Jared B. Fox, PhD1, Frederic E. Shaw, MD, JD2 (Author affiliations at end of text)
Each year in the United States, an estimated 100,000 deaths could
be prevented if persons received recommended clinical preventive care (1).
The Affordable Care Act has reduced cost as a barrier to care by
expanding access to insurance and requiring many health plans to cover
certain recommended preventive services without copayments or
deductibles.
To establish a baseline for the receipt of these services
and to begin monitoring the effects of the law, CDC analyzed responses
from persons aged ≥18 years in the National Health Interview Survey
(NHIS) for the years 2011 and 2012 combined.
This report summarizes the
findings for six services covered by the Affordable Care Act.
Among the
six services examined, three were received by less than half of the
persons for whom they were recommended (testing for human
immunodeficiency virus [HIV] and vaccination for influenza and zoster
[shingles]).
Having health insurance or a higher income was associated
with higher rates of receiving these preventive services, affirming
findings of previous studies (2 
).
Securing health insurance coverage might be an important way to
increase receipt of clinical preventive services, but insurance coverage
is not all that is needed to ensure that everyone is offered and uses
clinical services proven to prevent disease.
Greater awareness of
Affordable Care Act provisions among public health professionals,
partners, health care providers, and patients might help increase the
receipt of recommended services (3).
The analysis focused on responses to questions about the receipt
of six clinical preventive services recommended by the U.S. Preventive
Services Task Force (USPSTF) or the Advisory Committee for Immunization
Practices (ACIP).
The six preventive services are among dozens of
services for adults covered without copayments or deductibles under
certain health plans according to the Affordable Care Act,*
and were selected for this analysis because the recommendations closely
fit NHIS survey questions.
The six were as follows:
HIV testing,
smoking cessation discussion,
influenza vaccination,
pneumococcal
vaccination,
tetanus vaccination, and
zoster (shingles) vaccination.
However, the recommendations and NHIS questions are not a perfect match.
For example, cessation intervention is recommended for all forms of
tobacco use, but respondents were only asked about receiving smoking
cessation interventions.
The fit between the NHIS questions and the
recommendations varied among the six preventive services (Table 1).
NHIS is administered by in-person interviews to a nationally
representative sample of the noninstitutionalized, U.S. civilian
population.
For this analysis, NHIS data from the sample adult core
questionnaire in 2011 and 2012 were combined to increase sample sizes
and improve reliability of estimates.
In each household identified, one
adult (aged ≥18 years) from each family was randomly selected to
complete the questionnaire.†
NHIS 2011 and 2012 adult core samples included 33,014 and 34,525
respondents, respectively, and the overall response rates were 66.3% and
61.2%.
Participants were asked whether they had health insurance at the
time of the interview.
They were considered uninsured if they reported
currently not having private health insurance, Medicare, Medicaid,
Children's Health Insurance Program, a state-sponsored or other
government-sponsored health plan, or a military plan.
Respondents also
were defined as uninsured if they had only a private plan that paid for
one type of service (e.g., injury or dental care) or had only Indian
Health Service coverage.§
Multiple imputations were performed on family income to account for missing responses to income questions.¶
NHIS data were adjusted for nonresponse and weighted to provide
national estimates of insurance status and receipt of preventive care;
95% confidence intervals were calculated, taking into account the
survey's multistage probability sample design.
Generalized linear
modeling and the t-test were used to calculate prevalence ratios and
statistical significances of differences in preventive services receipt
between
1) persons who were insured and those who were uninsured,
2)
those with current family incomes >200% of the federal poverty level
(FPL) ($46,100 for a family of four in 2012**)
and those with incomes ≤200% of the FPL, and
3) those with any private
health insurance and those with only public coverage.
For the six services examined, prevalence of receipt of service
was as follows:
zoster vaccination, 17.9%;
influenza vaccination, 39.4%;
HIV testing, 41.7%;
smoking cessation discussion, 52.0%;
pneumococcal
vaccination, 61.4%; and
tetanus vaccination, 62.0% (Table 2).
