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Medicaid Coverage for Abortion Care Elusive Even in States Where It Is Legal

12:56 pm in Uncategorized by RH Reality Check

Written by Steph Herold for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

Evidence-Based Advocacy is a monthly column seeking to bridge the gap between the research and activist communities by profiling provocative new abortion research that activists may not otherwise be able to access.

Passed in 1976, the Hyde Amendment prohibits federal Medicaid funding for abortion procedures. Under Hyde, a person with Medicaid as their health insurance can only use their insurance to cover the cost of an abortion if the pregnancy is the result of rape or incest, or the pregnancy endangers that person’s life. While Hyde has placed these deplorable restrictions on abortion coverage for almost 40 years, some states have attempted to correct this injustice — 17 states use their own funds voluntarily to cover abortion. While advocates fight to repeal Hyde and restore federal funding for abortion through Medicaid, we assume that abortion access in the 17 “Hyde-free” states is much more equitable than in the 34 states that do not provide such coverage. But are people in states with voluntary Medicaid coverage of abortion actually able to use Medicaid to pay for an abortion? Do they have insurance coverage of abortion both in theory and in practice?

Two new research briefs from Ibis Reproductive Health document the reality of Medicaid coverage of abortion in Arizona and Maryland, two  of the 17 states that use their own funds to pay for abortions. Arizona is court-ordered to provide states funds to cover “medically necessary” abortions, while Maryland offers voluntary Medicaid coverage regardless of the pregnancy circumstance. In an ideal world, these requirements would mean that individuals in Maryland and Arizona would have no trouble using their state Medicaid to pay for an abortion. As you can probably guess, this is a far cry from what’s really happening in these states.

Ibis conducted in-depth interviews with abortion providers in Maryland to gauge their experiences seeking Medicaid coverage for their patients’ abortions. These providers explained that while their state Medicaid theoretically covers abortion regardless of the circumstances, in practice, it rarely covered abortion at all. Providers reported insurmountable challenges engaging with the Medicaid office. For example, Medicaid staff did not know when and if abortions qualify for coverage, the complicated billing process through Medicaid was confusing and time-consuming, and Medicaid did not reimburse for providing abortions that should have been covered. These barriers sometimes led providers to stop working with Medicaid altogether. This systemic level incompetence is unacceptable and obviously does not meet the needs of people seeking abortions and clinics providing that health care service. 

To gain a more robust understanding of the circumstances in Arizona, Ibis interviewed abortion providers about their experiences with Medicaid and also spoke with low-income women about their how they paid for their abortions. Similar to the Maryland findings, Arizona’s Medicaid coverage does not meet women or provider’s needs. Women shared that it’s extremely difficult to enroll in Medicaid, that Medicaid rarely covers abortion services even in “qualifying circumstances,” and that they often go without other reproductive health care, such as pap smears and pre-natal care, because Medicaid refused to cover these costs as well. Just like in Maryland, abortion providers reported that they face administrative challenges dealing with Medicaid, and that Medicaid often refuses to cover abortion care because a woman’s medical condition is, unbelievably, “not life threatening enough.”

Both abortion providers and women seeking abortion services were incredibly critical of the Medicaid system. One woman interviewed in Arizona summarized her experience this way:

“I had to put off a lot. I sacrificed so much just so I could come up with the money…Like, my light, I had to do payments ’cause they were about to shut it off…and it was embarrassing…I had to survive off food boxes too…I had to sacrifice real quick.”

We’ve come to expect and denounce these awful circumstances in states in which Medicaid doesn’t cover abortion, but these Ibis research reports reveal that having Medicaid coverage of abortion doesn’t necessarily guarantee access to timely safe abortion care ostensibly covered by a state. Medicaid coverage is in theory an invaluable resource, but in reality it is not accessible at all if the system does not work properly or actually cover the procedures it is supposed to cover. As the experiences of low-income women and abortion providers in both Arizona and Maryland suggest, mandating Medicaid coverage of abortion is a far cry from guaranteeing that people can access an abortion when they need one.

