Impact of the Affordable Care Act on the Cooper Women’s Care Impact of the Affordable Care Act on the Cooper Women’s Care Center Center

This Original Clinical Investigations is brought to you for free and open access by the Rowan University Journals at Rowan Digital Works. It has been accepted for inclusion in Cooper Rowan Medical Journal by an authorized editor of Rowan Digital Works. For more information, please contact rdw@rowan.edu. Recommended Citation Malik, Amanda and Franzblau, Natali (2019) "Impact of the Affordable Care Act on the Cooper Women’s Care Center," Cooper Rowan Medical Journal: Vol. 1 : Iss. 1 , Article 1. DOI: 10.31986/issn.2578-3343_vol1iss1.1 Available at: https://rdw.rowan.edu/crjcsm/vol1/iss1/1 Cooper Rowan Medical Journal: https://rdw.rowan.edu/crjcsm

Federally sponsored health insurance programs began covering these screenings shortly after the ACA was signed, and beginning August 2012, all new and non-grandfathered private insurance plans were required to cover these services as well. 1 In addition to emphasizing preventive care, the ACA made health insurance mandatory, imposing fines for those who do not obtain insurance. The ACA also facilitated the ability to purchase insurance through exchanges, and provided incentives for individual states to expand eligibility for Medicaid. Prior to ACA, Medicaid eligibility was restricted to low-income children, pregnant women, the elderly, and individuals with disabilities. Thirty-one states and the District of Columbia opted to expand Medicaid, and in those states low-income adults became eligible. In New Jersey, Medicaid was expanded to include all adults with an income below 138% of the federal poverty line. This expansion had the potential to greatly impact women who had previously been uninsured as well as the providers who serve Medicaid enrollees.
Currently there is mixed evidence on the impact of ACA on services provided and how it may have changed the populations accessing care. Lau and colleagues found that post-ACA, young adults had 1 significantly increased rates of preventive visits, including annual dental visits, routine examinations, and blood pressure and cholesterol screenings. However, the same population had unchanged rates of other preventive services, such as influenza vaccination. 2 Research by Barbarescu and co-investigators also suggests that the ACA's mandated cost-free preventive coverage did not lead to a significant increase in use of these services, at least among young adults. 3 Early research into the impact of the ACA on women's utilization of preventive reproductive services appear to be insignificant, 4 but previous research regarding access by women shows that cost-free coverage, particularly of contraception, does increase its use. In states such as Delaware and Iowa where contraceptive coverage was mandated prior to the ACA, women were 5% more likely to use effective contraception than in states without such laws. 5 This study aimed to assess changes in the utilization of Women's Health services as well as changes in the year of 2010, the year in which the ACA was signed into law and its provisions began to take effect.       Table 5). The breakdown of insurance types in both pre-and post-ACA time periods are also shown in table 5. However, none of these changes were statistically significant.

DISCUSSION
The key observation from this study was the significant increase in gynecologic visits at the Cooper WCC While we also hypothesized that the age of the patient population would increase, as more women who had no children or older children would now seek preventative care and gynecology care, the data did not bear this out.

LIMITATIONS
There are several limitations to our study. First, the cross-sectional design did not allow us to control for the many additional variables that likely impacted the data we examined, such as localized changes in pregnancy rates. While observational studies such as ours are convenient and inexpensive, there are many restrictions to the assumptions that can be made based on the results. Additionally, relying on historical data meant we were unable to fill gaps in missing data. For each analysis of age, race, and insurance type, several hundred patients had to be removed due to incomplete data.
A limitation in our study is the progressive nature of ACA policies, which were rolled out over several years. The staggered rollout of policies makes a simple before and after comparison difficult, especially considering the relatively short time that some regulations and policies have been in place. Many authors of early Medicaid expansion studies using only 2014 data note that changes in utilization are likely to need more than one or two years to materialize, and several longer studies note changes in later years that were not observed in earlier years 6 . We felt it was important to include year by year analysis of visit volume for this reason, though we were unable to control for the timeline of changes within the scope of this study.
In addition to the implementation of ACA policies, several other changes took place between 2005-2015 that likely impacted the visit types and demographics of patients at the Cooper WCC. One such change was the addition of a nurse practitioner in 2010. The changing birth rate over the time periods selected, both at Cooper and in New Jersey, could have also impacted these numbers.

CONCLUSIONS
Over the last 7 years, the Affordable Care Act has had considerable impacts on our healthcare system, some of which are not yet fully elucidated. It will likely take several more years before the effects of new policies, both intentional and unintentional, become evident in the literature. However, it is already clear that women's health care has been affected by the ACA, due to the opportunities for increased insurance enrollment, especially in Medicaid expansion states, and the preventive services for women that are now covered at no cost to the individual. At the Cooper Women's Care Center, these national policy changes likely contributed to the increase in the percentage of gynecologic visits as well as the increase in patients using Medicaid. In clinics such as the Cooper WCC, it is clear that healthcare policies designed to increase access to preventive services can have an impact.