Did ACA Implementation Enable Victims of Intimate Partner Violence?

Between 2002 and 2015, researchers found an increase in the percentage of intimate partner violence (IPV)—related emergency department (ED) claims paid by private insurance in the United States. This finding suggests the Affordable Care Act (ACA) may have increased women’s willingness and ability to seek medical attention for IPV-related injuries and disclose IPV as the source of the injuries, according to a study published in Women’s Health Issues.

Defined by the CDC, IPV describes any physical or sexual violence, stalking, or psychological harm by a current or former partner or spouse. The violence can occur among heterosexual or same-sex couples and does not require the presence of sexual intimacy.

“About 1 in 4 women and nearly 1 in 10 men have experienced contact sexual violence, physical violence, and/or stalking by an intimate partner during their lifetime and reported some form of IPV-related impact,” according to the CDC. In addition, it is estimated more than 43 million women and 38 million men experience psychological aggression by an intimate partner in their lifetime.

Women who experience physical injuries due to IPV are more likely to use health care services than women without IPV experience, while there is emerging evidence that victims tend to incur medical costs associated with IPV-related injuries.

Female survivors of IPV may pay for services using their own funds instead of using private insurance for a myriad of reasons. However, recent research has suggested “women often pay out of pocket out of fear that their abuser will find out they have sought medical attention and/or that their insurance provider would use their IPV history to deny, revoke, or increase their health insurance premiums.”

Researchers point out that prior to 2010 (when the ACA was implemented), US insurance companies had the option of classifying IPV as a preexisting condition. This way, the company could calculate potential treatment costs for a current or former victim, then require the individual to pay a higher premium or deny coverage if the costs associated with treatment were significant.

In the current study, researchers analyzed ED visits among female patients aged 15 and older via National Hospital Ambulatory Medical Care Survey data. The data reflect a nationally representative sample of all ED visits between 2002 and 2015. The survey included randomly selected ED and out-patient settings from the 50 states and Washington DC. Information from 2004 was excluded from the analysis as cases of IPV were substantially different, potentially reflecting a coding error or coding changes relative to previous years.

Using the International Classification of Disease, Ninth Revision, Clinical Modification researchers identified codes for rape, spouse abuse, adult abuse, history of violence, and counseling.

Of the 188,448 total ED visits, 652 (0.35%) were identified as cases of IPV, representing 2,576,417 national ED visits for IPV-related injuries from a total of 749,418,720 national visits.

The analysis revealed:

• The annual rate of increase for IPV-related ED visits was 4.27% (via linear regression)
• Based on a sample of 150,396 ED visits, women were more likely to visit an ED for an IPV-related injury in 2010 (odds ratio [OR], 2.04; 95% CI, 1.19—3.47; P =.009), 2013 (OR, 2.37; 95% CI, 1.14-4.02; P = .021), and 2014 (OR, 2.63; 95% CI, 1.33-5.23; P = .006), compared with 2002
• Women were more likely to self-pay for IPV-related care (OR, 1.46; 95% CI, 1.02-2.08; P = .039) than to use insurance
• Women aged 65 to 74 (OR, 0.15; 95% CI, 0.05-0.43; P < .001) and 75 years and older (OR, 0.20; 95% CI, 0.08-0.53; P = .001) were less likely to visit an ED owing to IPV, compared with women aged 25-44
• No significant differences by race, ethnicity, or census region in the proportion of ED visits for IPV related injuries were found

When analyzing differences in payment methods for IPV-related ED visits before the ACA (2002-2009, n = 93,336) and after (2010-2015, n = 55,527), investigators found women were more likely to use self-pay/charity for IPV-related ED visits relative to other ED visits before ACA enactment.

“Self-pay/charity for IPV-related ED visits was almost 2 times higher compared with private insurance before ACA enactment (OR, 1.85; 95% CI, 1.24-277; P = .003),” authors wrote. They continued, “in contrast, there were no statistically significant differences in payment method type post-ACA implementation.”

Data showed that in total, 34 of every 10,000 ED visits from 2002 to 2015 were by women seeking care for IPV-related injuries. Researchers hypothesize the increase in rates of severe IPV among women are due to changing social and cultural norms regarding gender-based violence, insurance policy changes, and medical care access.

In addition, “given the large body of literature indicating that job instability directly affects marital conflict and IPV rates…it is possible that the current findings are a result of financial instability during the Great Recession (starting in December 2007) and the subsequent slow recovery that continued to affect household resources well into 2014,” researchers said.

Future research ought to be conducted into the cause of the increase of IPV in recent years, authors argued. The findings also highlight the important impacts the ACA had on women in general and IPV survivors in particular.

“Current presidential proposals and legal challenges to the ACA may lead to an environment where women and IPV survivors will have to disproportionately shoulder the cost of their victimization once again,” researchers concluded.

Reference:

Mariscal TL, Hughes CML, Modrek S. Changes in incidents and payment methods for intimate partner violence related injuries in women residing in the United States, 2002 to 2015. Womens Health Issues. Published online May 15, 2020. doi:10.1016/j.whi.2020.05.002