CLINICAL OBSTETRICS AND GYNECOLOGY Volume 58, Number 2, 323–335 Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
Women’s Health in the Age of Patient Protection and the Affordable Care Act JOANNE ARMSTRONG, MD, MPH Aetna, Sugar Land, Texas Abstract: The Patient Protection and Affordable Care Act of 2010 is the most sweeping health care legislation in a generation. The goal of the legislation is to increase access to both public and private insurance, and to improve the affordability and quality of care. Many provisions of the bill have a direct impact on the women’s health care services. This paper provides an overview of the bill’s provisions that have the largest impact on women’s health care and provides data on the impact of the bill to date. Key words: The Patient Protection and Affordable Care Act (ACA), health care reform, women’s health
affordability of both health insurance and health care services, and improve the quality of care. Achieving these ambitious goals requires extensive reform, and the resulting complex legislation includes more than 400 provisions (Table 1) with planned implementation staggered over 8 years. Most of the provisions of the ACA are not sex specific, but benefit women by improving access to health insurance coverage, expanding the scope of benefits provided by their insurance plans, and reducing cost sharing (deductibles, coinsurance, and copayments) for some health services.1 One provision of the ACA, though, is specifically designed to increase both access to and reduce cost sharing for targeted women’s health services. The Women’s Health Amendment (Section 2713 to the Public Health Services Act) mandates health insurance coverage without cost sharing for an array of preventive services focused on reproductive health including contraceptive technology and counseling, breast pumps and breastfeeding counseling, and other services discussed below. This paper will review the
Introduction The Patient Protection and Affordable Care Act (ACA) was enacted into federal law on March 23, 2010, and is the largest, most complex and far-reaching piece of health care legislation since the passage of Medicare and Medicaid in 1965. The primary goals of the ACA are to increase the number of individuals who have access to health insurance, improve the Correspondence: Joanne Armstrong, MD, MPH, Aetna, 3 Sugar Creek Blvd, Sugar Land, TX. E-mail: [email protected] The authors declare that they have nothing to disclose. CLINICAL OBSTETRICS AND GYNECOLOGY
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VOLUME 58
/
NUMBER 2
/
JUNE 2015
www.clinicalobgyn.com | 323
324
Armstrong
TABLE 1.
Selected Provision of the Patient Protection and Affordable Care Act
Provision
Year Implemented
Description
Adult dependent coverage to age 26
2010
Coverage of preventive benefits without cost sharing Coverage of preventive benefits for women without cost sharing Prohibits lifetime/annual dollar limits on essential health benefits
2010
Extends dependent coverage for adult children up to age 26 for all individual and group policies that offer dependent coverage Requires new health plans to provide coverage without cost sharing for qualifying preventive services
Prohibits cancellation of coverage Insurance plan appeal process
2012
Requires coverage without cost sharing for specified women’s preventive health services
2010
Prohibits individual and group health plans from placing lifetime limits on the dollar value of coverage. Restricts annual limits on the dollar value of coverage (and eliminates annual limits in 2014) Prohibits cancellation of insurance coverage except in cases of fraud/intentional misrepresentation Requires new health plans to implement an effective process for appeal of health plan decisions and establish an external review process Establishes the Patient-Centered Outcomes Research Institute (PCORI) to conduct comparative effectiveness research Reduces annual market basket updates for inpatient and outpatient hospital services, long-term care hospitals, inpatient rehabilitation facilities, and psychiatric hospitals and units and adjusts payments for productivity Creates the Center for Medicare and Medicaid Innovation to test new payment and delivery system models Provides a 10% Medicare bonus payment for primary care services and to general surgeons practicing in health professional shortage areas Eliminates cost sharing for Medicare-covered qualified preventive services State incentives to develop medical homes for Medicaid covered individuals Provides grants to states to develop, implement, and evaluate alternatives to current tort litigation system Prohibits federal payments to states for Medicaid services related to certain hospital-acquired infections Incentivizes Medicare providers organized as accountable care organizations (ACOs) to share in the cost savings related to quality performance Requires insurers to report the percentage of premium dollars spent on medical costs pay rebates payable to policyholders if the share of the premium spent on medical costs is less than specified thresholds Reduces rebates paid to Medicare advantage plans and provides bonus payments to high-quality plans based on ‘‘star ratings’’ Imposes an excise tax of 2.3% on the sale of any taxable medical device Increases the Medicare Part A (hospital insurance) tax rate on wages by from 1.45% to 2.35% on earnings
