PRE ACA: HEALTH INSURANCE

Employer35%

As Dependent on Employer

policy23%Personal

7%

Medicaid12%

Other Pub-lic4%

Uninsured19%

Women 2012

Employer58%

Personal7%

Medicaid10%

Other Public

5%

Uninsured20%

Men 2012

S T E V E M I L E S , M DM I L E S 0 0 1 @ U M N . E D U

THE AFFORDABLE CARE ACT AND WOMEN’S HEALTH INSURANCE

The speaker has no commercial interests or conflicts of interest bearing on this talk.

SEX ≠ GENDERSex

Biological state of being female, male or transgender and biological attributes (e.g., risk of breast cancer, pregnancy, etc).

Gender

Cultural norms allocating shape aspirations, opportunities and power differently by sex (e.g., gender disparities in salary, job opportunities, child rearing costs etc.).

The disadvantages that women experience in obtaining health care are largely due to gender-norms in the broader society.

Health care reform can partly offset the effects of gender-based disadvantages as these affect women’s access to affordable health care. Health care reform has little effect on gendered roles and opportunities that set the stage for disparities in health care access.

Commonwealth Fund.: Analysis of Current Population Surveys by N. Tilipman and B. Sampat.

PRE-ACA: UN-INSURED WOMEN AGE 19 - 64

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

2

4

6

8

10

12

14

16

18

20

Millions Not Insured

18

Underinsured : Insured all year but experienced one of the following: a) medical expenses >10% of income; or medical expenses 5% or more of income if low-income (<200% of poverty); or per-person deductible equaled 5% or more of income. Commonwealth Fund Biennial Health Insurance Surveys (2003, 2007, and 2010).

PRE-ACA: % OF WOMEN 19–64 UNDER-INSURED

2003 2007 20100

5

10

15

20

25

30

35

40

45

Under 200% FPL Over 200% FPL

Woman and child: $28,000

POVERTY AND WOMEN’S PREVENTIVE CARE

<133% FPL 133-250 250-400 >400% FPL0

2

4

6

8

10

0

20

40

60

80

100

Millions Pap % M'gram

FPL=$19,530 for family of 3.

Commonwealth Fund Biennial Health Insurance Survey (2010) and Women and the Affordable Care Act 2010.

<$23000

of uninsured women

PRE-ACA: UNINSURED WOMEN WENT WITHOUT MAMMOGRAMS, PAP TESTS AND MEDICATIONS

Mammography in past 2 yrs 40-64

Pap within past 3 yrs 18-64

Didn't fill prescription

0102030405060708090

Uninsured Insured

National Center for Health Statistics, Health Interview Survey 2012. Commonwealth Fund Biennial Health Insurance Survey 2012. Chart design from Kaiser Family Foundation.

%

PRE-ACA: GROWING NUMBERS OF WOMEN 19-64 Y.O. HAD PROBLEMS PAYING MEDICAL BILLS.

Note: FPL=Federal Poverty Level. * Had problems paying medical bills, contacted by a collection agency for unpaid bills, had to change way of life in order to pay medical bills, or has outstanding medical debt. Commonwealth Fund Biennial Health Insurance Surveys (2005 and 2010).

%*

Below FPL 100-199% FPL >200% FPL0

10

20

30

40

50

60

70

2005 2010

WOMEN MORE LIKELY THAN MEN TO HEAD SINGLE PARENT HOUSEHOLDS

24.61

.9

10

2

Households (mil-lions)

Married couples w kids

Unmar-ried coup w kids

Mother only

Father only

PRE-ACA: ERODING OLDER DEPENDENTS’ COVERAGE

1997 2002 2005 20100

5

10

15

20

25

30 Dependent (15 years and Older) Cov-erage

US Census Bureau. Survey of Income and Program Participation

First year ACA required job policies to cover 3 million minors and young people under 26.

MEDICAL DEBT

• Women more vulnerable to medical bankruptcy:• Lower earnings.

• Less elastic budgets.

• Higher child care burdens.

• 30% more likely to take high interest consumer loans, e.g., use credit cards to pay for health care.

PRE-ACA: INSURANCE SEX DISCRIMINATION

• 95% of top 10 plans in all states practiced gender rating.

• 25 y.o. women pay up to 84% more for insurance than men.

• 13% of plans for 30 y.o. women provided maternity coverage.

• 60% of plans charge a woman non-smoker more than a man smoker.

• Pre-existing gender conditions included having had a C-section, been a victim of sexual assault or domestic violence.

Data from 2009, National Women’s Law Center. “Still Nowhere to Turn.”