These findings also make clear that at the federal level, repealing the Hyde Amendment is a necessary but not sufficient condition for ensuring access to safe abortion care for people in need. In addition to advocating for the repeal of the Hyde Amendment, Ibis provides action steps to improve the experiences that women and providers have with Medicaid. They suggest streamlining the Medicaid enrollment and application process, educating patients, providers, and Medicaid staff about the law, increasing reimbursement rates for abortion providers and lowering the administrative burden of dealing with Medicaid offices, as well as involving pro-choice stakeholders and organizations in advocating for these changes. Many abortion funds, such as the Massachusetts and California Funds, are already doing this — it would be wonderful to see mainstream pro-choice organizations take this on as well.

Pushing for Medicaid reform is not sexy, especially when we’re talking about insurance enrollment and doing away with bureaucratic red tape. The pro-choice movement has a lot on its plate, but in order to guarantee abortion access for all, we have to put as much effort into making Medicaid a just and equitable system as we put into our efforts to repeal Hyde and guarantee private insurance coverage of abortion. Medicaid can be a critical resource in theory, but in order to meet the needs of low-income people, the system must function properly in reality. And we must address the reality, however complex and daunting, that repealing the Hyde Amendment doesn’t guarantee universal abortion care coverage for low-income people.

President Obama: Women Stood for You. Stand With Us and Remove Abortion Restrictions From Your Budget

12:43 pm in Uncategorized by RH Reality Check

Written by Ashley Hartman for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

This election, I was proud to work with many young people to engage our communities and campuses in the issues that impact us. One issue that engaged many young women in the election work I did this year in Ohio was access to health care, especially pregnancy related services, such as pre- and post-natal care, maternity care, and abortion care. Sixty-five percent of 18-to-24 year-olds believe abortion should be legal all or most of the time, which is higher than any other age group. I am lucky to have employer-funded health insurance that allows me to access a full range of preventive services, including all pregnancy-related services.

Sadly, not all women — even women with insurance — have access to these services. Current law unfairly limits insurance coverage for abortion for women with government-funded insurance. This is because federal dollars are withheld from covering a woman’s abortion except in limited circumstance.

It seems unfair to withhold insurance coverage or try to influence a woman’s decisions about whether to end a pregnancy just because of the type of insurance she has. These are decisions best made by a woman, her family, faith and doctor, not politicians.

These laws also put the lives of women at risk. When a woman is pregnant, it is important that she has access to safe medical care. Providing insurance coverage insures she will be able to see a licensed, quality health care provider.

Even if we don’t personally agree with abortion, it is unfair to restrict insurance coverage, or try to influence a woman’s decision about whether to end a pregnancy, just because she has government-funded health insurance.

I care about women in Ohio, which is why I supported Barack Obama. He pledged to ensure all women have access to essential reproductive health care services.

Women and youth voters played a huge impact in Obama’s win this year. Not only did young people, 18-to-24 turn out for the president in 2008, they continued to turn out for him as they entered their late twenties. This demonstrates how important issues such as insurance coverage for abortion are to this generation.

Now my generation must hold Obama accountable to his commitments. That includes urging President Obama to submit a budget to Congress without unfair restrictions on coverage for abortion care. Obama Administration, take note that women will be watching to see if you live up to your commitments to women’s health care.

The Sliding Scale of Sin: Tyndale Publishers and Contraception Without a Co-Pay

11:41 am in Uncategorized by RH Reality Check

Written by Imani Gandy for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

Recently, the district court for District of Columbia granted a request by Tyndale House Publishers to block the Affordable Care Act birth control benefit ensuring that employer-sponsored health insurance include coverage of contraception without a co-pay. (Jessica Mason Pielko wrote about the ruling here.)

Like so many other organizations, both religious and secular, for-profit and non-profit, Tyndale’s complaints are the same: the birth control benefit in the ACA infringes upon their right to religious freedom:

Tyndale and its owners are Christians who are committed to biblical principles, including the belief that all human beings are created in the image and likeness of God from the moment of their conception/fertilization. But Defendants’ recently enacted regulatory mandate under PPACA forces Tyndale to provide and pay for drugs and devices that it and its owners believe can cause the death of human beings created in the image and likeness of God shortly after their conception/fertilization. The government’s mandate exempts what it calls “religious employers,” but denies that status to Tyndale House Publishers through its arbitrary definition.

