As conservatives in Congress and the Trump administration plow forward on efforts to repeal and replace much of the Affordable Care Act (ACA), one pattern that has become clear is that their efforts would directly and indirectly imperil coverage for and access to reproductive healthcare under Medicaid and private insurance. The opening bid on those efforts — the American Health Care Act, which passed the House of Representatives on May 4 — is frightening in its potential impact.1
The most prominent effect of the House-passed bill would be to eliminate health insurance coverage for millions of U.S. residents, 14 million by 2018 and 24 million by 2026, according to an analysis of an earlier draft of the bill by the Congressional Budget Office (CBO).2 That would mean the loss of coverage for family planning services and supplies, maternity care, sexually transmitted infection testing and treatment, cervical cancer screening, and numerous other important services.
Medicaid Takes Largest Hit
Medicaid would bear the brunt of these losses. The legislation effectively would phase out the ACA’s Medicaid expansion for low-income adults with incomes up to 138% of the federal poverty level by scaling back federal reimbursement to states. More broadly, the legislation would overhaul Medicaid financing by imposing a so-called per capita cap: a maximum amount the federal government would reimburse states per enrollee, designed so that federal spending would be progressively lower, compared to expected growth in Medicaid’s costs. Instead, states could choose to receive a so-called block grant, which would scale back federal spending even more sharply while allowing states to ignore a host of federal Medicaid protections, including many related to family planning and maternity care. Combined, these changes would reduce federal investment in Medicaid by $839 billion over the first decade and far more over time, according to the CBO analysis.2 That would force states to scale back eligibility, benefits, and payments to providers unless states were somehow able to make up the difference.
Private insurance also would be hit hard. The House legislation would restructure current tax credits that make ACA marketplace coverage affordable for low-income residents. The revised credits could be used to buy coverage anywhere in the individual insurance market and would be available to more people than under the ACA. However, unlike today, they would not properly adjust for income or local costs, and they would be less generous than they are today for most recipients, particularly low-income, rural, and older Americans. Millions would lose coverage.
At the demand of House conservatives, the bill also would allow states to opt out of several key ACA protections for private insurance. That includes the essential health benefit package, which requires individual market plans to cover 10 core categories of care. Coverage for maternity care is on that list and has been a frequent target of criticism by conservatives. Prior to the ACA, the vast majority of individual market insurance plans excluded maternity coverage, or covered it only at an additional high premium and with strict limitations.3 States also would be allowed to ease ACA prohibitions on charging higher premiums based on health status. These two provisions combined would undermine the ACA’s popular protections for people with pre-existing conditions.
What About Reproductive Health?
On reproductive health specifically, the bill includes a provision to exclude Planned Parenthood affiliates from receiving reimbursement for care provided to Medicaid enrollees (for a one-year period, although conservatives surely would look to extend that ban later). Moreover, it includes multiple provisions that would undermine private insurance coverage of abortion.
Most notably, it would prevent the use of federal tax credits to purchase any plan that covers abortion (except in a few extreme circumstances); because almost everyone buying individual market insurance would be eligible for several thousand dollars in tax credits, this effectively would eliminate abortion coverage in that market.
The bill does not directly affect the ACA’s contraceptive coverage guarantee or its broader requirement for plans to cover a wide range of preventive services without patient out-of-pocket costs. Repealing these provisions likely would violate the arcane rules around “budget reconciliation,” a special procedure that allows for bills to pass the Senate with a simple majority, rather than the 60 votes needed to overcome potential filibusters. Under those rules, all provisions in the bill must have a direct impact on the federal budget or risk removal.
However, on the same day the House passed its bill, President Trump used an executive order on “religious liberty” to signal his administration’s intent to undermine the contraceptive coverage guarantee through new regulations.4 At publication of this column, it is not yet clear when that regulatory action will happen or what form it will take.
Watch Legislation Closely
The House bill’s prospects in the Senate are unclear. Numerous senators, governors, and outside groups across the political spectrum have criticized the legislation. Even within the 52 members of the Senate Republican caucus, there are stark disagreements between moderates and conservatives, and between senators representing states with and without Medicaid expansions.
If the Senate manages to craft and approve its own version of a repeal-and-replace bill, it is far from certain that the House will be able to muster the votes to approve whatever changes the Senate makes.
REFERENCES
- 115th Congress. H.R. 1628 - American Health Care Act of 2017. Available at: http://bit.ly/2pD7Tzr. Accessed May 18, 2017.
- Congressional Budget Office. H.R. 1628, the American Health Care Act, incorporating manager’s amendments 4, 5, 24, and 25. Available at: http://bit.ly/2mVZpz3. Accessed May 18, 2017.
- National Women’s Law Center (NWLC). Nowhere to Turn: How the Individual Health Insurance Market Fails Women. Washington, DC, 2008.
- The White House, Office of the Press Secretary. Presidential Executive Order Promoting Free Speech and Religious Liberty. Available at: http://bit.ly/2pDOoXq. Accessed May 18, 2017.
GOP efforts to repeal and replace the Affordable Care Act could directly and indirectly imperil coverage for and access to reproductive healthcare under Medicaid and private insurance.
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