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Senate Republicans' plan to repeal and replace Obamacare, called the Better Care Reconciliation Act, would make it harder for Americans to access health care, and specifically make it harder for women to access crucial health benefits — from birth control to maternity coverage. This may come as no surprise, given that the bill was written by 13 men.
The Affordable Care Act made several changes to improve women's access to health care in the US. The law expanded contraceptive access, required (at long last) private small-group insurers to cover maternity care, and broadened the number of people who could access Medicaid — which pays for half of all births in this country.
These advances mattered to public health when you think about how poorly American women fare compared with women in other rich countries when it comes to several health outcomes. (We have some of the worst maternal health and mortality outcomes in the developed world, and life expectancy for women is going down.) They also gave women some relief from worrying about the cost of accessing very basic health services.
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Doctors and reproductive health advocates are saying the GOP's Senate health care billlooks like a big step backward. On Thursday, the bill was released to the public after a secretive deliberation process, and the Senate is expected to cast a vote on it next week. Here are the four key ways this bill could undermine the health of American women.
Medicaid is incredibly important for reproductive health: The program for low-income Americans pays for half of all births, including two-thirds of unplanned births. Three-quarters of the public dollars spent on family planning are Medicaid dollars, and in 17 states, Medicaid programs also cover abortion with state dollars.
The core idea behind the Better Care Act is cutting spending on health care for the poor to finance tax cuts for the rich, as Vox's Andrew Prokop explained. In practice, this means phasing out Medicaid expansion (which made more people eligible for the program) by 2021.
But that's only the beginning. "Once the Medicaid expansion is repealed, Republicans get to work on Medicaid itself, tying the amount it can spend to an inflation index that lags behind how much health care actually costs," Vox's Ezra Klein explains. This will involve converting Medicaid to a "per capita cap" system, which means states would only allot a fixed sum of money to each enrollee, instead of covering all their medical bills. "The result is Medicaid will be able to cover fewer people and cover less of their health care in the future," Klein added.
If fewer people can access Medicaid, and Medicaid is skimpier, that means fewer people can get the women's health and reproductive services that do things like cover cancer screenings, improve access to birth control, and make sure moms and babies have health care throughout a pregnancy and in the months after a baby is born.
If you search the latest draft of the bill and its amendments for language about Planned Parenthood, you won't find it. But provisions about "prohibited entities" are basically attempts to defund Planned Parenthood.
In essence, these sections of the bill say groups that are primarily engaged in family planning services, reproductive health, and providing abortions (other than abortions that are medically necessary or responses to cases of incest or rape) — and whose Medicaid receipts exceeded $350 million in fiscal year 2014 — are barred from receiving federal dollars through several health programs, most importantly Medicaid, for one year.
One group obviously meets that description: Planned Parenthood.
If passed, the provision would mean that if a woman has Medicaid as her health insurance plan, she can't go to Planned Parenthood for her health care and get those services covered. Planned Parenthood would no longer be able to be reimbursed for these services.
Three-quarters of the public dollars spent on family planning in this country are Medicaid dollars. And right now 2.5 million people rely on Planned Parenthood for a range of health care services, like birth control and cancer screenings.
The nonpartisan Congressional Budget Office said that defunding Planned Parenthood will leave thousands of women without access to health care services — and will also result in more unintended pregnancies.
In addition to the attempt to defund Planned Parenthood, there are other ways the bill will make it more difficult for women to access health care.
Effective January 2018, the bill would ban individuals and small employers from using their tax credits to buy health plans that cover abortion (except for when a pregnancy is the result of rape or incest, or an abortion necessary to save the life of the mother).
"If your plan covers abortion services today, it may not cover abortion services as of January 2018 if this bill were to pass," health law expert Nicholas Bagley told Vox.
Before the ACA went into place, an anti-abortion faction of Congress wanted to make sure federal tax credits to help people buy private insurance on the Obamacare exchanges couldn't be used to pay for plans that provided abortions.
The result was that under Obamacare, private health insurance plans on the exchanges could pay for elective abortions — but couldn't use money from federal tax credits and subsidies to cover those costs. (Instead, insurers were required to have a separate premium for abortion coverage and pay for that coverage through a special fund.)
"With this change, all qualified health plans can't include abortions," said Laurie Sobel, associate director for women's health policy at the Kaiser Family Foundation. It also means employers cannot get tax credits if their plans include abortion coverage. "The effect is that it'll strongly discourage smaller employers from offering coverage that includes abortion," Sobel added.
There's a third way the Senate bill curtails coverage for abortion: It includes a provision banning insurance issuers from accessing funds in the State Stability and Innovation Program — a $115 billion pool of money states could use to keep insurance plans from leaving the market or to lower premiums, among other things — if they offer abortion coverage (again, outside cases of rape, incest, or when a pregnancy endangers a woman's life).
"That means insurers can only pull funds from the program if they do not include abortion coverage beyond Hyde restrictions," Sobel said, referring to the 1976 Hyde Amendment, which restricts federal money from being used to fund elective abortions.
All together, these changes will likely eliminate abortion coverage in the individual health insurance marketplace for individual health insurance nationwide, and have a chilling effect on employer sponsored coverage of abortion too, explained Adam Sonfield, senior policy manager at the Guttmacher Institute, a research and policy organization for sexual and reproductive health and rights.
So access to health care and abortion will be more limited through the defunding of Planned Parenthood (assuming health centers wind up closing), and coverage will be more limited through these restrictions on tax credits and access to funding. That's going to make getting a safe abortion very difficult for a lot of people.
In an attempt to make the insurance marketplace fairer and more viable, the Affordable Care Act required insurance plans sold on the individual market or the fully insured small-group market, and through Medicaid expansion, to cover a list of 10 "essential health benefits."The 10 included pretty basic medical care — like pregnancy and maternity care, as well as mental health and addiction treatment, and lab tests.
Republicans in Congress have consistently tried to scrap this part of the law. And with their latest proposal, they'll have another shot at the EHBs. In a push to win support from the more conservative Freedom Caucus, lawmakers are making EHB requirements optional for states.
"The Senate bill seems to allow states to opt out of Obamacare's marketplaces and essential health benefits requirement," Sarah Kliff explained.
And opting out of the EHBs will be easier than ever. The original ACA included a waiver provision, but states could only take advantage of it if they demonstrated an insurance plan would cover as many people but wouldn't cost more. The new Senate bill would allow states to get a waiver whether or not they could demonstrate they'd cover as many people, and whether or not the coverage would be as comprehensive. "Instead they could get a waiver if they show their plan wouldn't cost the federal government any more," Bagley explained.
Before the ACA, only 11 states required maternity coverage on the individual and small-group markets. And this is what we may be looking at if the GOP gets its way on health care reform. If the Better Care Act passes, it could mean we could turn back to a time before the Affordable Care Act, when some 88 percent of plans on the individual market did not provide maternity coverage.
The Senate chose to try to pass their health reform bill through "budget reconciliation," a process that allows bills to pass with only 50 votes, as Vox's Dylan Scott explained.
The reconciliation process was designed for dealing with bills related to the federal budget, and in particular budget deficit reductions. Under Senate rules (the Byrd Rule in particular), bills passed this way are supposed to be focus on the budget.
Anything in the bill designed for other purposes is suspect and may be stripped out — and the abortion coverage restrictions and defunding of Planned Parenthood are two things that may violate these Senate rules. If the bill is allowed to stand as is, though, it's going to have a major impact on women and, eventually, their children.