A higher percentage of adults with health insurance received five of
six recommended clinical preventive services (all but HIV testing)
compared with those who were uninsured (Table 2).
Among those five services, the service receipt prevalence ratio for
those with insurance compared with those without insurance ranged from
1.2 for tetanus vaccination to 3.4 for pneumococcal vaccination (Table 2).
However, service receipt for persons with health insurance was <50%
for three of six recommended clinical preventive services.
Persons with family incomes >200% of the FPL received five of
six recommended clinical preventive services at a statistically
significant higher prevalence compared with those with incomes below
that threshold (Table 3).
Among those five services, the service receipt prevalence ratio for
those with family incomes >200% of the FPL compared with those with
incomes ≤200% of the FPL ranged from 1.1 for pneumococcal vaccination to
1.9 for zoster vaccination (Table 3).
Persons with private health insurance received three of six
recommended clinical preventive services at a higher prevalence, and
three of six at a lower prevalence, compared with those with only public
insurance (Table 4).
Discussion
The findings in this report indicate that during 2011–2012, large
portions of the adult population were not receiving recommended
preventive care, those with insurance were more likely to receive
recommended preventive services than those without coverage, and those
with higher income were more likely to receive recommended care.
This
supports previously published studies, including one that found
prevalence ratios in the range of 1–3 for those with insurance receiving
recommended preventive services compared with those without coverage (2 ).
However, even among persons with insurance and higher income, in this
analysis, receipt of recommended preventive services was suboptimal.
This report could serve as a baseline for tracking the effects of
the Affordable Care Act on the receipt of six preventive services.
Although the law began to require certain plans to cover clinical
preventive services in September 2010, the data from 2011–2012 provide a
feasible baseline for measuring the law's effects because
1) a high
number of persons remained uninsured during 2011–2012,
2) there was
little awareness of the preventive care provisions of the new law, and
3) many plans in existence before enactment of the Affordable Care Act
were not subject to the preventive services provisions (4–6).
The findings in this report are subject to at least four
limitations.
First, this was a cross-sectional study, and associations
between receipt of a service and other factors do not imply a causal
relationship.
Second, insurance coverage and income level are just two
of many factors that might be associated with service receipt rates.
This analysis does not include possible confounders such as education,
health status, or other factors.
Third, receipt of preventive services
was self-reported and might be subject to recall bias.
Finally,
inferences from these results are limited by differences in time between
when the questions were asked and when the services were received.
For
example, NHIS identifies whether the respondent is insured at the time
of interview; however, depending on the service, NHIS asks whether the
respondent received preventive care in the last 12 months, last 10
years, or ever during their lifetime.
Currently uninsured respondents
might have received preventive care during a time when they had
insurance, or vice versa.
In addition, NHIS is limited to
noninstitutionalized civilians, excluding certain populations (e.g., the
institutionalized and the military) that might be especially likely to
receive recommended preventive services.
All new private health plans, alternative benefit plans for the
newly Medicaid eligible, and Medicare now provide coverage without
copayments or deductibles for recommended clinical preventive services.
By expanding access to insurance and requiring many plans to cover
recommended clinical preventive services, the Affordable Care Act is
expected to reduce barriers to receipt of recommended preventive care.
The number of uninsured persons aged <65 years is expected to drop
from 55 million in 2013 to 30 million in 2017 (7).
Lack of insurance, however, is not the only barrier to receiving
services; a number of other factors likely will continue to inhibit
receipt of preventive care.
First, many persons are currently insured
under "grandfathered" health plans not required to provide coverage
without copayments or deductibles for all recommended preventive
services (8).
Second, other barriers, such as transportation
costs and lack of a regular physician, might inhibit receipt of
recommended preventive care.
Finally, even after the Affordable Care Act
is implemented fully, millions of persons are expected to remain
uninsured (7).
