In recent days, Americans have watched the congressional debate on repealing the Affordable Care Act move from mere partisan posturing to a cacophony of amendment proposals, grandstanding, and political jockeying. The stakes are high for many, including the 2.7 million New Yorkers estimated to be at risk of losing coverage in the event of an ACA repeal. And repealing the ACA would also jeopardize the nation’s largest demographic: women.
In a joint letter to Congress last month, numerous healthcare organizations, including the National Partnership for Women & Families, the American Academy of Pediatrics, the American College of Nurse-Midwives, the American Congress of Obstetricians and Gynecologists, and the National Association of Nurse Practitioners in Women’s Health, raised their objections in urgent tones. “It would be unacceptable for the Senate to adopt legislation that would cause millions of women and families to suffer, lose access to care and coverage, and pay higher healthcare costs,” they wrote. “We believe that this would turn back the clock and reverse hard-won progress on gains in women’s access to healthcare and coverage.”
The clock would not need to be turned very far: As recently as 2014, as the ACA first took effect, only 12 percent of individual market plans included maternity benefits, and millions of American women without workplace health insurance were living with inadequate care or none at all. In 45 states (though not New York or New Jersey), pregnancy was considered a preexisting condition, allowing insurers to reject expectant mothers from coverage. Eight in ten plans on the individual market failed to cover maternity care at all; among the remaining few, most only offered such care as a rider, tacked on for an additional price.
By including maternal and newborn care in its mandated “essential health benefits,” the ACA undid many of these obstacles to care for pregnant women and new mothers: The Century Foundation has estimated that 13 million women would lose maternal care coverage without the ACA.
Considering the United States’ shockingly high rate of maternal mortality, the basic protections afforded by the ACA were long overdue. Yet even as the ACA sought to expand women’s healthcare, some states found loopholes. Republican-controlled Texas, for example, managed to close women’s health clinics and restrict access to abortions and contraception — even as deaths from complications of pregnancy and childbirth doubled; the state now has the highest maternal mortality rate in the developed world.
Without insurance coverage, the authors of the aforementioned letter to Congress noted, pregnant women can face tens of thousands of dollars in out-of-pocket costs for even a normal labor and delivery. Removing ACA rules would also allow insurers to return to charging women more for such “health conditions” as C-sections, injuries resulting from domestic abuse, and irregular periods, and eliminate required coverage for domestic violence screening. Such a decision would be disastrous for families and do little to reduce the overall cost of care: Adding maternity coverage increased average monthly premiums by a mere $8 to $14, according to a recent third-party assessment.
To Jennifer Pomeranz, interim chair, department of public health policy and management, at New York University’s College of Global Public Health, lawmakers’ cavalier treatment of reproductive health is outrageous: “It would be unheard of to deprive a person of any other medically approved prevention or treatment method except in the context of reproductive health.”
In New York State, several attempts have been made to combat the possible effects of ACA repeal. Last January, the week of Trump’s inauguration, the New York State Assembly passed the Comprehensive Contraceptive Coverage Act, which would uphold ACA requirements for co-pay-free birth control — including emergency contraception such as Plan B, which the ACA doesn’t require coverage for. That same month, the New York State Assembly passed the Reproductive Health Act, which would ensure New York women access to late-term abortions. So far, the state senate has refused to vote on either bill.
Such state-level provisions may be the future haven for women’s healthcare. “The ACA was modeled after Massachusetts’ law, so states can do a lot,” says Pomeranz. “States can require most but not all health insurance plans to provide certain services, and states can provide funds to increase Medicaid coverage in the absence of federal funds.” New York offered expanded Medicaid coverage even before the ACA, she adds. Still, many state-level gains could be threatened by repeal, including New York’s recently expanded Medicaid coverage for breast cancer detection and prevention, which could face cuts if Congress scales back spending on the program.
These cuts, combined with proposals to halt all government reimbursement for care at Planned Parenthood for one year, could leave New York’s women on Medicaid in danger of losing access to essential care. Abortion services, despite the outsize attention paid to them, account for just 3 percent of Planned Parenthood’s budget, the bulk of which goes to holistic care, including Pap smears, breast exams, STD and HIV screenings, vaccines, contraception, and educational services. Of the 2.5 million people who visit Planned Parenthood each year, the majority are at or below the federal poverty line.
Planned Parenthood of New York City’s five clinics currently receive nearly $12 million in federal funds each year, dollars that would disappear if Republicans succeed in their defunding proposals. “Many doctors do not accept Medicaid for preventative services,” Pomeranz points out. “For many women, Planned Parenthood is their primary location for healthcare. Defunding or otherwise penalizing Planned Parenthood will likely make it harder for low-income women to get birth control, screenings for cervical cancer and mammograms, and well-women care.” Planned Parenthood is also an important resource for many LGBTQ New Yorkers, who are historically underinsured and rely on the organization for services including HIV testing and transition-related care. (New York is one of just sixteen states where Planned Parenthood offers hormone therapy.)
In the event that such defunding does succeed, however, women in New York would have at least a little reprieve: Abortions covered by Medicaid are paid for by state, not federal, funds, and are thus not at risk under current congressional proposals. In the event that neighboring states crack down on abortion services, it is possible that the Empire State might see women crossing state lines for services — a phenomenon already underway in the Midwest and South, and which was common in the wake of New York becoming the first state to legalize abortion in 1970: By the end of 1971, 61 percent of abortions in New York were performed on out-of-state residents.
The ACA repeal would also likely spur a rise in unwanted pregnancies. Already, close to half of annual pregnancies are unexpected, and restricting access to contraception would be devastating for American women, and society as a whole. “Allowing women the option to wait until they are mentally and financially ready to have a child will impact both of their futures,” says Pomeranz. “Opposition to contraception directly compromises the woman and child’s long-term health and financial future.”
Beyond the ethical argument for healthcare for all, dropping millions of girls, women, mothers, and infants from coverage would bring devastating economic and medical outcomes over the long term. It should perhaps come as no surprise that these concerns are frequently passed over in mainstream debate: The needs of women, and particularly lower-income women and women of color, have historically been treated as marginal, or else as an unsavory inconvenience. Nevertheless, lawmakers, employers, and insurers alike ought to heed the grave consensus of the medical community: As we choose the fate of women, we are setting a course for our collective future.