1. McSpedon, Corinne Senior Editor


Women, especially low-income women, may lose the most.


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The expansion of state Medicaid programs and subsidies made available under the Affordable Care Act (ACA) extended health care benefits to many low-income Americans. Women, who are more likely than men to be poor, have particularly benefited from these and other ACA reforms since the law was signed in 2010. Rules mandating pregnancy-related coverage and preventing insurance companies from charging women higher premiums for the same coverage as men have changed the landscape of health care, making comprehensive coverage affordable to many women for the first time.


The American Health Care Act (AHCA), which was supported by the president and passed by House Republicans to replace the ACA in May, may roll back many of these reforms unless the Senate makes significant changes. At the time of this writing, the Senate announced the appointment of a 13-member committee (all male) to come up with its own version of the AHCA.


Why are women poorer than men? The U.S. Census Bureau estimates that almost 15% of women were living in poverty in 2015 compared with 12% of men.1 In childhood, there are few differences in poverty rates by sex, but women are more likely than men to experience poverty throughout the rest of their lives.1


The reasons for these greater rates of poverty among women are complicated and due to a combination of economic and sociocultural factors, which in turn affect a woman's ability to access and afford health care. Pregnancy and motherhood can obviously affect a woman's educational and work opportunities. Women are also more likely to leave the workforce to raise children and to work part time, and they tend to be employed in lower-paying fields, such as in the retail and hospitality industry. But they're also not paid the same salaries as men to perform the same jobs, despite having equal or greater amounts of education and experience.2 According to the U.S. Census Bureau, women working full-time, year-round jobs make 80% of a man's salary.1 Mothers and women of color make even less when their salaries are compared with those of white, non-Hispanic men.3 (Even in female-dominated professions like nursing, male nurses consistently earn more than female nurses.4)


Women provide more unpaid caregiving to both children and other family members compared with men.5 They are also much more likely to be a custodial parent-the U.S. Census Bureau estimated in a 2013 report that 82% of custodial parents were mothers whereas 18% were fathers, percentages that have not changed significantly in the past 20 years.6 The same report noted that 32% of custodial mothers had incomes below poverty levels, compared with 16% of custodial fathers.6


Women's health under the ACA. Being pregnant, needing a cesarean section,7 and having a history of domestic violence8 were considered "preexisting conditions" before the implementation of the ACA. Health insurance companies kept lists of "medical conditions," and having one of these conditions-such as pregnancy and pending surgery or hospitalization-led to an automatic policy denial.7


Banning preexisting condition exclusions has been one of the most popular aspects of the ACA, and it has helped to ensure that millions of women can obtain coverage for essential, often lifesaving care, explained Alina Salganicoff, PhD, vice president and director of women's health policy at the Henry J. Kaiser Family Foundation, during a Webinar, "Potential Changes to Health Care Access and Coverage: What's at Stake for Women?," sponsored by the Kaiser Family Foundation in March, before the fate of the AHCA was known.


In addition to making it possible for women to purchase affordable policies that include coverage for family planning and pregnancy, the ACA has helped to ensure women receive prenatal, postpartum, and preventive services with little or no cost sharing. The health care law also requires that all marketplace and for-profit employer health insurance plans fully cover the cost of any contraceptive method approved by the U.S. Food and Drug Administration. (Salganicoff pointed out that abortion is not one of the "essential health benefits" the ACA requires insurance plans to cover. States can choose not to allow abortion coverage in plans on its exchanges, and 25 have done so.)


This low- and no-cost care coverage offers an opportunity to break the cycle of poverty among women and girls who otherwise wouldn't be able to afford or access family planning services, preventing them from gaining control of their reproductive health and accessing the educational and job opportunities that can lead to social and economic mobility.


Replacing the health care law. The bill passed by the House will phase out funding for expansion of state Medicaid plans and alter the way in which people buy insurance in state marketplaces. Some of these options would allow states to reject certain ACA mandates, including those, such as the essential health benefits, that directly benefit low-income women.


The House bill did not revoke the mandate to cover preexisting conditions, but the Republican replacement plan would essentially remove this protection by allowing states to decide whether to opt out of an ACA mandate requiring health plans to charge all people of the same age the same premiums. Although pregnant women would still have the option of buying health care coverage after such a rule change, for instance, insurance companies could charge them more than men of the same age, effectively making the coverage unaffordable.


The public is divided but supports fixing the ACA. According to a Kaiser Health Tracking Poll from April 4, Americans are split in their opinion of the ACA, with the same percentage-46%-indicating they view it favorably and unfavorably.9 This deep division, combined with Republicans' own division over how to replace the ACA, makes the future affordability and accessibility of women's health care coverage uncertain.


There is reason to hope, however, that the ACA reforms that have helped to level the playing field for women may remain. The same Health Tracking poll showed that a large majority-75%-of those polled think "President Trump and his administration should do what they can to make the law work."9


Yet there's no guarantee women will benefit from any health care rules enacted by the current administration. In April, President Trump signed a law giving states the option of refusing Title X funding for Planned Parenthood and affiliated clinics that offer essential preventive health and family planning services in addition to abortion services, reversing a rule instituted by President Obama before he left office (regardless of the services a clinic offers, federal funds cannot be used for abortions). Cutting off Title X funding to these clinics-which offer essential health screenings and family planning services to millions of low-income and uninsured Americans-means these women will have fewer clinics to choose from, and the clinics they can visit will not offer the range of reproductive health care services offered by Planned Parenthood, which provides twice the number of contraceptive services as federally qualified health centers.10


An uncertain future. As health care insurers seek stability and direction from the administration to remain in state exchanges, Republicans will need to either take steps to support some ACA reforms or offer a replacement plan. So far, there have been mixed signals about their intentions. In February, the administration introduced regulatory changes designed to stabilize the health care exchange markets during the next year, encouraging health plans to continue to participate.11 But a March 25 tweet from the president soon after Republicans pulled their first attempt at a health care replacement law from the floor of the House was less encouraging: "ObamaCare will explode[horizontal ellipsis]"


If the Senate and House bills cannot be reconciled and Republicans do not take measures to fund or revise the ACA, thereby allowing it to fail, this poses a threat not only to the health insurance industry and state exchanges but to the estimated 20 million people who have gained health care coverage under the law-about half of whom are women. Many of these women have limited economic means and experienced, for the first time, the opportunity to obtain the coverage and care they need during their reproductive years. Tied to the fate of the ACA is the question of whether such care will continue to be comprehensive, affordable, and accessible to this vulnerable population.-Corinne McSpedon, senior editor




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10. Heisler EJ, Elliott VL Factors related to the use of Planned Parenthood affiliated health centers (PPAHCs) and federally qualified health centers (FQHCs). Washington, DC: Congressional Research Service; 2017 Apr 5. R44295. [Context Link]


11. Centers for Medicare and Medicaid Services, Department of Health and Human Services. 45 CFR Parts 147, 155, and 156. Patient Protection and Affordable Care Act: market stabilization [proposed rule]. Washington, DC: Federal Register 2017 10980-998 [Feb 17]. [Context Link]