Are You Covered? Associations Between Patient Protection and Affordable Care Act Knowledge and Preventive Reproductive Service Use

Abstract

Purpose:

Sexual and reproductive health conditions (eg, infections, cancers) represent public health concerns for American women. The present study examined how knowledge of the Patient Protection and Affordable Care Act (PPACA) relates to receipt of preventive reproductive health services among women.

Design:

Cross-sectional online survey.

Setting:

Online questionnaires were completed via Amazon Mechanical Turk, a crowdsourcing website where individuals complete web-based tasks for compensation.

Participants:

Cisgendered women aged 18 to 44 years (N = 1083) from across the United States.

Measures:

Participants completed online questionnaires assessing demographics, insurance status, preventive service use, and knowledge of PPACA provisions.

Analysis:

Chi-squares showed that receipt of well-woman, pelvic, and breast examinations, as well as pap smears, was related to insurance coverage, with those not having coverage at all during the previous year having significantly lower rates of use. Hierarchical logistic regressions determined the independent relationship between PPACA knowledge and use of health services after controlling for demographic factors and insurance status.

Results:

Knowledge of PPACA provisions was associated with receiving well-woman, pelvic, and breast examinations, human papillomavirus vaccination, and sexually transmitted infections testing, after controlling for these factors. Results indicate that expanding knowledge about health-care legislation may be beneficial in increasing preventive reproductive health service use among women.

Conclusion:

Current findings provide support for increasing resources for outreach and education of the general population about the provisions and benefits of health-care legislation, as well as personal health coverage plans.

Keywords

education/communications awareness strategies health policy strategies women specific populations population health interventions

Introduction

Various sexual and reproductive health conditions including unintended pregnancy, sexually transmitted infections (STIs), and reproductive cancers pose significant public health concerns for American women. As such, research has long heralded the importance of, and benefits associated with, engagement in preventive health behaviors for the promotion of health and well-being.¹ Despite this evidence, preventive service use is often below recommended levels in the United States. In fact, the United States lags behind similar developed countries in terms of women’s health service utilization—only about half of women receive the preventive care they require.^2,3 Given that women have more involved reproductive health-care needs, preventive health-care service utilization is relevant for women across the reproductive life span.⁴ A significant proportion of women’s preventive services center around reproductive health including services such as contraception, testing for STIs, and sterilization.⁵ Further, women’s access to preventive reproductive health-care services serves the interest of both the current generation as well as birth outcomes and the health of future generations.²

In order to address preventive service underutilization and improve health and well-being, prior research has indicated that several aspects of the health-care system need to be considered. Barriers to the health-care system include health insurance access, gaps in reproductive education, and lack of knowledge regarding insurance coverage and benefits.^1,6,7 Historically, a major barrier to use of preventive services has been cost, specifically cost of insurance coverage. A growing economic divide exists in health-care access—negatively impacting poor and minority women—which highlights the increased need for an emphasis in attainable and comprehensive reproductive health care.⁸

Recently, there has been a push for access to a more comprehensive set of preventive reproductive health services for women in the United States.⁸ The Patient Protection and Affordable Care Act (PPACA), also known as “Obamacare,” was passed in 2010 as a reform to the existing US health-care system. The PPACA attempted to improve aspects of health care that have significant implications for our nation’s well-being, disease prevention, and overall health-care costs. One goal of the PPACA was to improve access to affordable health-care services for all Americans through increased access to and coverage for preventive health services (eg, influenza vaccination, cholesterol screens).⁵ Reduced cost of services makes these services more readily accessible to economically disadvantaged populations who may otherwise be unable to engage in these services. Evidence suggests that among uninsured (or underinsured) individuals, the postponement of preventive services is frequently attributed to prohibitive cost.⁹ In addition, the PPACA had the overarching goal of improving access for those who have been historically disadvantaged by the health-care system.¹⁰ One such disadvantaged group thought to benefit from PPACA coverage expansion was women, particularly low-income and minority women who were frequently un- or underinsured.^1,11,12

The PPACA set out to increase access to services among women by reducing the cost barrier for services in 2 ways: (1) increasing access to affordable insurance coverage and (2) mandating that this insurance coverage considers women’s reproductive care needs and covers care with no cost-sharing responsibilities for the woman. The implementation of these PPACA changes endeavored to improve the overall health among women, and the country as a whole, through the inclusion of coverage regarding a number of preventive health services for women’s reproductive health.¹³

