Senate Republicans released a new version of their health care bill that would have serious ramifications for women’s health care: It would allow health insurers to offer plans that don’t cover maternity care, no longer require health plans to cover birth control and other preventive services, and make it much more difficult to buy plans on the individual health insurance market that cover abortion.
Among Obamacare’s sweeping changes to the US health care industry were a few with big implications for women’s health. For the first time, insurers were required to cover maternity care, preventive care, and birth control. And they couldn’t charge people more for preexisting conditions, including things like having had a C-section, having irregular periods, or literally just being pregnant.
“They were basically enacted to address longstanding discriminations against women,” said Alina Salganicoff, director of women’s health policy at the Kaiser Family Foundation.
The latest Senate plan would relax those requirements. The newest version of the Better Care Reconciliation Act would allow insurers to sell plans on the individual market that don’t comply with the Affordable Care Act requirements as long as they sold at least one plan compliant with ACA rules.
Noncompliant plans don’t have to cover the 10 essential health benefits, including maternity coverage. Nor would they have to cover preventive services, including mammograms, birth control, or well-woman checkups. Those noncompliant plans could also charge people more based on preexisting conditions.
The likely result, experts told Vox’s Sarah Kliff, is that sicker people would stick to the comprehensive, compliant plans. But if more young, healthy people chose cheaper plans, the compliant ones would have fewer customers and become more and more expensive.
But young and healthy women would face a risky choice — between an expensive plan that covers everything and a cheaper but skimpy plan that could, in the long run, end up costing them much more.
Pregnancy could be expensive. Unplanned pregnancy could be catastrophically expensive.
Nearly 6.6 million women bought health insurance through Obamacare’s marketplaces in 2017, according to the Kaiser Family Foundation. The Senate bill is supposed to give them more options, including cheaper, bare-bones plans. Those plans are usually described as being meant for younger, healthier people who don’t have complicated or expensive health issues.
But many younger, healthier women can encounter a very common and expensive health condition: They can get pregnant. Skimpier plans are risky for young women who are trying not to get pregnant as well as for women who want to have children, Salganicoff said.
“If you buy one of those plans that doesn’t include maternity care and you become pregnant, you are essentially uninsured for your pregnancy-related expenses,” she said. “Clearly, these plans are targeted toward healthy, younger people to lower their costs, [but] these are the same women that are at risk for pregnancies.”
Skimpier plans would also be allowed to charge customers for preexisting conditions. In the past, the list of conditions that can make insurance more expensive has included previous C-sections, menstrual irregularities, and urinary tract infections, all common among women.
If a woman is on one of the noncompliant plans and becomes pregnant, Salganicoff said, she should expect to spend a lot of her own money. The cost of giving birth in the US can vary dramatically, but one study in California in 2014 found an uncomplicated birth could cost from around $3,000 to $37,000, and a C-section could cost up to $71,000.
“They will have insurance, but they could be potentially uninsured for all their maternity care and all of their preventive care, including contraceptive coverage,” she said. Salganicoff said it’s paramount that women read the fine print and understand the trade-offs before they purchase a cheap insurance plan.
Once a woman chooses a plan, that’s it — she can’t switch to a better one if she becomes pregnant until the next insurance enrollment period.
“The fact that you get pregnant in July does not allow you to switch to a plan with pregnancy care,” said Adam Sonfield, senior policy manager at the Guttmacher Institute, a research and policy organization for sexual and reproductive health and rights. “That assumes you could find a plan that would cover maternity care anyway.”
Theoretically, women who suspect they could get pregnant in the next few years could enroll in the more expensive, Obamacare-compliant plan for a year or two to be safe, but 45 percent of US pregnancies are unplanned.
The costs for women who are actively trying to not get pregnant would also jump dramatically. Birth control pills can cost up to $600 a year. The cost to get an IUD can range anywhere from $187 to $736, depending on where you live.
In 2012, nearly 21 percent of women paid out of pocket for their birth control pills and other contraceptives. Two years later, that had dropped to just 3.6 percent.
Making abortions more difficult to access
People buying insurance on the individual market couldn’t use federal subsidies, tax credits that help people afford insurance, to pay for the skimpier, noncompliant plans. They could only use them to pay for plans that follow Obamacare’s rules, which experts say are likely to become more expensive.
But women who buy those plans could run into roadblocks in another common medical scenario: getting an abortion.
Federal dollars can’t be used to fund abortions, so women who get their health insurance through Medicaid already didn’t have abortion coverage, unless it was a case of rape or incest, or their life was endangered by the pregnancy. The Affordable Care Act allowed private health insurance plans on the exchanges to cover abortions, but they couldn’t use federal money to do so.
The Senate plan would take those restrictions further. Consumers and small businesses would be banned from using government subsidies to buy a plan that covers abortion (again, except in extreme cases).
“With this change, all qualified health plans can’t include abortions,” Laurie Sobel, associate director for women’s health policy at the Kaiser Family Foundation, told Vox’s Julia Belluz last month.
The latest version would also ban people who are using flexible health savings accounts, including accounts provided by an employer, from buying high-deductible insurance plans that cover abortions.
The proposed rules on tax credits are “enough that it seems unlikely you’ll see any plans covering abortion,” Sonfield said.
“They’re trying to put restrictions everywhere they can,” he said. “The goal is to eliminate abortion coverage. To them, it doesn’t look like health care, but obviously, to the women who rely on it, it is.”