Dramatic changes could be on the horizon for women’s health care should the controversial American Health Care Act of 2017 (AHCA) become law.
In May, the House of Representatives passed the AHCA, a bill that would replace many elements of the Affordable Care Act (ACA). The legislation is now being considered by the Senate, where it’s future is uncertain.
From contraceptive coverage to maternity care to abortion services, women have much at stake under the bill, said Kandice A. Kapinos, PhD, an economist who specializes in maternal health care at the nonpartisan RAND Corporation.
Dr. Kandice Kapinos
Here’s a look at the primary provisions of the AHCA and how they may impact women’s health.
1. Tax credits change
Under the ACA, individuals receive tax credits based on income, which means higher subsidies for patients who are lower income, older, and who live in areas with more expensive coverage. The AHCA would calculate tax credit assistance based primarily on age, and the bill would repeal the ACA’s cost-sharing protections for low-income individuals.
“How these credits are calculated [under the AHCA] will really affect lower-income women,” Dr. Kapinos said. “They will pay more under these calculations because their credits will be lowered. The other women who will be negatively affected by those changes will be women in rural or high-cost areas where care is on average more expensive.”
2. Essential health benefits waiver
The ACA required that marketplace plans and Medicaid expansion plans cover 10 benefit categories, including maternity care, preventive services, mental health, and hospitalizations and emergency care. Under the AHCA, states could apply for a waiver to define their own essential health benefits starting in 2020, leaving states free to exclude certain benefits such as maternity care or pregnancy-related services.
In addition, the AHCA would rescind the essential health benefit requirement for Medicaid expansion programs, meaning that patients in expansion plans would not be entitled to coverage for all 10 categories.
3. Medicaid changes
To reduce federal spending, the AHCA would shift the Medicaid program from an open-ended matching system to an annual fixed amount of federal funds. To this end, states would get to choose between a per capita cap funding approach or a block grant structure. Under a block grant, states would receive a fixed amount of funding for Medicaid that would increase by a specified amount each year. Under a per capita cap, federal funding would be capped based on the number of beneficiaries, or separate caps could be applied per Medicaid coverage groups such as children, adults, seniors, and disabled individuals.
Both capped approaches would limit a state’s ability to respond to rising costs, new and costly treatments, or public health emergencies such as Zika, according to a summary of the AHCA by the Kaiser Family Foundation. Women could get the short end of the stick if states decide to limit the number of women enrollees or if they limit certain benefits, Dr. Kapinos said. For instance, states could decide to cover only lower-cost contraception services, such as birth control pills, rather than more expensive methods such as an IUD, she said. A per capita cap approach would still require states to cover family planning services, but there would no longer be an enhanced federal matching rate for family planning services provided to most beneficiaries, the Kaiser summary notes. Under the block grant option, family planning services would no longer be a mandatory benefit for nondisabled women on Medicaid.
4. Preexisting conditions
The AHCA would retain the current ban on coverage denials for preexisting conditions. However, the bill would charge patients a penalty if they did not maintain continuous insurance coverage and then tried to regain insurance. These patients could pay higher premiums for 1 year or states could obtain a waiver that allows insurers to consider an individual’s health status for 1 year, enabling them to charge higher rates for prior health conditions.
“They could charge you more if you’re pregnant and you haven’t had insurance for more than 2 months,” Ms. Kapinos said. “They could only charge you a higher amount for 1 year and they can’t deny you coverage, but effectively what happens, the woman who’s pregnant would be sent to a higher-risk pool and be charged higher premiums. That could be a big deal for women, especially lower-income women.”
5. Planned Parenthood gets defunded
Although federal law already bans federal funds from paying for most abortions, the AHCA would stop Planned Parenthood from receiving federal Medicaid funding for 1 year. The AHCA would provide additional funds to other community health centers, but the bill does not require the health centers to use the money to provide women’s health services.
An AHCA analysis by the Congressional Budget Office found that withholding Medicaid payments to Planned Parenthood for 1 year would reduce access to care for women in some low-income communities and would result in thousands of unintended pregnancies that would ultimately be financed by Medicaid.
“That means a woman who’s covered by Medicaid and would go to Planned Parenthood to say, get a Pap smear, couldn’t go there and do that because they’re not going to let Medicaid reimburse Planned Parenthood,” Ms. Kapinos said. “That has real implications for access in areas where there aren’t a lot choices to get this kind of preventive care.”
On Twitter @legal_med