Ten Ways That Repealing and Replacing the Affordable Care Act Could Affect Women
|10 Ways That Repealing and Replacing the ACA Could Affect Women|
Women have much at stake as the nation debates the future of coverage in the United States. Because the ACA made fundamental changes to women’s health coverage and benefits, changes to the law and the regulations that stem from it would have a direct impact on millions of women with private insurance and Medicaid. President Trump and the Republican leadership in Congress have forwarded numerous proposals to repeal and replace significant portions of the Affordable Care Act (ACA). The American Health Care Act (AHCA) is the first formal legislation introduced in the 115th Congress to repeal and replace elements of the ACA. It would eliminate individual and employer insurance mandates, effectively end the ACA Medicaid expansion, cap the Medicaid program, and make major changes to the methodology used to determine the federal tax subsidies available to assist individuals who purchase private insurance.
ACA’s Impact on Coverage and Access for Women
Since the ACA’s passage, the uninsured rate has declined to record low levels. Between 2013 and 2015, the uninsured rate among women ages 19 to 64 fell from 17% to 11% (Figure 1). This drop was due in large part to the Medicaid expansion that was adopted by 31 states and DC, and the availability of federal tax credits to subsidize premium costs for many low and modest-income women and men. In addition to coverage improvements, fewer women face affordability barriers since the ACA was enacted. Women have consistently been more likely than men to report that they delay or go without needed care because of costs. The ACA addressed some of these financial barriers by providing subsidies for premiums and cost sharing, eliminating out of pocket costs for preventive services, lifting the lifetime limits on expenses insurance will cover, and requiring minimum levels of coverage for ten Essential Health Benefit categories. Since its passage, the share of women who report that they delayed or went without care due to costs has fallen (Figure 2). This drop has been particularly marked among low-income women, although costs continue to be a greater challenge for this group as well.
1. Medicaid Eligibility: Expansion and Work Requirements
Medicaid has been the foundation of coverage gains under the ACA. Eliminating federal funds for the ACA’s Medicaid expansion could leave many of the nation’s poorest women without a pathway to coverage.
Women comprise the majority of Medicaid beneficiaries—before the passage of the ACA and today. Prior to the ACA, compared to men, women were more likely to qualify for Medicaid because of their lower incomes and because they were more likely to meet one of the program’s eligibility categories: pregnancy, parent of a dependent child, over 65, or disability. The ACA eliminates the program’s “categorical” requirements, allowing states to extend Medicaid eligibility to all individuals based solely on income. In the 31 states and DC that have chosen to expand Medicaid, individuals with household incomes up to 138% of Federal Poverty Level (FPL) qualify, and the federal government finances 95% of the costs.1
It is estimated that by 2015, 11 million adults had gained coverage as a result of the ACA’s Medicaid expansion. This opened the door for continuous coverage to pregnant women who often became ineligible for coverage 60 days after the birth of their baby and had no other pathway to coverage as new mothers. The Medicaid expansion has also helped women who do not have children gain access to coverage, since before the expansion they were ineligible for coverage in most states. The AHCA withdraws the enhanced federal funds for the Medicaid expansion as of January 1, 2020 except for beneficiaries enrolled as of December 31, 2019 who do not have a break in eligibility for more than 1 month. This loss of federal financing would leave states without the funds needed to continue supporting this expansion, potentially forcing some states to roll back eligibility for parents to the very low levels that were in place before the ACA (Figure 3). For example, a single mother of two living in Louisiana or Indiana would not have qualified for Medicaid if her income exceeded $4,687. The Congressional Budget Office (CBO) estimates that, under the AHCA, some states that have already expanded their Medicaid programs would not continue that coverage (some states might also begin to reduce coverage prior to 2020), and that no new states will adopt the expansion.
The AHCA would amend the federal Medicaid statute to allow states to require some beneficiaries, including parents of children 6 and older and adults without disabilities, to show proof of employment. States would have flexibility to design the details of the work requirement within federal guidelines and would receive additional federal support to help cover the administrative costs of this change.
