Women of color have benefited immensely from the Affordable Care Act (ACA). Through the ACA, coverage for women of color grew at more than twice the rate of women overall between 2013 and 2015. Of particular importance is the ACA’s role in addressing women of color’s reproductive health needs, both through its requirement for insurers to cover 10 essential health benefits and provide no-cost preventive services and through its option for states to expand Medicaid. As a result, the uninsured rates among black women, Asian American and Pacific Islander (AAPI) women, and Latinas have declined significantly, and women of color have increased their regular usage of a doctor’s office, clinic, or health center.
Yet despite this progress, conservatives in Congress recently waged an all-out assault on health care with little regard for the impact it would have on women of color. Three congressional repeal bills—the House-passed American Health Care Act (AHCA), the Senate’s Better Care Reconciliation Act (BCRA), and the Senate’s so-called skinny repeal bill—failed to become law but nonetheless threatened to reverse the gains attained through the ACA for millions of women of color and their families.
After it became clear that neither the AHCA nor the BCRA could muster sufficient support to reach the president’s desk, the Senate made a last-ditch effort to pass the skinny repeal bill, legislation that would have repealed part of the ACA without a replacement bill. That measure did not pass the Senate, in a dramatic vote in which three Republicans—Sens. Lisa Murkowski (AK), Susan Collins (ME), and John McCain (AZ)—voted no. All of these bills would have harmed women of color and exacerbated already pervasive health disparities.
Women of color face extraordinary health disparities
Historically, women of color have faced significant obstacles regarding their access to reproductive health care. As a result, health disparities and racial biases are still prevalent, even with the gains achieved through the ACA. While unintended pregnancy rates are down overall, the rates for Latinas and black women still outpace the rate for white women: The rate of unintended pregnancies for Latinas is 58 percent, and the rate for black women is 79 percent—more than double the 33 percent rate for white women. The pregnancy-related mortality rate for black women is more than triple the rate for white women.
Further, black women ages 45 to 64 have the highest rates of breast cancer and maternal mortality, while Latinas have the highest rates of cervical cancer. Cancer is also the leading cause of death for AAPI women. Women of color have higher rates of pre-existing conditions such as diabetes, asthma, hepatitis B, and HIV/AIDS—and because of the coverage gap, they are more likely to die from these conditions. The coverage gap applies to states without Medicaid expansion, where people’s incomes are too high to qualify them for Medicaid but not high enough for them to participate in the ACA marketplace. All these conditions would be exacerbated if women of color were locked out of health care coverage.
Generally, communities of color experience worse health care outcomes because of income inequality, barriers to care, lack of insurance, and lack of a consistent medical provider. Women of color are also more likely to be underinsured, uninsured, and eligible for Medicaid. If women of color live in states where Medicaid has not been expanded to cover more individuals and families, they are more likely to receive lower-quality care, especially if they are low-income. And many women of color currently fall into the coverage gap, particularly in states where Medicaid has not been expanded, and they remain uninsured. Despite the significant drops in the uninsured rates among black, Latina, and AAPI communities, these systemic barriers continue to lead to health care disparities.
Key similarities and differences among the repeal bills
The three versions of the ACA repeal bills share key similarities that could threaten reproductive health care for women of color: repealing individual and employer-mandated coverage and defunding Planned Parenthood. First, all three bills would have repealed the provision in the ACA that requires most individuals to purchase insurance, often referred to as the individual mandate. Without the mandate, many individuals would likely opt out of the market, causing a sharp increase in premiums. The resulting decline in outreach efforts would also lead to fewer people being insured and lower Medicaid enrollment. Passage of the AHCA would have resulted in 24 million people losing coverage by 2026; passage of the BCRA would have resulted in 22 million people losing coverage in the same time frame. The skinny repeal bill—an ill-conceived option pitched as a streamlined repeal effort by targeting the individual and employer mandates and the medical device tax—still would have resulted in 16 million people, including many women of color, becoming uninsured. And although it would not have cut Medicaid, premiums for those with private insurance would have increased by 20 percent, making insurance unaffordable for many women. The Center for American Progress estimates that this would have cost individuals $1,238 in higher premiums. All three bills would have resulted in millions of women of color losing their health care coverage.