2010 2010
Comparative effectiveness research supported
2010
Changes in Medicare provider rates
2010
Center for Medicare and Medicaid Innovation Created Medicare payment for primary care
2011 2011
Medicare preventive benefits
2011
Medicaid medical homes created Medical malpractice grant to support innovation Medicaid nonpayment for hospital-acquired infection
2011
Accountable Care Organizations in Medicare incentivized Commercial Minimal Medical Loss Ratio (MLR) established for Insurers
2011 2011 2012 2011
Medicare advantage payment reform
2102
Tax on medical devices
2013
Medicare tax increase
2013
www.clinicalobgyn.com
Women’s Health and the Affordable Care Act
325
TABLE 1. (Continued) Provision
Year Implemented
Medicaid payments to primary care
2013
Flexible spending accounts capped
2013
CHIP program extended
2013
Expands Medicaid coverage
2014
Individuals required to have health insurance Subsidies for health insurance premium and cost sharing
2014
Guarantee availability (‘‘issue’’) of insurance and underwriting changes Annual limits on value of insurance coverage Essential health benefits Medicare payment reduction for hospital-acquired infections Tax on high cost insurance plans (‘‘Cadillac Tax’’)
2014 2014 2014 2014 2014 2018
key provisions of the ACA that have the greatest influence on access to women’s health care services and provide data on the impact of the legislation to date.
Insurance Coverage Before the ACA Health insurance in the United States is provided through a variety of mechanisms. The largest source of private sector
Description
over $200,000 for individual taxpayers and $250,000 for married couples filing jointly and imposes a 3.8% assessment on unearned income for higher-income taxpayers Increases Medicaid payments for primary care services provided by primary care doctors to 100% of the Medicare payment rate for 2013 and 2014 (financed with 100% federal funding) Limits the amount of contributions to a flexible spending account for medical expenses to $2,500 per year with annual cost of living adjustment Extends funding for the Children’s Health Insurance Program (CHIP) through 2015 Expands Medicaid (in states that agree to comply) to all individuals not eligible for Medicare under age 65 (children, pregnant women, parents, and adults without dependent children) with incomes up to 138% FPL Requires US citizens and legal residents to have health coverage or pay a tax that increases over time Provides tax credits and subsidies to eligible individuals to purchase insurance through the exchanges Requires guaranteed issue and renewability of health insurance regardless of health status. Allow underwriting based only on limited factors Prohibits annual limits on the dollar value of coverage Creates an essential health benefit package that provides a comprehensive set of services, limiting annual cost sharing to specified limits Reduces Medicare payments to certain hospitals for hospital-acquired conditions by 1% Imposes a 40% excise tax on insurers of employersponsored health plans on benefits provided to employees that exceed a predetermine threshold ($10,200 for individual coverage and $27,500 for family coverage)
coverage is employment-based insurance. Public sector sources include government programs such as Medicare. They also include programs such as Medicaid and the State Children’s Health Insurance Program (CHIP) that provide assistance to eligible children and adults generally without premium obligation. Depending on the program, funding may come from premiums (that may be paid directly by individuals or indirectly by their employers), payroll taxes, or general tax revenues. The www.clinicalobgyn.com
326
Armstrong
financial risk associated with medical expenses is spread across the covered population. Before the ACA, individuals outside of these insurance arrangements, such as unemployed or self-employed individuals, had few options to obtain the most affordable coverage. In 2012, among the 98 million women aged 18 to 64 years, 58% had insurance through an employer-sponsored arrangement; 7% purchased private insurance on their own through the individual market; 12% qualified for Medicaid; and 19% were uninsured.2 The major barrier to insurance coverage is cost. During the past decades, the United States experienced a significant increase in health care spending, driving a concurrent rise in health insurance costs and a decline in the proportion of the US population with insurance coverage. Between 1970 and 2010, medical spending rose from 7.2% to 18% of gross domestic product, reaching $2.7 trillion in 2011.3 Health insurance premium costs rose 80% from 2003 to 2013, reaching an average of $16,251 for family coverage and $5884 for an individual.4 Millions of Americans were priced out of the market, even those with the opportunity to purchase coverage through, and paid in part by, employers.5 The net effect of these trends was the steady increase between 2000 and 2010 in the number of Americans without health insurance coverage, reaching 16.3% of the population or 50 million people by 2010.6 Among the uninsured were 19 million women aged 18 to 64 years and 7 million children.7 In addition to the uninsured, some women who were insured in the individual market had limited coverage of certain services important to women such as comprehensive maternity care and prescription contraceptives. Further, these plans commonly excluded preexisting conditions. As a result, some women covered under these plans received inadequate preventive and primary care. In 1 survey, among underinsured-women, 38% reported delayed www.clinicalobgyn.com