What sets Tyndale apart from other companies challenging the birth control benefit, some of which have been successful in their challenges, and some of which have not, is that Tyndale is self-insured, whereas companies like Hobby Lobby purchase group health insurance plans from a commercial insurance carrier. In other words, Tyndale wholly assumes and underwrites the risk for providing health care to its employees (and pays for it out of its own coffers), while Hobby Lobby pays premiums to an outside insurance company. That it is self-insured means that Tyndale is paying directly for the insurance coverage of the contraception that it views as sinful, and the court found that this distinguishable fact rendered the birth control benefit sufficiently violative of Tyndale’s right to religious freedom.  

Now, the court did not reach this decision in a vacuum, mind you. The Obama Administration’s compromise with the United States Conference of Catholic Bishops (USCCB) paved the way. 

If you recall, the contraception kerfuffle began in February 2012 over one question: should employers be required to offer health insurance plans that cover contraception? In an effort to compromise with the USCCB and other religious organizations that balked at the notion of providing “slut-pills” to women, the Obama Administration allowed religiously-affiliated employers to avoid providing contraception coverage, and instead required health insurance companies to offer it directly. The Obama Administration allowed certain religious employers to keep their fingers entirely out of the contraception pie, and put the onus on insurance companies to fill the contraceptive gap. And in so doing, the Administration ceded that paying for contraception is, in and of itself, participation in sin, thus paving the way for self-insured organizations to raise Establishment Clause and Religious Freedom Restoration Act (RFRA) claims that will be (and are being) analyzed differently than the claims raised by organizations that are commercially insured.

Notwithstanding the distinction between self-insurance and regular commercial insurance, the claims challenging the birth control benefit are specious — both constitutionally and as a matter of church doctrine. Still, women’s rights activists and attorneys must adjust and re-frame the argument to take into account this new development in the birth control benefit lawsuits.  

Rather than focusing on who is paying money for what healthcare services, a better way to look at it — and, indeed, the most sensible way to look at it — is that companies providing a full range of health-care services, including contraception, are offering their employees a choice to participate in sin or not, just as employees who pay wages to their employees are offering employees that same choice.

Imagine if Tyndale filed a lawsuit challenging federal minimum wage laws. Would it make sense to allow Tyndale to argue that it should be exempt from paying its employees a fair wage out of fear that its employees would use that money to purchase contraception? Of course not. The religious nexus between paying employee wages and subsequent employee commission of sin is too great.

It might surprise you that Catholic scholars agree — at least one does. As Dr. Jeff Mirus of CatholicCulture.org notes, sometimes the remote participation in immorality is unavoidable:

In the absence of a contrary declaration by the Magisterium of the Church (to which I would submit immediately), it seems clear to me that the purchase of health insurance which includes some elements of immoral coverage is a matter of remote material cooperation with evil in a situation where it is all but impossible to avoid that remote cooperation. Just as we may morally pay taxes even though some tax money is used immorally and we may morally patronize various business which use a portion of their earnings immorally (and in fact this is inescapable in the modern world), so too I believe that if there is no reasonable way to avoid health insurance with some elements of immoral coverage, then it is not immoral to purchase such coverage.

If purchasing a group health insurance plan that includes contraception constitutes “participation” or “cooperation in evil,” then that participation is remote at best. For example, adhering to a hypothetical regulation requiring religiously-affiliated employers to shove contraception down the throats of female employees would certainly be a direct participation in evil. Requiring religiously-affiliated employers to purchase insurance that includes contraception coverage, on the other hand, is a remote participation in evil. And the Obama administration’s compromise — relieving religiously-affiliated organizations of the obligation to pay for contraception directly, and instead, shifting that burden onto insurance companies — falls somewhere between a remote participation in evil and a direct participation in evil.

It’s a sliding scale of sin.

The question becomes, at what point along the scale between remote participation in evil and direct participation in evil does the balance tip in favor of women and against religious organizations that believe it is their religious duty to ensure that women are stripped of the freedom to choose whether or not they want to use contraception and brand themselves as sinners?

