Written by Jodi Jacobson, editor of RHRealityCheck.org – News, commentary and community for reproductive health and justice.
Today, President Obama will sign into law the Affordable Health Care for America Act. Many aspects of the Act apply across the board to Americans regardless of age, sex, health history or employment status. Some of the provisions are of particular importance to women. Below is an initial summary of the wins, losses, and remaining challenges for women’s health and rights.
Elimination of "pre-existing conditions:"
The Act bars insurance companies from denying coverage to children due to pre-existing conditions, including children up to age 19. This provision becomes effective 6 months after signing.
The Act bars insurance companies from discriminating against adults based on pre‐existing conditions, health status, and gender. This is a critical provision for women, but one that does not become effective until 2014.
Why is this important? To date, insurance companies have discriminated heavily against women in various markets by categorizing as "pre-existing conditions" a wide range of health concerns and conditions. For example, insurance companies have rejected victims of domestic violence and rape and have classified women who have undergone cesarean sections as having "pre-existing conditions." In some cases, prior pregnancies have been considered pre-existing conditions. The new bill expressly prohibits insurers from rejecting an applicant based, essentially, on being a woman. Again, this provision does not go into effect until 2014.
Increases access to OB-GYN and midwifery care:
Plans can not require pre-authorization or referral for OB-GYN care. This provision becomes effective 6 months after signing. New policies sold on the insurance exchanges would be required to cover a range of benefits, including maternity care.
According to the Association of Certified Nurse-Midwives, the original bill in the House of Representatives, since replaced by the Act to be signed today by the President, would have expanded access to midwifery care by addressing inequities in how Certified Nurse‐Midwives (CNMs) are
reimbursed under Medicare, provided funding for home visitation by nurses for Medicaid families during or after pregnancy and improved Medicaid coverage of freestanding birth centers—a high‐quality, high‐value option for women and their families, according to the Association of Certified Nurse-Midwives. As of this writing it is not clear whether the bill to be signed today includes these provisions, but look for updates.
Partial elimination of gender rating:
Many insurance plans charge women more for insurance coverage than they do men of the same age and health status, a practice known as "gender rating." The Act eliminates this practice for some women but not for others. Gender rating (and other forms of rating) for individuals and small employers (up to 100 employees) will be prohibited. It will not apply to plans offered by employers with more than 100 employees, unless a state allows large employers to enter the insurance exchanges after 2017. In the latter case, rating rules apply to all large employer coverage in that state. The National Women’s Law Center offers materials that explain the practice of and implications for women of gender rating.
Free preventive care under new plans.
The Act requires new private plans to cover preventive services with no co‐payments and exempts preventive services from deductibles. Effective 6 months after enactment. This requirement will apply to all plans beginning in 2018. Preventive care is of course critical for all ages and both sexes, but dramatically expands women’s access to screening for cervical and breast cancer and other forms of preventive reproductive and sexual health care unique to women.
Expands funding for and access to community health centers and primary health care doctors.
The Act increases funding for Community Health Centers, to allow for nearly double the amount of access in terms of patients seen over the next 5 years. This funding becomes effective in fiscal year 2010 and is an essential aspect of health care particularly for low-income women and their families.
Expanded access to Medicaid and the Children’s Health Insurance Program
The Act expands eligibility for Medicaid to include all non‐elderly Americans with income below 133 percent of the Federal Poverty Level (FPL) and increases assistance to all states to help cover the costs of additional people to be covered under Medicaid, the nation’s public health insurance program for the low income population. The Act also maintains current funding levels for the Children’s Health Insurance Program (CHIP) through fiscal year 2015.
More than 20-million low-income women currently receive coverage for their health and long-term care through Medicaid, and the majority of adult beneficiaries of Medicaid (69 percent) are female. By expanding the eligibilty requirements, the Act will expand coverage to low-income women and children who urgently need primary preventive and curative care. This is without doubt a plus for women.
A Kaiser Family Foundation brief states:
In order to qualify for Medicaid, women must meet both categorical and income criteria. That means that one must fit into a certain “category” such as being pregnant, a mother of a child under 18, 65 or older, or having a disability. Each of these groups has different income elibiligy criteria, which vary from state to state.
Medicaid income thresholds for adults have been, however, very low. And states the KFF brief, "because women are more likely than men to fall into one of the categories and are more likely to be poor, women are more likely to qualify for Medicaid. Many very low-income women, however, do not qualify no matter how poor they are because they do not fall into one of the eligibility categories."
