Women, Private Health Insurance, and the Affordable Care Act

Published:November 24, 2015DOI:https://doi.org/10.1016/j.whi.2015.10.008
      In the run up to the passage of the Affordable Care Act (ACA), many of the law's proponents were actively engaged in advocacy that promoted the law's benefits for women. In particular, there was much attention to the numerous provisions that addressed the long-standing inequities and discriminatory practices adopted by many private insurance plans that disproportionately disadvantaged women. These included charging women higher rates than men, while also excluding benefits important to women, such as maternity care and contraception. As we approach the end of the ACA's third open enrollment period, it is a good time to step back and reflect what we are learning about how the private insurance reforms and expansions have affected access to coverage for women and to identify where gaps remain.

      Access to Coverage

      One of the key goals of the ACA was to expand coverage to the uninsured through a combination of Medicaid expansions, private insurance reforms, and tax credits. Although the ACA's Medicaid expansions have broadened coverage for many, but not all, of the nation's poorest women (
      • Ranji U.
      • Salgincoff A.
      Medicaid and women's health coverage two years into the Affordable Care Act.
      ), the law also has done much to improve access to affordable private insurance coverage for millions with modest and middle incomes by offering subsidized premium assistance. In addition, coverage rates for young adults have also greatly improved owing to the law's requirement that employer plans offer workers the option of keeping adult children up to age 26 enrolled as dependents. But, as will be discussed, this option has also presented some unanticipated challenges for young women.
      The ACA also instituted a series of private insurance reforms to alleviate some of the long-standing barriers to coverage, many disproportionately affecting women. Historically, insurance carriers selling plans on the individual insurance market adopted policies that specifically placed women at a disadvantage, either by charging them higher premiums than men for the same level of coverage (a practice called gender rating), limiting their scope of benefits, such as excluding maternity care or contraception, or in some cases, excluding coverage for certain preexisting conditions, including pregnancy. The ACA bans plans from instituting these policies.
      In the first 2 years of insurance expansions, women represented 54% of enrollees in Marketplaces using the healthcare.gov platform (

      Office of the Assistant Secretary for Planning and Evaluation (ASPE). (2015). Health insurance coverage and the Affordable Care Act. Available: http://aspe.hhs.gov/sites/default/files/pdf/83966/ib_uninsured_change.pdf. Accessed October 27, 2015.

      ), despite the fact that they were less likely to be uninsured. This may not be surprising given that women are more likely than men to manage family health, have contact with the health system, and have higher rates of chronic health problems as well as experience cost-related barriers to care. For these reasons, the elimination of many of the structural barriers to insurance along with offer of subsidies could have made enrollment in insurance coverage a higher priority for women than men.

      Affordability

      Although the affordability of coverage and care is a problem that affects both sexes, women are consistently more likely than men to report cost-related barriers to care (
      • Salganicoff A.
      • Ranji U.
      • Beamesderfer A.
      • Kurani N.
      Women and health care in the early years of the ACA: Key findings from the 2013 Kaiser Women's Health Survey.
      ). Many women for whom health insurance was previously out of financial reach are now enrolled in Marketplace plans and use tax credits to offset premiums and other out-of- pocket costs. In a national survey conducted by the

      Kaiser Family Foundation. (2015). Women's Health Insurance Coverage. Available: http://kff.org/womens-health-policy/fact-sheet/womens-health-insurance-coverage-fact-sheet/. Accessed November 11, 2015.

      in the fall of 2014, the vast majority of women enrolling in marketplace plans were income eligible for some level of financial assistance such as tax credits to offset their premium costs (94%) or caps on their out-of-pocket costs for deductibles, coinsurance and copayments (75%).
      Despite the availability of these financial protections and assistance, many newly covered women still feel ill-prepared to address their medical costs. The same Kaiser survey found that 40% of low-income women enrolled in Marketplace plans reported they were not confident they could afford usual medical costs and 62% lacked confidence they could afford major medical costs. This was lower than the rate reported by uninsured women, but higher than the rate for low-income women with employer-sponsored insurance (Figure 1).
      Figure thumbnail gr1
      Figure 1Financial challenges experienced by low-income women, by insurance type, fall 2014. “Uninsured” includes people who lacked coverage as of the interview date. Low income is defined as household income below 250% of the federal poverty level. *p < .05 versus uninsured. ESI, employer-sponsored insurance.
      (Source: Kaiser Family Foundation analysis of the 2014 Kaiser Survey of Low-Income Americans and the ACA.)
      Recent reports have found that some new enrollees are losing their coverage because they are not renewing their Marketplace plans or making their premium payments (

      Centers for Medicare and Medicaid Services. (2015). Effectuated enrollment snapshot. Available: www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-09-08.html. Accessed October 19, 2015.