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2. Capping Federal Medicaid Spending
Medicaid provides health coverage to nearly one in five women in the U.S. Capping the program would limit the federal dollars that states would receive for a program that pays for half of births, three-quarters of all public family planning, and provides supplemental coverage for nearly 1 in 5 senior women on Medicare.
Since its inception in 1965, Medicaid has evolved to become a leading source of coverage for low-income women of all ages. The program provides health coverage to one in four women of reproductive age and one in four Latinas and African American women. Over the years, the program has also expanded to be the largest payor of maternity care and publicly-funded family planning in the U.S.
Medicaid is financed by a combination of federal and state dollars. For most beneficiaries, the federal government pays a percentage of costs, ranging between 50-75% depending on the state. Beginning in 2020, the AHCA would convert federal Medicaid funding from an open-ended matching system to an annual fixed amount of federal dollars for five enrollment groups (the elderly, individuals with disabilities, children, newly eligible adults, and all other adults). States could choose a “block grant” (for payment of services for children under 18 and poor parents of dependent children) or a “per capita cap” structure, which would save federal funding, but shift more responsibility to states to pay more of their own dollars if they want to sustain the program at current levels.
While fixed federal financing would affect all individuals insured by Medicaid, one area that is particularly important for women is the program’s coverage of family planning services. Currently, the federal government requires coverage of family planning services and supplies and pays for 90% of the cost of these services, a higher match than for all other services.2 This higher federal payment rate provides states with an incentive to cover the full range of contraceptive methods. Under a per capita cap structure, states will still be required to cover family planning services, but there will no longer be an enhanced federal matching rate for family planning services provided to most beneficiaries. As a result, there may be less up-front financial incentive for states to cover the more expensive methods of contraception like IUDs, even though they are highly effective at preventing unintended pregnancies. Should states select a block grant option, family planning services would no longer be a mandatory benefit for non-disabled women on Medicaid.
If a state chooses a per capita cap structure, the AHCA would not change the financing structure for stand-alone family planning expansions that are currently in place in over half the states. These limited scope programs have allowed states to extend Medicaid coverage for family planning services to low-income women and men who do not have other family planning coverage. Since the AHCA’s per capita cap does not apply to these programs, states could continue to receive a 90% federal matching rate for them. These programs may become increasingly important to women because the CBO predicts that under this bill the number of uninsured will rise by 24 million over the next 10 years and these Medicaid family planning program are often an important source of reproductive care for uninsured women.
Both capped financing approaches would limit states’ ability to respond to rising costs, new and costly treatments, or public health emergencies such as the opioid epidemic or Zika. States may decide to make programmatic cuts such as cutting provider payments, particularly when facing fiscal pressures. For example, on average, Medicaid pays ob-gyns 76% of the Medicare rate3 and a smaller share of the commercial rate. If states were to make further cuts to provider payments or to plans, the pool of participating providers could shrink in response to reduced rates, would it make it harder for many women enrollees to find a participating ob-gyn or cause them to experience delays to schedule appointments for needed care.
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3. Medicaid and Planned Parenthood
Planned Parenthood provides reproductive health services for many low-income women across the nation. Cutting off federal Medicaid payments to the organization could limit the availability of the most effective contraceptives, as well as STI and cancer screenings for many women on Medicaid.
Many low–income women obtain reproductive care at safety-net clinics that receive public funds to pay for the care they provide. The network includes a range of clinics that provide a broad range of primary care services, such as community health centers (CHCs) and health departments as well as specialized clinics that focus on providing family planning services. The largest organization of specialized family planning clinics is Planned Parenthood, which receives federal support through reimbursement for care delivered to women and men on Medicaid, as well as grant funds from the federal Title X family planning program. Despite comprising only 10% of the safety-net clinic that provided subsidized family planning services in 2010, Planned Parenthood clinics served 36% of women (2.4 million women) seeking contraceptive care at these centers (Figure 5).
