Playing politics with women's health

In the 18 days between House Republicans’ introduction of the American Health Care Act and its withdrawal, women’s health was in the spotlight. With House Speaker Paul Ryan now stating that he’s going to try again on legislation to “replace” the Affordable Care Act, it’s worth looking at some of the ways the ACA has benefited women – and how actions from Congress and the Trump administration could affect women’s insurance coverage and access to care.

Women gained coverage under the ACA

The ACA’s biggest achievement was reducing the percentage of the population without health insurance. It did this by allowing states to expand Medicaid coverage to adults with incomes up to 138% of the federal poverty level, and by creating state-based marketplaces where individuals could buy plans -- which are subsidized if their incomes are under 400% of the federal poverty level. The Kaiser Family Foundation looked at insurance data from 2013, just before the ACA took full effect, and 2015. In those two years, the uninsured rate among women ages 19 to 64 dropped from 17% to 11%.

Because the Supreme Court ruled that the ACA’s Medicaid expansion should be voluntary instead of required, its benefits have been unevenly distributed. At the beginning of 2017, 31 states and the District of Columbia have expanded Medicaid, and proponents in other states are working to join the list. Due to their greater risk of living in poverty and greater likelihood of being in one of the program’s eligibility categories (pregnancy, parent of a dependent child, over age 65, or living with a disability), women have historically accounted for the majority of Medicaid beneficiaries, and that has remained the case in the ACA era. Now, though, women in expansion states with incomes up to 138% FPL don’t have to worry about losing coverage 60 days after delivering a baby or when a child celebrates a milestone birthday.

In the individual market for private insurance, all consumers with records of health problems or older ages have benefited from provisions that a) prohibit insurers from denying coverage or charging higher premiums based on pre-existing conditions and b) specify that premiums for older enrollees can be a maximum of three times the cost of those for younger enrollees. Women have enjoyed a particular benefit, though, because prior to the ACA many insurers charged women more for health insurance – a practice known as gender rating. Prior to the ACA, the National Women’s Law Center found that 95% of the best-selling plans in state capitals’ individual insurance markets practiced gender rating.

Quality of coverage: what plans must and can't include

The ACA addressed another inequity in health coverage by requiring that insurers cover 10 essential health benefits. Many of these, including prescription drugs and mental-health services, benefit women and men alike.  (See Kim Krisberg’s post on essential health benefits for more details.) However, the inclusion of maternity care on the list of essential benefits became the subject of debate during the consideration of both the ACA and the AHCA. Back in 2009, columnist Michael Hiltzik noted in the Los Angeles Times that only 12% of policies in the individual market offered maternity coverage. He gave three reasons why all insurance policies should cover maternity care: Males are involved in pregnancy, too; society has a strong interest in healthy mothers and babies; and universal coverage is the only way to make maternity coverage affordable. Indeed, as The New York Times’ Margot Sanger-Katz explains, coverage for many expensive health conditions – from schizophrenia to rheumatoid arthritis – is only affordable and sustainable when all insurers must cover services for a broad range of health needs.

The ACA lists the categories of essential health benefits, and leaves HHS with the task of defining them in detail. Under the Obama administration, HHS gave the states flexibility to define these benefits. If the Trump administration wanted to lower standards for insurance plans, though, they could write skimpy standards for the benefits, which would supersede existing state requirements for more-comprehensive coverage.

Separate from the essential health benefits list is the ACA’s requirement for insurers to cover preventive services without consumer cost-sharing. All adults with private insurance are entitled to receive routine immunizations and evidence-based screenings and counseling (e.g., colonoscopies in adults age 50 and older) without being charged co-payments, co-insurance, or payment towards deductibles. In addition, insurers must cover certain preventive services for women without cost-sharing. For all these categories of preventive services, the law specifies that coverage is based on recommendations from an expert group: for immunizations, the Advisory Committee on Immunization Practices; for screenings and counseling, the US Preventive Services Task Force; and for women’s services, the Health Resources and Services Administration.

HRSA’s current list of preventive services for women (updated in December 2016) includes screening for breast and cervical cancer, well-woman visits, screening and counseling for alcohol misuse and for interpersonal and domestic violence, and all FDA-approved methods of contraception. Additional legislation would be required to repeal the ACA provision requiring insurers to cover HRSA-specified services for women, but the Trump administration has the ability to change HRSA’s list. Given that HRSA is part of the Department of Health and Human Services and that as a member of Congress Price expressed skepticism that any woman finds birth control unaffordable, it’s not hard to imagine a new list of preventive services from HRSA that contains far fewer items.

In contrast to Tom Price’s views on contraception’s affordability, PerryUndem just conducted a national survey and found 33% of women voters 18-44 said they couldn't afford to pay more than $10 for birth control if they had to buy it on the day of the survey, and 14% couldn't afford to pay any amount.

The House GOP bill also limited insurers' ability to cover one particular kind of healthcare: abortions. The AHCA would have banned abortion coverage in plans sold through state marketplaces; prohibited using federal tax credits to buy non-marketplace plans that cover abortion; prevented small employers from receiving tax credits if their plans cover abortions in cases other than rape, incest, or a pregnancy threatening the woman’s life; and use of tax credits by those who've recently left a job to pay for policies available under COBRA if those policies cover abortion. These provisions would likely lead to most insurers eliminating abortion coverage from their plans -- with the end result that only women who could afford to pay out-of-pocket for abortions would have access to this form of healthcare.

