Womencare

Obamacare Ruling Part II: States Can Deny Medicaid Expansion

If you thought the Supreme Court ruling that upheld Obamacare was good news, you were right...partially

When SCOTUS gave its "thumbs-up" to ACA it affirmed numerous positive benefits for women, including the elimination of gender ratings - insurance companies' practice of charging women more for premiums than men, annual wellness exams and screenings without copays, eliminating lifetime and annual caps on coverage, prenatal care and coverage, and coverage for reproductive care, including contraception, among others.

But the Court also altered Obamacare in a very fundamental way: it limited expansion of Medicaid to voluntary participation rather than the mandatory expansion ACA originally called for.

Medicaid expansion, along with state health insurance exchanges, is the linchpin of President Obama’s plan to provide insurance coverage to 30 million low-income uninsured Americans.

Under existing Medicaid rules low-income non-elderly individuals who don’t have children, or those who aren’t disabled or elderly, aren’t eligible for Medicaid. ACA changed this by including in its mandatory expansion all adults with incomes below 138% of the federal poverty level—$15,415 for an individual; $26,344 for a family of three. By establishing a standard eligibility floor, adults without children who don’t currently qualify for coverage and who can’t afford private insurance, will now be able to obtain insurance coverage via their state’s Medicaid program. In return for states expanding their Medicaid program, the federal would pay close to 100 percent of the costs to insure these newly-eligible individuals starting in 2014.  

Here’s the hitch, thanks to the Supreme Court’s ruling: states can now refuse to expand their Medicaid coverage, which will impact millions of low-income women (and men) in states that refuse.  

This has real implications for low-income women

Women already account for 68 percent of Medicaid’s recipients. And it’s estimated that of 15 million adults who now qualify for Medicaid under ACA, 10 million are women.

Two-thirds of these women (6.6 million) are in their prime reproductive years (19-44). In states that refuse to expand Medicaid these women won’t have insurance coverage and thus no access to critical reproductive or prenatal care: Services like annual breast and cervical cancer screenings, Pap tests, birth control and other family planning services, prenatal care, gestational diabetes screenings, or annual wellness exams, for example.

Given the financial and other costs to states caring for uninsured, the estimated 2.8% increase they would incur in their budgets to expand Medicaid is a small price to pay. Women, especially, gain with insurance coverage, in important ways. When reproductive care (including access to contraception and abortion) is denied or limited, unplanned pregnancies go up, though denial/limitation of care is not the sole reason for this.

Coincidentally, states now with the highest numbers of uninsured are also among those with the highest rates of unintended pregnancies and they are also among those where governors have already declined to expand Medicaid or are strongly leaning toward declining.

 

SOURCE: Guttmacher Institute

 

Expanded Medicaid and older women

While much of the focus recently in health care reform has been on the health and financial impact to women in their childbearing years – in large part because of sustained attacks and limitations on reproductive rights in many states – the fact is that millions more low-income women will be hurt in states that refuse to expand their Medicaid programs.

One group of women, especially, is uniquely vulnerable.

Known as “low income near elderly women”, these 55-65 year-olds account for 3.7 million of the uninsured nationally.  

These women aren’t yet eligible for Medicare. They lack insurance coverage, in part due to the same reasons as younger women: they work in low-wage jobs without insurance benefits, are underemployed, or unemployed, and until passage of Obamacare weren’t eligible for Medicaid.

But there are other age-specific concerns and challenges these women face:

• If they are unemployed, they are less likely than younger women to find employment due to age discrimination, which makes it even more difficult for them to afford private insurance;

• Their lack of health coverage is frequently the result of factors that include losing coverage due to spousal death, disability or unemployment;

• Older women may also lack insurance coverage due to an elder spouse’s eligibility for Medicare, which leaves them frequently unable to obtain private health insurance due to preexisting conditions and illnesses and/or due to prohibitive cost.

Older women also face unique health challenges not experienced by younger women.

“They're in menopause, they have a higher likelihood of pre-existing conditions, they're at a heightened risk for all types of cancers, they're becoming more frail and less mobile, and they don't get preventive care. So, they tend to get sicker and more expensive to deal with when they do finally make it into Medicare."

Under expanded Medicaid provisions, approximately 1.2 million of these women are now eligible for coverage. But once again, in states that don’t expand their Medicaid coverage these women will pay a steep price.  