To date, about half of the 50 states have not yet
implemented the law's expansion of Medicaid, leaving an estimated 40% of
their adult residents who have been uninsured in the last 2 years
without access to affordable care (9).
Studies have indicated
that 60%–74% of children who are eligible for Medicaid are uninsured, in
part as a result of failure to renew enrollment in Medicaid (10).
Efforts to increase enrollment and coverage retention could help these
populations maintain continuous coverage, thereby increasing receipt of
preventive services and reducing avoidable complications from illness,
long-term health care costs, and premature deaths (10).
Office of Health System Collaboration, Office of the Associate Director for Policy, CDC; 2Center for Surveillance, Epidemiology, and Laboratory Services, CDC
(Corresponding author:
References
- National Commission on Prevention Priorities. Preventive
care: a national profile on use, disparities, and health benefits.
Washington, DC: Partnership for Prevention, National Commission on
Prevention Priorities; 2007. Available at http://www.prevent.org/data/files/initiatives/ncpppreventivecarereport.pdf
.
- CDC. Use of selected clinical preventive services among adults—United States, 2007–2010. MMWR 2012;61(Suppl) .
- Frieden TR. Six components necessary for effective public health program implementation. Am J Public Health 2014;104:17–22.
- Kaiser Family Foundation; Health Research and Educational
Trust. Employer health benefits: 2011 annual survey. Menlo Park, CA:
Kaiser Family Foundation; Chicago, IL: Health Research and Educational
Trust; 2011. Available at http://kaiserfamilyfoundation.files.wordpress.com/2013/04/8225.pdf .
- Kaiser Family Foundation; Health Research and Educational
Trust. Employer health benefits: 2012 annual survey. Menlo Park, CA:
Kaiser Family Foundation; Chicago, IL: Health Research and Educational
Trust; 2012. Available at http://kff.org/report-section/ehbs-2012-section-13.
- Reed ME, Graetz I, Fung V, Newhouse JP, Hsu J. In
consumer-directed health plans, a majority of patients were unaware of
free or low-cost preventive care. Health Aff (Millwood) 2012;31:2641–8.
- Congressional Budget Office. Insurance coverage provisions of
the Affordable Care Act—CBO's February 2014 baseline. Washington, DC:
Congressional Budget Office; 2014. Available at http://www.cbo.gov/sites/default/files/cbofiles/attachments/43900-2014-02-ACAtables.pdf .
- Kaiser Family Foundation; Health Research and Educational
Trust. Employer health benefits: 2013 annual survey. Menlo Park, CA:
Kaiser Family Foundation; Chicago, IL: Health Research and Educational
Trust; 2013. Available at http://kaiserfamilyfoundation.files.wordpress.com/2013/08/8465-employer-health-benefits-20131.pdf .
- Rasmussen PW, Collins SR, Doty MM, Garber T. In states' hands:
how the decision to expand Medicaid will affect the most financially
vulnerable Americans. Issue Brief (Commonw Fund) 2013;23:1–8.
- Sommers BD. Why millions of children eligible for Medicaid and
SCHIP are uninsured: poor retention versus poor take-up. Health Aff
(Millwood) 2007;26:w560–7.
What is already known on this topic?
Rates of receipt of some clinical preventive
services by adults are low, but higher for persons with insurance
coverage or higher incomes.
The Affordable Care Act's expansions of
health insurance access and coverage requirements for clinical
preventive services were developed to increase access to health services
to improve the health of the population.
What is added by this report?
Analysis of combined adult responses to the
National Health Interview Survey in 2011 and 2012 indicated that persons
with health insurance were more likely to have received five of six
recommended preventive services than persons without insurance.
However,
regardless of insurance status, receipt was below 50% for three
services and ranged from 17.9% for zoster vaccination to 62.0% for
tetanus vaccination.
What are the implications for public health practice?
Increased insurance coverage might lead to a
substantial increase in receipt of preventive care and improvements in
population health.
