While it's estimated that 16.4 million people have become insured since the Affordable Care Act took effect, public opinion on President Obama's legacy initiative has never been overwhelmingly positive. House Republicans have tried to repeal or modify the ACA more than 50 times, a promise many of them made to their constituents back home. Much of the debate around the ACA has centered around the mandated health provisions concerning women — contraceptive services, sexually transmitted disease care, screening for intimate partner violence, amongst others. But while the legislation stands to benefit women, women's opinions on the Affordable Care Act are scattered. According to a recent study, more women either disagree or don't know how they feel about the ACA than agree with its passage.
The study, published this June in the Journal of Women's Health, took its data from a population-based Internet survey of 1,078 women in September 2015. The majority of the women were college educated and had private, commercial, or employer-based health insurance. They were spread pretty evenly over the political spectrum, with slightly more women identifying as Democrats. Results from the study revealed that 27 percent of these women agreed with the passage, 35 percent disagreed, and 38 percent didn't know how they felt.
"This study was a part of a larger project we conducted in 2013 on women's preferences for and experiences with health services, with an emphasis on reproductive health services," says study co-author Dr. Kelli Stidham Hall by email. "Our goal was to identify groups of women who may have particular knowledge gaps about the ACA and its implications for their own reproductive health care access, or those who may hold negative attitudes — groups that may ultimately benefit from targeted public health interventions."
The study authors were concerned that the "polarizing policy dialogue" surrounding the ACA and women's healthcare has become the general public's main exposure to information about healthcare reform, which may be a major reason why so many people either don't understand it or consider it to be bad. They hypothesized that while political affiliation would influence women's ACA attitudes, other factors like sociocultural experiences and religious beliefs played a major role in the spectrum of opinion as well. But, perhaps more importantly, the authors realized that within all the rhetoric, the debate around the ACA was missing the voices of actual women, a critical barrier to it's implementation across the country.
To be expected, higher proportions of women who were older, white, Republican, and married disagreed with the ACA. But surprisingly a history of pregnancy, prescription contraceptive use, and recent health service was not associated with an attitude about the ACA.
"This is an interesting finding in that it is not what we would have expected," says Hall. "It is reasonable to hypothesize that women with potentially greater need for reproductive health services would be more favorable toward the ACA given its general insurance, and especially contraceptive, coverage. But among these women, that didn't hold true."
Research released this July by the Perelman School of Medicine at the University of Pennsylvania revealed that the ACA is saving the average contraception pill user $255 per year and IUD-recipients $248 per year. The ACA requires that private health insurance plans cover the cost of prescription contraceptives, helping many women who previously did not have access to birth control because of financial barriers.
The majority of young women within the study reported not knowing how they felt or were neutral; those who agree or disagreed with the ACA were split evenly. This is in line with similar research. In a 2014 survey by the Urban Institute, the policy group found that in regards to the ACA, "Those most likely to have no opinion are the groups most likely to benefit from the law — those in fair/poor health, those with lower incomes, the uninsured, nonwhites and Hispanics, high school graduates (or less), and the young."
Another surprising revelation within the study was that some Democratic women still had doubts about the ACA. While 53 percent of Democratic women agreed with its passage, 36 percent of women were neutral or did not know how they felt.
"We had not conceived of this group being one of which public health efforts should target specifically, but this finding definitely requires further consideration," says Hall. "Compared to other political groups, Democratic women in population-based studies in the U.S. like ours happen to also be disproportionately racial/ethnic minority, poor, and underinsured ... Thus, Democratic women with limited knowledge and acceptability of the ACA may particularly benefit from public health efforts to promote understanding and use of their reproductive health care coverage under the ACA."
Hall and her colleagues' work, while specific to women, echoes the neck-in-neck opinion the majority of the Americans feel about the ACA. In a April 2015 Gallup poll, 43 percent of people said the believed the ACA would make things worse for the U.S. healthcare situation in the long run, while 37 percent said it would make things better. Hall says that new research suggests that favorability of the ACA is growing — more women are starting to take advantage of the ACA's provisions which is needed progress — but the majority of monitoring efforts have not focused on seeing the difference in opinion across gender, age, race, and education level. This is a much needed next step to understand the ACA's actual impact on women and to make sure the women who need it most are taking advantage of this care.
The vast confusion surrounding the ACA and how it can benefit women reveals the need for educational efforts that make the case for actual insurance enrollment. Both sides of the aisle have been focused on swaying opinion that the ACA is good or bad for the country; meanwhile, much less of an effort has been made to explain how it actually works. No wonder so many women don't know have an opinion on the act, in spite of a number of public figures and celebrities supporting it.
"We believe that acceptability and understanding of the ACA and its women's health benefits is a basic foundation required before women in the U.S. can fully realize greater access to reproductive health care and improved health and wellbeing," says Hall. "Now we need to focus on helping women understand the details of their insurance plans, how to actually engage the health system, and how to be sophisticated consumers of reproductive healthcare."
You can learn more about how the Affordable Care Act intersects with women's healthcare needs here.
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