preventive care screening due to cost.8 Only 66% had a pap test in the prior 3 years. For women above 50 years, only 51% of women had a mammogram in the prior 2 years, and only 33% had a colon cancer screening test in the past 5 years.8 Similarly, for women covered under Medicaid before the ACA, coverage of preventive benefits varied considerably according to state policy. For example, in a 2009 survey of 44 Medicaid plans, 31 states did not cover preconception counseling for enrolled women.9
An Important Caveat to Understanding the ACA: Grandfathered Health Insurance Plans To understand the impact of the ACA on women, it is critical to understand that some plans are ‘‘grandfathered’’ and, thus, exempt from following some provisions of the ACA. The exemption impacts the benefits and costs for people covered by those plans. Grandfathered insurance plans are those that existed before March 23, 2010, and have not substantially changed in ways that either reduce benefits or increase costs for consumers. (Once these changes occur, the plan becomes nongrandfathered.) For example, grandfathered plans must cover adult children up to age 26 years but do not have to cover preventive care without cost sharing and may be allowed to exclude individuals for preexisting conditions. Consumers can find out what type of plan they have by asking their employers’ benefits administrator. The grandfathered status of a plan and the overlapping nature of some of the provisions of the ACA (such as expanded access to Medicaid and the requirement that plans offer essential health benefits) raise some challenges in the analysis of the outcomes associated with specific provisions of the ACA.
Women’s Health and the Affordable Care Act PROVISIONS OF THE ACA THAT EXPAND ACCESS TO HEALTH INSURANCE
A primary goal of the ACA is to significantly increase the number of Americans with health insurance. To achieve this, the legislation expanded access to public and private insurance. The key provisions that benefit women are outlined in greater detail below and include: (1) The extension of insurance coverage of adult children up to age 26 on their parents’ private insurance plans that provide dependent coverage. (2) Federal incentives for states to increase the income threshold for Medicaid eligibility. (3) The establishment of state-based or federal-based ‘‘exchanges’’ or ‘‘marketplaces’’ for individuals to purchase private insurance, coupled with tax credit subsidies for low-income individuals. (4) Other supporting policies including guaranteed issue, prohibition of preexisting conditions, underwriting changes, and the individual mandate. Coverage of Adult Children Up to Age 26 on Parent’s Plan One of the earliest implemented and most popular provisions of the ACA requires insurers to extend family plan–dependent coverage for all children until age 26. The current policy applies regardless of marital, residency, employment, or educational status. Before the 2010 implementation, insurance coverage often ended at age 19 or upon completion or withdrawal from a qualifying institution of higher education. This is a particularly vulnerable demographic because about half of this age group are college students. Only two-thirds are employed, and when employed, generally the group has low-income jobs.10 Before the implementation of the ACA, an estimated 35.6% of the young adults aged 19 to 25 years or 10.2 million were uninsured. Within 2 years of implementation, 2.5 million young adults gained
327
insurance coverage attributed to the law and the uninsured rate for this age group decreased to 27.0%.11 As of 2012, there were about 8 million remaining uninsured individuals in this age group.11 The majority of them are estimated to be eligible for Medicaid in states that expanded the threshold of eligibility under the ACA. Beyond increasing access to insurance, early evidence suggests that this provision of the ACA is addressing an unmet need. Early data indicate a 9% increase in the receipt of mental health services in the age group compared with people aged 27 to 29, an important result especially for women who have high rates of depression.12 Medicaid Expansion Medicaid, the joint state-federal health insurance program for low-income Americans, is the largest and most important medical safety net program for women, covering 48% of all births in the United States and 12% of nonelderly women for general medical care.13 Medicaid also finances about 75% of all publicly funded family planning services in the United States, and all states use Medicaid funds to cover the cost of breast and cervical cancer screening for certain low-income uninsured women.14 Medicaid eligibility varies by state, by life event, and level of poverty required for eligibility. This variability in coverage over the course of a woman’s reproductive life results in important ‘‘holes’’ in the safety net. Before the ACA, federal law required states to extend eligibility for pregnancyrelated care to pregnant women with incomes up to 133% of the federal poverty level (just below $15,300 for an individual in 2013). States also had the flexibility to provide coverage to women earning much more, and many states did.9 (The District of Columbia had a limit of 300%.) Medicaid pregnancy-related covered services include prenatal care, delivery, postpartum care, family planning, and other services related to a complicated pregnancy. The flexibility in program design also created a www.clinicalobgyn.com
