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Medicaid at 50: Marking a Milestone for Women's Health

      When Medicaid was enacted 50 years ago, no one could have imagined that this relatively modest program would become the backbone of coverage for millions of low-income women. Today, Medicaid provides health and long-term coverage to more than 1 in 10 women. For women in particular, the program has served as a critical safety net by providing coverage for a wide spectrum of services that other government programs and private insurance did not, from contraceptives and pregnancy-related care to long-term care services and supports. Medicaid's 50th anniversary is an opportune time to look back at some of the program's achievements as they have affected women and to take stock of the challenges the program will continue to face in the coming years.

      Medicaid: Filling Coverage Gaps

      Although Medicaid was never envisaged as a “woman's” program, its roots in welfare unintentionally created a critical pathway to coverage for our nation's poorest women. Over time, it could be said that the program has incrementally expanded in response to shortcomings in Medicaid itself, as well as in other public programs like Medicare and Title X family planning, and in private insurance. Among adults, program eligibility was initially limited to mothers receiving cash payments through the Aid to Families with Dependent Children (AFDC) program and to seniors qualifying for Supplemental Security Income (SSI program). Over the years, federal eligibility rules have been broadened to include low-income pregnant women, infants and children, and seniors. For those who qualify for assistance, Medicaid coverage provides a critical lifeline to medical and long-term care services. As one example, in 2013 just over one-half of uninsured women reported having had a recent pap test, compared with three in four women with private insurance or Medicaid (Figure 1).
      Figure thumbnail gr1
      Figure 1Women with Medicaid coverage report better access to care than uninsured women. Note: Data are from 2013. Provider visit and Pap test among women ages 18 to 64. Mammogram among women ages 40 to 64. *p < .05 vs. Medicaid.
      SOURCE:

      Kaiser Family Foundation. (2013). Medicare's role for older women. Available: http://kff.org/womens-health-policy/fact-sheet/medicares-role-for-older-women/. Accessed March 10, 2015.

      Kaiser Women's Health Survey.
      The program has evolved from coverage for “deserving” poor mothers and seniors eligible for welfare payments at its inception, to one that, if fully expanded as envisioned under the Affordable Care Act (ACA), could serve all of the nation's poorest citizens (Table 1). The 2012 Supreme Court ruling, however, effectively made the ACA Medicaid expansion optional for states, resulting in the perpetuation of inconsistent eligibility policies across the nation. For states that have expanded Medicaid, the ACA eliminated categorical restrictions that had defined eligibility narrowly and disqualified many very poor adults. The ACA expanded eligibility to nearly all non-elderly adults with incomes at or below 138% of the federal poverty level (FPL), or about $16,105 for an individual in 2015. As of March 2015, 29 states (including Washington, DC) have expanded eligibility for Medicaid, but 22 states are not moving forward with the ACA Medicaid expansion at this time (

      Kaiser Family Foundation. (2015). Status of state action on the Medicaid expansion decision. Available: http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/. Accessed March 12, 2015.

      ). Because the ACA provided Medicaid eligibility for low-income adults, it did not provide financial assistance to purchase Marketplace coverage for those below 100% of the FPL.
      Table 1Medicaid at 50: Milestones in Women's Health
      YearPolicy Action
      1965Medicaid signed into law by President Lyndon Johnson as Title XIX of the Social Security Act, a federal–state partnership entitlement program in which participating states would receive federal matching funds to provide a defined set of medical and long-term care benefits to those who qualify.
      1972“Family planning services and supplies” added as a mandatory benefit.
      1976Hyde Amendment first passed, attached to a federal appropriations bill, prohibiting federal Medicaid payments for abortions except when the life of the mother would be endangered. Rape and incest added as exceptions later.
      1978Enactment of rule requiring a 30-day waiting period for Medicaid beneficiaries seeking sterilization.
      1985Institute of Medicine issues, Preventing Low Birthweight, calling for expanded access to prenatal care and specifically more investment in Medicaid (
      Institute of Medicine
      Preventing low birthweight.
      ).
      1986Federal statute amended, states are not permitted to restrict freedom of choice of provider for family planning services.
      1988The Medicare Catastrophic Coverage Act of 1988 (MCCA) requires states to pay Medicare premiums and cost sharing for low-income beneficiaries and established new eligibility rules for institutionalized individuals whose spouses remain in the community to prevent spousal impoverishment. (These provisions were maintained after the MCCA was repealed in 1989.)
      1981–1989Multiple expansions in eligibility for pregnant women, ultimately requiring all states to cover pregnant women in families with incomes of ≤133% FPL. Many states set higher eligibility levels.
      1993The Clinton Administration begins approving Section 1115 waivers to states allowing more statewide expansion demonstrations. Rhode Island and South Carolina were the first states to receive waivers to establish family planning only expansion programs.
      1996Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) replaces Aid to Families with Dependent Children (AFDC) program with Temporary Assistance for Needy Families (TANF) and ends the formal linkage between cash assistance and Medicaid eligibility. PRWORA also includes a 5-year ban on federal Medicaid funds for new legal immigrants.
      1999The U.S. Supreme Court rules in Olmstead v. L.C. requiring states to provide community-based services to individuals for whom institutional care is inappropriate.
      2000Breast and Cervical Cancer Prevention and Treatment Act allows states to opt to extend Medicaid coverage to uninsured women diagnosed with breast or cervical cancer.
      2003The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 established drug coverage for Medicare, transferring drug coverage for “dual eligible” beneficiaries from Medicaid to Medicare.
      2010Affordable Care Act (ACA) is passed, allowing states to extend Medicaid eligibility to all eligible individuals with incomes of ≤138% of the federal poverty level.
      2012The U.S. Supreme Court rules in National Federation of Independent Business v. Sebelius, effectively making Medicaid expansion optional for states.
      About one-quarter of the 16.5 million women ages 19 to 64 who were uninsured during 2013 will not be able to benefit from the ACA coverage expansion. An estimated 1.9 million poor women live in states that have not expanded Medicaid and therefore do not qualify for Medicaid or tax credits to buy coverage on the state marketplaces. It is likely that there are at least an additional 2.2 million women who will remain ineligible for Medicaid or Marketplace participation owing to their immigration status (

