Women’s Health Insurance Coverage
Health insurance coverage is a critical factor in making health care accessible to women. Women with health coverage are more likely to obtain needed preventive, primary, and specialty care services, and have better access to new advances in women’s health. Among the 98 million women ages 18 to 64, most have some form of coverage. However, the patchwork of different private sector and publicly-funded programs in the U.S. leaves one in five women uninsured. The Affordable Care Act (ACA) of 2010 includes several measures that are changing the profile of women’s coverage as the law is implemented fully.
Sources of Health Insurance Coverage
Employer-sponsored insurance covers 58% of women between the ages of 18 and 64 (Figure 1). Women are less likely than men to be insured through their own job (35% vs. 43% respectively) and more likely to be covered as a dependent (23% vs.15%).1 Medicaid, the state-federal program for the poor, covers 12% of non-elderly women. Typically, only very low-income women who are pregnant, have children living at home, or who have a disability have been able to qualify for the program. Individually purchased insurance, which people buy on their own, is used by just 7% of women. Medicare and other government health insurance cover a small fraction (4%) of women under age 65. For non-elderly women, coverage is limited to women who either have a disability (Medicare) or are covered through the military (TRICARE). Uninsured women account for 19% of women ages 18 to 64. They typically do not qualify for Medicaid, do not have access to employer-sponsored plans, and either cannot afford or do not qualify for individual policies.
Employer-Sponsored Insurance: Approximately 57 million non-elderly women in the U.S. receive their health coverage from their own or their spouse’s employer. Historically, full-time employment has provided the greatest opportunity for obtaining job-based coverage.
- Women in families with at least one full-time worker are more likely to have job-based coverage (71%) and less likely to be uninsured (15%) than women in families with only part-time workers (33%) or without any workers (28%).1
- Women are more vulnerable to losing their insurance compared to men, as they are more likely to be covered as dependents. This places a woman at greater risk of losing coverage if she becomes widowed or divorced, her spouse loses a job, or her spouse’s employer drops family coverage or increases premium and out-of-pocket costs to unaffordable levels.
- In 2013, annual insurance premiums averaged $5,884 for individuals and $16,351 for families, nearly doubling in cost over the past ten years. Workers currently pay for an average of 18% of premiums for individual coverage and 29% for family coverage.2
Individual Insurance: Nearly 7 million women purchase insurance on their own. This type of insurance often provided more limited benefits than job-based coverage and was costly. In many states, insurers charged women more than men for the same coverage levels, a practice known as gender rating. Also, pre-existing medical conditions triggered coverage denials in the individual market, depending on the insurer and state regulations.
- Historically, these plans did not cover certain services that are important to women, such as maternity care, prescription medications, or treatment for mental health conditions such as depression. It is expected that many people currently covered in these plans will purchase coverage in Health Insurance Marketplaces newly opened under the ACA, which require plans to cover all of these services to some degree and offer subsidies to purchase this coverage for those who are income eligible. Furthermore, in 2014 plans available in Marketplaces will be prohibited from gender rating and denying coverage based on pre-existing conditions.
Medicaid: According to Medicaid program statistics, in 2010, 19.3 million low-income women (18 to 64 years) were enrolled in Medicaid.3 Women make up two-thirds of the adult Medicaid population, but only low-income women who are pregnant, mothers of children who are 18 years or under, disabled, or over 65 can qualify for Medicaid. Women without children and disabilities typically have not been eligible regardless of how poor they were, but this will change in many states in 2014 when Medicaid eligibility is broadened to more people.
- Among all insurers, Medicaid disproportionately carries the weight of covering the poorest and sickest population of women. Approximately 82% of non-elderly women on Medicaid have incomes below 200% of the Federal Poverty Level (FPL). One in three (33%) women on Medicaid rate their health as fair or poor, compared to 10% of low-income women covered by employer-sponsored insurance and 15% of low-income, uninsured women.1
- Medicaid finances nearly half of all births in the U.S.,4 accounts for 75% of all publicly-funded family planning services5 and nearly half (43%) of all long-term care spending.6
- Over the past decade, several states (31 states) have expanded programs that use Medicaid funds to cover the costs of family planning services for low-income women and all states have established Medicaid programs to pay for breast and cervical cancer treatment for certain low-income uninsured women.7
Uninsured Women: Approximately 19 million women are uninsured. Uninsured women are more likely to have inadequate access to care, get a lower standard of care when they are in the health system, and have poorer health outcomes.8 Compared to women with insurance, uninsured women have lower use of important preventive services such as mammograms and Pap tests and are two to three times as likely to forgo medical services due to cost (Figure 2).9, 10
Women who are younger, poorer, and of color (especially Latinas) are particularly at risk for being uninsured (Figure 3).
