Gender equity and the “repeal/replace” question.

A PHS 795 student raises important questions about gender equity and intergenerational effects from potential repealing and replacing of the ACA:

In our past few lectures, we discussed the criteria for assessing health insurance policy as well as the Trump Administration’s impact on health care reform. A brief article from Kaiser Health News suggests that women may incur a disproportionate cost as a result of ACA reform (or dismantlement) because of foreseen policy changes regarding the coverage of maternity care.

 

According to the article, an estimated 13% of women who purchased health insurance on the individual market (not public insurance or employer-provided insurance) had coverage for maternity care in 2009. The ACA mandated that all plans must cover maternity care, endorsing it as an essential preventive service. With an incoming administration reevaluating what qualifies as preventive care, women who purchase health care in the post-ACA individual market may find few plans that cover maternity care.

We talked about “fairness” as a criterion for health insurance policy, and this piece raises questions on whether these potential changes in coverage are fair to women. I had one question that wasn’t addressed by this article: Is it fair to future children, and should we consider future children in evaluating health policy changes. If we recall Dr. Ehrenthal’s lecture on the life-course trajectory of health, early interventions when a child is in utero can affect birth outcomes and may impact early childhood development. When we evaluate health insurance policy changes, should we consider those affected aside from the single patient? If so, how do we evaluate “secondary” (non-patient) players in policy?

(Note: When I refer to a child in utero, I assume that the mother intends to carry the child to full term.)

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3 thoughts on “Gender equity and the “repeal/replace” question.

  1. Stigma against women’s reproductive health care needs is certainly a factor in insurance companies’ refusal to adequately cover birth control and maternal health care. The ACA mandate has improved access to this care for many women. However, we discussed in class about adverse selection and the ways that insurance companies try to attract young, healthy buyers into the risk pool. Although birth control and maternal care, especially birthing care, is expensive, young, healthy women whose only health care need is reproductive and maternal are very low cost, compared to older and sicker patients. One would think that the market would drive companies to offer good reproductive health plans, even without the ACA mandate. It is interesting to see how market factors and stigma and discrimination against women’s health factor together.

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  2. This is an extremely important conversation not just in the conversation of health care for women but about the future of medicaid. Recently, President Elect Trump has made two really important appointments that will shape policy regarding medicaid, medicaire, and the ACA. The first appointment is Republican Tom Price as head of HHS the second change is the nomination of Seema Verma as head of Centers for Medicare and Medicaid Services. The latter appointment makes a great deal of sense given that Seema has been the main consultant on Indiana’s medicaid program as was a clear choice given the Vice President’s positionality as Governor of the Hoosier state. Of particular, importance to this conversation is the draconian impact of missing an insurance payment, where folks can be denied coverage for over 1 year. It is a sad day when we create policy to deter people from being screened given all of our work in public health to get folks in the clinic and screened. So, these appointments really undue much of the gains we have made in public health. We need to be cautious that we do not follow Indiana’s model as this is not the direction we need to follow. I am in the belief that if you cannot pay your premiums that you should not be banned from seeking health services….this is at complete odds of a system that has been trying to be preventative in nature.

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  3. This is another really strong example of how influential politics is to our health system. If we were examining cost alone, birth control would be a no-brainer for health insurance companies. There’s a statistic that is often floated: for every dollar spent on contraceptives/family planning, $7.09 is saved by the state in future medicaid costs (See article by the Guttmacher Institute) But maternity care is also extremely cost-effective if you compare the cost of an uncomplicated birth to a complicated one (and while pre-natal care cannot eliminate all complications, in does improve the likelihood of an uncomplicated birth). So it seems that these are not questions about fairness or even about overall cost-effectiveness because using both of those criteria, contraceptives and maternity care would be automatic benefits, regardless of health insurance.

    Another treat to women’s health under the new administration is in the changes to publicly funded programs. Our safety net has traditionally taken care of young women seeking to avoid pregnancy and pregnant women when the private market has failed to do so. In 1989, the Federal government imposed an eligibility floor for pregnant women at 133% but most states have much higher eligibility (See Kaiser Family Foundation link). Also, Medicaid programs often fund Family Planning Only Waivers that cover the extend medicaid eligibility for those who are uninsured/underinsured to cover the cost of contraceptives and sexual health screenings (Currently 27 states have such a program, and many had them before the ACA) These programs could very well change if Medicaid was administered by block grants. Since many of the decisions are made at the state level, it will be interesting to see if states change their existing programs or leave them intact.

    Here are links to the articles I mentioned, if interested:
    Guttmacher:
    https://www.guttmacher.org/fact-sheet/publicly-funded-family-planning-services-united-states.

    Pregnancy Eligibility in the US (KFF) :
    http://kff.org/health-reform/state-indicator/medicaid-and-chip-income-eligibility-limits-for-pregnant-women-as-a-percent-of-the-federal-poverty-level/?activeTab=map&currentTimeframe=0&selectedDistributions=medicaid-title-xix

    Family Planning Waivers:
    http://kff.org/medicaid/state-indicator/family-planning-services-waivers/?currentTimeframe=0

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