      Kaiser Family Foundation. (2014b). Unpublished analysis based on The coverage gap: uninsured poor adults in states that do not expand Medicaid. Available: http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid-an-update/. Accessed March 10, 2015.

      ). Federal law has a 5-year ban on Medicaid for new immigrants, and undocumented immigrants are ineligible for marketplace subsidies. Despite the importance of the ACA in broadening access to coverage, especially for low-income populations, millions of women still lack a pathway to affordable coverage.

      Key Issues in Women's Coverage

      Over the years, Medicaid has played an important role for poor women of all ages, providing a wide range of benefits, including hospital and physician care, prescription drugs, cancer treatment, as well as assistance with Medicare expenses and nursing home care. For women in particular, the role of Medicaid in covering reproductive care and related services and the financial protections provided to older women have made a difference in the lives of millions.
      In response to increasing rates of infant mortality, especially in the South, Medicaid eligibility levels were increased incrementally throughout the late 1980s and early 1990s to promote access to early prenatal care to improve birth outcomes. Today, federal law requires Medicaid to cover pregnant women with incomes of up to 133% of the FPL for up to 60 days postpartum, but many states go beyond this threshold. These expansions are credited with reductions in infant mortality and low birth weights (
      • Currie J.
      • Gruber J.
      The efficacy and cost of recent changes in the Medicaid eligibility of pregnant women.
      ) and improved health outcomes for children (

      Miller, S., & Wherry, L. (2015). The long-term health effects of early life Medicaid coverage. Available: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2466691. Accessed March 12, 2015.

      ). Before the ACA, pregnancy was considered a preexisting condition in the individual insurance market, and most individual policies required a waiting period or costly riders for maternity coverage. Therefore, Medicaid was virtually the only pathway to coverage for uninsured, low-income, pregnant women. As a result of eligibility expansions, Medicaid is the leading payer of maternity care, financing nearly one-half of all births in the United States (
      • Markus A.
      • Andres E.
      • West K.
      • Garro N.
      • Pellegrini C.
      Medicaid covered births 2008-2010, in the context of the implementation of health reform.
      ). The ACA Medicaid coverage expansion in 29 states offers more continuous Medicaid eligibility to women who previously would have lost coverage after the postpartum period.
      In addition to supporting healthy pregnancies, federal and state Medicaid policies encourage access to family planning services. In 1972, family planning was added as a mandatory Medicaid benefit, with the federal government providing a monetary incentive for states to make family planning coverage as broad as possible by picking up 90% of costs, a considerably higher match than for other services. Family planning services are also exempt from out-of-pocket charges, and beneficiaries have “freedom of choice” to obtain confidential and sensitive family planning care from any Medicaid provider of their choice, even if it is “out of network.” This has become particularly important, because nearly three-quarters of reproductive age women on Medicaid are enrolled in managed care arrangements. Medicaid family planning expanded again in the early 2000s, when many states began seeking federal waivers to provide family planning services to women who no longer qualified for or lost Medicaid eligibility after having a baby or for other reasons. Today, Medicaid accounts for three-quarters of all publicly funded family planning services in the United States (

      Guttmacher Institute. (2012). Public funding for family planning, sterilization and abortion services, FY 1980-2010. Available: http://www.guttmacher.org/pubs/Public-Funding-FP-2010.pdf. Accessed March 9, 2015.