Medicaid is also the largest source of public funding for family planning services in the United States, financing contraceptive services for millions of low-income women. A Guttmacher issue brief, Medicaid’s Role in Family Planning, provides an overview of Medicaid’s role in financing and providing access to family planning services for low-income women. Expansion of Medicaid services means an expansion of critical family planning and contraceptive services for women, one reason that increased access to health care helps reduce the number of unintended and unwanted pregnancies and by extension the need for abortion.
Improves access to and benefits offered under Medicare:
Women make up a majority of those dependent on Medicare services. Kaiser Family Foundation notes that Medicare is a critical source of health insurance coverage for virtually all older women in the U.S. and for many younger women who have permanent disabilities.
Today, 22 million women–one in five adult women–rely on Medicare for basic health insurance protection, and women make up 57 percent of the Medicare population. Medicare helps to make health care more affordable for older women at a time in their lives when they are most likely to have multiple health problems that require ongoing and often costly medical treatment.
The Act will reduce the economic burden of health care among women and improve their access to services by reducing costs for prescription drugs by
- providing new, free annual wellness visits to the basic services provided;
- eliminating out‐of‐pocket copayments for preventive benefits under Medicare, such as cancer and diabetes screenings;
- providing better chronic care; and
- reducing overpayments to private Medicare Advantage plans.
The Act also fills the Medicare prescription drug "donut hole. According to Kaiser, the donut hole is a "unique feature" of the Medicare Part D drug benefit is the coverage gap. Part D enrollees are required to pay 100 percent of total drug costs after their spending exceeds the initial coverage limit and before reaching the catastrophic coverage limit. In 2010, most Part D plans have a coverage gap, which totals $3,610 in drug costs for plans offering the standard Medicare Part D benefit; by 2019, the gap is projected to be nearly $6,000.
The Act addresses this in 2010 by providing Medicare beneficiaries who go into the donut hole with a $250 rebate, after which they will receive a pharmaceutical manufacturers’ 50 percent discount on brand‐name drugs, increasing to a 75 percent discount on brand‐name and generic drugs to close the donut hole by 2020.
At the broadest scale, the statement from the National Organization for Women (NOW) most succinctly articulates the basic losses in this round of health care reform:
The bill covers only 32 million of the 47 million uninsured in this country, does not contain a meaningful public option and provides no pathway to a single payer system like Medicare for all.
While these aspects of reform affect all people, they again also disproportionately affect women.
Other losses with disproportionate or specific implications for women include:
Continuation of age-rating
The bill continues to permit age-rating, the practice of imposing higher premiums on older people. " This practice has a disproportionate impact on women," notes the National Organization for Women, "whose incomes and savings are lower due to a lifetime of systematic wage discrimination."
Continuation of gender-rating
The bill also permits gender-rating to continue under some policies. "Some are under the mistaken impression that gender-rating has been prohibited," states NOW, "but that is only true in the individual and small-group markets."
Larger group plans (more than 100 employees) sold through the exchanges will be permitted to discriminate against women — having an especially harmful impact in workplaces where women predominate.
NOW states: "We know why those gender- and age-rating provisions are in the bill: because insurers insisted on them, as they will generate billions of dollars in profits for the companies. Such discriminatory rating must be completely eliminated."
Lack of coverage for immigrant women
Under the Act, immigrants, a highly vulnerable population, will continue to face high barriers to acessing basic health care. The bill imposes a 5-year waiting period on permanent, legal residents before they are eligible for assistance such as Medicaid, and prohibits undocumented workers from even using their own money to purchase health insurance through an exchange.
According to the National Latina Institute for Reproductive Health (NLIRH), "If passed, the reconciliation package (being considered in the Senate this week) will cover an estimated 9 million uninsured Latinos and increase funding for community health centers, which is a lifeline for many in our neighborhoods. In addition, 4.4 million Americans in Puerto Rico and territories will receive $6.3 billion in new Medicaid funding, increased flexibility in how to use federal funding, access to the Exchange and $1 billion in subsides for low-income residents."