328
Armstrong
broad variation across states in terms of what perinatal care services they cover. In a 2009 survey of 44 Medicaid plans, for example, 8 states did not cover any breastfeeding support services for women enrolled in Medicaid.9 Eligibility for Medicaid participation in nonpregnant women, however, is much more restrictive than for pregnant women and changes significantly after delivery. Across all states in 2012, the median floor for parents was 28% of the federal poverty limit ($3127 for an individual).15 The majority of women who are covered under Medicaid during pregnancy typically lose their coverage 60 days after delivery, leaving them uninsured both before and between pregnancies, thus missing opportunities for follow-up care for pregnancy complications, for contraception planning, and for preconception services. The ACA attempted to fill these coverage gaps by making Medicaid a more universal program for individuals. The law provides enhanced federal funding for states to reset the floor for eligibility and cover all women—pregnant and nonpregnant— with incomes up to 133% of the federal poverty limit. A separate provision of the Act provides financial help to buy private insurance in the newly created health care exchanges (discussed more below) for individuals beginning at 133% of the federal poverty limit and phasing out at 400% of the federal poverty limit. The proposed mandatory expansion of Medicaid, originally written into the law, was challenged by multiple states. A 2012 decision by the US Supreme Court ruled that mandatory enforcement of Medicaid expansion was not permissible, thus making Medicaid expansion optional for states. Still, the attractive financing of the expansion—it is fully funded by the federal government for 3 years and then is phased down to 90% by 2020—has resulted in wide state participation. To date, 27 states, including the District of Columbia, are implementing the expansion, and additional www.clinicalobgyn.com
states may expand moving forward.16 The impact on coverage has been substantial. Enrollment growth in states that expanded Medicaid coverage to low-income adults added 4.2 million adults in
Women’s Health in the Age of Patient Protection and the Affordable Care Act JOANNE ARMSTRONG, MD, MPH Aetna, Sugar Land, Texas Abstract: The Patient Protection and Affordable Care Act of 2010 is the most sweeping health care legislation in a generation. The goal of the legislation is to increase access to both public and private insurance, and to improve the affordability and quality of care. Many provisions of the bill have a direct impact on the women’s health care services. This paper provides an overview of the bill’s provisions that have the largest impact on women’s health care and provides data on the impact of the bill to date. Key words: The Patient Protection and Affordable Care Act (ACA), health care reform, women’s health
affordability of both health insurance and health care services, and improve the quality of care. Achieving these ambitious goals requires extensive reform, and the resulting complex legislation includes more than 400 provisions (Table 1) with planned implementation staggered over 8 years. Most of the provisions of the ACA are not sex specific, but benefit women by improving access to health insurance coverage, expanding the scope of benefits provided by their insurance plans, and reducing cost sharing (deductibles, coinsurance, and copayments) for some health services.1 One provision of the ACA, though, is specifically designed to increase both access to and reduce cost sharing for targeted women’s health services. The Women’s Health Amendment (Section 2713 to the Public Health Services Act) mandates health insurance coverage without cost sharing for an array of preventive services focused on reproductive health including contraceptive technology and counseling, breast pumps and breastfeeding counseling, and other services discussed below. This paper will review the
Introduction The Patient Protection and Affordable Care Act (ACA) was enacted into federal law on March 23, 2010, and is the largest, most complex and far-reaching piece of health care legislation since the passage of Medicare and Medicaid in 1965. The primary goals of the ACA are to increase the number of individuals who have access to health insurance, improve the Correspondence: Joanne Armstrong, MD, MPH, Aetna, 3 Sugar Creek Blvd, Sugar Land, TX. E-mail: [email protected] The authors declare that they have nothing to disclose. CLINICAL OBSTETRICS AND GYNECOLOGY
/
VOLUME 58
/
NUMBER 2
/
JUNE 2015
www.clinicalobgyn.com | 323
324
Armstrong
TABLE 1.