Indeed, the implementation of the PPACA has enabled millions of previously uninsured Americans (particularly women) to receive health insurance coverage and access preventive services at reduced cost.¹⁴ Women have demonstrated an increased likelihood to choose and maintain use of effective contraceptive methods and preventive care when these services are provided at reduced cost.¹⁶ Although the PPACA policy allows American women greater access to preventive reproductive health services, it does not ensure that all eligible women understand or initiate use of these services. As such, it is crucial to examine factors related to health behavior decision-making to increase preventive service utilization and thus improve health outcomes.¹⁷ Identifying barriers and facilitators to women’s preventive health-care service utilization will allow researchers to craft targeted interventions to improve women’s health.

Purpose of the Study

The health belief model can be used to conceptualize women’s engagement in preventive reproductive services. This model has been used previously in research to understand the barriers and facilitators of individuals’ engagement in health behavior change and has been used to evaluate decision-making processes related to preventive services.^18,19 Although a complete illustration of the health belief model is provided in Figure 1, in practice, separate components of the health belief model (eg, perceived barriers) are commonly used individually to assess their utility in predicting engagement in preventive behaviors.¹⁹

Figure 1.

The Health Belief Model (modified slightly from Glanz et al, 2002, p. 52, to include a path from perceived benefits versus barriers to likelihood of behavioral change).¹⁵

The present study focuses on the modifying factors of group differences (ie, age, race/ethnicity, socioeconomic status, and education) and cues to action (ie, the passage of the PPACA and promotion of preventive reproductive health services as essential health benefits to be covered without cost sharing) in relation to perceived benefits and barriers in determining the likelihood of use of preventive reproductive health services. The purpose of the present research is to understand women’s knowledge of their health insurance coverage options, the consistency of their health insurance coverage, and how these factors are associated with preventive reproductive health-care service utilization.

Method

Design

A survey was administered nationally to women using Amazon Mechanical Turk (MTurk). The MTurk is a crowdsourcing website where individuals who are referred to as “workers” complete web-based tasks, typically in exchange for monetary compensation. Multiple studies evaluating MTurk have found that research participants (“workers”) are generally representative of the US population.^20
–22 The MTurk samples have been shown to align closely with the regional distribution of the country.²³ Previously established research findings have also been successfully replicated using MTurk samples,^20,23,24 and it has been shown that MTurk workers are more likely to answer quality control questions correctly than participants recruited through established high-quality Internet panels.²⁰

Data were collected from February until April 2016. A total of 1108 participants completed questionnaires assessing their demographic characteristics, insurance status for the previous year, use of preventive health services, and knowledge of the PPACA. Eligibility criteria for the study were ages 18 to 44, a resident of the United States, able to read English, and willing to provide informed consent. The MTurk requires that individuals be at least 18 years of age in order to register a worker account. Those above the age of 44 were excluded, as reduced reproductive health risk levels and less need for certain services among this age-group lead to reduced rates of utilization of many of the reproductive health-care services that were evaluated.²⁵ The current study aimed to survey a varying age range of adult women who were likely to be affected by the PPACA and utilize preventive health services.

Those who identified as cisgender (ie, an individual whose gender identity corresponds to the sex assigned to them at birth) males were not recruited. Twenty-five individuals who were identified as something other than cisgender female were excluded from analyses, resulting in 1083 participants. Participants were compensated $0.45 for their time after successfully completing the study. All study procedures were approved by the institutional review board at Virginia Commonwealth University.

Sample

Sample demographic information is shown in Table 1. The average age of participants was 31 years. The sample was majority white and largely consisted of those who identified as heterosexual and were married. The sample was well-educated, as 73% had achieved an associate’s degree or higher and 13.7% held some sort of graduate-level degree. Participants were also generally of higher income, with 50.3% reporting an annual income of $50 000 or higher. Participants reported residency in 49 US states and Washington, DC, with North Dakota being the only state not reported. When compared with the 2014 population estimates from the US census bureau for each state,²⁶ the geographical distribution of the participants in the sample was highly correlated (r = .94, P < .001).