Keep your damned Medicaid off my state

States that have said they won’t voluntarily expand Medicaid are among those with already high numbers of uninsured. Florida and Texas, for example, have roughly 3 million people who are now eligible under expanded Medicaid provisions, according to Kaiser Family Foundation. But, according to Texas governor, Rick Perry:

“To expand this program is not unlike adding a thousand people to the Titanic.”

Perry shouldn’t do metaphors or analogies because he’s, well, a metaphor gaffe machine. People lost their lives on Titanic because there weren’t enough lifeboats for those already on the ship. But, okay, let’s stick with his metaphor for now: The “ship” (in this case, Texas), already has 1.7 million people without insurance (these would be the ones drowning if they were aboard Titanic). Expanded Medicaid coverage is like adding additional lifeboats. More lifeboats equal fewer people drowning.  

Meanwhile in Florida, a few Southern states to the east of Texas, there are 1.3 million uninsured now eligible for Medicaid coverage thanks to Obamacare. Sorry, I don’t have a snappy Gov. Rick Scott metaphor to include, but Scott did create a humongous $19 billion fish story about how much it would cost the Sunshine State to expand Medicaid.   

 

SOURCE: Kaiser Family Foundation & Urban League

At the moment, governors in five other states have also said, “Thanks, but no thanks” to expanded Medicaid: Iowa, Louisiana, Mississippi, Nebraska, and South Carolina.

Between these five states there are over 1 million people who are now eligible for Medicaid. And over 700,000 of them are women who will be left without insurance, thanks to their governors. Clearly, these governors are more concerned with maintaining rigid ideology than doing what’s best for their residents. And of course, 34 other states are still uncommitted, holding off until after the election. GOP governors in these states are no doubt hoping (praying, probably) that Mitt Romney will win the presidency and “get rid of” Obamacare, along with Planned Parenthood and who knows what else.

As we all know, elections have consequences, so if you need a little motivation to vote this year (and a cool graphic talking point to convince others to vote), here you go:

 

SOURCE: Ezra Klein's WONKBLOG

 

Supreme Court Upholds ACA: What the decision means for women - Part I

The nearly two-week-old Supreme Court ruling upholding ACA as constitutional signaled a substantial victory for women, who will gain a great deal from the law.

Even so, the victory isn't without a downside. There remain significant challenges ahead over the Court's narrowing of ACA's Medicaid expansion provision and what that means, in addition to ongoing lawsuits challenging the ACA contraception mandate. Both of these will be addressed in Part II.

For now, let's go with the good news.

The Court's decision affirms significant health benefits for women. Many of these have been spelled out and touted frequently for months, but now that the law stands, these benefits deserve greater coverage and additional analysis.  

No more gender discrimination 

The biggest benefit for women is elimination of "gender ratings" - the practice used by insurance companies to charge women more for health coverage than men.

Starting in 2014, women will no longer pay higher insurance premiums than men just for being women. 

This is big. Insurance companies have for years charged women higher premiums than men for the same coverage and benefits. State legislative efforts have addressed this problem and ten states now prohibit or modify gender rating practices: California, Oregon, Washington, Montana, Colorado, Minnesota, New York, New Jersey, Massachusetts, and New Hampshire. Montana outlaws all gender rating.

It's instructive to understand that where in the country a woman lives determines how much more she pays for insurance: in the Midwest, parts of the Southwest and a good chunk of the South women pay up to 25 percent more for their health insurance, while in many Upper Midwest states women now pay between 25- and 50-percent more; and in Arkansas and Wyoming - the two worst states for "gender rating" - women pay up to 150 percent more for the same coverage as men, simply because they are female.  

On an annual basis, women shell out over $1 billion annually in higher health premiums than men – quite a chunk of change.

The insurance industry has justified this practice by arguing that women use more health services than men, even though routine coverage for maternity care is excluded by a majority – 87 percent – of insurance companies. And these companies are well-known: Aetna, Blue Cross Blue Shield, Humana, United Health Group, and Wellpoint.

Gender rating is pervasive and occurs within insurance plans from state to state and across plans within the same state, according to a 2009 detailed report by the National Women's Law Center. 

Aside from the fairness of ending this practice, women will also gain economically. It means more money in our pockets. Would that we could wipe out pay disparities this easily. 

Additional pluses of ACA for women include:

• An end to sex discrimination in any federal health program or health programs and services that receive or benefit from federal funds. From the NWLC Report: 

"The Affordable Care Act applies nationally and eliminates gender rating in the individual market, requires all plans on the individual market to provide maternity coverage, and prohibits sex discrimination in health plans from insurance companies that receive federal funds or are conducted by the federal government." 