Selected Provision of the Patient Protection and Affordable Care Act
Provision
Year Implemented
Description
Adult dependent coverage to age 26
2010
Coverage of preventive benefits without cost sharing Coverage of preventive benefits for women without cost sharing Prohibits lifetime/annual dollar limits on essential health benefits
2010
Extends dependent coverage for adult children up to age 26 for all individual and group policies that offer dependent coverage Requires new health plans to provide coverage without cost sharing for qualifying preventive services
Prohibits cancellation of coverage Insurance plan appeal process
2012
Requires coverage without cost sharing for specified women’s preventive health services
2010
Prohibits individual and group health plans from placing lifetime limits on the dollar value of coverage. Restricts annual limits on the dollar value of coverage (and eliminates annual limits in 2014) Prohibits cancellation of insurance coverage except in cases of fraud/intentional misrepresentation Requires new health plans to implement an effective process for appeal of health plan decisions and establish an external review process Establishes the Patient-Centered Outcomes Research Institute (PCORI) to conduct comparative effectiveness research Reduces annual market basket updates for inpatient and outpatient hospital services, long-term care hospitals, inpatient rehabilitation facilities, and psychiatric hospitals and units and adjusts payments for productivity Creates the Center for Medicare and Medicaid Innovation to test new payment and delivery system models Provides a 10% Medicare bonus payment for primary care services and to general surgeons practicing in health professional shortage areas Eliminates cost sharing for Medicare-covered qualified preventive services State incentives to develop medical homes for Medicaid covered individuals Provides grants to states to develop, implement, and evaluate alternatives to current tort litigation system Prohibits federal payments to states for Medicaid services related to certain hospital-acquired infections Incentivizes Medicare providers organized as accountable care organizations (ACOs) to share in the cost savings related to quality performance Requires insurers to report the percentage of premium dollars spent on medical costs pay rebates payable to policyholders if the share of the premium spent on medical costs is less than specified thresholds Reduces rebates paid to Medicare advantage plans and provides bonus payments to high-quality plans based on ‘‘star ratings’’ Imposes an excise tax of 2.3% on the sale of any taxable medical device Increases the Medicare Part A (hospital insurance) tax rate on wages by from 1.45% to 2.35% on earnings
2010 2010
Comparative effectiveness research supported
2010
Changes in Medicare provider rates
2010
Center for Medicare and Medicaid Innovation Created Medicare payment for primary care
2011 2011
Medicare preventive benefits
2011
Medicaid medical homes created Medical malpractice grant to support innovation Medicaid nonpayment for hospital-acquired infection
2011
Accountable Care Organizations in Medicare incentivized Commercial Minimal Medical Loss Ratio (MLR) established for Insurers
2011 2011 2012 2011
Medicare advantage payment reform
2102
Tax on medical devices
2013
Medicare tax increase
2013
www.clinicalobgyn.com
Women’s Health and the Affordable Care Act
325
TABLE 1. (Continued) Provision
Year Implemented
Medicaid payments to primary care
2013
Flexible spending accounts capped
2013
CHIP program extended
2013
Expands Medicaid coverage
2014
Individuals required to have health insurance Subsidies for health insurance premium and cost sharing
2014
Guarantee availability (‘‘issue’’) of insurance and underwriting changes Annual limits on value of insurance coverage Essential health benefits Medicare payment reduction for hospital-acquired infections Tax on high cost insurance plans (‘‘Cadillac Tax’’)
2014 2014 2014 2014 2014 2018
key provisions of the ACA that have the greatest influence on access to women’s health care services and provide data on the impact of the legislation to date.