Table 1.

Sample Demographic Characteristics.^a

Characteristic	Mean (SD)/Percentages (n)
Age, years	31.0 (SD = 6.61)
Race/ethnicity
Caucasian	77.1% (833)
African American	9.3% (100)
Hispanic/Latino	5.4% (58)
Asian	5.1% (55)
American Indian/Alaskan Native	1.0% (11)
Native Hawaiian or other Pacific Islander	0.3% (3)
Multiracial	1.7% (18)
Other	0.3% (3)
Sexual Orientation
Heterosexual	82.3% (887)
Lesbian	2.8% (30)
Bisexual	13.6% (147)
Other	1.4% (13)
Education
Middle school	0.4% (4)
GED	2.0% (22)
High school	19.1% (206)
Vocational school	5.6% (60)
Associates degree	16.9% (182)
Bachelor’s degree	42.4% (458)
Graduate degree (master’s, doctorate)	13.7% (148)
Relationship status
Not currently dating or in a relationship	20.1% (216)
In a newer relationship with 1 person (less than 12 months)	10.3% (111)
In a long-term relationship with 1 person (12 months or longer)	26.9% (289)
Married	40.7% (437)
Dating/in a relationship with more than 1 person	1.9% (20)

Abbreviations: GED, general education development; SD, standard deviation.

^aN = 1083.

Measures

Demographic characteristics

Participants were asked to report their age, gender, sexual orientation, race/ethnicity, relationship status, income, and education level.

Health insurance status

A question was posed about the consistency of participants’ health insurance coverage during the previous year. The item assessing consistency of health insurance coverage during the previous year was a modified version of the item used by Geisler and colleagues²⁷ and included the following response options: (1) “I was not insured at all in the past year,” (2) “I was insured for 1 to 6 months out of the last year, (3) “I was insured for 7 to 11 months out of the last year,” and (4) “I was insured for all 12 months of the last year.” This item was scored so that higher values indicated having insurance for a longer period of time during the previous year.

Preventive reproductive health service utilization

Participants were asked to provide information about their preventive reproductive health-care-seeking behavior during the previous year for the majority of the health services that were analyzed. Participants were asked to indicate what, if any, preventive reproductive health services they utilized over the previous year (ie, well-woman examinations, pelvic examinations, breast examinations, and STI testing) using a yes/no response format for each item. Receipt of a pelvic examination or breast examination was scored on this dichotomous scale as individual items to indicate each type of service use. Receipt of a well-woman examination in the last year was determined through combining responses for well-woman examinations and physicals, where a “yes” response to either item indicated that they had received a well-woman examination. Similarly, receipt of STI testing was determined through combining responses for gonorrhea/chlamydia, HIV, syphilis, and genital herpes screening, where a “yes” response to any item indicated receipt of STI testing. Human papillomavirus (HPV) vaccination was evaluated on a lifetime basis using a dichotomous scale for those who were aged 26 or below at the time that the HPV vaccine became available to women in 2006. Because of the medical guidelines surrounding pap smears, receipt of this service was evaluated through the question “when was the last time that you received a pap smear,” so that responses could be applied to the suggested 3-year time frame. Responses to this item were coded as having a pap smear 1 to 3 years ago as “yes” and never having a pap smear or having a pap smear longer than 3 years ago as “no.”

Knowledge of the PPACA

In order to gauge participant knowledge of the PPACA, a knowledge questionnaire modeled after one created by Gross and colleagues²⁸ was administered. Items were derived from the Essential Health Benefits developed under the PPACA. Essential Health Benefits are benefits that health insurance plans sold through the state marketplaces, individual and small-group plans sold outside of the marketplaces, and Medicaid plans are required to cover as of January 2014.²⁹ This questionnaire contained 10 knowledge questions, which asked whether certain provisions related to the Essential Health Benefits associated with women’s preventive reproductive health care are included as part of the health-care law or not, with response options of “true” and “false.” Using the Flesch-Kincaid reading grade-level test, the questionnaire items were determined to be at a 12th-grade reading level. Further, based on the model of Gross and colleagues,²⁷ following each knowledge item, participants were asked to indicate their level of certainty that their response was correct on a 1 (not sure at all) to 5 (extremely sure) scale.

