Repeal. Replace. Repair.

Whatever shape the next iteration of policy change takes in health, it will affect every American.  Health is an everyday experience, and the trials of accessing health care services and the importance of health insurance coverage touches every American life.

Another reality of health care in America is that it is experienced differently by women and men.  Sex differences in health care utilization are well documented. These differences are driven by a range of factors that may also influence how health care policies applied broadly affect men and women differently.

It’s increasingly apparent that impending changes to health care policy are certain to occur in some form, specifically altering the financing and organization of health care delivery shaped by the Affordable Care Act (ACA), also known as Obamacare.  Media reports describe how Obamacare repeal may affect everyone.  Yet the form these policy changes take matters greatly – and differently – for women and men across the country, and also – of course – for children and families. Below I outline briefly how repealing and/or replacing the ACA may affect women, especially reproductive-age women, in ways that are distinct and relevant.

Repeal

Full repeal of the ACA would have an impact on health insurance coverage, access to preventive care, and access to essential health care services, including maternity care.

Insurance coverage

In 2012, my School of Public Health colleagues Jean Abraham, Beth Virnig and I published a study showing that 25% of all reproductive-age women were uninsured at some point in 2009, the year before the ACA was signed into law. Implementation of the ACA provided additional health insurance options for women at or below 400% of the federal poverty level, by offering expanded access to coverage through state Medicaid programs, health insurance exchanges, and federal subsidies for purchasing coverage.  These new coverage options would be eliminated with repeal.  Women of color would be disproportionately affected by the loss of coverage options.

ACA repeal would also undo regulations that require health plans to charge the same premiums to men and women (women were previously charged much higher prices for coverage than men), to offer coverage to individuals with pre-existing health conditions (which may include things like a prior cesarean delivery), and eliminates lifetime limits on coverage and annual amounts that plans spend. All of this could add up to more expenses for women, under ACA repeal.

Preventive services and essential health benefits

Among those who were already insured before Obamacare passed, the law changed how health insurance worked for reproductive-age women by expanding access to preventive care without cost sharing. Starting in August 2012, all health plans covered the following preventive services for women without cost sharing:  annual well-woman visits; screening for gestational diabetes; human papillomavirus testing; screening and counseling for sexually-transmitted infections including HIV; contraceptive methods; breastfeeding support, supplies and counseling; and screening and counseling for interpersonal and domestic violence. Repeal of Obamacare may mean a return to out-of-pocket costs for these services. Professor June Carbone’s recent post to the Gender Policy Report analyzes the implications of the such changes in coverage for American fertility, especially among poorer women and Latinas.

Obamacare also requires that qualified health plans include certain services (such as maternity care) as essential health benefits, and repeal would remove the requirement that plans include the following ten benefit categories: (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. This may spur a return to the pre-Obamacare days, when only 12% of individual health plans included maternity care, and such plans were substantially more costly.

Replace

The form that an Obamacare replacement may take is yet unknown.  Much of the effects of a replacement plan would depend on changes to the elements of the ACA described above in the section on “repeal.”  Changes may be made to modify currently-existing benefits or to make large-scale changes.

Replacement plans may make tweaks to ACA provisions, or revamp major aspects of the healthcare delivery system. For example, the ACA includes a number of provisions with specifically address care related to pregnancy and childbirth. State Medicaid programs finance nearly half of all births in the U.S., and the ACA includes additions to Medicaid such as coverage for prenatal smoking cessation support and for childbirth in licensed, freestanding birth centers.  Some of these may be retained in a replacement plan, but the broader question around replacement of Obamacare is whether there may be fundamental changes to the Medicaid program, such as block grants.

There are some lesser-known aspects of the ACA that have profound effects on reproductive-age women.  Obamacare includes grants to states to support home-visiting programs for pregnant women and new mothers, and also to provide services to women who develop postpartum depression. The ACA also established new workplace protections for breastfeeding mothers, requiring employers with 50 or more employees to provide their workers with a private place to express breastmilk and ample break time to do so.  It is quite unclear whether such provisions would be revised, updated, or even remembered when a replacement plan is drafted.

Others have highlighted key aspects of potential replacement plans, based on Republican ideas and proposals, but most do not account for the particular aspects of the law that disproportionately or solely affect women.

Repair

While it is an unlikely strategy, from a political perspective, there is a possibility that full-scale repeal and replacement of the ACA may not occur. Indeed, some GOP leaders have alluded to the possibility of “repair” of the ACA, with a focus on some of the persistent challenges that health care policymakers (and American families) have faced, from decades past to the present, including high out-of-pocket costs, variable quality of care, and limited access to health insurance and to health care services.

Many factors are at play in determining the path ahead, but whether the fate of the ACA is repeal, replace, or repair, the next steps in federal health policy reform will likely have enormous consequences for women.