US HEALTH CARE: HIGH COSTS AND LOW LIFE EXPECTANCY

Jap

Sp It

Fin

UK

Ast

lia

Sw

e

Fra

Ger

Aus

t

Can

Net

h

Sw

z

Nor

US

A

$0

$2,000

$4,000

$6,000

$8,000

$10,000

75

80

85

90

$/person F Life Exp M Life exp

OECD 2014

Jap

Sp It

Fin

UK

Ast

lia

Sw

e

Fra

Ger

Aus

t

Can

Net

h

Sw

z

Nor

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$0

$2,000

$4,000

$6,000

$8,000

$10,000

0123456789

$/person Inf Mort

OECD 2014

$/PERSON-YR & INFANT MORTALITY /1000

SUMMARY: WOMEN’S HEALTH ACCESS PRE-ACA

• Women’s access to affordable health care falling due to: • Lower wages

• Lack of health insurance in her own name

• Disproportionate responsibility for raising minors• (Dependents losing coverage in employer-based policies.)

• Women with financial barriers to healthcare more likely to:• Forgo essential health services.

• Use high interest credit cards.

• Have higher health care debt, be chased by debt collectors and lose credit ratings.

• Women’s and perinatal outcomes were poor.

WHAT IS THE ACA?

WHAT IS THE ACA?

• Guaranteed Issue & no pre-existing conditions

denial .• No cancel on claim.• Limited copays on essential prevention,

etc.

Four Standardized PRIVATE Insurance

Policies sold by feds or states on sliding scale.

Federal incentives to encourage states to expand Medicaid health insurance. (Some states require

extreme poverty to get Medicaid.)

Aren’t I scary?

ACA LAW REFERENCES TO MEN AND WOMEN

Woman / Women -158

• Women’s Health Initiative Tobacco cessation for pregnant women on Medicaid.

• Abortion

• Pregnancy

• Domestic Violence

Man / Men - 1

• A passing mention in the Women’s Health Initiative.

SEXUALIZING THE BODY POLITIC

• Abortion (40 mentions)• Funds research to assess the already researched issue

of abortion/miscarriage mental health outcomes

• Assures that the ACA will not pre-empt state abortion laws.

• Protects conscientious objection.

• These provisions did not recruit any Republican votes but may have brought in some anti-abortion Democrat votes.

HUH? 15-44 Y.O. BREAST CANCER OUTREACH

7% of breast cancers occur in women under 40.

20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+0

50

100

150

200

250

300

350

Breast Cancer Prevalence/100,000 by ageMam’gram Screening Rate 2010

ACA(Breast CA Outreach)

Medicare

PSA images for breast cancer screening

ACA bars Mammogram co-pays

-----73%-----

-63%-

--71%--

SUMMARY: ACA FOR WOMEN

• Eliminated insurance sex discrimination.

• Bars copays on preventive services and prenatal care.

• Forced insurers to cover dependents’ up to age 26.

• Created subsidized group markets for insurance.

• Expanded Medicaid but allowed each state to opt-out.

The ACA was not designed to address the structural disadvantages of women (wage gap, family leave, elder parents caregiving, and disproportionate share of the costs of child raising).

SPIN

REPLACING BAD POLICIES WITH GOOD ONES IS NOT CANCELLATIONS

Guaranteed Issue

No cancel on claim

No restrictions on preexisting conditions

• Blue Cross had transferred her to a new plan that saved her $1,200 / year, capped her out-of- pocket drug costs far below her old policy. She kept her doctor and cancer facility.

• When advised of this, she said that “can’t be true.” “I personally do not believe that.”

• Ad funded by Koch Brothers. She is married to GOP party official and politically active.

“My insurance was cancelled because of ObamaCare.”

“I feel lied to.”“Now, the out-of-pocket costs are

so high, it’s unaffordable. If I do not receive my medication, I will die.”

REP. MICHAEL MCCAUL (R-TX)[NET WORTH: $300 MILLION]

“Mr. Speaker, I lost my health plan. I have five kids. My premiums have gone up significantly, and I don’t know if I can keep all the same doctors that I had to treat my kids.” Dec 5, 2013

TEXAS LEFT THE MOST PERSONS UNINSURED BY NOT EXPANDING MEDICAID: 1.05 MILLION.

DEATH PANELS?

• 112 million adults and 17 million kids cannot be denied coverage for preexisting conditions.

• 60 million have expanded mental health & substance abuse coverage.

• 8 million seniors have improved drug coverage because of Medicare reform.

• 105 million Americans have lifetime limit on health care costs removed.

THE ACA IS A BUDGET BUSTER

ACA AND PARTISANSHIP

The ACA passed:• The Senate passed on a party line vote.

• The House passed (all Republicans and 34/256 Democrats voted Nay.)

Republicans forced 54 unfruitful votes to repeal ACA.

ACA OUTCOMES

PERCENTAGE OF PERSONS WITHOUT INSURANCE DECREASING

Women equally participated in this decline!

UNINSURED RATES BY GENDER BEFORE/AFTER ACA (2014)

Women Men0

2

4

6

8

10

12

14

16

18

20

15.3

17.7

9.8

13

Before ACAAfterACA

Note: Women’s uninsurance rates were lower than men’s pre-ACA because of Medicaid.

http://www.enrollamerica.org/about-us/our-mission/

% 5.5%

4.7%

INSURANCE PRICE DISCRIMINATION AGAINST WOMEN ENDED

PERSONAL SAVINGS ON CONTRACEPTION

Pre-ACA, women spent 44% of annual health $ on birth control. Now, women spend 22%.