Participant responses were first scored on a scale of 0 to 10, indicating simply the number of correct responses provided. This method yielded a low reliability for this sample (α = .32). The items were then scored with participants’ certainty levels taken into consideration. For this scoring method, the model of Gross and colleagues was used, and the number of items that participants got correct and indicated that they were either “very sure” or “extremely sure” about were categorized as being correct, while incorrect item responses and correct item responses that were followed with “moderately sure,” “slightly sure,” or “not sure at all” were considered incorrect. This method yielded a much higher level of reliability for this sample (α = .77). This second method of scoring was ultimately used in analyses in order to account for the effects of random guessing, as previous research has reported a large difference between those who answered items correctly and those who answered items correctly with a high level of certainty.²⁷ When items were scored based on the number of items that participants got correct and had indicated that they were “moderately sure,” “very sure,” or “extremely sure” about their responses as being correct, and either incorrect or correct responses followed with “slightly sure” or “not sure at all” considered incorrect, results were consistent with the scoring method used for analyses in the present study. As was found by Gross and colleagues²⁷ in their use of the PPACA knowledge questionnaire, educational attainment was positively related to PPACA knowledge in the current study (r = .142, P < .001).

Analysis

In order to reduce random response rates and promote greater data quality, 3 quality assurance items were included. Two of these items were true/false items, and the third was a short answer item. Participants were notified in the informed consent document that if they failed to correctly answer 2 out of 3 of these items, then they would not receive compensation. Additionally, participant data were deemed invalid and removed for those individuals who failed 2 out of 3 of the quality assurance items. Internet Protocol addresses were also collected initially as a quality control measure to ensure that participants had not submitted duplicate entries. A small portion of the overall sample (n = 289, 11%) was removed for providing duplicate entries.

Data were examined for invalid responses as determined through response to the quality assurance items placed throughout the survey, and missing data were excluded from analyses. The sample sizes within and between some analyses vary slightly as a result of the exclusion of these data, as well as considerations of criteria for inclusion that vary depending on the service being evaluated (ie, STI testing and pap smears). Analyses evaluating receipt of the HPV vaccine was evaluated on a lifetime basis for those who were 26 years or younger at the time the vaccine was made available in 2006, in order to exclude individuals who were not eligible for vaccination. Analyses evaluating receipt of STI testing were limited to only those participants who reported being sexually active during the previous 3 months, in order to exclude individuals who had a lower risk of STI contraction.

The medical guidelines for pap smears that have been in place since 2012 recommend that women aged 21 and older receive a pap smear every 3 years, as long as results are normal.³⁰ Using these guidelines, receipt of this service was evaluated through the question “when was the last time that you received a pap smear,” so that open-ended responses could be re-coded and applied to the suggested 3-year time frame. Responses were then dichotomized into “yes” and “no” responses based on whether participants reported receiving a pap smear within the previous 3 years. Also to remain in accordance with recommended screening guidelines, only participants who were aged 21 and older at the time of surveying were included in analyses evaluating pap smear receipt.

In multivariable analyses, demographic characteristics (age, race/ethnicity, sexual orientation, relationship status, education) and duration of health insurance coverage were controlled for, as they have been associated with both service use and knowledge of the PPACA in prior research.^9,13,30,31

Results

Knowledge of the PPACA and Demographic Characteristics

The average score on the questionnaire that assessed knowledge of the policies within the PPACA was 1.56 (standard deviation [SD] = 2.00), indicating that participants, on average, got 1.56 out of 10 knowledge items correct. As shown in Table 2, when considering only whether participants correctly responded to the knowledge items, the percentage of correct responses for individual items ranged from 34.4% to 89.0%. However, when considering participants’ confidence in their response along with whether they correctly responded to the knowledge items, the percentages of correct responses for individual items ranged from 4.5% to 43.7%. As previously noted, when compiling total knowledge scores for participants, using the former method resulted in much lower reliability (α = .32) than the latter method of scoring (α = .77); thus, consistent with prior work,²⁷ the latter method was used in analyses.

Table 2.

PPACA Knowledge Questionnaire Items.