However, low rates of service receipt even among
those with insurance suggest that additional efforts beyond insurance
coverage expansion might be needed to increase offering and use of
services.
|
Clinical preventive service (age group)
|
Recommendation
|
Question to NHIS participants
|
Key distinctions for this analysis of use of recommended services
|
|
HIV test (age 18–65 years)
|
HIV infection screening is
recommended for persons aged 15–65 years. Screening is recommended for
other age groups at increased risk. Recommended screening interval for
the general population is not specified.*
|
To adults aged ≥18 years: "Except for tests you may have had as part of blood donations, have you ever been tested for HIV?"†
|
NHIS asks this question to those aged ≥18 years. Those aged 15–17 years are not included in the analysis.
|
|
Smoking cessation discussion (age ≥18 years)
|
Tobacco cessation interventions
are recommended for those who use tobacco products. A recommended
screening interval for the general population is not specified.*
|
To adults aged ≥18 years who
currently smoke cigarettes every day or some days: "During the past 12
months, has a doctor or other health professional talked to you about
your smoking?"
|
Adults who use tobacco only in forms other than cigarettes are not included in the analysis.
|
|
Influenza vaccination (age ≥18 years)
|
Annual vaccination against influenza is recommended for all persons aged ≥6 months.§
|
To adults aged ≥18 years: "During
the past 12 months, have you had a flu shot?" and "During the past 12
months, have you had a flu vaccine sprayed in your nose by a doctor or
other health professional?" A"yes" response to either question is coded
as vaccination received.
|
This analysis focuses on adults aged ≥18 years.
|
|
Pneumococcal vaccination (age ≥65 years)
|
Pneumococcal vaccination is
recommended for all persons aged ≥65 years and for persons with certain
other risk factors aged <65 years.§
|
"Have you ever had a pneumonia shot?"†
|
This analysis focuses on those aged ≥65 years.
|
|
Tetanus vaccination (age ≥19 years)
|
Vaccination with Td booster (or 1-time dose of Tdap) for all adults aged ≥19 years.§
|
To adults aged ≥18 years: "Have you received a tetanus shot in the past 10 years?"
|
This analysis focuses on those aged ≥19 years for consistency with the recommendation for adults.
|
|
Zoster (shingles) vaccination (age ≥60 years)
|
Zoster vaccination is recommended for adults aged ≥60 years.§
|
To adults aged ≥50 years: "Have you ever had the zoster or shingles vaccine, also called Zostavax?"†
|
This analysis focuses on those aged ≥60 years for consistency with the recommendation for adults.
|
|
Clinical preventive service (age group)
|
Insured receiving service
|
Uninsured receiving service
|
Prevalence
ratio,
insured/
uninsured*
|
(95% CI)
|
Total receiving service
|
|
No.
|
%
|
(95% CI)
|
No.
|
%
|
(95% CI)
|
%
|
(95% CI)
|
|
HIV test (ever) (age 18–65 years)
|
40,823
|
41.5
|
(40.7–42.2)
|
11,641
|
43.1
|
(41.9–44.3)
|
1.0†
|
(0.9–1.0)
|
41.7
|
(41.1–42.4)
|
|
Smoking cessation discussion (within 12 mos) (age ≥18 years)
|
8,935
|
59.1
|
(58.0–60.3)
|
3,497
|
32.7
|
(31.1–34.4)
|
1.8§
|
(1.7–1.9)
|
52.0
|
(51.0–53.0)
|
|
Influenza vaccination (within 12 mos) (age ≥18 years)
|
54,217
|
44.2
|
(43.6–44.7)
|
11,888
|
14.7
|
(13.9–15.4)
|
3.0§
|
(2.9–3.2)
|
39.4
|
(38.9–40.0)
|
|
Pneumococcal vaccination (ever) (age ≥65 years)
|
13,585
|
61.7
|
(60.6–62.7)
|
113
|
18.1
|
(9.1–27.0)
|
3.4§
|
(2.1–5.6)
|
61.4
|
(60.3–62.4)
|
|
Tetanus vaccination (within 10 years) (age ≥19 years)
|
51,872
|
63.7
|
(63.0–64.3)
|
11,431
|
53.7
|
(52.6–54.8)
|
1.2§
|
(1.2–1.2)
|
62.0
|
(61.5–62.6)
|
|
Zoster vaccination (ever) (age ≥60 years)
|
18,297
|
18.4
|
(17.6–19.2)
|
868
|
6.3
|
(4.2–8.4)
|
2.9§
|
(2.1–4.1)
|
17.9
|
(17.1–18.7)
|
|
Clinical preventive service (age group)
|
Income >200% FPL receiving service
|
Income ≤200% FPL receiving service
|
Prevalence
ratio,
higher income/
lower income*
|
(95% CI)
|
|
No.