The AHCA would prohibit federal Medicaid payments to Planned Parenthood for one year, even though federal law already prohibits federal dollars from being used to pay for abortions other than those to terminate pregnancies that are a result of rape, incest or a threat to the pregnant woman’s life. The AHCA provides additional funds to CHCs, presumably to compensate for loss of a major provider of care to women, but there are no specifics in the bill that would require the health centers to use these funds to provide services to women. There is also concern that the CHCs do not currently have the capacity to fill the gap in the availability of care left by the loss of Planned Parenthood as a participating Medicaid provider. 4 Not all CHCs provide the same range of services as Planned Parenthood, and care at CHCs could be more costly than that provided by specialized family planning providers like Planned Parenthood.5 The CBO’s March 13, 2017 analysis of the AHCA stated that cutting off Medicaid payments to Planned Parenthood for one year would result in loss of access to services in some low-income communities because it is the only public provider in some regions. The report also stated that the policy would result in thousands of additional unintended pregnancies that would be financed by Medicaid.6 Other Republican proposals to repeal the ACA do not ban funds to Planned Parenthood, but there have been numerous legislative initiatives over the years sponsored by the Republican leadership that would have eliminated all federal funds to the organization.
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4. Abortion Coverage
Private and public coverage of abortion is currently limited in many states through the federal Hyde Amendment and state laws. The AHCA would go further than the ACA to restrict the availability of abortion coverage through private insurance policies.
Since 1976, the federal Hyde Amendment has limited the use of federal funds for abortion only to cases when the pregnancy is a result of rape or incest or is a threat to the woman’s life. Since its first passage over 40 years ago, the amendment has dramatically limited coverage of abortion under Medicaid, as well as other federal programs.7
In private insurance, the ACA explicitly bars abortion from being included as part of the Essential Health Benefit package defined by states and allows states to ban all plans in their Marketplaces from covering abortion. States can also ban abortion coverage in all state regulated private plans.8 As of March 2017, 25 states have laws limiting or banning coverage of abortion in ACA Marketplaces, and of these, 10 states ban abortion coverage in both the Marketplaces and in the private insurance market.
To ensure no federal dollars are used to subsidize abortion coverage, the AHCA would no longer make this a state option, rather it would ban abortion coverage in all Marketplace plans as well as prohibit the use of federal tax credits to purchase any plans that cover abortion that are available outside the Marketplace. The bill would limit employer coverage of abortion by disqualifying small employers from receiving tax credits if their plans cover abortion beyond Hyde limitations. It also prohibits the use of tax credits for all individuals seeking a COBRA policy that includes abortion coverage after leaving a job, regardless of employer size. This could have the impact of discouraging employers from including abortion coverage in their employees’ health plans.
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5. Tax Credits, Premium and Cost-Sharing Subsidies
The AHCA would set the level of tax credit assistance using primarily age, and would repeal the cost-sharing protections for low-income individuals. Because women have a lower income than men at all ages, this approach could place women at a disadvantage compared to men.
Women comprise more than half (54%) of ACA marketplace enrollees in the 34 states that use the federally facilitated marketplace, healthcare.gov. Approximately eight in ten (81%) Marketplace beneficiaries receive a premium tax credit, which offsets premium costs and makes them more affordable. In 2015, more than one-third (37%) of women who purchased insurance on their own were low-income ($23,540 for a single person) compared to 31% of men. 9 The current subsidy structure under the ACA provides higher levels of subsidies to those who are low-income, older, and who live in areas with more expensive coverage. The AHCA, in contrast, takes a very different approach to the allocation of subsidies, and reduces the amount that the federal government would contribute to subsidies with the goal of reducing federal spending. The AHCA provides a flat tax credit based on age only up until an income of $75,000 for a single individual, and phases out at higher incomes. This would result in a large decrease in tax subsidies to older Marketplace enrollees compared to what is available to them today. The AHCA sets aside additional federal funds to assist older enrollees, but how those funds are allocated to individuals is still to be determined by the Senate. Nonetheless, under the AHCA’s tax credit methodology, people with lower incomes would receive significantly less than they do under current law. A higher share of women is poor or low-income than men, because women are more likely than men to head single parent households, work part-year or part-time, are paid less than men for similar work, and take breaks from the workforce to stay home and care for children and aging parents. As a result, this approach could disproportionately disadvantage women. In addition, the AHCA repeals the cost-sharing subsides available today under the ACA that provide additional protection from the high costs of deductibles, cost-sharing, and co-insurance to individuals with incomes below 250% of the federal poverty level.
