Women’s Health Insurance Coverage
Health insurance coverage is a critical factor in making health care affordable and accessible to women. Among the 97 million women ages 19 to 64 residing in the U.S., most had some form of coverage in 2013. However, gaps in private sector and publicly-funded programs left over one in six women uninsured. This factsheet reviews major sources of coverage for women residing in the U.S. in 2013 (the most recent year that data is available from the US Bureau of the Census), for the year prior to the Affordable Care Act’s (ACA’s) major coverage expansion and discusses the likely changes and impact of the law on women’s coverage in future years.
Sources of Health Insurance Coverage
Approximately 55 million women ages 19-64 (57%) received their health coverage from their own or their spouse’s employer in 2013 (Figure 1). Women are less likely than men to be insured through their own job (35% vs. 44% respectively) and more likely to be covered as a dependent (22% vs. 13%). 1
- Women in families with at least one full-time worker are more likely to have job-based coverage (68%) than women in families with only part-time workers (23%) or without any workers (12%).1
- Because women are more likely than men to be covered as dependents, a woman is at greater risk of losing her insurance 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 2014, annual insurance premiums for employer sponsored insurance averaged $6,025 for individuals and $16,834 for families, increasing by 69% over the last decade. Workers currently pay for an average of 18% of premiums for individual coverage and 29% for family coverage with the employers picking up the balance.2
In 2013, about 5% of women (approximately 5 million women) purchased insurance on their own. Historically, this type of insurance often provided more limited benefits than job-based coverage and was costly. The ACA made a number of changes to this market that went into effect in 2014.
- Prior to the passage of the ACA, insurers in many states charged women more than men for the same coverage levels, a practice known as gender rating. Also, pre-existing medical conditions could trigger coverage denials in the non-group market, depending on the insurer and state regulations.
- Despite their cost, many individually purchased policies did not include coverage of certain services that are important to women, such as maternity care, prescription medications, or treatment for mental health conditions such as depression.
- The ACA made changes in the non-group market through a number of insurance reforms and by expanding access to coverage through state-based health insurance exchanges in 2014, known as Marketplaces. Individuals can purchase policies through the state Marketplace, and those who qualify based on income can receive federal tax credits which lower costs of insurance and some can purchase coverage with limits on cost-sharing. In addition, this coverage is available without limits on pre-existing conditions or differential charges based on gender or health status. All non-group plans also must cover certain “essential health benefits” (EHBs) that fall under 10 different categories, including maternity and newborn care, mental health, and preventive care.
The state-federal program for low-income individuals, Medicaid covered 13% of non-elderly women. Historically, to qualify for Medicaid, women had to have very low incomes and be in one of Medicaid’s eligibility categories: pregnant, mothers of children 18 and younger, disabled, or over 65. Women who didn’t fall into these categories typically were not eligible regardless of how poor they were. The ACA allowed states to eliminate these categorical requirements and broaden Medicaid eligibility to most individuals with incomes less than 138% of the Federal Poverty Level (FPL) regardless of their family or disability status or age, effective January 2014.
- Among all sources of coverage, Medicaid disproportionately carries the weight of covering the poorest and sickest population of women. Approximately 73% of non-elderly women with Medicaid had incomes below 200% of the FPL. Three in ten (29%) women covered by Medicaid rate their own health as fair or poor, compared to 7% of women covered by employer-sponsored insurance and 13% of uninsured women.1
- Medicaid finances nearly half of all births in the U.S.,3 accounts for 75% of all publicly-funded family planning services4 and nearly half (43%) of all long-term care spending, which is critical for many frail elderly women.5
- Over half of the states (29 states) have established programs that use Medicaid funds to cover the costs of family planning services for low-income women and most states have limited scope Medicaid programs to pay for breast and cervical cancer treatment for certain low-income uninsured women.6
Approximately 17 million women (17%) ages 19 to 64 were uninsured in 2013. These women often have inadequate access to care, get a lower standard of care when they are in the health system, and have poorer health outcomes.7 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).8
- Low income women and women of color are at greater risk of being uninsured (Figure 3). Single mothers are much more likely to be uninsured (24%) than women in households with two or more adults (15%).
- Two in three (66%) of uninsured women are in families with at least one adult working full-time and 83% 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 27% of women in Texas to 3% of women in Massachusetts (Table 1).