Items	% Correct	% Correct With High Confidence
Nongrandfathered plans must cover select preventive care and wellness services without charging deductibles, copays, or coinsurance (T)	63.9%	14.0%
Immunizations are considered preventive care (T)	89.0%	34.7%
Nongrandfathered plans must include maternity and newborn care as an essential health benefit (T)	74.6%	21.3%
Nongrandfathered plans are not required to provide breastfeeding support, counseling, and equipment to those who are pregnant and nursing (F)	58.3%	8.2%
Nongrandfathered plans must cover all types of birth control methods without charging deductibles, copays, or coinsurance (T)	55.0%	15.5%
Nongrandfathered plans must cover preventive laboratory services, such as cardiovascular disease and diabetes screenings (T)	71.8%	14.8%
Medicaid is not required to provide preventive screenings at no cost to the patient (F)	67.8%	12.2%
Grandfathered plans are not required to follow the essential health benefit requirements (T)	34.4%	4.5%
Grandfathered plans must cover all types of birth control methods without charging deductibles, copays, or coinsurance (F)	58.3%	6.8%
Nongrandfathered plans include preventive screenings (eg, breast cancer screenings, pap smears) as essential health benefits, making these services free for the individual (T)	70.6%	20.6%

Abbreviations: F, false; PPACA, Patient Protection and Affordable Care Act; T, true.

The PPACA knowledge scores were unrelated to race/ethnicity, sexual orientation, relationship status, and income. However, a 1-way analysis of variance test identified significant differences based on education level, F_6,1013 = 4.568, P < .001. A post hoc Tukey test showed that participants with graduate degrees (M = 2.19, SD = 2.39) had significantly higher PPACA knowledge scores than those with a general education development (M = 0.75, SD = 1.07), a high school diploma (M = 1.26, SD = 1.85), or a bachelor’s degree (M = 1.48, SD = 1.95), with no other significant differences emerging. Age was significantly positively related to PPACA knowledge, r = .07, P < .05.

Knowledge of the PPACA and Insurance Coverage

The majority of participants reported having insurance coverage for all 12 months of the previous year (77.4%, n = 838), while 7.3% (n = 79) reported having insurance for 7 to 11 months out of the year, 7.2% (n = 78) reported having insurance for 1 to 6 months out of the year, and 8.0% (n = 87) reported not being insured at all during the previous year.

A 1-way analysis of variance test identified significant differences in knowledge of the PPACA based on the duration of insurance coverage over the previous year, F_3,1018 = 1.062, P < .01. A post hoc Tukey test showed that those who had insurance coverage for all 12 months out of the previous year (M = 1.61, SD = 2.06) had significantly higher PPACA knowledge scores than those who did not have insurance at all during the previous year (M = 0.95, SD = 1.76), with no other significant differences present.

Insurance Coverage and Preventive Service Use

Chi-square analyses using Bonferroni adjustments were conducted to determine whether the amount of time during the past year that an individual possessed health insurance coverage was related to differences in the receipt of pap screening, well-woman examinations, pelvic examinations, breast examinations, HPV vaccination, and STI testing. Preventive health service use was transformed into binary categories of receiving or not receiving each service. There were significant differences in the receipt of various types of reproductive cancer screening (Table 3). Receipt of a well-woman examination, a pelvic examination, and a breast examination in the past year, as well as receipt of a pap smear within the past 3 years, all showed a similar pattern of difference in service use across insurance coverage duration. Those who did not possess insurance coverage at all during the previous year had significantly lower rates of use for each type of reproductive cancer screening than those who possessed insurance coverage during some or all of the previous year. However, there were no significant differences in receipt of HPV vaccination or STI testing services based on duration of insurance coverage over the previous year.

Table 3.

Differences in Service Use Based on Duration of Insurance Coverage During the Previous Year.^a

Service Type	N	Not Insured At All in the Last Year (n = 87)%	Insured for 1 to 6 Months of the Last Year (n = 78)%	Insured for 7 to 11 Months of the Last Year(n = 79)%	Insured for All 12 Months of the Last Year(n = 838)%	χ²
Well-woman examination, last year	1082	23.0^b	51.3^c	68.4^c,d	71.0^d	88.100^e
Pelvic examination, last year	1080	18.4^b	46.2^c	49.4^c	60.5^c	60.943^e
Breast examination, last year	1078	14.9^b	33.8^c	36.7^c	53.2^d	57.272^e
HPV vaccination, last year	1076	3.4^b	9.2^b	7.6^b	6.8^b	2.324^f
STI testing, last year	873^g	16.7^b	36.9^b	37.3^b	31.6^b	8.066^f
Pap smear, last 3 years	1044^h	38.1^b	64.9^c	72.7^c,d	80.5^d	79.225^e

Abbreviations: HPV, human papillomavirus; STI, sexually-transmitted infection.