      ). Anecdotally, some reports note that many feel that they cannot keep up with the payments, even though they are receiving tax subsidies to help secure their coverage and others report problems providing the documentation needed to continue to qualify for assistance (). It is not known at this time whether there are gender-based differences in continuity rates, but as will be discussed in the following section, women may be more likely to see the value in keeping their insurance given the broad scope of benefits that they are entitled to by most private plans at no cost to them.

      Benefits

      The ACA also strengthened the scope of many benefits important to women. For women with private insurance plans of any kind, the inclusion of first dollar coverage for preventive services is a particularly important improvement. In addition, the establishment of “essential” health benefits means that women with individual and small group policies are now covered for maternity care, preventive care, and mental health. Most private health plans (both employer and individually purchased) must now cover, without cost sharing, evidence-based recommended preventive services obtained from in-network providers. The range of services include clinical preventive services that receive an A or B rating from the United States Preventive Services Task Force, immunizations, and certain preventive services for women such as contraception, well-woman visits, gestational diabetes screening, breastfeeding support, and intimate partner violence screening and counseling. About one-half of these preventive services are recommended only for women and the remainder for both sexes. The evidence on the early impact on the utilization of preventive services and on health is mixed, with some finding modest improvements (
      • Han X.
      • Yabroff R.
      • Guy Jr., G.P.
      • Zheng Z.
      • Jemal A.
      Has recommended preventive service use increased after elimination of cost-sharing as part of the Affordable Care Act in the United States?.
      ,
      • Fedewa S.A.
      • Goodman M.
      • Flanders W.D.
      • Han X.
      • Smith R.A.
      • Ward E.
      • Jemal A.
      Elimination of cost-sharing and receipt of screening for colorectal and breast cancer.
      ), although others have not found much difference (
      • Richman I.
      • Asch S.M.
      • Bhattacharya J.
      • Owen D.K.
      Colorectal cancer screening in the era of the Affordable Care Act.
      ). An area with some evidence of change is in reduced out-of-pocket spending for contraceptive services (
      • Sonfield A.
      • Tapales A.
      • Jones R.K.
      • Finer L.B.
      Impact of the federal contraceptive guarantee on out of pocket payments for contraceptives: 2014 update.
      ,
      • Becker N.V.
      • Polsky D.
      Women saw large decrease in out-of-pocket spending for contraceptives after ACA mandate removed cost sharing.
      ). It is too soon to tell, however, whether this new coverage will reduce unintended pregnancy by increasing the share of women using contraceptives or who are shifting to more effective methods such as intrauterine devices or implants.
      Carriers are permitted to apply “reasonable” medical management techniques to control costs and promote efficient delivery of preventive services when there are no specific guidelines for frequency, method, or duration. In response to reports (
      • Sobel L.
      • Salganicoff A.
      • Kurani N.
      • Wiens J.
      • Hawks K.
      • Shields L.
      Coverage of contraceptive services: A review of health insurance plans in five states.
      ,

      National Women's Law Center. (2015). State of women's coverage: Health plan violations of the Affordable Care Act. Available: www.nwlc.org/sites/default/files/pdfs/stateofcoverage2015final.pdf. Accessed October 26, 2015.

      ) about coverage gaps attributable to medical management, many disproportionately affecting women's services, the federal government has issued clarifying guidance to insurance carriers regarding coverage of contraceptive services, BRCA testing and counseling, well-woman visits, and breastfeeding services. There has been little federal or state oversight, however, to ensure insurance companies have adapted their medical management policies to comply with the guidance.
      In stark contrast with many other reproductive health services, abortion coverage stands out as one benefit that has eroded since the ACA's enactment. The law allows states to ban Marketplace plans from including abortion coverage. Twenty-five states have passed laws barring all Marketplace plans from covering abortions and seven of these states also restrict all private insurance sold in the state, with the exception of self-insured plans, from covering abortion. In some states, abortion for all pregnancies, including those resulting from rape or incest, is excluded from coverage (
      • Salganicoff A.
      • Beamesderfer A.
      • Kurani N.
      • Sobel L.
      Coverage for abortion services and the ACA.
      ,

      U.S. Government Accountability Office (GAO). (2014). Health insurance exchanges: Coverage of non-excepted abortion services by qualified health plans. Available: www.gao.gov/assets/670/665800.pdf. Accessed October 19, 2015.