At the same time immigrant women are left vulnerable. In its statement on health reform, NLIRH pointed to these serious weaknesses:
- Over half of all immigrants are women, and 53 percent of all immigrants are from Latin America. The bill does not allow undocumented immigrants to buy health insurance in the exchange, and maintains a five-year waiting period for Medicaid for lawfully residing residents. The exclusion of new immigrants from Medicaid is not only unjust, but also bad public health policy.
- And although the reconciliation provisions are better than what the Senate originally proposed, residents of Puerto Rico are still a long ways away from receiving Medicaid and other federal health care support at the same level as other states of the Union.
Elimination of abortion care in private insurance market:
Despite the President’s promise that no American would be worse off after health reform than before, the majority of women now covered by private insurance plans now have access to coverage for abortion care, a fundamental aspect of women’s health care.
Under the language currently in the Act, incorporated at the insistence of Senator Ben Nelson (D-NE) and with the acquiescence of the White House, the Senate and House leadership, women will now lose coverage for abortion care for policies paid for with private dollars. The implications of the Nelson language have been addressed in detail in previous articles published by RH Reality Check, but include the following:
- Requires every enrollee–female or male–in a health plan that offers abortion coverage to write two separate checks for insurance coverage. One of these checks would go to pay the bulk of their premium, the other would go to pay the share of that premium that would ostensibly cover abortion care. Such a check would have to be written separately whether the share of the premium allocated for abortion care is .25 cents, $1.00, or $3.00 of the total premium on a monthly, semi-annual or annual basis. Employers that deduct employee contributions to health care plans from paychecks will also have to do two separate payments to the same company, again no matter how small the payment.
- Eliminates the provision in earlier versions of the Senate bill and in the original Capps language in the House bill to ensure that there is at least one insurance plan in each exchange that offers and one that does not offer abortion coverage.
- Prohibits insurance companies by law from taking into account cost savings when estimating the costs of abortion care and therefore the costs of premiums for abortion care.
- Includes "conscience clause" language that protects only individuals or entities that refuse to provide, pay for, provide coverage for, or refer for abortion, removing earlier language that provided balanced non-discrimination language for those who provide a full range of choices to women in need.
A George Washington University Study suggests that the implications of this language include:
- moving the industry away from current norms of coverage for medically indicated abortions.
- inhibiting development of a supplemental coverage market for medically indicated abortions.
- "Spillover" effects as a result of administration of Stupak/Pitts will result in dramatically reduced coverage for potentially catastrophic conditions.
Women’s groups see this as a major loss. "This battle was fought on the bodies of women and immigrant women," states NLIRH.
In the eleventh hour, President Barack Obama caved to the demands of a handful of anti-choice Democrats by agreeing to use the lives of women as trade. He will use his pen to add weight to the already cumbersome abortion restrictions in the health care bill. Latinas, immigrants, and women of color are deeply affected by any language restricting abortion access – because women of color and immigrants are disproportionately poor, they are less likely to be able to pay for reproductive health care out-of-pocket, which puts them at risk for seeking alternative, unsafe abortion methods. While health reform might lead to more Latinas being covered, it leaves out a significant portion of the population. By excluding and stigmatizing immigrants and women who need abortions, we are pushing them to the shadows of our health care system and placing unfair burden on the already-strained system of community health care centers and emergency rooms. Over half of all immigrants are women, and 53 percent of all immigrants are from Latin America; though it has yet to be signed by the President, this bill is outdated already.
In the coming months, and to truly fulfill his campaign promises, President Obama–along with Speaker of the House Nancy Pelosi and Senate Majority Leader Harry Reid–must lead the nation and the Congress in making the following changes to the foundation of health reform put in place today.
At a minimum, the Administration and Congress should:
- Amend the health reform bill to establish a public option thereby increasing competition in the health insurance market. As most analysts note, the public option is popular and also would prevent insurance companies from increasing rates by exhorbitant amounts as recently happened in California.
- Eliminate the Nelson language in the health reform bill and revoke the Executive Order signed by the President.
- Eliminate gender-rating in all policies, starting in 2011.
- Eliminate pre-existing conditions for all people in 2011. It is not clear why we need to wait four years for insurance policies to eliminate pre-existing conditions. Between this moment and four years from now, untold numbers of people will have to pay exhorbitant premiums to get coverage in high-risk pools due to pre-existing conditions. It is nice to know these will be eliminated, but waiting four years defeats the purpose.
- Remove the 5-year cap on immigrants who are legal residents and allow undocumented workers to use their own funds to purchase health insurance through an exchange.