Insurance Coverage Before the ACA Health insurance in the United States is provided through a variety of mechanisms. The largest source of private sector
Description
over $200,000 for individual taxpayers and $250,000 for married couples filing jointly and imposes a 3.8% assessment on unearned income for higher-income taxpayers Increases Medicaid payments for primary care services provided by primary care doctors to 100% of the Medicare payment rate for 2013 and 2014 (financed with 100% federal funding) Limits the amount of contributions to a flexible spending account for medical expenses to $2,500 per year with annual cost of living adjustment Extends funding for the Children’s Health Insurance Program (CHIP) through 2015 Expands Medicaid (in states that agree to comply) to all individuals not eligible for Medicare under age 65 (children, pregnant women, parents, and adults without dependent children) with incomes up to 138% FPL Requires US citizens and legal residents to have health coverage or pay a tax that increases over time Provides tax credits and subsidies to eligible individuals to purchase insurance through the exchanges Requires guaranteed issue and renewability of health insurance regardless of health status. Allow underwriting based only on limited factors Prohibits annual limits on the dollar value of coverage Creates an essential health benefit package that provides a comprehensive set of services, limiting annual cost sharing to specified limits Reduces Medicare payments to certain hospitals for hospital-acquired conditions by 1% Imposes a 40% excise tax on insurers of employersponsored health plans on benefits provided to employees that exceed a predetermine threshold ($10,200 for individual coverage and $27,500 for family coverage)
coverage is employment-based insurance. Public sector sources include government programs such as Medicare. They also include programs such as Medicaid and the State Children’s Health Insurance Program (CHIP) that provide assistance to eligible children and adults generally without premium obligation. Depending on the program, funding may come from premiums (that may be paid directly by individuals or indirectly by their employers), payroll taxes, or general tax revenues. The www.clinicalobgyn.com
326
Armstrong
financial risk associated with medical expenses is spread across the covered population. Before the ACA, individuals outside of these insurance arrangements, such as unemployed or self-employed individuals, had few options to obtain the most affordable coverage. In 2012, among the 98 million women aged 18 to 64 years, 58% had insurance through an employer-sponsored arrangement; 7% purchased private insurance on their own through the individual market; 12% qualified for Medicaid; and 19% were uninsured.2 The major barrier to insurance coverage is cost. During the past decades, the United States experienced a significant increase in health care spending, driving a concurrent rise in health insurance costs and a decline in the proportion of the US population with insurance coverage. Between 1970 and 2010, medical spending rose from 7.2% to 18% of gross domestic product, reaching $2.7 trillion in 2011.3 Health insurance premium costs rose 80% from 2003 to 2013, reaching an average of $16,251 for family coverage and $5884 for an individual.4 Millions of Americans were priced out of the market, even those with the opportunity to purchase coverage through, and paid in part by, employers.5 The net effect of these trends was the steady increase between 2000 and 2010 in the number of Americans without health insurance coverage, reaching 16.3% of the population or 50 million people by 2010.6 Among the uninsured were 19 million women aged 18 to 64 years and 7 million children.7 In addition to the uninsured, some women who were insured in the individual market had limited coverage of certain services important to women such as comprehensive maternity care and prescription contraceptives. Further, these plans commonly excluded preexisting conditions. As a result, some women covered under these plans received inadequate preventive and primary care. In 1 survey, among underinsured-women, 38% reported delayed www.clinicalobgyn.com
preventive care screening due to cost.8 Only 66% had a pap test in the prior 3 years. For women above 50 years, only 51% of women had a mammogram in the prior 2 years, and only 33% had a colon cancer screening test in the past 5 years.8 Similarly, for women covered under Medicaid before the ACA, coverage of preventive benefits varied considerably according to state policy. For example, in a 2009 survey of 44 Medicaid plans, 31 states did not cover preconception counseling for enrolled women.9
An Important Caveat to Understanding the ACA: Grandfathered Health Insurance Plans To understand the impact of the ACA on women, it is critical to understand that some plans are ‘‘grandfathered’’ and, thus, exempt from following some provisions of the ACA. The exemption impacts the benefits and costs for people covered by those plans. Grandfathered insurance plans are those that existed before March 23, 2010, and have not substantially changed in ways that either reduce benefits or increase costs for consumers. (Once these changes occur, the plan becomes nongrandfathered.) For example, grandfathered plans must cover adult children up to age 26 years but do not have to cover preventive care without cost sharing and may be allowed to exclude individuals for preexisting conditions. Consumers can find out what type of plan they have by asking their employers’ benefits administrator. The grandfathered status of a plan and the overlapping nature of some of the provisions of the ACA (such as expanded access to Medicaid and the requirement that plans offer essential health benefits) raise some challenges in the analysis of the outcomes associated with specific provisions of the ACA.