At a certain point, the Catholic Church and other religious organizations must let their flock make their own choices. At a certain point, participation or cooperation in evil becomes far too remote to constitute an infringement on religious liberty. And ultimately, the pseudo-religious complaints about providing contraception, or paying for contraception must give way to common sense, fairness, and justice, whether or not employers pay directly for contraception, or do so through insurance carriers.

Certainly, the distinction between full insurance and self-insurance is an important one, and the religious outcry over the birth control benefit made it necessary for the Obama Administration to compromise, perhaps without giving much thought to how such a compromise would play out in the courts.  But the result of that compromise has paved the way for courts to hang their constitutional hat on the difference between self-insurance and “regular” insurance when it is a distinction without a difference.  

Tyndale claims that paying directly for contraception is a grievous violation of its religious freedom, and as a matter of law, courts are not permitted to nitpick those claims. Tyndale says it’s a sin? Fine. It’s a sin. But realistically, Tyndale could just as easily argue that paying workers a fair wage — or indeed any wage — is a religious violation, and I’m fairly certain that we can all agree that would be an absurd argument.

So what’s the point?

The point is this: We must begin discussion contraception access in terms of fairness. We must view access to contraception for women as being as important as the right to minimum wage.

The argument over contraception is not a religious one. It’s an argument about equality, health care, prevention, and basic human rights. We musn’t lose sight of that.

The Sound of Silence: Catholic Hierarchy’s Lack of Response to Abuse of Women by “Project Prevention”

8:23 am in Uncategorized by RH Reality Check

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Written by Jeanne Flavin for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

Recently, an all-Catholic coalition of 43 dioceses, hospitals, church agencies, schools and other religious-owned or operated but public entities filed a dozen separate lawsuits against the Obama administration, protesting the requirement that insurance plans covering secular employees include contraceptive services. These lawsuits follow on the heels of the U.S. Conference of Catholic Bishops’ high-profile attacks on nuns and Girl Scouts.

What I find as interesting as who Catholic leaders have chosen to attack is when they choose to be silent.

I “get” that many Catholics have a moral objection to contraceptive use (though presumably this group does not include the 98 percent of sexually-active Catholic women who report ever using a contraceptive method other than natural family planning). I also concede that the selectivity of the “right to life” position is nothing new; the Church has yet to file lawsuits against Texas Governor Rick Perry and the state of Texas for their staggering stream of executions.

Still, it seems reasonable that the same Catholic officials who are incensed by the prospect of insurance coverage for contraception would take strong issue with Project Prevention, a program that pays a targeted group of women to be sterilized or use long-acting forms of contraception. A search of the Internet, however, indicates that Catholic leadership has said absolutely nothing on the matter.

Project Prevention is a national organization based in North Carolina that claims chapters in 27 states. It has a presence in the United Kingdom and Kenya and has floated plans to expand to Haiti, South Africa and Australia. Project Prevention pays $300 for women who “abuse” drugs or alcohol to undergo long-term birth control or sterilization. Project Prevention targets only the reproductive capacity of some low-income women; the organization does nothing to address women’s need for comprehensive reproductive health care, effective drug treatment programs, mental health services, and social, economic and educational support. Moreover, Project Prevention encourages dangerous stereotypes about the women and their children. (This video challenges such characterizations.)

Project Prevention has garnered considerable publicity since its founding in 1997, having been featured on national television shows and in most major newspapers. Its Facebook page features status updates such as:

“Excited to write several checks to addicts this morning, but most excited that 6 [women] were under age 20″ and “No better way to start my morning than writing 14 checks to addicts/alcoholics who obtained long term birth control.”

Earlier this year, Project Prevention proudly celebrated a milestone, having paid 4,000 women to undergo long-term birth control and sterilization.

Despite Project Prevention’s visibility, I could not find evidence that a single spokesperson of a major Catholic organization has ever weighed in on their activities.