|
%
|
(95% CI)
|
No.
|
%
|
(95% CI)
|
|
HIV test (ever) (age 18–65 years)
|
31,948
|
40.2
|
(39.4–40.9)
|
25,815
|
44.6
|
(43.5–45.7)
|
0.9†
|
(0.9–0.9)
|
|
Smoking cessation discussion (within 12 mos) (age ≥18 years)
|
6,068
|
53.5
|
(52.2–54.8)
|
6,404
|
50.4
|
(48.9–51.9)
|
1.1§
|
(1.0–1.1)
|
|
Influenza vaccination (within 12 mos) (age ≥18 years)
|
40,110
|
42.8
|
(42.2–43.4)
|
26,201
|
33.4
|
(32.6–34.3)
|
1.3†
|
(1.3–1.3)
|
|
Pneumococcal vaccination (ever) (age ≥65 years)
|
8,268
|
64.4
|
(63.1–65.6)
|
5,449
|
56.2
|
(54.5–57.9)
|
1.1†
|
(1.1–1.2)
|
|
Tetanus vaccination (within 10 years) (age ≥19 years)
|
38,893
|
65.0
|
(64.4–65.7)
|
24,840
|
56.6
|
(55.7–57.5)
|
1.1†
|
(1.1–1.2)
|
|
Zoster vaccination (ever) (age ≥60 years)
|
12,025
|
21.4
|
(20.4–22.4)
|
7,177
|
11.3
|
(10.3–12.3)
|
1.9†
|
(1.7–2.1)
|
|
Clinical preventive service (age group)
|
Private insurance receiving service
|
Only public insurance receiving service
|
Prevalence
ratio,
private/
public*
|
(95% CI)
|
|
No.
|
%
|
(95% CI)
|
No.
|
%
|
(95% CI)
|
|
HIV test (ever) (age 18–65 years)
|
31,605
|
38.6
|
(37.8–39.3)
|
9,218
|
53.0
|
(51.6–54.3)
|
0.7†
|
(0.7–0.8)
|
|
Smoking cessation discussion (within 12 mos) (age ≥18 years)
|
5,399
|
55.3
|
(53.9–56.8)
|
3,535
|
65.8
|
(64.0–67.5)
|
0.8§
|
(0.8–0.9)
|
|
Influenza vaccination (within 12 mos) (age ≥18 years)
|
38,470
|
42.4
|
(41.8–43.1)
|
15,738
|
48.9
|
(47.9–49.9)
|
0.9§
|
(0.8–0.9)
|
|
Pneumococcal vaccination (ever) (age ≥65 years)
|
6,807
|
66.1
|
(64.8–67.4)
|
6,769
|
56.9
|
(55.3–58.4)
|
1.2§
|
(1.1–1.2)
|
|
Tetanus vaccination (within 10 years) (age ≥19 years)
|
36,917
|
65.7
|
(65.1–66.4)
|
14,946
|
57.9
|
(56.9–58.9)
|
1.1§
|
(1.1–1.2)
|
|
Zoster vaccination (ever) (age ≥60 years)
|
10,305
|
20.4
|
(19.4–21.4)
|
7,984
|
15.7
|
(14.6–16.7)
|
1.3§
|
(1.2–1.4)
|