      ). More than one-half of states have Medicaid family planning programs, but some are questioning whether they are still needed in light of the ACA's broader Medicaid expansion, and a handful have eliminated their programs altogether (

      Molozanov, D. (2015). Five states allow women's health Medicaid programs to lapse [Blog post]. Available: http://www.regblog.org/2015/01/07/molozanov-women-medicaid/. Accessed March 12, 2015.

      ).
      In stark contrast with other reproductive health services, abortion stands out as the one for which Medicaid plays a very limited role. The federal Hyde Amendment prohibits federal spending on abortions, except in cases of rape, incest, or when the woman's life is in danger, and does not make an exception for the health of the woman. Seventeen states use their own unmatched funds to cover “medically necessary” abortions, but the remaining 33 states and Washington, DC, only cover abortions in very limited circumstances, making cost an additional barrier for women in those states. The median cost for a first trimester abortion is estimated to be $490 (
      • Roberts S.
      • Gould H.
      • Kimport K.
      • Weitz T.
      • Greene Foster D.
      Out-of-pocket costs and insurance coverage for abortion in the United States.
      ), presenting a formidable cost barrier to most of the low-income women that Medicaid covers. The ACA reinforced this coverage limitation and women who become eligible as a result of the Medicaid expansions will still not have access to abortion coverage in many states (

      Kaiser Family Foundation. (2014a). Coverage for abortion services and the ACA. Available: http://kff.org/womens-health-policy/issue-brief/coverage-for-abortion-services-and-the-aca/. Accessed March 10, 2015.

      ).
      In 1991, the Centers for Disease Control and Prevention (CDC) established the National Breast and Cervical Cancer Early Detection Program to provide breast and cervical cancer screenings to underserved women. The program successfully identified many low-income women with cancer; unfortunately, those who were uninsured had no coverage for treatment. To fill these gaps, congress passed the Breast and Cervical Cancer Prevention and Treatment Act of 2000 to give states the option to extend Medicaid coverage to uninsured women who have been diagnosed with cancer through the CDC program. All states have taken up this option, but eligibility requirements vary between states. As with the family planning programs, some states may begin to question the need for this program in light of the ACA's broader full scope Medicaid eligibility expansions.

      Key Issues for Older Women

      Despite providing important benefits, on average Medicare only covers one-half of health care expenses and does not pay for hearing aids, eyeglasses, or dental care, nor does the program cover extended nursing home stays or personal care needs—all critically important to most senior women. Medicare charges relatively high cost sharing, which is particularly challenging for women who on average have greater health expenses than men and have accrued less income and savings over their lifetimes (
      • Salganicoff A.
      • Cubanski J.
      • Ranji U.
      • Neuman T.
      Health coverage and expenses: Impact on older women's economic well-being.
      ). For some poor seniors, Medicaid provides wraparound coverage to Medicare, paying for premiums and deductibles as well as services that Medicare does not cover. Women comprise 68% of this dually eligible group of seniors, and reflecting the higher poverty rates among minority women, a disproportionate share of Black (38%) and Latina (40%) women are in this group (

      Kaiser Family Foundation. (2013). Medicare's role for older women. Available: http://kff.org/womens-health-policy/fact-sheet/medicares-role-for-older-women/. Accessed March 10, 2015.

      ).
      One of the very unique features of Medicaid is that it covers more than traditional medical services and includes personal care services that help frail or elderly women with disabilities to remain in the community. For those who need more intensive services, such as a nursing home, Medicaid also pays for institutional long-term care in the United States, which Medicare does not cover. Compared with men, women are more likely to require these services because they have more chronic conditions, higher rates of physical and cognitive impairments, and are more likely to live alone (
      • Salganicoff A.
      Women and Medicare: An unfinished agenda.
      ). As a result, women represent about two-thirds of all residents of nursing homes and residential care communities, and Medicaid shoulders more than one-half of those costs (
      • Harris-Kojetin L.
      • Sengupta M.
      • Park-Lee E.
      • Valverde R.
      Long-term care services in the United States: 2013 overview.
      ). There is no other comparable public or private program of its scope and magnitude and, as the number of women living longer continues to increase, the need for these services will only grow.

      Moving Forward

      One of the key concerns that will face policymakers is provider participation and access to care. Because states establish Medicaid eligibility, benefits, and payment levels within broad federal guidelines, there are considerable state-level differences in coverage, benefits, and access to care. Many states have set provider rates far below the prevailing Medicare and private insurance rates (

      Kaiser Commission on Medicaid and the Uninsured. (2012). How much will Medicaid physician fees for primary care rise in 2013? Available: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/8398.pdf. Accessed March 9, 2015.

