Women’s Health Insurance Coverage
Health insurance coverage is a critical factor in making health care affordable and accessible to women. Among the 97.5 million women ages 19 to 64 residing in the U.S., most had some form of coverage in 2014. However, gaps in private sector and publicly-funded programs left almost one in eight women uninsured. One of the Affordable Care Act’s (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, and expands access to coverage through a combination of Medicaid expansions, private insurance reforms, and premium tax credits. This factsheet reviews major sources of coverage for women residing in the U.S. in 2014, the first full year of 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 57 million women ages 19-64 (58%) received their health coverage from their own or their spouse’s employer in 2014 (Figure 1). Women are less likely than men to be insured through their own job (34% vs. 43% respectively) and more likely to be covered as a dependent (24% vs. 16%). 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 (32%) or without any workers (15%).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. The ACA also requires employer plans that offer dependent coverage to give workers the option of keeping adult children up to age 26 enrolled as dependents. An estimated 40% of women between the ages of 18 and 25 are covered as dependents under a parent’s or a spouse’s plan. 1
- 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. On average, workers paid 18% of premiums for individual coverage and 29% for family coverage with the employers picking up the balance.2
The ACA expanded access to the non-group or individually purchased insurance market by offering premium tax credits to help individuals afford to purchase coverage in state-based health insurance exchanges (also known as Marketplaces). It also included many insurance reforms to alleviate some of the long-standing barriers to coverage in the non-group insurance market, many disproportionately affecting women. In 2014, about 8% of women (approximately 7.7 million women) purchased insurance on their own. 1 This includes women who purchased private policies from the ACA Marketplace in their state, as well as from private insurers that operate outside of Marketplaces.
- In the fall of 2013, ACA Marketplaces opened in every state with coverage becoming effective in 2014. Individuals can purchase policies through the state Marketplace. Those with incomes below 400% of the FPL also qualify for assistance in the form of federal tax credits which lower costs of premiums, and those with income below 250% FPL can purchase coverage that limits cost-sharing requirements. In a national survey conducted in Fall 2014, nearly all (94%) of women in marketplace plans had income below 400% FPL, the upper limit for premium credits and 75% had incomes below 250% FPL, the threshold for cost sharing reductions.3
- The ACA set new standards for all direct purchase plans, including new plans available through the Marketplace as well as those that existed prior to the ACA. Historically, insurance carriers selling plans on the individual insurance market adopted policies that specifically placed women at a disadvantage, either by charging them higher premiums than men for the same level of coverage (a practice called gender rating) or disqualifying them for coverage because they had certain pre-existing medical conditions, including pregnancy. The ACA bars plans from instituting these policies.
- Many of the pre-ACA individually purchased policies did not include coverage for certain services that are important to women, such as maternity care, prescription medications, or treatment for mental health conditions such as depression. As a result of the ACA, all direct purchase 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 16% of non-elderly women in 2014. 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. However, not all states have taken up this option, as is discussed further below.
- Among all sources of coverage, Medicaid disproportionately carries the weight of covering the poorest and sickest population of women. Approximately 70% of non-elderly women with Medicaid had incomes below 200% of the FPL. More than one in four (27%) women covered by Medicaid rate their own health as fair or poor, compared to 6% of women covered by employer-sponsored insurance and 11% of 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, which is critical for many frail elderly women.6
- Over half of the states (28 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.7
Approximately 12.8 million women (13%) ages 19 to 64 were uninsured in 2014. 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.8 Compared to women with insurance, uninsured women have lower use of important preventive services such as mammograms and Pap tests and are more likely to forgo medical services due to cost.9 Uninsured women have a harder time getting in to the health care system. In a survey conducted in Fall 2014, uninsured women were less likely to have a regular source of care compared to women with any form of insurance.3
Profile of Uninsured
- Low-income women, women of color, and immigrant women are at greater risk of being uninsured (Figure 2). Single mothers are much more likely to be uninsured (18%) than women in two-parent households (10%).
- The majority of uninsured women live in a household where someone is working: 69% are in families with at least one adult working full-time and 82% 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 22% of women in Texas to 5% of women in Massachusetts and Rhode Island (Table 1).
As the ACA enters the third full year of implementation, policymakers face a number of issues in achieving the law’s main goal of expanding coverage.
The ACA was initially 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 January 2016, 31 states and the District of Columbia have decided to expand their state Medicaid programs but 19 states have not. As a result of these policy choices, it is estimated that 1.5 million uninsured women with incomes below poverty in 2014 who had been expected to qualify for Medicaid under the original design of ACA fall under the so-called “Medicaid coverage gap” (Figure 3). Nationally, these women account for 12% of uninsured women, and they are in the coverage gap because they do not meet pre-ACA Medicaid eligibility criteria, they live in one of the 19 states that are not expanding Medicaid under the ACA, and they have incomes below the threshold for premium tax credits (100% FPL) in the Marketplaces.
- The 19 states that have not expanded Medicaid are heavily concentrated in the South. In some states, more than a third of uninsured women fall into the coverage gap and would likely qualify for Medicaid if their states expanded eligibility as the ACA envisioned (Table 2).
- Black (29%) and Hispanic (23%) women together account for approximately half of women in the coverage gap, while the remaining share are White (45%) and other races (4%).
- Undocumented individuals are also ineligible for Medicaid and are prohibited from purchasing insurance on the Marketplaces. An estimated 16% of uninsured adult women (2 million women) residing in the US are undocumented.