Thus, insurance plans that participate in the new health exchanges can't discriminate against women, nor can care providers in these plans deny treatment or discriminate against women.

Coverage for essential benefits, screenings

ACA also defines a set of essential health benefits and services that must be included in individual and small employer health plans. States will determine the scope of these “essential benefits”, but at a minimum they must include benefits in 10 areas “essential” to basic health: (1) ambulatory patient services, (2) emergency services, (3) hospitalization, (4) maternity and newborn care, (5) mental health and substance use disorder services, including behavioral health treatment, (6) prescription drugs, (7) rehabilitative and habilitative services and devices, (8) laboratory services (9) preventive and wellness services and chronic disease management, and (10) pediatric services, including oral and vision care. 

Women will gain from many of these items and services, like prenatal and maternity care, prescription drugs, mental health care and pediatric care (including oral and vision care). For women struggling with serious illnesses and conditions, the addition of these essential benefits can’t come soon enough. 

No more preexisting conditions clauses

• An end to "preexisting condition" requirements.

Women are now routinely denied coverage for conditions like pregnancy, which only 3 percent of private health insurance plans cover; and if a woman has had a Caesarian Section she can also be denied coverage.

Other so-called preexisting conditions that insurance companies use to deny coverage to women include prior treatment and care related to abuse, treatment for mental health issues, like depression, and prior treatment for serious illnesses, like cancer. 

Free annual screenings, no caps on coverage

In 2011, new preventive services were made available to approximately 20 million women, without co pays or cost-sharing. These include mammograms, cervical cancer screenings, prenatal care, flu and pneumonia shots, and regular well-baby and well-child visits. In August of this year, services will be expanded to include:

• well-woman visits – to address health needs across a woman’s lifespan, screening for gestational diabetes, domestic violence screening, breastfeeding supplies and contraceptive services, among others.

• ACA will incorporate preventative care coverage in all health plans beginning in 2014, to include annual Pap tests, mammograms, contraception, domestic violence screenings, depression screenings, and other recommended screenings, all without copayment or deductibles. 

• Another benefit: Under the Affordable Care Act, nursing mothers will be given breaks while at work (in companies with 50 or more employees) to nurse and employers must provide a private place for nursing moms to express breast milk - a provision that encourages the healthy practice of breastfeeding.

• Elimination of lifetime and annual coverage limits on care. Lifetime limits on coverage were eliminated in 2010; annual limits will come to an end in 2014.

Getting rid of these caps is a huge win, especially for women facing cancer, HIV/AIDS and other serious illnesses and conditions that require long-term care and treatment - often both in and out of hospitals, routine tests, and expensive prescription drugs.

Lesbian and gay women benefit, too 

Gay and lesbian women benefit in many of the same ways as women, overall: through annual wellness screenings, gender neutral premiums, non-discrimination in purchasing health care and in treatment, and elimination of caps on coverage. 

They also benefit from increased protection against discrimination based on sexual orientation in purchasing health care and in care and treatment.

LGBT individuals report frequently avoiding medical treatment and checkups due to factors like mistreatment and discrimination based on their sexual orientation, according to numerous studies.

• Under the Patient's Bill of Rights embedded in the new law, insurance companies and health care providers are prohibited from denying coverage or discriminating against individuals because of an individual’s sexual orientation, gender, race, health condition, and disability, for example. 

Additionally, because of the high cost of health insurance, many lesbian and gay women (and other women, too) avoid purchasing insurance altogether.

• The health exchange "supermarkets" scheduled to open in states beginning in 2014 will offer a greater choice of private health plans at lower cost and provide options for selecting plans that cover domestic partnerships and families.

• One other plus for lesbian and gay women in ACA is the addition of new data collection on lesbian and gay health needs, starting in 2013. HHS Secretary, Kathleen Sebelius, sees this as a critical step in pinpointing LGBT health needs and working to address them.

Expanded benefits for women on Medicare

Women enrolled in Medicare have already seen positive changes in their coverage. For those who reached the “donut hole” for prescription drug coverage – meaning they reached the ‘cap’ on what insurance will pay for prescription drugs – the ACA kicked-in starting in 2011, to provide a 50 percent discount on brand name prescription drugs and 7 percent on generics.

• This coverage will expand until 2020 when those in the donut hole will pay just 25 percent co pays for brand name drugs and 25 percent co pays for generics.

• A one-time wellness exam is now available to women when they first enroll in Medicare. 

