The Affordable Care Act (ACA) has been one of the most significant advancements for women’s health and economic security in a generation. The law expanded coverage to millions of uninsured people through financial assistance and public insurance and also improved the quality of existing coverage, including by expanding access to reproductive and maternal health services and by prohibiting discrimination against women and people with preexisting conditions. Yet its fate remains uncertain. On November 10, the U.S. Supreme Court will hear oral arguments in California v. Texas, a case that will determine the constitutionality of the ACA. Specifically, the high court will determine whether the individual mandate is unconstitutional and whether the remainder of the law is inseverable from that provision. Especially with Justice Ruth Bader Ginsburg’s recent passing, the benefits and consumer protections that women have gained and come to rely on could swiftly be eliminated. In short, if the ACA is repealed, coverage for more than 20 million people and the significant benefits and consumer protections that have been gained under the law are at stake.
Compounding this issue, the ACA repeal would come at a time when the coronavirus pandemic and resulting economic crisis have already burdened women. For instance, unprecedented job losses have resulted in the loss of insurance coverage; barriers to maternal and reproductive health care have been erected; the providers women rely on—who were already underfunded—have been stretched to capacity; and health disparities that have historically burdened Black and Latina women have been exacerbated and compounded. Repealing the ACA during the pandemic would no doubt cost women—especially women of color, women with disabilities, women with low incomes, and young women.
First, repealing the ACA would reduce access to treatments and vaccines during the pandemic and allow COVID-19 survivors to be discriminated against in the insurance market, thus lengthening the time that the crisis will likely affect women and their families. Second, the economic crisis has already harmed women the most, and eliminating coverage and allowing gender rating and coverage caps would shift additional costs on to women. Lastly, existing barriers to maternal and reproductive health services, both those created during and before the pandemic, would likely be exacerbated.
1. Repealing the ACA would prolong and worsen the effects of the pandemic for women and their families
While a repeal of the ACA would be chaotic and devastating even in typical times, the current pandemic would only magnify its effects. Without coverage, women could experience barriers to a COVID-19 treatment and vaccine—which could prolong the effects of the pandemic. These barriers would be most devastating, however, for women of color given the health inequities associated with COVID-19. Compared with white, non-Hispanic people, Black people are 2.6 times more likely to contract the virus, 4.7 times more likely to be hospitalized, and 2.1 times more likely to die from the disease. Similarly, American Indian and Alaska Native people contract the virus at 2.8 times the rate, are hospitalized at 5.3 times the rate, and die at 1.4 times the rate of white, non-Hispanic people. And Latinx people are 2.8 times more likely to contract the virus, 4.6 times more likely to be hospitalized, and 1.1 times more likely to die from COVID-19 than white, non-Hispanic people.
Even worse, if the ACA is repealed, COVID-19 survivors could be discriminated against when seeking insurance coverage. Without ACA protections, insurers in the individual market could—once again—charge enrollees more or deny them coverage if they have a preexisting condition. This could affect the more than 7 million Americans who have been infected with COVID-19, as it could be deemed a preexisting condition.
Even before the pandemic, a Center for American Progress analysis found that nearly 68 million women—more than half of girls and nonelderly women in the country—had a preexisting condition. If insurers are able to make the determination as to whether a person has a preexisting condition, conditions ranging from HIV/AIDS to breast cancer to the nearly 6 million annual pregnancies could again be included in this category. And importantly, Black, Latinx and American Indian and Alaska Native people have higher rates of COVID-19 as well as certain chronic conditions such as cervical cancer and diabetes, so eliminating coverage and protections for people with preexisting conditions would harm these communities the most.
2. Women’s financial security would be threatened by an ACA repeal
Women have lost the majority of jobs since the start of the pandemic. In fact, multiple studies have pointed to the fact that the current recession is tougher on women than men. One U.S. Bureau of Labor Statistics analysis explains that unlike past recessions, “the [coronavirus] crisis has battered industry sectors in which women’s employment is more concentrated—restaurants and other retail establishments, hospitality, and health care.” Additionally, school closures have forced women, who are more likely to be primary caregivers for young children or sick family members, to reduce hours or leave their jobs—which can also result in coverage loses. In particular, Black and Latina mothers are more likely than white mothers to be the sole or primary breadwinners of their households, so they will be hit hardest by the additional financial burdens. Before the pandemic, there was already a wage gap between women and men—a gap that is exacerbated by race and ethnicity, given that Black, Latinx, and American Indian and Alaskan Native populations experience poverty rates that are significantly higher than those of non-Hispanic, white populations. Perhaps as a result, women were already more likely than men to forgo or delay accessing recommended care due to costs.