      ). In states permitting abortion coverage in Marketplace plans, the ACA requires insurance carriers to follow complex procedures to ensure that funds used for abortion are segregated from other premium payments so that no federal funds, even in the form of premium subsidies, are used to pay for abortions. As some predicted before the law was signed (), these administrative barriers may have had a chilling effect on insurers' willingness to offer plans that include abortion. In fact, in seven of the states without Marketplace abortion coverage bans, no Marketplace plans included abortion coverage in 2015. As a result, in 2015 women enrolled in Marketplace plans in 32 states lacked abortion coverage in their new policies (
      • Salganicoff A.
      • Sobel L.
      Abortion coverage in marketplace plans in 2015.
      ).
      Finally, another unanticipated gap is for maternity care. Although the ACA specifically lists maternity care as 1 of the 10 essential health benefits that all small and individual policies must cover, labor and delivery costs may not be covered for young women enrolled on their parent's employer plan. Although young women insured as dependent children are required to be covered for most of their prenatal visits and screening services as a result of the preventive services requirements, employer plans (≥50 workers) are not required to cover labor and delivery costs for this group (unlike spousal dependents, who are guaranteed coverage for pregnancy-related care though the Pregnancy Discrimination Act). This gap has been cited in advocacy efforts to establish pregnancy as a life event triggering a “special enrollment period” (
      • Vera V.
      The cost of insuring pregnant women.
      ,

      U.S. Senate. (2015). Letter to Secretary Burwell, March 2, 2015. Available: www.help.senate.gov/imo/media/03022015-Honorable_Sylvia_Matthews_Burwell-Affordable_Care_Act.pdf. Accessed October 27, 2015.

      ), but still has not been resolved.

      Network Adequacy and Confidentiality

      Having financial protections and benefits is critical, but so is having a network of providers that offers access to the full range of services from primary to specialty care. Although this is important to both sexes, this is especially important to women because of their distinct health needs, particularly around reproductive health. As the ACA implementation has rolled out, there have been reports of plans narrowing provider networks in efforts to keep premium costs as low as possible (
      • Corlette S.
      • Volk J.
      • Berenson R.
      • Feder J.
      Narrow provider networks in new health plans: Balancing affordability with access to quality care.
      ). Federal and state laws require Marketplace plans to include essential community providers that serve predominantly low-income, medically underserved individuals, including Title X family planning clinics and Federally Qualified Health Centers in their networks (
      • Peña C.J.
      • Sobel L.
      • Salganicoff A.
      Federal and state standards for “essential community providers” under the ACA and implications for women's health.
      ).
      Essential community providers often provide services that are specifically developed to address the health needs of low-income individuals, including language services, patient support services, coordination of health and social services, and location in a low-income community. The 2014 Kaiser survey found that 23% of women in Marketplace plans said they could not get appointments with a provider of their choice and 20% reported they were told that the provider did not take their insurance (Figure 2). This has special relevance to some newly insured women who may have had ongoing relationships with providers, such as family planning clinics, that may not participate in their new private plans.
      Figure thumbnail gr2
      Figure 2Access to appointments among women, by insurance type, fall 2014. *p < .05 versus employer-sponsored insurance (ESI)/other private. “Uninsured” includes people who lacked coverage as of the interview date. Low income is defined as household income below 250% of the federal poverty level.
      (Source: Kaiser Family Foundation analysis of the 2014 Kaiser Survey of Low-Income Americans and the ACA.)
      Another issue related to networks affects young women on a parent's plan who live in a different area than their parents and who may have trouble finding local in-network providers. As a result, young women who obtain care from an out-of-network provider because they cannot find a nearby in-network provider will have higher out-of-pocket costs, and will likely not qualify for no-cost coverage of preventive services, such as contraception. This insurance pathway has also raised some unanticipated privacy challenges for young adults when a parent, the primary policy holder, is issued an explanation of benefits whenever the dependent adult obtains medical care paid for by an insurer. This is particularly significant for sensitive services, such as mental health and reproductive care. Although a handful of states have adopted policies developed to protect the confidentiality of adult dependents, further evaluation is needed to monitor the implementation and effectiveness of these policies (
      • Sedlander E.
      • Brindis C.
      • Bausch S.
      • Tebb K.
      Options for assuring access to confidential care for adolescents and young adults in an explanation of benefits environment.
      ). Ongoing oversight by state and federal agencies can ensure that networks are broad enough to meet the full range of reproductive health care needs of newly enrolled populations. New approaches also need to be developed by plans and agencies to assure that patient privacy is maintained.
      In conclusion, the availability of subsidies and other insurance reforms in the ACA have addressed many of the shortcomings in insurance that disproportionately affected women. There are, however, gaps in coverage and access that warrant continued oversight and monitoring including affordability, medical management practices, and adequate provider networks. These measures ensure that women have access to the broad range of health services they need and to which they are now entitled. Furthermore, there are specific issues of privacy, gaps in labor and delivery coverage, and gaps in network adequacy that disproportionately affect young women enrolled in their parent's plans, which remain to be addressed.
      Although many of the ACA's provisions specifically help to make coverage available, affordable, and meaningful for women, we still have much to learn about the effect the law has had on women's health and access to care. As research on the impact of the insurance expansions and reforms emerges, it will be important for future studies to address not only the broad questions about the ACA's role, but to also shed light on how women's access to health care has been affected, and to inform the development of new policies to address gaps in coverage and care.

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      Biography

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

      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.