• Women in Medicare plans also now receive annual preventative screenings without co pays for cervical cancer (Pap smears and pelvic exams), diabetes, cholesterol, and HIV, in addition to mammograms, bone density tests, and vaccinations for flu, pneumonia and hepatitis B.  

Federal subsidies to help pay for insurance

For individuals and families with income up to up to 400% of the federal poverty level ($43,320 for an individual or $88,200 for a family of four in 2009), subsidies will be available to help cover the cost of premiums. The subsidies apply to any individual or family that meets income requirements, who purchases insurance through the state exchanges, or who pays more than 9.5 percent toward an employer-provided plan, or has an employer plan that doesn’t cover at least 60 percent of covered benefits.

• Quick example: a 45-year old single woman who earns $25,000 a year (217% of FPL) would receive a subsidy/tax credit of $3,882. This would cover 69 percent of the cost of a basic health care plan ($5,609 annually), according to Kaiser Family Foundation's Health Reform Subsidy Calculator.

It’s a bit trickier for individuals and families not eligible for a private plan. ACA initially required states to expand Medicaid coverage to insure individuals and families that otherwise would fall through the cracks of private coverage.

But the Supreme Court ruled that ACA’s Medicaid expansion requirement must be optional, so at present it isn't clear which states will opt to expand. Currently, governors in 15 states are leaning against or have said outright that they won’t expand coverage, even though the federal government will pick up the tab for several years. More on this in Part II. ^(*)   

New provisions for women with serious medical conditions

Finally, women with HIV/AIDS, cancer, or other serious medical conditions benefit in several other significant ways:

• Starting in 2014 women will no longer be denied health coverage for a pre-existing condition. Annual screenings for HIV/AIDS will also be covered at no cost.

The law also expands access to lower-cost prescription drugs to treat these conditions, through Medicaid and Medicare and via the new essential benefits packages to take effect in 2014.

Additionally, for women who are currently denied coverage because of preexisting conditions, ACA has established the Pre-Existing Condition Insurance Plan (PCIP) – a temporary program that provides health care coverage until 2014. After this, insurance companies will no longer be allowed to deny coverage based on a preexisting condition. PCIP covers primary and specialty care, hospital care and prescription drugs.

It’s estimated that 30 percent of people affected by HIV and AIDS are uninsured due to denial of coverage, so new benefits and provisions available in the Affordable Care Act have enormous consequences for women, who represent 25 percent of all new HIV diagnoses.

• The Affordable Care Act also expands access to lower-cost health coverage, puts in place policies to enhance quicker approval for Medicaid coverage once a person is diagnosed with HIV, and helps via federal subsidies to help pay for health coverage and prescription drugs.  

All of these are real lifelines to women diagnosed with these serious conditions and illnesses.

In its scope ACA reflects the changing dynamics of our society and women’s role in it: women are over half the U.S. population, with unmet health needs and concerns, who have been denied coverage and discriminated against in health care for generations. For the first time we have the beginnings of health reform that will make it possible for everybody to have health care, to address many of the worst abuses in the health care industry, and provide benefits and services for women that have long been absent from health care.

Are there bumps ahead to implement ACA? Yes, but this has been true of every progressive policy, from abolishment of slavery, to creation of Social Security and Medicare, to Civil Rights and Equal Pay laws, to clean water and air laws. There are and always have been factions that work to weaken, undermine and repeal such laws and it is no different with health care reform.  

The other side of this is that no law is perfect. Every generation works to expand and strengthen these laws and policies. The same is true for the Affordable Care Act.

So, despite bumps in the road, or disappointment in what ACA does or does not include, women have achieved a significant and historic victory that far outweighs the challenges and “bumps”.

Because women have such a huge stake in health care reform, we also have a huge role in educating ourselves and others to ACA’s benefits and to ensure that the law works for us. Its success going forward is at least partly in our hands.

With a pivotal presidential and congressional election just four months away, it's imperative that women keep this in mind as we weigh which candidates will stand with us and support our needs and concerns.

 

^(*) Expansion of Medicaid coverage to insure millions more uninsured Americans faces resistance. GOP governors in eight states have already signaled they will not expand Medicaid coverage and seven others are leaning in this direction. It isn't entirely clear yet, either, how many states will now choose to opt out of creating state health exchanges, but many of the same governors openly refusing to expand Medicaid coverage are also balking at this provision.

Part II will address some of these concerns and challenges and provide updates on Republican efforts in the House to repeal ACA, in addition to related challenges, like the possibility that some states could tighten restrictions for Medicaid eligibility, and how lawsuits challenging the reproductive health mandate will impact ACA..