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6. Insurance reforms
The ACA banned many of the long-standing discriminatory practices in the individual insurance market that translated into higher cost burdens for women. While the AHCA is precluded from addressing these requirements because they do not directly affect federal spending, future legislative and administration action could eliminate or modify these reforms affecting women’s coverage and costs.
Dependent Coverage and Annual and Lifetime Caps
A popular element of the ACA is the provision that requires private health insurers that offer dependent coverage to children to allow young adults up to age 26 to remain on their parents’ insurance plans. This provision was the first in the ACA to take effect, and it increased the availability of insurance to an age group that historically had a high uninsured rate (Figure 6). In 2015, 39% of women ages 19 to 25 reported that they were covered as a dependent.10 Individual and group health plans are also prohibited from placing lifetime or yearly limits on the dollar value of coverage for essential health benefits.
Gender Rating and Pre-Existing Conditions
Prior to the ACA, non-group insurers in many states charged women who purchase individual insurance more than men for the same coverage, a practice called gender rating.11 Yet, plans sold on the individual market often did not cover many important services for women, such as maternity care, mental health services, and prescription drugs.12 Insurance companies were also permitted to deny or stop renewing coverage to individuals with a “preexisting condition,” which included several conditions common among women such as pregnancy, mental illness, or a prior C-section. An estimated 6.5 million women purchased coverage on the individual insurance market in 2011, and many of these women paid higher rates than men. Prior to the ACA, most of the women in this market were of reproductive age, working, and had incomes below 250% FPL.13 The ACA bans gender rating and pre-existing condition exclusions. The AHCA would not change this, but individuals who do not maintain continuous coverage would incur a penalty in the form of higher premium rates (30%) for one year when they try to obtain health insurance after having a coverage gap.
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7. Essential Health Benefits
The ACA instituted new rules that require all plans in the individual market as well as Medicaid expansion programs to cover ten categories of benefits. Of particular importance to women has been the inclusion of maternity care, preventive services, and mental health.
|ACA Required Essential Health Benefits|
The ACA requires all Marketplace plans and Medicaid expansion programs to cover ten categories of “essential health benefits” (EHB). Each state chooses a benchmark benefit plan, which sets the floor for services that plans in that state must cover within each EHB category.14
Prior to the ACA, there were few federal requirements on what private plans in the individual market had to cover. The ACA established a floor for benefits that individual market plans must cover with the goal of reducing variation and adverse selection by standardizing “meaningful coverage.” This is particularly important for women, as they are the exclusive users of maternity care and more frequent users of services in some other EHB categories, such as prescription drugs and mental health. Mental health services in particular were routinely excluded in individual plans prior to the ACA. Depression, anxiety, and eating disorders are all more common among women than men.
The AHCA rescinds the EHB requirement for Medicaid expansion programs, meaning that beneficiaries in this group would not be entitled to coverage for all ten categories. Medicaid requires states to cover some of the categories, such as hospitalization and maternity and newborn care, but others such as prescription drugs are optional and at state discretion. The AHCA does not address the requirement in private plans because that would be beyond the scope of a reconciliation bill. However, other Republican proposals would lift the requirement with the goal of giving individuals the flexibility to buy plans that are more reflective of their anticipated health needs (Appendix 1). While the idea of choice sounds appealing to some, it is antithetical to the way that insurance operates by spreading the costs and risks to the pool of insured individuals. Plans that include a broader range of benefits would be considerably more expensive than they are today.
