One of the big questions on Americans’ minds about the Republican Obamacare replacement plan is: What happens to the Affordable Care Act’s birth control benefit?
Under Obamacare, women who have private insurance haven’t had to pay anything extra, beyond their insurance premiums, to get the birth control method of their choice — from hormonal pills to highly effective (and expensive) long-term methods like IUDs. Women also haven’t had to pay extra for other preventive health services, including Pap smears, STI screening, and prenatal care.
The short answer is that the American Health Care Act (AHCA), the GOP’s new plan, doesn’t touch the birth control benefit.
It also keeps intact other Obamacare requirements that made that health care law such a game-changer for women’s health: covering women’s preventive health services with no cost-sharing, covering maternity care as an essential health benefit, and making sure women can’t get charged more for insurance just because they’re women.
But there are some big caveats here. For one thing, the AHCA goes after women’s health care in other ways — notably by defunding Planned Parenthood, cutting Medicaid benefits, and dramatically restricting private insurance coverage for abortion.
And while it’s true that the AHCA doesn’t scrap many of Obamacare’s major women’s health policies, that doesn’t mean those policies — especially on birth control — are guaranteed to remain in place under Trump.
The GOP replacement plan doesn’t touch major women’s health mandates
Before Obamacare, women were routinely charged more than men for insurance premiums, and coverage of basic women’s health needs like birth control and maternity care was inconsistent.
Under Obamacare, however, private insurance plans and the Medicaid expansion have to cover key preventive services for women — like birth control, STI and HIV screenings, well-woman visits, prenatal care, breastfeeding support and supplies, and screening for domestic violence. For women with insurance, those services are free — insurers can’t charge cost-sharing or copays. (Women on Medicaid already had access to free contraception, but not necessarily all 18 FDA-approved methods.)
The Republican replacement plan wouldn’t do anything to this list of key preventive services, Adam Sonfield, senior policy manager at the reproductive health research organization the Guttmacher Institute, said.
“This bill does all sorts of absolutely awful things for health care generally, and for reproductive health care specifically — but this isn’t one of them,” Sonfield said. “This bill doesn't touch the birth control benefit for private insurance.”
That doesn’t necessarily mean Republicans wanted to keep these Obamacare benefits intact. Many fiscal conservatives consider the no-cost preventive services to be a burdensome regulation, and many social conservatives have religious or moral objections to birth control.
But Republicans were constrained by the budget reconciliation process they plan to use to pass the bill. Reconciliation requires just 51 votes instead of 60, but it’s also limited to policies that directly impact the federal budget.
Maternity care and pediatric care, meanwhile, are on the list of 10 “essential health benefits” that all individual and small group plans have to include. Women could be charged copays for those services, but insurance at least needs to cover them.
The AHCA keeps intact that list of 10 essential health benefits, unlike an earlier leaked draft of the replacement plan. But it does get rid of a requirement applying those 10 essential benefits to Medicaid expansion. That means some lower-income Americans would get fewer coverage guarantees.
The bill also gets rid of Obamacare’s cost-sharing limits — the bronze, silver, gold, and platinum plans that dictate how much customers can expect to pay out of pocket. That, Sonfield said, could mean that some plans will “technically” cover maternity care — but that the costs women have to pay out of pocket “might go through the roof.”
But the Trump administration can easily undo these mandates on its own, without Congress
Congress may not be able to touch Obamacare’s list of key preventive services, including birth control, with this particular bill. But Trump doesn’t need Congress to change those requirements. His administration can do it through regulations.
The regulatory process is how birth control became a part of Obamacare in the first place. When Congress passed the bill, there was one problem with the law’s mandate to cover preventive women’s health care: Nobody had an official, comprehensive list of what counted as key preventive services for women. So panels of experts on women’s health weighed in with their recommendations, and then the health department had to endorse those recommendations and turn them into official regulations.
Now, however, the health department is run by Secretary of Health and Human Services Tom Price — who is very much not a fan of the birth control benefit. And it wouldn’t be too difficult for the new health department to simply endorse a different set of women’s health recommendations, multiple health policy experts told Vox. That could involve going through the formal process of writing new regulations, or it could even be something more informal.
It’s just not clear yet what the administration will do, and which women’s health benefits it might target. The birth control benefit was one of the most highly politicized parts of Obamacare, so it may be the most at risk.
But the requirement is very popular among Americans:
Because it’s so popular, however, the Trump administration might not try to reverse it directly. Instead, Sonfield said, they could decide to let an extremely broad executive order on religious freedom do a lot of the work for them.
A draft of such an order was leaked in February. Among other things, it would have allowed any employer to be completely exempt from the birth control benefit for any religious or moral reason. Under this incredibly broad standard, a lot of employees wouldn’t be able to access the contraceptive benefits they are entitled to under the law through their company insurance.
Poor women will have a much harder time getting basic women’s health care under this plan
The Republican plan could also reduce women’s ability to get birth control in another, less obvious way. Only about 60 percent of American women under 64 get health care coverage through their employer, or through their parents’ employers. The rest get insurance on the private market, through Medicaid, Medicare, or the military, or aren’t insured at all.
The Republican health care plan will probably make a lot of poor women lose their Medicaid coverage, which means losing their birth control coverage. Nearly one in five women under 64 get their coverage through Medicaid, and one early estimate found that 4 to 6 million Medicaid enrollees will lose their insurance under the Republican plan.
Medicaid is “absolutely essential to reproductive health in this country,” Sonfield said. About two-thirds of unplanned births in the US are paid for by public insurance programs, and Medicaid accounts for most of that spending. Most women who need publicly subsidized birth control also get it through Medicaid.
The AHCA could cut the Medicaid program dramatically. It not only stops Medicaid expansion in 2020; over time, it would shift $370 billion in Medicaid spending from the federal government to the states. And a lot of states will probably have to cut costs by kicking people off the Medicaid rolls, reducing services, or paying providers less.
On top of that, the Republican health care bill defunds Planned Parenthood — which is a major provider of family planning services, including birth control, under Medicaid.
So the most direct threat from the Republican plan is to poor women. The plan would dramatically change what kind of care women on Medicaid could expect to get at low cost. But it also affects women of all income levels who rely on Planned Parenthood for birth control and check-ups, or women with private insurance who need an abortion. The birth control mandate, meanwhile, is safe from Congress — but the Trump administration could adjust it through regulation at any time.