preventive service receipt, particularly for immunizations, mammograms, cervical cancer screenings, and blood pressure management services.^{47, 48, 53, 54} Overall, implementing a policy that authorizes non-physician team members, such as nurses, pharmacists, and community health workers, to support primary care providers in the education or provision of preventive services can be an effective approach to address provider time constraints and increase the provision of preventive services.^{55, 56} States are beginning to explore financing options to sustain the workforce of non-licensed providers, allowing for more clinics to adopt team-based models of care.⁵⁷

The movement to improve the quality of care provided has also led to the development of new models of care that hold promise for increasing receipt of recommended services. For example, the National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home Recognition program is the program that HRSA is using to certify HRSA-funded health centers as PCMHs across the nation. It has a “must-pass” standard that requires PCMH-recognized clinics to monitor receipt of preventive care services, chronic care measures, and/or immunization coverage for their patient population.³⁰ Studies suggest adoption of this PCMH model increases preventive service receipt.^58–60 Emerging payment models being explored by the CMS Center for Medicare and Medicaid Innovation are also expected to drive improvement in preventive service receipt.⁶¹ Meaningful use of certified electronic health record (EHR) systems through the Medicare and Medicaid EHR Incentive Programs, for example, includes components that require providers to use clinical decision support tools to provide evidence-based care and develop registries to identify patients who are not up-to-date on their recommended preventive care. The 2019 launch of the Merit-based Incentive Payment System, a new quality reporting system that adjusts payments for services provided to Medicare beneficiaries based on providers’ performance measures, is expected to accelerate and sustain this movement towards value-based payment.⁶² These types of systems are anticipated to improve receipt of appropriate clinical preventive services.