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8. Preventive Services
Currently, all private plans, Medicaid expansion programs, and Medicare must cover recommended preventive services without cost sharing. Important services for women include: breast and cervical cancer screening, osteoporosis screening, pregnancy related services, well woman visits, and contraception.
In addition to EHBs, the ACA included a related requirement that all private plans cover federally-recommended preventive services without charging cost-sharing. In contrast to EHBs, which apply to individually purchased plans and Medicaid expansion only, the preventive services requirement applies to all forms of private insurance, including employer-sponsored and individual market plans. Prior to the ACA, the only federal–level requirements that applied to group plans were for coverage of a minimum length of stay after a delivery, availability of reconstructive surgery following a mastectomy, and parity for mental health services. The preventive services coverage requirement also applies to the Medicaid expansion and Medicare programs. This means that most adults with some form of private or public insurance now have coverage without cost-sharing for all of the services recommended by the U.S. Preventive Services Task Force (USPSTF), immunizations recommended by the federal Advisory Committee on Immunization Practices (ACIP), and services for women recommended by the Health Resources and Services Administration.15
Among the slate of services covered, many are exclusively for women or address conditions that have a disproportionate impact on women (Figure 7). These services address some of the most common conditions for women, including breast cancer, cardiovascular disease, and obesity. For older women, the preventive services policy means that Medicare now covers the full cost of mammograms, pap smears, and bone density screenings, which were previously subject to 20% co-insurance before the passage of the ACA.
The AHCA maintains preventive services requirements for private plans, but would repeal the preventive services requirements that are now included as benefits that must be provided to the Medicaid expansion population. Preventive services for adults are covered at state option for other Medicaid beneficiaries. States could roll back coverage of preventive services for this group. Other proposals, including Speaker Ryan’s A Better Way proposal and Secretary Price’s Empowering Patients First Act, would repeal the preventive services policy for all plans in order to allow individuals to buy less expensive plans that are more limited in scope and lessen the federal requirements for health plans (Appendix 1). While plans might still cover some these services, individuals could be charged co-insurance and copayments for these services as was the case before the ACA was enacted.
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9. Contraceptive Coverage
Today, the majority of women with private insurance have no cost contraceptive coverage. This preventive benefit has reduced women’s out-of-pocket spending on birth control and made the most effective, but often costly, contraceptive methods affordable for most insured women. This provision could be eliminated or modified through regulatory changes without the need for Congressional action.
Current law requires that most private plans include coverage of all FDA-approved contraceptive methods for women at no additional cost. Research has found that the requirement has had a large impact in a short amount of time. For example, in the first two years that the policy was in effect, the share of women with any out of pocket spending on oral contraceptives fell sharply to just 3.6% of women with employer-sponsored insurance (Figure 8).16 Similar effects have been documented for other contraceptives, including IUDs.17
The AHCA does not specifically address the contraceptive coverage requirement. However, President Trump and Secretary Price have expressed support for advancing “religious freedom,”18 and this provision has been at the heart of two cases that have reached the Supreme Court where employers have claimed that the requirement violates their religious beliefs. The contraceptive coverage requirement was implemented through a series of agency regulations that included contraception in the package of women’s preventive services, defined the religious exemption and accommodation available to houses of worship and faith-based nonprofits respectively, and clarified that plans must cover 18 contraceptive methods. Since these requirements are in regulations, the Trump Administration can issue new regulations and guidance to permit employers and insurers to cover fewer methods, or to exempt more employers with religious objections without the need for congressional action.19
If the federal requirement is eliminated or scaled back, the scope of contraceptive coverage would again be shaped by employers, insurance plans, and state policy. More than half (28) of states have laws requiring plans in their states to cover contraceptives, but these are more limited than the ACA. Only five of the 28 states require coverage of the full range of contraceptives without cost sharing, but even these state-level mandates do not apply to self-funded plans, which cover most insured workers.20
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10. Pregnancy-Related Care
Today, pregnant and postpartum women have a greater range of protections and benefits than they did prior to the ACA. These range from mandatory maternity and newborn coverage, to no-cost prenatal screening, and breastfeeding supports.