Project Prevention was originally called Children Requiring a Caring Kommunity or “C.R.A.C.K.” The old name reflects the organization’s focus on crack cocaine rather than substances like alcohol, tobacco or prescription medicines that also pose a threat to fetal health but are more commonly used by white and middle-class women. Because another classy thing about Project Prevention is that more than half of its clients are racial or ethnic minorities. Mind you, founder Barbara Harris insists that Project Prevention doesn’t target any particular race. As she explains:

“We target drug addicts, and that’s it. Skin color doesn’t matter, and we believe all babies matter, even black babies,” and “If you’re a drug addict, we’re looking for you, and I don’t care what color you are, because we don’t even know what color your baby will be, because often these babies come out all different colors. They’re mixed.”

The heads of major Catholic organizations apparently have not seen fit to issue an official statement of any kind in the face of Project Prevention’s thinly veiled racial prejudice or its promotion of contraceptive use.

Disturbing? You haven’t heard the half of it. Project Prevention’s recruitment strategies rely on referrals from probation offices, jails, drug treatment programs, methadone clinics and law enforcement agencies. There have been reports of workers (and others) being paid a $50 referral fee.

“Project Prevention is growing and even making inroads into state institutions,” Harris has boasted. “We’ve had many organizations, county and state agencies come on board and start referring women to us. We have jails that allow our volunteers in to tell inmates about our program. We have drug treatment programs that are referring women to us. We have methadone clinics that have our information posted on the walls, and probation departments-just many, many agencies, in a lot of states, that are learning about us and making referrals to us.”

To recap: You have an organization that for 15 years has sustained a highly-publicized campaign of paying low-income women of color who struggle with drug problems to be sterilized or subjected to long-acting birth control, and which relies on government agents for referrals and government-funded agencies to provide the contraception and sterilization services.

In light of this, we might expect Catholic leadership to be at least as vocal in their opposition to Project Prevention as they are toward the coverage of women’s voluntary contraceptive use (or, say, the Girl Scouts).

Instead, we hear… crickets.

Download

Perhaps others, like me, find it increasingly difficult to listen to what some Catholic leaders have to say on the subject of morality when their silence on Project Prevention and many other matters of significant moral import has been nothing short of deafening.

It Don’t Come Easy: Changing Health Insurance in America, Part Two

9:05 am in Uncategorized by RH Reality Check

Written by Lucinda Marshall for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

Cross-posted with permission from Pre-Existing Pundit.

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Several days ago, I wrote about the ordeal I have been going through trying to move my health insurance from Kentucky to Maryland.  Because I had a health insurance policy with Anthem Blue Cross in Kentucky, the local Blue Cross was obligated to offer me what is called a guarantee issue conversion policy that does not require underwriting (a good thing since I have several pre-existing conditions that would otherwise make it difficult for me to obtain health insurance).

As I reported earlier, the Maryland conversion policy was almost no insurance at all so one of the options I wanted to explore was what kind of policy CareFirst (the Blue Cross company that serves the Washington, DC metro area, including the Virginia and Maryland suburbs) would offer me if I lived in the District instead of in Maryland. I asked CareFirst to send me the information and when it arrived it was a stunner.  We are talking about maybe a 15-mile difference in location and the same company.  But the policies were radically different, which CareFirst attributes to insurance laws which vary by location.

If you live in Maryland, there is a $250 deductible and  for most things, you pay 25 percent, the plan pays 75 percent up to a very unrealistic lifetime maximum of $250,000 (most plans have a $1,000,000 maximum or no limit).  There is no cap on out-of-pocket expenses.  Premium for a 55 year old woman? $443.22, less than my Kentucky policy but for a lot less coverage and substantial risk.

But hop on the Metro and move into the District and wowswers–the guaranteed conversion plan there has a $750 deductible, pays 80 percent instead of 75 percent and there is a $3500 cap on out of pocket expenses for an individual.  There was nothing that I saw about a lifetime maximum.  Sounds good so far, but there is a catch and it is a big one–the premium.  Are you sitting down? $1448.  Per month. Aside from CEO’s of health insurance companies, not too many people can afford that. Read the rest of this entry →

New Jersey’s Governor is Taking His Time on a Rape Kit Bill

9:12 am in Uncategorized by RH Reality Check

"Chris Christie"

"Chris Christie" Governor of NJ, by Marissa Babin on flickr

Written by Martha Kempner for RH Reality Check. This diary is cross-posted; commenters wishing to engage directly with the author should do so at the original post.