^aColumns with different superscripts (b, c, d) differ significantly (Bonferroni corrected).

^eP < .001.

^fns indicates not significant.

^gAnalysis included individuals who were sexually active only.

^hAnalysis included individuals aged 21 and over only.

As shown in Table 4, three-quarters of participants who were aged 21 or older reported having received a pap smear in the past 3 years. Additionally, two-thirds had obtained a well-woman visit in the past year, over one half had received a pelvic examination in the last year, just under one half had received a breast examination in the last year, and very few had received an HPV vaccination in their lifetime (8.10%). Around one-third of those who had been sexually active within the last 3 months had received STI testing during the past year. A series of multivariable logistic regressions controlling for age, race/ethnicity, sexual orientation, relationship status, and education were conducted to determine the independent influence of insurance duration on preventive service use. Also shown in Table 4, duration of insurance coverage during the previous year predicted receipt of a pap smear in the last 3 years, a well-woman examination in the past year, a pelvic examination in the past year, and a breast examination in the past year, after controlling for demographic characteristics. However, insurance duration did not predict lifetime HPV vaccination or STI testing during the previous year.

Table 4.

Duration of Insurance Coverage During the Previous Year and the Use of Preventive Reproductive Health Services.

Item	Response and Percent
Item	N	Yes, % Reporting	No, % Reporting	AOR^a (95% Confidence Interval)
Well-woman examination, past year	1082	65.98%	34.02%	1.724^b (1.485-2.001)
Pelvic examination, past year	1080	56.12%	43.88%	1.624^b (1.394-1.893)
Breast examination, past year	1078	47.94%	52.06%	1.694^b (1.455-1.972)
HPV vaccination, lifetime	739^c	8.10%	91.90%	1.147^d (0.941-1.397)
STI testing, past year	873^e	31.37%	68.63%	1.070^d (0.883-1.296)
Pap smear, past 3 years	1044^f	74.95%	24.05%	1.694^b (1.455-1.972)

Abbreviations: AOR, adjusted odds ratio; HPV, human papillomavirus; STI, sexually transmitted infection.

^aMultivariable logistic regression analyses controlling for age, race/ethnicity, relationship status, and education.

^bP < .001.

^cAnalysis included individuals who were aged 26 or younger when the HPV vaccine was made available.

^dns indicates not significant.

^eAnalysis included individuals who were sexually active only.

^fAnalysis included individuals aged 21 and over only.

Knowledge of the PPACA and Preventive Service Use

Another series of multivariable logistic regressions controlling for age, race/ethnicity, sexual orientation, relationship status, education, and insurance duration were conducted to determine the independent relationship between PPACA knowledge and preventive service use. As shown in Table 5, knowledge of the PPACA predicted having received a well-woman examination, pelvic examination, breast examination, and STI testing during the previous year, as well as lifetime HPV vaccination after controlling for demographic characteristics and duration of insurance coverage during the previous year. However, knowledge of the PPACA did not predict receipt of a pap smear during the previous 3 years.

Table 5.

Knowledge of the PPACA and the Use of Preventive Reproductive Health Services.