Cutting off payments to important providers

Another appalling element of the House Republicans’ bill was that it would have prohibited federal Medicaid payments to Planned Parenthood for one year. This isn’t about federal dollars paying for abortions, because the Hyde Amendment already prohibits federal funds paying for abortions (except in cases of rape, incest, or a pregnancy threatening the woman’s life). What it would mean is that federal Medicaid would pay all providers for the services they render, except for one – and that one happens to primarily serve women, and provide sexual and reproductive health services to thousands of low-income women who live in areas with few other sources of this kind of care. Cutting off Medicaid funding to Planned Parenthood would imperil many low-income women’s access to the most effective forms of contraception, as well as STI testing and cancer screenings. In “Ten Ways That Repealing and Replacing the Affordable Care Act Could Affect Women,” the Kaiser Family Foundation’s Usha Ranji and colleagues write:

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.

Many of Planned Parenthood’s more than two million clients go to Planned Parenthood because it’s their preferred source of care. As the Guttmacher Institute’s Kinsey Hasstedt reports, Planned Parenthood health centers are more likely to offer extended evening and weekend hours and provide the full range of contraceptive options on-site when compared to non-Planned Parenthood federally qualified health centers (also called FQHCs, or community health centers) and health departments – other common sources of care for women whose care is covered by Medicaid or the Title X program. And these other sources of care are unlikely to be able to fill the hole that would be left if Planned Parenthood health centers had to close or reduce their services under a loss of federal funding. Hasstedt writes:

In 332 of the 491 counties that Planned Parenthood health centers served in 2010, Planned Parenthood served at least half of the women obtaining publicly supported contraceptive services from a safety-net health center.5,6 In 103 of these counties, Planned Parenthood sites served all of these clients. Nearly one-third of all women in need of publicly funded contraceptive services lived in the 332 counties where Planned Parenthood served all or most safety-net family planning clients.

A 2016 survey of clients at Title X–funded health centers reinforces the importance of Planned Parenthood to the women it serves. Twenty-six percent of clients at a Planned Parenthood site reported that it was the only place they could get the services they need.

If federal funding to Planned Parenthood were to be cut off, community health centers would do all they could to try and fill the gap, but would fall far short. FQHC expert Sara Rosenbaum (disclosure: a colleague at the George Washington University Milken Institute School of Public Health) explains in a Health Affairs blog post that “to assume that health centers are in a position to fill the void left by barring a health care provider of Planned Parenthood’s importance to Medicaid beneficiaries—even providers as attuned to the needs of their communities and accessible as community health centers—is simply wrong.”

Texas officials claimed community health centers could fill the gap when they made Planned Parenthood ineligible to receive money from the state-funded program for reproductive-health services to low-income residents (a replacement for the federally funded program that didn’t let them discriminate against specific providers). However, researchers found some changes to contradict that claim in the counties served by Planned Parenthood affiliates that became ineligible for funding: In those counties, the program paid for fewer women to get some of the most effective forms of contraception, and Medicaid-covered births rose among women who'd previously received injectible contraceptives (which must be administered every three months). In estimating the impact of the AHCA, the Congressional Budget Office calculated that reduced access to contraception would result in thousands more births being covered by Medicaid, at a cost of $77 million over 10 years.

On the positive side, states with more Planned Parenthood clinics per capita have lower rates of teen births and STI diagnoses, Miranda Yeaver reports. And whether or not voters are aware of the specific population-level benefits of Planned Parenthood, they recognize its importance: A Kaiser Family Foundation poll found 75% support continuing Planned Parenthood's Medicaid payments.

Medicaid isn’t the only source of Planned Parenthood funding that’s at risk in future legislation. Planned Parenthood health centers also receive funding through the Title X grant program, which funds health centers that provide sexual and reproductive health services to clients with low incomes. After several states enacted policies that would have restricted specific providers from receiving Title X funding, the Obama administration issued a rule clarifying that states cannot exclude providers from the program based on factors unrelated to the quality of care they provide. Under the Congressional Review Act, Congress can vote to undo regulations finalized in the last six months of the previous presidency. With a tie-breaking vote from Vice President Mike Pence in the Senate, the 115th Congress voted to undo the Obama administration’s prohibition on state Title X programs discriminating against qualified providers.

This move from Congress means Title X funding to Planned Parenthood is in peril in states where elected officials are willing to cut off low-income women’s access to reproductive healthcare. Future Congressional actions could go farther and cut off all Title X funding entirely. House Republicans have previously tried to eliminate all funding for the Title X program from the federal budget. Eliminating the Title X program would reduce access to highly effective contraception, STI testing and treatment, and cancer screenings – overall, it would be disastrous for public health. I don’t understand why people who claim to be fiscal conservatives would cut a program that results in millions of dollars in Medicaid savings, or why those who call themselves “pro-life” would make a move that would result in many more abortions.

I fear that we’ll keep seeing proposed legislation and regulations that would reduce women’s access to affordable health insurance, important health services, and essential healthcare providers. When these proposals come out, it’s worth asking whether the people behind them know or care enough about women’s health.

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