THE COMMONWEALTH FUND Oceans Apart: The Higher Health Costs of Women in the U.S. Compared to Other Nations, and How Reform Is Helping Ruth Robertson, M.Sc. Senior Research Associate, Affordable Health Insurance The Commonwealth Fund Media Teleconference July 12th, 2012 EMBARGOED: Not for release before 12:01 a.m. ET, Friday, July 13, 2012

Exhibit 1. About This Study Most data are from the Commonwealth Fund International Health Policy Survey in Eleven Countries, 2010. A general population survey conducted by telephone by Harris Interactive and country contractors March-June 2010. Countries included: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. For this analysis, the sample was restricted to females ages 19-64 (n=8,197). The report also includes data from the Commonwealth Fund Biennial Health Insurance Surveys 2003, 2007 and 2010, and the March Annual Supplement to the Current Population Survey (CPS) (2001 – 2011).

Exhibit 2. Summary of Main Findings Millions of U.S. Women Lack Adequate Health Insurance 18.7 million women uninsured in 2010, up from 12.8 million in 2000. 16.7 million women underinsured in 2010, up from 10.3 million in 2003. U.S. Women Report Highest Rates of Health Care Affordability Problems Among Eleven Countries More than two of five (43%) U.S. women skipped needed care because of cost in past year; 77% of U.S. women uninsured during the year. In ten other countries the rate was no more than 28%. Nearly two of five (39%) spent $1,000 or more out of pocket on health care in past year (excluding premiums), compared to no more than 24% in ten other countries. One quarter (26%) had problems paying medical bills, more than double the rate in ten other countries; 51% of U.S. women uninsured during the year had medical bill problems. The Affordable Care Act is Already Helping Women And Will Provide Near Universal Coverage With Comprehensive Benefits Starting 2014

Exhibit 3. Nearly 19 Million U. S Exhibit 3. Nearly 19 Million U.S. Women Ages 19 - 64 Uninsured in 2010, Up 6 Million 2000 - 2010 Millions of U.S. women, ages 19 - 64 Source: Analysis of the Current Population Survey March 2001 – 2011, by N. Tilipman and B. Sampat of Columbia University for The Commonwealth Fund

Exhibit 4. Increasing Numbers of U. S Exhibit 4. Increasing Numbers of U.S. Women Have Health Insurance That Does Not Adequately Protect Them From Large Medical Bills Percent of U.S. women, ages 19-64 who were underinsured* *Underinsured defined as insured all year but experienced one of the following: medical expenses equaled 10% or more of income; medical expenses equaled 5% or more of income if low-income (<200% of poverty); or deductible equaled 5% or more of income. Note: FPL refers to federal poverty level Source: Commonwealth Fund Biennial Health Insurance Surveys (2003, 2007, 2010).

Exhibit 5. Women in the United States Have The Highest Rates of Cost-Related Problems Getting Needed Care Percent of women, ages 19-64, who experienced any access problem because of cost in the past year* United States International *Experienced any of the following because of cost: did not fill a prescription for medicine or skipped doses; had a specific medical problem but did not visit a doctor; skipped or did not get a medical test, treatment, or follow-up that was recommended by a doctor. **Combines “Insured now, time uninsured in past year” and “Uninsured now”. Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries

Exhibit 6. Women in the United States Have Highest Rates of Spending $1,000 or More on Out of Pocket Medical Expenses Percent of women, ages 19-64, who had out-of-pocket medical expenses in the past year of $1,000 or more (excluding premiums) United States International *Combines “Insured now, time uninsured in past year” and “Uninsured now”. Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries

Exhibit 7. Women in the United States Report Problems Paying Medical Bills at More Than Double the Rate of Women in Ten Other Countries. Percent of women, ages 19-64, who had a serious problem paying or were unable to pay medical bills in the past year United States International *Combines “Insured now, time uninsured in past year” and “Uninsured now”. Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries

Exhibit 8: The Affordable Care Act Is Already Helping Women Provisions Specifically Focused On Improving Women’s Health 20.4 million women benefited from requirement insurance plans (non-grandfathered) cover preventive care (e.g. mammograms, pap tests) without cost sharing, and direct access to obstetrics and gynecology services. Beginning August 2012, new set of preventive services for women covered without cost- sharing including family planning services. Medicaid covers smoking cessation support for pregnant women and care from free- standing birth centers. Breaks to express breast milk for new mothers in firms with 50 or more employees. Other Provisions That Are Helping Women Gain Access To Affordable Health Insurance And Health Care 6.6 million young adults ages 19–25 stayed on or joined parents’ health plans in 2011 who would likely not have been able to do so prior to the law; 3.1 million were women. More than 2 million women with Medicare have saved $1.2 billion in prescription drug costs from the phase-out of the Medicare “donut hole.” Nearly 25 million women with Medicare benefitted from preventive services without cost sharing. 7 states and DC expanded Medicaid eligibility for adults, covering 600,000 more people. 39.5 million women benefitted from ban on insurance companies imposing lifetime benefit limits, 5.5 million benefited from ban on rescissions. 62,000 enrolled in pre-existing condition insurance plans, more than half are women.