Before the ACA, pregnant women seeking insurance in the individual market were routinely turned away as having a pre-existing condition. Furthermore, many individual plans did not cover maternity services because it was not required in this market. Some individual plans offered separate maternity coverage as a rider which could be costly, ranging from roughly $15 to $1600 a month.21 Some plans also imposed a waiting period before the rider took effect. These discriminatory practices were limited to the individual market because coverage for maternity services has been required for decades under Medicaid and in most employer-sponsored plans due to the Pregnancy Discrimination Act, which requires it for firms with at least 15 employees. The ACA changed this by including maternity and newborn care as part of the EHB package that must be included in new individual private plans as well as under Medicaid expansion and making other improvements in coverage for pregnant and post-partum women. While a few states had required individual plans in their states to cover maternity services prior to the ACA, most did not.
|ACA Reforms Improving the Availability of Maternity Care|
The AHCA would weaken some of the protections for pregnant women that are currently in place. By halting funds for Medicaid expansion, some new mothers would lose coverage once the 60-day postpartum period ends and become uninsured. The AHCA does not change the EHB for individually purchased plans, or repeal preventive services and workplace requirements in the private sector. However, as stated earlier, some Republican proposals would repeal the EHB and preventive services requirements with the goal of giving policyholders more flexibility to choose their own coverage in order to purchase less expensive plans (Appendix 1). Some have raised the possibility of excluding maternity coverage for those who will not need it such as men and older women. This would mean that the risk pool for plans that include maternity services would primarily be comprised of women who anticipate using maternity care, and would likely greatly increase costs for women who sought such coverage. Furthermore, given that nearly half of pregnancies are unintended and unanticipated, some women would buy coverage that does not include maternity care and therefore would effectively be uninsured for all their pregnancy-related needs if they become pregnant. The AHCA would also maintain the ban on pre-existing conditions, but it is contingent on maintaining continuous coverage. Those who have gaps in coverage would have to pay a penalty of 30% higher premium costs for one year. Low-income women who lose their Medicaid eligibility post-partum could be the most vulnerable as they may need to take time off from work to care for their newborn but may be too poor to purchase coverage.
Today, women’s health coverage levels are at an all-time high. In addition to the coverage gains in the Marketplaces and Medicaid, many of the long-standing discriminatory practices in the individual insurance market that translated into higher cost burdens for women have been banned. Minimum standards for benefits that individual plans must cover through the EHB and the preventive services requirements for all private plans have assured that most insured women have coverage for a broad range of recommended services that they need such as maternity care, mental health services, and preventive services such as mammograms, pap smears, and contraceptives. Recent polling shows that the American public values these protections, including those for poorer women (Figure 9). In addition, while the AHCA would prohibit federal Medicaid funds to Planned Parenthood for one year, 75% of Americans say they favor continued federal funding for Planned Parenthood.22
Speaker Ryan has proposed a three-pronged strategy that starts with the AHCA, a reconciliation bill that alters subsidies for private insurance, eliminates the Medicaid expansion, bans Medicaid funding to Planned Parenthood, and places a cap on Medicaid spending. This proposal alone will have considerable impact on women, particularly low-income women who rely on subsidies and those who are on Medicaid. While the AHCA reconciliation bill requires only 51 votes in the Senate, another prong in the Republican strategy includes separate legislation that might repeal the EHB and preventive services requirements, but would require 60 votes in the Senate to circumvent a filibuster. Short of legislation, many of the ACA’s regulations can be amended through a third prong of federal-level administrative actions. Given the gains that women have made in access to meaningful and affordable coverage, they have much at stake in the current debate over the future of our nation’s private and public insurance programs.Appendix