Item	Response, Percent, and PPACA Knowledge Score
Item	N	Yes, % Reporting, PPACA Knowledge Score, M (SD)	No, % Reporting, PPACA Knowledge Score, M (SD)	AOR^a (95% Confidence Interval)
Well-woman examination, past year	1023	65.98%, 1.68 (2.07)	34.02%, 1.16 (1.78)	1.109^b (1.028-1.196)
Pelvic examination, past year	1021	56.12%, 1.75 (2.12)	43.88%, 1.19 (1.77)	1.128^b (1.052-1.209)
Breast examination, past year	1020	47.94%, 1.73 (2.07)	52.06% ,1.30 (1.90)	1.075^c (1.007-1.148)
HPV vaccination, lifetime	739^d	8.10%, 1.62 (2.02)	91.90%, 1.44 (2.01)	1.088^c (1.003-1.180)
STI testing, past year	813^e	31.37%, 1.74 (2.10)	68.63%, 1.41 (1.94)	1.106^c (1.024-1.196)
Pap smear, past 3 years	998^f	74.95%, 1.60 (2.06)	24.05%, 1.25 (1.80)	1.047^g (0.963-1.137)

Abbreviations: AOR, adjusted odds ratio; HPV, human papillomavirus; M, mean; PPACA, Patient Protection and Affordable Care Act; SD, standard deviation; STI, sexually-transmitted infection.

^aMultivariable logistic regression analyses controlling for age, race/ethnicity, relationship status, education, and duration of health insurance coverage.

^bP < .01.

^cP < .05.

^dAnalysis included individuals who were aged 26 or younger when the HPV vaccine was made available.

^eAnalysis included individuals who were sexually active only.

^fAnalysis included individuals aged 21 and over only.

^gns indicates not significant.

Women of Color and Preventive Service Use

A series of multivariable logistic regressions controlling for age, sexual orientation, relationship status, education, and insurance duration were conducted to examine how the predictors of insurance duration and knowledge of the PPACA functioned among women of color (N = 227). Insurance coverage significantly predicted the use of all 6 preventive health services among this group of women. Although the results of the regressions were not statistically significant for receiving a well-woman examination, pelvic examination, and breast examination, a pap smear in the past 3 years, and lifetime HPV vaccination in this smaller group, knowledge of the PPACA behaved similarly as a predictor of service use among women of color as it did among the entire sample (ie, had comparable effect sizes). Further, it was found that knowledge of the PPACA was a significant predictor of having received STI testing during the previous year among women of color (odds ratio = 1.075, 95% confidence interval = 0.888-1.229, B = .044, standard error = .083, P <.05).

Discussion

The present study was among the first to evaluate the role of PPACA knowledge in preventive sexual and reproductive health service utilization among women. Results from this study help in further understanding of factors that contribute to female use of preventive reproductive health services. Findings highlight that expanding access to health insurance coverage is just one component necessary to increase utilization of preventive services.

The PPACA

The PPACA aimed to increase access to insurance coverage and reduce health-care-related spending.³² The legislation also sought to shift the health-care industry toward a proactive rather than a reactive approach to health care and provide increased access to care for underserved populations.^5,32

Patient Protection and Affordable Care Act knowledge and preventive service utilization

Gross and colleagues²⁷ found that those who knew more about the PPACA held more favorable attitudes toward the legislation and suggested that increasing knowledge about the legislation results in considerably higher approval rates. Present findings support the notion that increasing health-care legislation knowledge would result in higher rates of preventive reproductive health service utilization among women. This finding underscores the importance of outreach efforts frequently built into health-care legislation to increase knowledge of the legislation. However, participant PPACA knowledge in the current study also shows that accurate legislation knowledge is still quite low. The average number of correct responses provided was 1.5 out of 10 when level of certainty about the response was taken into consideration. These results are alarming considering that, overall, the sample was highly educated. Previous work (and findings from the present study) has demonstrated that those with less education typically understand less about the changes implemented by the PPACA—suggesting that knowledge would likely be lower among the general population.^13,27

The association between these factors and preventive reproductive service use may offer support for intervention efforts delivered at the community level that are targeted toward those with lower educational attainment and those with less access to accurate information about health-care legislation. Findings suggest that preventive service utilization is optimized when individuals are provided with comprehensive and accurate information about their health insurance coverage options and benefits. This finding may be applicable to future health-care legislation. Results indicate that, when possible, legislation should include provisions and funding for enhancing outreach and enrollment.

Benefits of Insurance Coverage

Current findings support literature that suggests a lack of health insurance coverage and shorter duration of coverage are barriers to service use among women.^9,30,33,34 Results demonstrate that those who had coverage for the full year evidenced greater knowledge of the PPACA and use of preventive reproductive health services. Furthermore, findings provide support for the methods utilized by the PPACA and show that having insurance that covers preventive health services is associated with higher rates of utilization for such services. As such, potential amendments to the legislation should retain such components that appear advantageous in increasing preventive service utilization in order to decrease health system burden.

