A Lot to Lose: What’s on the Line for Women if the Affordable Care Act is Repealed

By Dania Palanker and Rachel Schwab

It’s the holiday season, but rather than visions of sugar plums dancing above our heads, we have visions of mammogram machines, birth control, doctor offices, and medical bills. Prior to the Affordable Care Act (ACA), women faced numerous barriers obtaining affordable health care. After years of insurance industry practices like gender rating and pre-existing condition exclusions, the ACA ushered in a new era for women’s health, eliminating those discriminatory and unfair insurance practices from the insurance market.

Yet today, millions of women are worried they will lose their access to health insurance through the health insurance marketplaces or Medicaid. More women are now covered through the individual market or as dependents on a parent’s plan. In part because of the ACA, Medicaid now provides health coverage to 17% percent of non-elderly adult women.Millions more could lose access to important services, such as maternity coverage and preventive services, including contraceptives. Women saw vast improvements under the ACA, and thus, women have much to lose if the law is repealed.

Here’s a look at what’s at stake for women as policymakers consider repealing the ACA:

Nondiscrimination Protections

The ACA banned sex discrimination in health care, including prohibiting insurance companies from charging women higher premiums. A common practice prior the ACA, known as gender rating, allowed insurance companies to charge female enrollees higher premiums. Insurers claimed that the rating difference stemmed from costs associated with pregnancy and higher instances of chronic conditions in women. But the rating differences existed in plans that did not cover maternity and varied so much between plans and states that the numbers seemed arbitrary. In most states, female non-smokers were charged higher premiums than male smokers for insurance that did not cover maternity services.

The ACA is also the first federal law to broadly prohibit sex discrimination in health care. The law prohibits insurance companies, health care providers, and other health care organizations from discriminating against women.

Ban on Pre-Existing Condition Exclusions

Until the ACA outlawed such practices, insurers in the individual market regularly denied coverage to women if they had pre-existing conditions, such as a previous caesarean delivery or a history of sexual assault. If a woman was able to enroll in coverage in the individual market, her insurance would likely not pay for any services related to a pre-existing condition – such as cancer treatment if the cancer existed before she enrolled in coverage (even if she was not diagnosed until after her coverage started). Sometimes, insurance plans would cancel a plan once a woman was diagnosed or started receiving costly health treatments. In worst cases, the cancellation would be retroactive leaving her with thousands of dollars in unpaid medical bills when she thought she was covered. Because of the ACA, all women are now guaranteed eligibility for health insurance regardless of any pre-existing conditions and health insurance plans cannot exclude services because they are related to pre-existing conditions.

Maternity Coverage and other Essential Health Benefits

Prior to the ACA, there were few national standards on health insurance, leaving many women without coverage for important medical services. In 2009, only 13% of health plans available to 30-year-old women in the individual market offered coverage of maternity care. In 2011, 18 percent of people enrolled in individual market coverage had no mental health benefits and 9 percent had no prescription drug benefits. Because of the ACA, maternity coverage, mental health services, prescription drugs, and other important health services are considered essential health benefits that are included in all individual and small group market plans.

Preventive Services

One of the most well-liked protections provided by the ACA is access to preventive care. Under the law, most health plans are required to cover a range of services for women without cost sharing, including contraceptives, cancer screenings, and immunizations. This provision led to a huge reduction in out-of-pocket spending for women, and also made birth control more accessible, including Long Acting Reversible Contraception (LARC), which are known to decrease the unintended pregnancy rate. In addition to reducing costs, the ACA enables women to see their OB/GYN without a referral, lowering barriers to ensure timely access to care.

What Can Women Expect Next?

As of now, the incoming Congress does not have the 60 votes needed to completely repeal the ACA. Instead, they plan to use the process of budget reconciliation to gut the legislation of all provisions directly related to the budget, such as premium tax credits, the individual mandate, and Medicaid expansion. Nondiscrimination provisions and other market reforms likely cannot be repealed through the reconciliation process, and instead are subject to the Senate filibuster. Thus, it will be difficult for the Senate to pass such a law.

However, repealing pieces of the ACA puts all of the protections for women’s health at risk. Without tax credits and the individual mandate, adverse selection will drive up the cost of health insurance and force millions of people – including women – out of coverage. In addition, women have a lot to lose even without Congressional action. The Trump Administration may have the power to redefine “women’s preventive services,” including or excluding any of the services currently falling under the coverage guarantee. Current federal guidance that enforces the ACA’s protections and ensures broad coverage of birth control, breast feeding support, mammograms, colonoscopies, and other preventive services can be weakened leaving only barebones protections in place. Based on the contentious debate over birth control coverage including litigation, it’s possible that we will see many methods of birth control put out of reach for low-income women.

Since the passage of the ACA, the uninsured rate among women of reproductive age has dropped by 36 percent. Women’s out-of-pocket spending on critical services such as birth control has dropped by 20 percent. Little wonder that, in the wake of threats to repeal the ACA, women everywhere are educating themselves about long-term birth control options. As new federal leaders take on the arduous task of health reform, they face difficult decisions about how to ensure women don’t lose the critical gains they have made in access to coverage and financial security.




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The opinions expressed here are solely those of the individual blog post authors and do not represent the views of Georgetown University, the Center on Health Insurance Reforms, any organization that the author is affiliated with, or the opinions of any other author who publishes on this blog.