Preventative Services for Women’s Health & Well Being

1. Preventative Services for Women’s Health & Well Being Francisco R. Velázquez, M.D., S.M., FCAP Managing Director, Quest Diagnostics Nichols Institute Vice President, Focus Diagnostics

2. Agenda • Population Changes and Demographics • Women and Healthcare • Women’s Health Status/Coverage • Health Interview Survey (selected topics) • Women’s Health and the 2008 Election • PPACA Publication: Women’s Health Perspective • Preventative Services/Research • Long-term Issues/Questions

3. 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 1U.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

4. 2010: Male 75.7 Female 80.8 Population 78.3 2020: Male 77.1 Female 81.9 Population 79.5 Expectation of Life at Birth 2010 – 2020 3 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

5. 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 Life Expectations by Sex, Age and Ethnicity 3

6. 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

7. National Population by Race United States 2010 7,8 7 US Census 2010 Census Data Demographic profiles. http://2010.census-gov/2010census/data last accessed Mary 23, 2011 8 Sharon R. Ennis, Merarys Rio-Vargas and Nora G. Albert. The Hispanic Population: 2010 2010 Census Brief, May 2011

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

9. 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, 2011 11 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, 2011 12 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

10. 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.

11. Women and Healthcare14-16 • 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, 2005 • 16 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.

12. 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 Ibid • 18 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 2010 • 20 Cancer Facts and Figures 2010. American Cancer Society. http://www.cancer.org/acs/groups/content/epidemiologysurveillance/documents/document/acspc-026238.pdf Accessed June 5, 2011 • 21 Hartker, M. MD and Reed, K: The Twelfth Annual Healthgrades Hospital Quality in America Study. Healthgrades, Inc. October 2009

13. 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 Women’s Health Insurance Coverage 22-26 22 Ibid 23 Glied S, Jack K, Rachin, J: Women’s Health Insurance Coverage 1980-2005, Women’s Health Issues: 2008 Jan-Feb; 18(1) 7-16 24 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, 2009 25 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.

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

15. Current Smoking 27Ibid

16. Alcohol Consumption 27Ibid

17. Leisure-time Physical Activity 27Ibid

18. Personal Care Needs 27Ibid

19. Women’s Health and the 2008 Election Top Issues for women 28 Coverage/Affordability Preventive Services & Primary Care Long-term Care/Medicare Reproductive Health 28Kaiser Health Tracking Poll: Election 2008 (conducted April 3-13, 2008) http://www.kff.org/womenshealth/h08_7822.cpm . Last accessed June 1, 2011

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

21. Coverage/affordability Preventative Services/Primary Care Long-Term Care/Medicare Reproductive Health Gender Ratings Imbalance Workplace “Reasonable Accommodations” Health Policy/Health Research PPACA Public Law: Women’s Health Perspective 30-34 30 Ibid 31 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) 18-99 32 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, 2011 33 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, 2011 34 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

22. 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, 2010 36 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 147 37 Women’s Health Research: Progress, Pitfalls and Promise, Institute of Medicine, The National Academy of Sciences Press. Consensus Report pp1-14, September 23, 2010 38 Consolidated Appropriations Act of 2008: 110th Congress, Public Law 110-161 H.R. 2764, December 26, 2007 39 Clinical Preventive Services for Women: Closing the Gaps, The National Academy of Sciences Press, Consensus Report, July 20, 2011 40 The Health Resources and Services Administration (August 1, 2011), http://www.healthcare.gov/news/factsheets/womenprevention08012ulla.html

23. 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* Covered Preventive Services for Women, Including Pregnant Women Services marked with an asterisk (*) must be covered with no cost sharing in plan years starting on or after August 1, 2012 35Ibid

24. 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

25. Health Resources and Services Administration-Supported Women’s Preventive Services: Required Health-Plan Guidelines 36,40Ibid

26. Key Issues Long-Term • Implementation • Affordability and Scope of Coverage • Primary Care and Prevention • Long-Term Care • Research / Policy • Excluded Populations • Economic Recovery

27. Questions…