The AHCA, the BCRA, and the skinny repeal bill would also have prohibited the funding of Planned Parenthood for one year, which could have had dire consequences for women of color, particularly in underserved communities. In 2014, Planned Parenthood’s client base included black women at 15 percent, Latinas at 23 percent, and AAPI women at 4 percent. And in the same year, approximately 60 percent of its clients used Medicaid as their primary form of health insurance. While some conservatives insist that community health centers can absorb Planned Parenthood’s clients, the reality is that many women would lose their only source of health care, because many community health centers are under-resourced and often struggle to meet the needs of their current patient loads. In addition, the proposed cuts to Medicaid would have had the most significant impact on women of color, as they are more likely to be covered by Medicaid. More than 31 percent of black women, 27 percent of Latinas, and 19 percent of AAPI women are currently enrolled in Medicaid. Over the next decade, the AHCA would have cut the Medicaid program by more than $800 billion, and the BCRA would have cut Medicaid by $772 billion. The majority of the coverage losses caused by the AHCA and the BCRA would have come from changes to the Medicaid program, namely by ending Medicaid expansion and implementing per capita caps. The per capita caps would have changed how Medicaid is financed by eliminating the entitlement to coverage for eligible individuals and the states’ guarantee to federal matching dollars with no preset limit. Furthermore, states would have been able to impose enrollment caps or waiting lists on their programs to cut spending. Cuts to the program would have left millions of low-income women of color and their families without health coverage, impeding access to a wide range of services, from preventive care to treatment of chronic conditions such as diabetes, mental health, and maternity care.
The AHCA and the BCRA would not have changed the requirement for coverage of preventive care, but states would have had the ability to opt out of offering coverage for certain essential health benefits. As a result, states could have dropped certain services such as maternity care or mental health care. According to CAP estimates, a woman could have paid as much as $17,320 for a maternity services rider if these bare-bones policies had been allowed into the marketplace.
Both the AHCA and the BCRA would have allowed states to impose work requirements as a condition of Medicaid coverage with specific exceptions, such as new mothers for the first 60 days postpartum. If states were to choose this option, new mothers enrolled in Medicaid would have to return to work after 60 days or meet another exception in order to remain enrolled. This requirement would have reinforced harmful stereotypes that stigmatize mothers of color by questioning their work ethic and perpetuating the false narrative that they are engaged in fraud or abuse of the system. For example, Kelleyanne Conway, the counselor to President Donald Trump, indicated that those on Medicaid who lost health insurance could always get a job, as if they do not already work. Eighty percent of adults enrolled in Medicaid are members of working families and a majority of them work themselves. This work requirement is rooted in racial and class bias about women on Medicaid and lacks an understanding of the realities of the nation’s working poor.
Finally, the AHCA and the BCRA would have imposed sweeping restrictions on insurance coverage of abortion, banning abortion beyond the Hyde Amendment exceptions. Hyde is the budgetary rider that prevents federal funds from paying for abortion care except in cases of rape, incest, or endangering the life of the mother. The AHCA would have allowed states to continue to regulate fully insured plans, but states would have been limited to using federal tax credits to purchase plans that did not cover abortion. The AHCA would have banned qualified health plans in the marketplace from covering abortion beyond the Hyde restrictions. It also would have prevented small employers from receiving tax credits if their plans covered abortion.
And unlike the AHCA, the BCRA would have banned abortion coverage beyond the Hyde restrictions in all marketplace plans, essentially preventing states from regulating their own insurance plans. Tax credits could not have been used to purchase private plans that included abortion coverage. The BCRA also attached the Hyde Amendment to the State Stability and Innovation Program, a new fund that was part of the BCRA and aimed to lower premiums or encourage insurer participation in the individual market. Therefore, plans that cover abortion would not have been eligible to receive payments from this fund.
Conclusion
Women of color need comprehensive health care—not just to protect their health but also to protect their economic security. The recent failure of the ACA repeal effort signals the need for a bipartisan effort in the Senate to improve health care. Congress should expand Medicaid, fully fund Title X and Planned Parenthood, and work to close the remaining coverage gap.
Women of color would have been made more vulnerable had any of the ACA repeal or replace bills passed into law. Repeal would make it extremely difficult to reduce the health care disparities that plague women of color and to ensure that they have the support they need to be healthy and economically stable.
Heidi Williamson is the senior policy analyst for the Women’s Health and Rights Program at the Center for American Progress.