One of the ACA’s primary goals was to expand access to insurance coverage to reduce the number of uninsured. The law requires that nearly everyone carry health insurance, through a combination of changes in private and public coverage. The ACA was designed so that individuals with very low incomes (< 138% of FPL) would qualify for Medicaid through an expansion of the program in all states, and that eligible uninsured individuals with incomes between 100-400% FPL would be able to receive subsidies in the form of tax credits if they purchased a plan through the Marketplace.
- A 2012 Supreme Court ruling effectively made Medicaid expansion optional for states. As of December 2014, 28 states and the District of Columbia have expanded their state Medicaid programs and 23 states have not. As a result of these policy choices, it is estimated that 1.9 million uninsured women with incomes below poverty in 2013 who had been expected to gain Medicaid under the original design of ACA fall under the so-called “Medicaid coverage gap” (Figure 4). They do not qualify for any assistance because they live in one of the 23 states that are not expanding Medicaid and they have incomes less than 100% FPL, which is below the threshold for premium tax credits.
- Undocumented individuals are also ineligible for Medicaid and are prohibited from purchasing insurance on the Marketplaces. In 2013, 13% of uninsured adult women residing in the US were undocumented.
Scope of Coverage
The ACA set new standards for the scope of benefits offered in private plans. All new private plans offered by state-based marketplaces must include coverage of broad categories of essential health benefits (EHBs) as of 2010, 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 without co-payments or other cost sharing. This includes pap tests, mammograms, bone density tests, as well as the HPV vaccine. Starting in August 2012, new private plans were also required to cover an additional set of preventive services for women, including prescribed contraceptives, breastfeeding supplies and supports such as breast pumps, screening for domestic violence, well woman visits, and several counseling and screening services.9 Abortion services are explicitly excluded from being included as EHBs and 25 states have enacted laws banning coverage of most abortions from the plans available through the state Marketplaces.10
Affordability of care is a concern for many women, not just those who are uninsured. In 2013, over one in ten (16%) of privately insured women reported she delayed or went without needed healthcare in the past year due to cost. Nearly three in ten women (28%) also reported that they or a family member in her household had trouble paying medical bills. 8 The ACA includes some measures directed at limiting out-of-pocket 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 mentioned above without cost-sharing.
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. The ACA makes major changes to the health insurance market and the second year of the coverage expansion is under way. From September 2013 to September 2014, encompassing the first open enrollment period, the rate of insurance coverage for adult women ages 18-64 increased by 4.9%.11 As the second year of the ACA expansion gets underway, it is expected that the number of uninsured women will further decrease as more sign up for coverage through the state Marketplaces and gain coverage through Medicaid. Some women, however, will not have a pathway to affordable coverage because their state is not expanding Medicaid or they are undocumented immigrants. For these women, the health care safety net will continue to be a critical source of care.
|Table 1: Health Insurance Coverage of Women Ages 19-64 in 2013, by State|
|Percent Distribution by Coverage Type|
|NOTES: Other public coverage, such as Medicare or military-related coverage, and other private coverage are not shown. N/A indicates that the sample size is too small to make reliable estimates.
SOURCE: Kaiser Family Foundation and Urban Institute analysis of 2014 Current Population Survey, U.S. Bureau of the Census.
Kaiser Family Foundation (KFF) and Urban Institute. Analysis of 2014 Current Population Survey. Bureau of the Census. (2014)
KFF/HRET. 2014 Employer Health Benefits Survey.
Markus A, et al. Medicaid Covered Births, 2008 through 2010, in the Context of the Implementation of Health Reform. Women’s Health Issues. (September, 2013)
A Sonfield, Alrich C and Gold RB. Public Funding for Family Planning, Sterilization and Abortion Services, FY 1980–2006. Guttmacher Institute. (2008)
Kaiser Commission on Medicaid and the Uninsured (KCMU). Estimates based on CMS National Health Accounts data. (2009)
Guttmacher Institute. State Policies in Brief, as of December 2014.
KCMU. The Uninsured: A Primer. (October 2013)
KFF. Women and Health Care in the Early Years of the ACA: Key Findings from the 2013 Kaiser Women’s Health Survey. (May 2014)
Some religious employers (houses of worship) are exempt from the contraceptive coverage requirement.
KFF. State Health Facts: State Restriction of Health Insurance Coverage of Abortion, 2014.
Urban Institute. Health Insurance Coverage under the ACA as of September 2014. (December 2014)