Duration of insurance coverage and preventive service use

The results of the current study revealed that the duration of health insurance coverage during the previous year was a significant predictor of service use. Specifically, women who had possessed insurance coverage for a longer period of time through the year were more likely to have utilized preventive health services. This finding supports the existing literature,^{1,25,35

–38} as well as the efforts of the PPACA to increase access to insurance coverage. However, it is also important to note that while insurance coverage was shown to influence service use, just over 77% of the sample had insurance coverage for all 12 months of the year, and rates of use for some services, such as breast examinations (48%), STI testing (31%), and HPV vaccination (7%), were still low. Rates of receipt for these services were also much lower than having had a well-woman visit or physical (64%) during the same time period.

Further, approximately 20% of the women who were insured for all 12 months of the previous year had not obtained a pap smear within the previous 3 years. Pap smears are a vital aspect of women’s health and prevention of severe negative health outcomes such as cervical cancer, making receipt of this service critical. Discovering that women who possessed insurance coverage during the entire length of the previous year had access to this preventive service and still did not obtain it may be cause for concern and is worth exploring in future research.

Limitations

Despite overall support for some hypotheses in the current study, several limitations must be considered. One limitation is use of a cross-sectional correlational design, which prevents any causal inferences. The sample was also majority white (76.7%) and highly educated, with more than 70% having received education beyond high school. As such, generalizability of the sample may be limited. This demographic distribution is likely a byproduct of Internet sampling, another limitation of this study. Although Amazon MTurk has the ability to recruit a nationally representative sample, participants self-select into specific studies. Therefore, it is possible that those who select to participate in a study about health and health-care legislation may differ from that of the general population. Further, self-reports of health behaviors and service receipt are likely to contain some measurement error. Participants may not be able to accurately recall the frequency or timing of participation in health services or may feel pressure to report receiving recommended preventive reproductive health services.³⁹ While using self-report data is a limitation of this study, online surveying resulted in a geographically representative national sample of women and provided insight into some of the factors that predict the use of preventive reproductive services.

SO WHAT?

Women require many unique health services, particularly during their reproductive years.⁴ However, historically, many women have been unable to utilize health services due to barriers including cost, access, and lack of health coverage.^8,11 As such, it is critical that women have access to comprehensive and affordable preventive services to increase well-being and decrease health-care system burden. Thus, health-care reform should remain a priority for women, as well as health-care providers and legislators.^4,17 The Patient Protection and Affordable Care Act (PPACA) reform sought to improve health insurance coverage and decrease cost sharing for underserved populations, as well as reduce cost for preventive services.^1,13 The current study indicates that expanding public knowledge about the PPACA (or any future health-care legislation) may be beneficial in increasing the use of preventive reproductive health services among women, generally. Further, improved knowledge, reductions in out-of-pocket spending, and increased access to health insurance are linked to increases in service utilization, particularly preventive health service utilization.^18,49 Indeed, health insurance coverage appears to be a significant predictor of engagement with the health-care system and utilization of preventive services, although utilization is far from ideal.⁵ Current findings provide support for increasing funds and resources to facilitate outreach and education of the general population about the provisions and benefits of health-care legislation. Despite benefits noted as a result of PPACA implementation, barriers including limited availability of services, problematic policies, and lack of awareness continue to impede women’s service use. Future research is necessary to elucidate mitigating factors in women’s preventive service utilization following PPACA reform.

Lastly, this study did not assess attitudes toward the surveyed preventive health services, perceptions of health risk, or attitudes toward medical professionals/organizations. Previous research has shown that lacking trust in medical services or providers is a barrier to utilization.^40,41 This may be particularly true among populations that are often “targets” of health promotion and intervention programs, such as young women, racial and sexual minorities, and those with lower incomes or education levels.^42

–46 Studies have also shown that people often feel uncomfortable or embarrassed during reproductive health-care screenings or may anticipate pain and as a result may choose to avoid them altogether.^47,48 Future studies should incorporate health risk perceptions, attitudes toward health services and providers, and provider discrimination in models of health-care service receipt after the PPACA.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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