There has been a sharp drop in the number of women without coverage since the ACA was passed, yet 12.8 million women remain uninsured. More than a quarter (29%) of women remaining uninsured are not eligible for assistance under the ACA because they are undocumented (16%) or they fall into the Medicaid coverage gap (13%) created by their state’s decision not to expand Medicaid. These 3.6 million women lack a pathway to affordable insurance coverage.
However, about a fifth of uninsured women are eligible for Medicaid but not enrolled and another quarter are income eligible for a subsidized Marketplace plan. About a quarter (26%) of uninsured women are not eligible for assistance under the ACA because they have an offer of employer-based insurance or have incomes above the levels for subsidies in the Marketplace. While further education about coverage options may be important to reach uninsured women, it may not be enough to convince some to take up coverage. Cost is the leading reason that uninsured women report for remaining uninsured (Figure 4).
Scope of Coverage:
The ACA set new standards for the scope of benefits offered in private plans. In addition to the broad categories of essential health benefits (EHBs) offered by state-based marketplace plans, 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.10 Abortion services are explicitly excluded from being included as EHBs and 25 states have laws banning coverage of most abortions from the plans available through the state Marketplaces, and an additional 7 states did not include abortion coverage in 2015 even though they had no bans. As a result, in 2015, women enrolled in Marketplace plans in 32 states lacked abortion coverage in their new policies.11
Affordability and Access:
Affordability of care is a concern for many women, not just those who are uninsured. While the ACA has expanded coverage, many of the women who have signed up for Marketplace plans are low-income, for whom out-of-pocket costs can be unaffordable. In 2014, 15% of women with Marketplace plans reported postponing care in the past year due to cost. Over one-third of women (36%) reported that they were not confident that they would be able to afford usual medical costs, despite having insurance (Figure 5).3 It is also important to ensure that women have access to care. There has been some concern that Marketplace plans have narrow provider networks that may not be able to meet the needs of enrollees. In fall 2014, one in five women with Marketplace coverage reported that they could not get an appointment because the provider didn’t accept their insurance. The ACA includes some measures directed at limiting out-of-pocket consumer costs that will protect some women with private insurance, such as 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 millions of women have gained coverage in the first two full years of implementation. As the third year of the ACA expansion gets underway, it may be more challenging to make inroads in reducing the number of uninsured. Furthermore, some women still lack 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 2014, by State|
|Percent Distribution by Coverage Type|
|Employer Sponsored||Direct Purchase||Medicaid||Other||Uninsured|
|NOTES: Other category includes: Medicare coverage, unknown private insurance, and military-related coverage. Percentages may not sum to 100% due to rounding. Some estimates are “N/A” because point estimates do not meet the minimum standards for statistical reliability.
SOURCE: Kaiser Family Foundation analysis of 2015 Current Population Survey, U.S. Census Bureau.
|Table 2: Distribution of Nonelderly Women, Ages 19-64, for ACA Coverage Among Those Remaining Uninsured as of 2015|
|Medicaid Eligible||Tax Credit Eligible||Ineligible for Financial
Assistance due to Income,
ESI Offer, or Citizenship
|NOTES: Percentages may not sum to 100% due to rounding.*LA’s Governor signed an Executive Order to adopt the Medicaid Expansion, which is expected to take effect by July 1, 2016. For purposes of this analysis, LA is considered an expansion state. ^ Tax credit-eligible population in Minnesota and New York include uninsured adults who are eligible for coverage through the Basic Health Plan. † Wisconsin covers adults up to 100% FPL in Medicaid under a waiver but did not adopt the ACA expansion. Some estimates are “N/A” because point estimates do not meet minimum standards for statistical reliability. “-“ indicates state does not have a Medicaid coverage gap.
SOURCE: Kaiser Family Foundation analysis of 2015 Current Population Survey, U.S. Census Bureau.
Kaiser Family Foundation analysis of 2015 Current Population Survey, U.S. Census Bureau. (2015). Methods available at: http://kff.org/health-reform/issue-brief/new-estimates-of-eligibility-for-aca-coverage-among-the-uninsured/.
Kaiser Family Foundation/Health Research & Educational Trust. (2014). Employer Health Benefits Survey.
Kaiser Family Foundation. (2015). Analysis of 2014 Survey of Low-income Americans. Methods available at: http://kff.org/health-reform/issue-brief/adults-who-remained-uninsured-at-the-end-of-2014/.
Markus A., Andres E., West, K.D., Garro, N., & Pellegrini, C. (2013). Medicaid Covered Births, 2008 through 2010, in the Context of the Implementation of Health Reform. Women’s Health Issues, 23(5), e273-e280.
Guttmacher Institute. (2008). Public Funding for Family Planning, Sterilization and Abortion Services, FY 1980–2006.
Kaiser Commission on Medicaid and the Uninsured. (2009). Estimates based on CMS National Health Accounts data.
Kaiser Family Foundation. (July 2015.) Medicaid and Family Planning: Background and Implications of the ACA.
Kaiser Commission on Medicaid and the Uninsured. (October 2013). The Uninsured: A Primer.
Kaiser Family Foundation. (May 2014).Women and Health Care in the Early Years of the ACA: Key Findings from the 2013 Kaiser Women’s Health Survey.
Some religious employers (houses of worship) are exempt from the contraceptive coverage requirement.
Salganicoff, A., & Sobel, L. (2015 Forthcoming). Women, Private Health Insurance, and the Affordable Care Act. Women’s Health Issues.