Exhibit 9. Premium Tax Credits and Cost-Sharing Protections Under the Affordable Care Act Poverty level Income Premium contribution as a share of income Out of Pocket limits % Medical Costs Covered On Average: Silver plan <133% Single: <$14,856 Family: <$30,657 2% (or Medicaid) Single: $1,983 Family: $3,967 94% 133%- 149% Single: $14,856 - <16,755 Family: $30,657 - <34,575 3.0%–4.0% 150%–199% Single: $16,755 - <22,340 Family: $34,575 - <46,100 4.0%–6.3% 87% 200%–249% Single: $22,340 - <27,925 Family: $46,100 - <57,625 6.3%–8.05% Single: $2,975 Family: $5,950 73% 250%–299% Single: $27,925 - <33,510 Family: $57,625 - <69,150 8.05%–9.5% 70% 300%–399% Single: $33,510 - <44,680 Family: $69,150 - <92,200 9.5% Single: $3,967 Family: $7,933 400%+ Single: $44,680+ Family: $92,200+ — Single: $5,950 Family: $11,900 All Plans Cover Essential Health Benefit Package at Four Levels of Cost-sharing: 1st tier (Bronze) actuarial value: 60% 2nd tier (Silver) actuarial value: 70% 3rd tier (Gold) actuarial value: 80% 4th tier (Platinum) actuarial value: 90% Catastrophic policy with essential health benefits package available to young adults and people whose premiums are 8%+ of income Note: Premium and cost-sharing credits are for silver plan. Source: Federal poverty levels are for 2012; Commonwealth Fund Health Reform Resource Center: What’s in the Affordable Care Act? (PL 111-148 and 111-152), http://www.commonwealthfund.org/Health-Reform/Health-Reform-Resource.aspx.

Exhibit 10. Percent of Women Ages 19 – 64 Uninsured by State, 2009-10 and Under the Affordable Care Act When Fully Implemented Affordable Care Act Fully Implemented (estimated) 2009-2010 NH WA VT ME NH MT WA VT ME ND MT ND OR MN ID SD WI NY MA OR MN WI NY WY MI SD MA PA RI ID WY MI RI IA NJ CT NE PA CT NV OH IA NJ UT IL IN WV DE NE OH MD NV DE CO VA KS MO DC UT IL IN WV MD CA KY CO VA CA MO DC NC KY TN KS NC AZ OK SC TN NM AR AZ OK AR SC MS AL GA NM MS AL GA TX LA TX LA FL FL <7% AK HI 7-<11% AK HI 11-<16% 20% of Women Ages 19-64 Uninsured 8% of Women Ages 19-64 Uninsured 16-<21% 21-30% Source: Analysis of the March 2011 and 2010 Current Population Survey by N. Tilipman and B. Sampat of Columbia University for The Commonwealth Fund, uninsured rates are two year averages. Estimates for Affordable Care Act when fully implemented, by Jonathan Gruber and Ian Perry of MIT using the Gruber Microsimulation Model for The Commonwealth Fund.

Exhibit 11. Conclusions 35 Million Women Uninsured or Underinsured in 2010 Uninsured up 46% since 2000. Underinsured up 62% since 2003. U.S. Women Report Highest Rates of Health Care Affordability Problems Among Eleven Countries U.S. women more likely than women in ten other countries to skip needed care because of cost, spend $1,000 or more out of pocket on health care, and have medical bill problems. Uninsured women are most at risk. The Affordable Care Act is Already Helping Women Preventive care without cost sharing for privately insured and Medicare. Coverage on parents plans to age 26. Pre-existing condition insurance plans. Consumer protections for health plans. Phase-out of Medicare prescription drug donut hole. In 2014 The Law Will Provide Near Universal Insurance and Improve Coverage Expanded options for affordable health insurance and new consumer protections. No preexisting condition exclusions or rating based on health or gender. Essential health benefits, 8.7 million people with individual market plans gain maternity benefits. Full implementation of both the insurance market and delivery system reforms in the law will be critical to closing the gap between the health care affordability experiences of women in the U.S. and those of women in other countries.