Yet given the pandemic, losing the financial security afforded by having insurance coverage would be even more devastating for women. The ACA provided financial assistance for private insurance coverage and expanded enrollment in the Medicaid program, which resulted in the uninsurance rate reaching a historic low. As a result, the uninsurance rate among women declined by nearly half from 2010 to 2016. An ACA repeal would merely undermine safety net programs when people need them the most. Women comprise 58 percent of Medicaid enrollees according to 2018 data, and Medicaid expansion resulted in a 13 percent decrease in the uninsurance rate of young women of reproductive age—19 to 44 years old—with low incomes. In particular, Medicaid’s no- and low-cost services afford necessary and preventive health care access to people with low incomes, a disproportionate number of whom are women of color due to systemic racism, sexism, and poverty. From 2013 to 2018, due to the ACA’s coverage expansions, fewer Black women and Latinas reported delaying care as a result of costs, narrowing the disparity between white women and women of color.
Women who maintain access to insurance coverage could also face increased costs. If the ACA’s prohibition on gender rating is repealed, insurers could once again charge women more for coverage in the individual and small-group markets simply for being women, reinstating a practice that collectively cost women $1 billion more than men each year. Additionally, the ACA created the Health Care Rights Law, which prohibits discrimination in health care on the basis of sex, race, color, national origin, age, and disability; notably, this marked the first time that a federal prohibition against sex discrimination was applied broadly to health care. Lastly, if the health care law is repealed, women with chronic conditions, such as HIV and cancer, could be subject to annual and lifetime limits—a practice prohibited under the ACA that allowed insurers to require plan enrollees pay out of pocket for all services after they reach a certain dollar threshold. These increased costs could easily price many women out of insurance in the middle of a public health crisis.
The ACA has also been associated with improving job opportunities. The majority of people in the United States access health coverage through their employer, yet by improving access to coverage that is not job-based, the ACA has afforded people the ability to leave or switch jobs with assurance that they won’t lose their coverage. Moreover, the ACA created at least 240,000 jobs in the health care industry from 2014 to 2016—and women comprise the majority of health care workers. The chaos that would result from repealing the ACA would be felt particularly acutely by those employed in these jobs.
3. Repealing the ACA would exacerbate existing barriers to reproductive and maternal health care services
According to the Centers for Disease Control and Prevention, pregnant people with COVID-19 have higher rates of hospitalization, admission to the intensive care unit, and mechanical ventilation. And alarmingly, Black pregnant women are disproportionately contracting COVID-19. Subsequently, there are concerns that the pandemic will exacerbate existing health inequities that have led to Black, as well as American Indian and Alaska Native women, dying from pregnancy-related complications at around three times the rate of white, non-Hispanic women. A repeal of the ACA in its entirety would result in reduced access to pre- and post-natal care for as many as 13 million people in the individual market because individual and small-group health plans would no longer be required to cover certain basic health care services—known as essential health benefits—including maternity and newborn care. Eliminating the expanded Medicaid eligibility created under the ACA could also worsen the crisis given that Medicaid expansion is associated with lower rates of maternal and infant mortality and covers 50 percent of births in the United States.
Moreover, due to the many unknowns that remain regarding how COVID-19 affects pregnant people, some individuals may want to delay or forgo pregnancy, necessitating access to comprehensive reproductive health services. The ACA requires most plans to cover birth control with no out-of-pocket costs. As a result, women have saved more than $1.4 billion a year in out-of-pocket costs on birth control pills. According to data from the National Women’s Law Center, 61.4 million women currently have access to birth control as well as other preventive services, such as well-woman visits, with no out-of-pocket costs—thanks to the ACA. Without requirements for these services to be covered, women would be forced to pay out of pocket or forgo care if they could not afford to. Illustratively, without insurance coverage, birth control pills could cost a woman up to $600 per year, and an intrauterine device could cost about $1,000 out of pocket.
Additionally, the pandemic has erected barriers that make it harder for women to access necessary and preventive care—both as a result of job losses and barriers to accessing care during the pandemic. As a result, women may have already delayed care in recent months; a repeal of the ACA would only lead to further delays given that plans would no longer be required to cover preventive screenings, mental and substance abuse services, rehabilitative services, and a host of other services.
Conclusion
President Donald Trump and his conservative allies in the Senate are not only forgoing their responsibility to address the dueling health and economic crises, they are also rushing to install a new, conservative justice on the Supreme Court who would tilt its balance in favor of striking down the ACA. With November oral arguments quickly approaching, this has increased the risk that the health care law will be repealed. Given the health benefits, protections against discrimination, and financial security that the ACA affords women, destroying the law would be immeasurably harmful to women at any time. But repealing the law in the midst of a global pandemic that has infected millions of Americans and killed more than 200,000 people in the United States would result in even more chaos and devastation.
Jamille Fields Allsbrook is the director of women’s health and rights for the Women’s Initiative at the Center for American Progress.
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