Women’s Health and the Affordable Care Act PROVISIONS OF THE ACA THAT EXPAND ACCESS TO HEALTH INSURANCE
A primary goal of the ACA is to significantly increase the number of Americans with health insurance. To achieve this, the legislation expanded access to public and private insurance. The key provisions that benefit women are outlined in greater detail below and include: (1) The extension of insurance coverage of adult children up to age 26 on their parents’ private insurance plans that provide dependent coverage. (2) Federal incentives for states to increase the income threshold for Medicaid eligibility. (3) The establishment of state-based or federal-based ‘‘exchanges’’ or ‘‘marketplaces’’ for individuals to purchase private insurance, coupled with tax credit subsidies for low-income individuals. (4) Other supporting policies including guaranteed issue, prohibition of preexisting conditions, underwriting changes, and the individual mandate. Coverage of Adult Children Up to Age 26 on Parent’s Plan One of the earliest implemented and most popular provisions of the ACA requires insurers to extend family plan–dependent coverage for all children until age 26. The current policy applies regardless of marital, residency, employment, or educational status. Before the 2010 implementation, insurance coverage often ended at age 19 or upon completion or withdrawal from a qualifying institution of higher education. This is a particularly vulnerable demographic because about half of this age group are college students. Only two-thirds are employed, and when employed, generally the group has low-income jobs.10 Before the implementation of the ACA, an estimated 35.6% of the young adults aged 19 to 25 years or 10.2 million were uninsured. Within 2 years of implementation, 2.5 million young adults gained
327
insurance coverage attributed to the law and the uninsured rate for this age group decreased to 27.0%.11 As of 2012, there were about 8 million remaining uninsured individuals in this age group.11 The majority of them are estimated to be eligible for Medicaid in states that expanded the threshold of eligibility under the ACA. Beyond increasing access to insurance, early evidence suggests that this provision of the ACA is addressing an unmet need. Early data indicate a 9% increase in the receipt of mental health services in the age group compared with people aged 27 to 29, an important result especially for women who have high rates of depression.12 Medicaid Expansion Medicaid, the joint state-federal health insurance program for low-income Americans, is the largest and most important medical safety net program for women, covering 48% of all births in the United States and 12% of nonelderly women for general medical care.13 Medicaid also finances about 75% of all publicly funded family planning services in the United States, and all states use Medicaid funds to cover the cost of breast and cervical cancer screening for certain low-income uninsured women.14 Medicaid eligibility varies by state, by life event, and level of poverty required for eligibility. This variability in coverage over the course of a woman’s reproductive life results in important ‘‘holes’’ in the safety net. Before the ACA, federal law required states to extend eligibility for pregnancyrelated care to pregnant women with incomes up to 133% of the federal poverty level (just below $15,300 for an individual in 2013). States also had the flexibility to provide coverage to women earning much more, and many states did.9 (The District of Columbia had a limit of 300%.) Medicaid pregnancy-related covered services include prenatal care, delivery, postpartum care, family planning, and other services related to a complicated pregnancy. The flexibility in program design also created a www.clinicalobgyn.com
328
Armstrong
broad variation across states in terms of what perinatal care services they cover. In a 2009 survey of 44 Medicaid plans, for example, 8 states did not cover any breastfeeding support services for women enrolled in Medicaid.9 Eligibility for Medicaid participation in nonpregnant women, however, is much more restrictive than for pregnant women and changes significantly after delivery. Across all states in 2012, the median floor for parents was 28% of the federal poverty limit ($3127 for an individual).15 The majority of women who are covered under Medicaid during pregnancy typically lose their coverage 60 days after delivery, leaving them uninsured both before and between pregnancies, thus missing opportunities for follow-up care for pregnancy complications, for contraception planning, and for preconception services. The ACA attempted to fill these coverage gaps by making Medicaid a more universal program for individuals. The law provides enhanced federal funding for states to reset the floor for eligibility and cover all women—pregnant and nonpregnant— with incomes up to 133% of the federal poverty limit. A separate provision of the Act provides financial help to buy private insurance in the newly created health care exchanges (discussed more below) for individuals beginning at 133% of the federal poverty limit and phasing out at 400% of the federal poverty limit. The proposed mandatory expansion of Medicaid, originally written into the law, was challenged by multiple states. A 2012 decision by the US Supreme Court ruled that mandatory enforcement of Medicaid expansion was not permissible, thus making Medicaid expansion optional for states. Still, the attractive financing of the expansion—it is fully funded by the federal government for 3 years and then is phased down to 90% by 2020—has resulted in wide state participation. To date, 27 states, including the District of Columbia, are implementing the expansion, and additional www.clinicalobgyn.com
states may expand moving forward.16 The impact on coverage has been substantial. Enrollment growth in states that expanded Medicaid coverage to low-income adults added 4.2 million adults in