      ). These low payment levels have been cited repeatedly as affecting provider willingness to participate in Medicaid, especially in states that pay the lowest rates and during economic downturns, when states look to Medicaid provider payments to cut program spending. The ACA temporarily increased Medicaid payment rates to primary care providers, but the provision expired at the end of 2014 and reimbursement rates are still below other payers. Because we are in the earliest stages of the ACA expansion, it remains unclear how the dual challenges of low provider participation and a growing Medicaid population will affect access to care.
      Over the years, Medicaid has grown from a safety net for women and children to one of the largest coverage programs in the nation. Unlike any other health program, Medicaid has ensured that millions of our nation's poorest women have had a pathway to coverage for a wide range of critical services. The ACA opened this pathway to millions more women who had been locked out either because they did not fit into the right “category” or because they were not “poor enough” to qualify for the program. However, because not all states are expanding Medicaid at this time, many poor women remain uninsured.
      Although the ACA has the potential to broaden Medicaid's reach to millions more women, many of the issues that have challenged the program, such as low provider participation, complex eligibility policy, and wide state-level variability in benefits and scope of coverage remain and policymakers often disagree sharply about future directions for the program. On its 50th birthday, the program has much to celebrate, but continued research and policy attention will be needed to assure that the program is strong enough to continue to serve the next generation of low-income women.

      References

        • Currie J.
        • Gruber J.
        The efficacy and cost of recent changes in the Medicaid eligibility of pregnant women.
        Journal of Political Economy. 1996; 104: 1263-1296
      1. Guttmacher Institute. (2012). Public funding for family planning, sterilization and abortion services, FY 1980-2010. Available: http://www.guttmacher.org/pubs/Public-Funding-FP-2010.pdf. Accessed March 9, 2015.

        • Harris-Kojetin L.
        • Sengupta M.
        • Park-Lee E.
        • Valverde R.
        Long-term care services in the United States: 2013 overview.
        National Center for Health Statistics, Washington, DC2013 (Available: http://www.cdc.gov/nchs/data/nsltcp/long_term_care_services_2013.pdf. Accessed March 9, 2015)
        • Institute of Medicine
        Preventing low birthweight.
        National Academies Press, Washington, DC1985
      2. Kaiser Commission on Medicaid and the Uninsured. (2012). How much will Medicaid physician fees for primary care rise in 2013? Available: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/8398.pdf. Accessed March 9, 2015.

      3. Kaiser Family Foundation. (2013). Medicare's role for older women. Available: http://kff.org/womens-health-policy/fact-sheet/medicares-role-for-older-women/. Accessed March 10, 2015.

      4. Kaiser Family Foundation. (2014a). Coverage for abortion services and the ACA. Available: http://kff.org/womens-health-policy/issue-brief/coverage-for-abortion-services-and-the-aca/. Accessed March 10, 2015.

      5. Kaiser Family Foundation. (2014b). Unpublished analysis based on The coverage gap: uninsured poor adults in states that do not expand Medicaid. Available: http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid-an-update/. Accessed March 10, 2015.

      6. Kaiser Family Foundation. (2015). Status of state action on the Medicaid expansion decision. Available: http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/. Accessed March 12, 2015.

        • Markus A.
        • Andres E.
        • West K.
        • Garro N.
        • Pellegrini C.
        Medicaid covered births 2008-2010, in the context of the implementation of health reform.
        Women’s Health Issues. 2013; 23: e273-e280
      7. Miller, S., & Wherry, L. (2015). The long-term health effects of early life Medicaid coverage. Available: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2466691. Accessed March 12, 2015.

      8. Molozanov, D. (2015). Five states allow women's health Medicaid programs to lapse [Blog post]. Available: http://www.regblog.org/2015/01/07/molozanov-women-medicaid/. Accessed March 12, 2015.

        • Roberts S.
        • Gould H.
        • Kimport K.
        • Weitz T.
        • Greene Foster D.
        Out-of-pocket costs and insurance coverage for abortion in the United States.
        Women's Health Issues. 2014; 24: e211-e218
        • Salganicoff A.
        Women and Medicare: An unfinished agenda.
        Generations. 2015; 39 ([in press])
        • Salganicoff A.
        • Cubanski J.
        • Ranji U.
        • Neuman T.
        Health coverage and expenses: Impact on older women's economic well-being.
        Journal of Women, Politics, and Policy. 2009; 30: 222-247

      Biography

      Alina Salganicoff, PhD, is Vice President and Director of Women's Health Policy for the Henry J. Kaiser Family Foundation. Her work focuses on health coverage and access to care for women, with an emphasis on challenges facing underserved populations, including low-income and uninsured women, and women of color.

      Biography

      Usha Ranji, MS, is Associate Director for Women's Health Policy at the Henry J. Kaiser Family Foundation. Her work examines the impact of national and local public policies on women's health care access and coverage.

      Biography

      Laurie Sobel, JD, is a Senior Policy Analyst for Women's Health Policy at the Henry J. Kaiser Family Foundation. Her work aims to understand how federal, state, and local policies influence health and access to services for women.