In March, the New Jersey State Senate overwhelmingly passed a bill to prevent sexual assault survivors from being charged for the rape kits used to collect forensic evidence.  The Assembly passed the measure in June. Months later, however, the bill remains “under review” on Governor Chris Christie’s desk prompting many advocates to ask what is taking him so long and some to start a petition demanding he take action.

Under federal law, health care providers must be reimbursed for the cost of these exams and the collection of evidence. They are supposed to look to government agencies for that coverage but bills are often sent to the assault survivor “due to administrative errors or attempts to get payment from a victim’s insurance company.”

The legislation that passed in New Jersey would prevent direct billing for any “routine medical screening, medications to prevent sexually transmitted infections, pregnancy tests and emergency contraception, as well as supplies, equipment, and use of space.”

Though it’s clear from his record (which includes “using a line-item veto to block funding in the state budget for clinics that provide family-planning services”) that woman’s rights and reproductive health are not a high priority for the Governor, it really is hard to understand why he’s dragging his feet on this bill.

All Those Alternatives to Planned Parenthood? In Texas, At Least, They Don’t Exist

7:47 am in Uncategorized by RH Reality Check

Written by Andrea Grimes for RHRealityCheck.org – News, commentary and community for reproductive health and justice.

Before I met with Texas State Representative Dan Flynn last month during Texas’ pro-choice lobby day, I truly believed that even the most passionate anti-choice conservative couldn’t look me in the face and tell me they didn’t really care whether I got the reproductive health care I needed. Who would seriously tell me their religious beliefs are more important than making sure hundreds of thousands of women just like me—women with high-risk HPV–don’t develop cervical cancer?

But like I said, that was before I sat in front of Rep. Flynn, in his Austin office next to his model airplanes and elect-Dan-Flynn gum, and told him how I’d lost my job and my health insurance and needed regular, affordable pap smears to keep an eye on my pre-cancerous cervical dysplasia. I told him Planned Parenthood could provide low-cost paps, breast exams and contraceptives to keep me healthy despite my lack of insurance, and I believed they should continue to be funded by government family planning dollars. He scoffed, waving around a handful of papers—spreadsheets and maps, it looked like—and told me that Planned Parenthood was nothing but a tax-evading abortion machine (he knew because he used to be a bank examiner and had heard some things from some people) and there were so many other options besides Planned Parenthood in Texas. I should and could go to one of those, he told me, so we could spread some of the wealth around to these smaller providers. It would be very easy, he said.

I asked him if he could give me that list he had in his hand, the long list of places I could get low-cost reproductive health care without insurance near my home in Dallas. He glanced at the list and rattled off some names, something about Dallas Emergency Services and Dallas County Hospital District. He didn’t exactly wait for me to get out my pen and pad. I filed out of Flynn’s office with the rest of the women I’d teamed up with for lobby day feeling surprised and disappointed. But I still wanted (needed!) to know where those low-cost health centers were that Flynn had referenced, because I knew the Texas Legislature to be hell-bent on cutting the family planning funds that keep Planned Parenthood and clinics like it afloat.

Planned Parenthood or not, I’d still need well-woman exams, birth control pills and suchlike, and I wanted to know where I could get these things if I had to spend weeks or months scraping by on a freelancer’s salary without health insurance. So here’s what I did: I spent my own time, money and energy trying to find a health care clinic that anti-choice conservatives, legislators and organizations would approve of—namely, to find a Federally Qualified Health Center or “look-alike” center that, by virtue of federal grant funding, cannot provide abortion services except in cases of rape, incest or threat to a mother’s life, as dictated by the 36-year-old Hyde Amendment. … Read more

The Health Care Bill and Women’s Health: Wins, Losses, and Challenges

8:01 am in Uncategorized by RH Reality Check

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.

WINS:

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.

LOSSES:

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. 

CHALLENGES:

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.