The ACA included a provision allowing dependents to be covered up to age 26, and it is estimated that more than 3 million young adults have been insured as a result of this policy.11 Approximately six in ten (59%) uninsured women are in families with at least one adult working full-time and 77% of uninsured women are in families with at least one part-time or full-time worker.1
- There is considerable state-level variation in uninsured rates across the nation, ranging from 30% of women in Texas to 4% of women in Massachusetts.1
The ACA and Women’s Coverage
Expanding Coverage: One of the ACA’s primary goals is to expand access to insurance coverage, significantly reducing the number of uninsured. The law requires that nearly everyone carry health insurance by 2014, through a combination of changes in private and public coverage. The ACA was written with the intention that individuals with very low incomes (< 138% of the federal poverty level) would qualify for Medicaid through an expansion of the program in all states, and that other uninsured individuals would be able to purchase policies through Marketplaces offering a choice of private plans. Individuals with incomes between 100% and 400% of poverty can receive assistance with the premium costs of plans in these Marketplaces through a graduated system of tax credit subsidies. These tax credits are not available to individuals with incomes below 100% of poverty. However, in July 2012, the Supreme Court issued a ruling that effectively made the Medicaid expansion optional for states. As of October, 2013, 26 states including Washington D.C. are moving forward with Medicaid expansion, and 25 states have decided not to expand Medicaid at this time.12 As a result of these policy choices, it is estimated that 2.4 million currently uninsured women who had been expected to gain Medicaid under the original design of ACA will not qualify because their state is not expanding the program and they also do not qualify for subsidies in the Marketplaces.13
Addressing Affordability: Affordability of care is a concern for many women, not just those who are uninsured. In 2013, one in three privately insured women reported she or a family member postponed needed healthcare in the past year due to cost.14 The new law includes some measures directed at limiting consumer costs that will affect women. These include caps on out-of pocket spending for certain low-income individuals and coverage for many preventive services without cost-sharing.
Scope of Coverage: The ACA mandates that plans in state-based exchanges cover broad categories of “essential benefits,” including outpatient and hospitalization care, maternity care, prescription drugs, rehabilitation, and mental health care. The law also requires that new private plans cover preventive services and vaccines recommended by federally-sponsored committees without co-payments or other cost sharing. This includes pap tests, mammograms, bone density tests, as well as the HPV vaccine. As of August 2012, new private plans were also required to cover an additional set of preventive services for women, including contraceptives as prescribed by a provider, breastfeeding supplies and supports such as breast pumps, screening for domestic violence, well woman visits, and several counseling and screening services. Some religious employers (houses of worship) are exempt from the contraceptive coverage requirement.15
With health reform implementation under way, it is important for women to understand their coverage options. For those joining Medicaid, they will need to understand their state’s policies regarding specific benefit levels and the network of available providers. Women enrolling in the Marketplace plans will have to evaluate their plan choices based on a number of factors, including whether plans cover the full range of women’s health services, the plans’ premium charges and other out of pocket costs, and the reach of the plans’ network of providers. The decisions that federal and state policy makers, insurance companies, and individuals make today and in the future will shape access to coverage and care for millions of women across the nation in the years ahead.
Kaiser Family Foundation (KFF) and Urban Institute. (2013). Analysis of 2012 Current Population Survey. Bureau of the Census.
KFF/HRET. (2013). 2013 Employer Health Benefits Survey.
KFF. (2013). Analysis of 2010 Medicaid Statistical Information System (MSIS) program data.
Markus A, et al. (September, 2013). Medicaid Covered Births, 2008 Through 2010, in the Context of the Implementation of Health Reform. Women’s Health Issues.
A Sonfield, Alrich C and Gold RB. (2008). Public Funding for Family Planning, Sterilization and Abortion Services, FY 1980–2006. Guttmacher Institute.
Kaiser Commission on Medicaid and the Uninsured (KCMU). (2009). Estimates based on CMS National Health Accounts data.
Guttmacher Institute. (2013). State Policies in Brief, October, 2013.
KCMU. (October 2013). The Uninsured: A Primer.
National Center for Health Statistics. (2012) Data from National Health Interview Survey, Health, United States, 2012.
The Commonwealth Fund. (2010). Realizing Health Reform’s Potential, Biennial Health Insurance Survey, 2010.
US Department of Health and Human Services. (June 2012). Number of Young Adults Gaining Insurance Due to the Affordable Care Act Now Tops 3 Million.
KFF. (October 2013). Status of State Action on the Medicaid Expansion Decision.
KCMU. (October 2013), The Coverage Gap: Uninsured Poor Adults that Do Not Expand Medicaid.
KFF. (October 2013) Kaiser Health Tracking Poll unpublished estimates.
HRSA (2011). Women's Preventive Services: Required Health Plan Coverage Guidelines.