• Birth control pill users save $255 / year.

• IUD users save $248.• Implant spending

down 72% from $239 to $91.

• Morning after pill down 90+% to $1.75.

$ Pill

$ IUD

Out of pocket spending

1/08 1/111/101/09 1/12 1/13

Health Aff 2015;34:1204-11

PLUS ÇA CHANGE …

Hobby Lobby - 2014 The owners of a privately held corporation may cite personal religious beliefs as a reason to not comply with insuring contraceptives. (PS1: Hobby Lobby argued that morning after pills caused abortion. )(PS2: It invests in manufacturers of the products it objected to.) Burwell v. Hobby

Lobby, 573 U.S. ___ (2014)

“Because I’m a man, number one and it’s really none of my business what women do.” “I don’t care if the federal government is telling me to buy my employees Jack Daniel’s or birth control. What gives them the right to tell me that I have to do that? That’s my issue.”-Michael Potter, CEO Eden Foods explaining his religion.

Eden Organic Foods-2014

ACA: 19-25 Y.O. % INSUREDNOTE: THIS IS LARGELY EMPLOYER BASED NOT MA COVERAGE

National Center for Health Statistics. June 2012. http://aspe.hhs.gov/aspe/gaininginsurance/rb.cfm

Percentage of Young Adults With Health Insurance,2009-2011 by Quarter & Age Group

MEDICAID EXPANSION

• If state increases Medicaid eligibility to 133% of poverty ($27,000 family of 3), • Feds cover all new enrollees for three years.

• Feds will pick up 96% of costs over next decade.

• Non expansion states account for 21 of the 35 states with uninsured rates over 15%.

• States that have not taken Medicaid expansion are leaving 4.8 million uninsured.

NYT 2015:Oct 30

PERCENT UNINSURED

2013 2015

ACA HAS IMPROVED THE NUMBER OF WOMEN WITH HEALTH INSURANCE BY:

• Reducing adult women’s uninsurance rate from and absolute rate of 17.5% to 5.5%.• 1.1 million women 19-25 are covered on parents plan.

• 56% of the 9.9 million market place sign ups are women.

• Covering more women on Medicaid (much more could be done).

• Banning regressive insurance premium structures.

• Covering dependent minors and young people.

ACA HAS IMPROVED THE QUALITY OF WOMEN’S HEALTH INSURANCE BY:

• 55 million women with private insurance now have access to mammograms, pap tests, prenatal and pregnancy care etc. with no copay or deductible.

• 8.7 million women gained maternity coverage. • HHS.

http://www.hhs.gov/healthcare/facts-and-features/fact-sheets/aca-working-women/index.html Sept, 16/2015

• http://aspe.hhs.gov/sites/default/files/pdf/77191/ib_mch.pdf

JOB LOCK: FEAR OF LOSING HEALTH BENEFITS KEEPS AN EMPLOYEE AT A JOB

• Deters people from retraining, starting a new company, seeking a better job, etc.

• Eliminating job lock would increase GDP growth .4% due to better worker health and entrepreneurialism.• CBO

Federal Reserve Bank. Report 246, 2015. RWJ, Ford Foundation, Urban Institute, 2013

ACA will decrease job lock for healthy persons in under insured service sector jobs.

ACA may not improve job mobility for chronically ill or disabled women.

ARE ACA PATIENTS ABLE TO SEE MDS?

In states with MA expansion: MD use by MA insured persons went up, but not for non insured.

In states without MA expansion MD use remained flat (or decreased.)AthenaCare and RWJ

MEDICAL DEBT

2003 . 2005 . . . . 2010 . 2012 . 201420

25

30

35

40

45

% Adults -Prob pay med bills past year% Adult delay Care for Cost in past yr.

Commonwealth Fund Biennial Health Insurance Survey 2014. Pub 2015.

NB: These % are half in insured vs uninsured families. CDC 2014.Note: Because of acquiring insurance, the health care costs went up so a larger percentate of families pay more than 10% of income for health care.

Adults ages 19–64 who selected a private plan or enrolled in Medicaid through marketplace or have had Medicaid for less than 1 year

No69% Yes

30%

Since getting your new health plan have you seen/needed to see any

specialists?

< 1 wk

15-30 days

Refused

Commonwealth Fund Affordable Care Act Tracking Survey, April–June 2014.

How long did you wait to get your first appointment?

Don’t know or refused 1%

8-14 days

>30 days

Have not tried

Still waiting

HAS ACA LED TO GRIDLOCK AT CLINICS?

ACA AND HEALTH CARE INFLATION

ACA doesn’t seem to be causing health care spending inflation.

Whitehouse.gov

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