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January 22, 2021

Legal Challenges to the Affordable Care Act During a Pandemic: What Is at Stake for Women in the US?

Author Affiliations
  • 1American College of Obstetricians and Gynecologists Darney/Landy Fellow, Ann Arbor, Michigan
  • 2Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
  • 3Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
  • 4Program on Women’s Healthcare Effectiveness Research, University of Michigan, Ann Arbor
JAMA Health Forum. 2021;2(1):e201584. doi:10.1001/jamahealthforum.2020.1584

As the coronavirus disease 2019 (COVID-19) pandemic worsens across the US, many people are feeling grateful for their health insurance coverage. For 20 million people in the US, their insurance coverage is due to the Affordable Care Act (ACA), the most transformational health care reform since the 1960s. Since the ACA’s passage more than a decade ago in 2010, a string of legal challenges has plagued the law, including the most recent US Supreme Court case California v Texas. Efforts to dismantle the ACA during the COVID-19 pandemic are of particular concern for women, who have reaped important benefits from the ACA.

Prior to the ACA, women faced unique barriers in accessing and paying for health care. Women enjoyed less access to employer-based coverage—the primary mechanism for obtaining health insurance coverage in the US—because they were more likely than men to be students, unpaid caregivers for young children or older adults, working part time, or unemployed. Additionally, 1 in 7 adults were denied insurance coverage due to “preexisting” conditions, which could include pregnancy, infertility, depression, and intimate partner violence. Moreover, women were also more vulnerable to out-of-pocket costs for health care services because they tend to be paid less than men (due to gender bias, disproportionate domestic workload, and other factors). These barriers intersect and are compounded for women of color, people who identify as LGBTQ, and those with lower incomes, who have been further marginalized by systemic racism, gender and sexual orientation discrimination, and economic injustice.

Even when women could obtain commercial insurance before the ACA, reproductive services that individuals were likely to need were often excluded from coverage. Pregnancy—the most common reason women use their insurance plans—was covered by only 44% of individually purchased plans and 81% of employer-sponsored plans before the ACA. Similarly, contraception was covered by only 34% of individual and 62% of employer-sponsored plans and represented 44% of out-of-pocket health care spending, on average, for privately insured women using birth control pills.1 Moreover, it was legal in many states for women to be charged more than men for plans with identical benefits. A practice called risk rating enabled plans to charge more to all groups assessed as having higher risks of higher expenditures for any reason allowed within state law, with significant variation in insurance rules across states. Because women are more likely, on average, to use their health plans, they could face higher premiums than men for identical coverage, which resulted in women paying an estimated $1 billion more annually for individual marketplace plans and higher premiums in group plans in businesses with a predominantly female workforce (eg, nonprofit organizations, child care).

Now, more than a decade after the ACA’s passage, robust literature documents how ACA provisions ushered in much-needed changes in health care access, utilization, and outcomes for women across the US. Uninsurance rates among working-age women fell by 39%—from 18% in 2008 to 11% in 2018—owing to ACA provisions around Medicaid expansion, subsidies to support marketplace plans, and the dependent coverage provision allowing young adults up to age 26 years to stay on their parents’ plan. Coverage gains have been particularly remarkable for some previously marginalized groups, with uninsurance rates falling from 28% to 13% for women aged 19 to 25 years and from 36% to 21% for lower-income households between 2008 and 2018. Postpartum women have also benefited, with uninsurance rates falling from 20% in 2011 to 11% in 2018.

Under the ACA, coverage is not only more accessible but also more affordable.2 The ACA banned gender rating, eliminated annual and lifetime plan spending caps, and required coverage of services women are likely to use, including maternity care. Subsequently, many women have experienced notable reductions in health-related financial hardships, cost-related delays in care, and medical debt.3,4 The ACA’s preventive services clause led to a dramatic reduction in women’s out-of-pocket spending on contraception and health maintenance examinations and improved utilization of these preventive services.1,5 As the list of services subject to first dollar coverage grows, it will be important to continue documenting the effects of these policies on women’s utilization of and spending for recommended care.

Emerging studies are documenting benefits of the ACA on health outcomes,6 including improvements in infant mortality rates, Black–White disparities in preterm birth rates, income-based disparities in unintended birth rates, self-reported health among young adults, symptomatology among women with mental health conditions, diagnosis of chronic conditions, and even mortality rates.

To be sure, there is much more work to be done. More than 1 in 10 women—10.8 million individuals—remain uninsured. Persistent disparities in uninsurance rates by race/ethnicity and citizenship call for robust efforts to advance equity in US health care policy. Out-of-pocket costs for many services, including maternity care,7 remain much too high. In one nationally representative survey in 2016, more than 25% of women reported spending $2000 or more on health care in the past year, and more than 30% reported skipping needed medical care due to cost. Compared with other wealthy nations, women in the US have the greatest burden of chronic illness, the highest rate of maternal mortality, and the least satisfaction with their health care.

More expansive policy solutions could improve health care value, equity, and outcomes. Payment reforms could incentivize high-value maternity services and care delivery models. Medicaid programs—the insurer for nearly half of all births in the US—should extend coverage for a full 12 months after delivery or whenever a pregnancy ends, recognizing that chronic conditions are the most common and fastest rising cause of maternal mortality in the US. Further expanding the options for individuals to obtain affordable, comprehensive health insurance—including outside of employment—could help to promote gender equity.

Now, more than ever—during the worst pandemic in a century—the need for comprehensive and equitable health care coverage is evident. This is no time for legal challenges to the ACA. We must instead build on its great progress to date. We call on US lawmakers to heed the demonstrated gains of the ACA and seek policy changes that further advance our clinical goals of high-value, equitable, person-centered health care for women and for all people in the US.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Villavicencio J et al. JAMA Health Forum.

Corresponding Author: Michelle H. Moniz, MD, MPH, Department of Obstetrics and Gynecology, University of Michigan, 2800 Plymouth Rd, Bldg 10, Room G016, Ann Arbor, MI 48109-5276 (mmoniz@med.umich.edu).

Conflict of Interest Disclosures: Dr Moniz reported receiving grants from the Agency for Healthcare Research and Quality and personal fees from the Society of Family Planning (scientific reviewer for fellowship research proposals) during the submitted work. No other disclosures were reported.

Funding: Dr Moniz is supported by the Agency for Healthcare Research and Quality, grant No. K08 HS025465.

Role of the Funder/Sponsor: The Agency for Healthcare Research and Quality played no role in the preparation, review, or approval of the manuscript or in the decision to submit the manuscript for publication.

Becker  NV, Polsky  D.  Women saw large decrease in out-of-pocket spending for contraceptives after ACA mandate removed cost sharing.   Health Aff (Millwood). 2015;34(7):1204-1211. doi:10.1377/hlthaff.2015.0127 PubMedGoogle ScholarCrossref
Lee  LK, Chien  A, Stewart  A,  et al.  Women’s coverage, utilization, affordability, and health after the ACA: a review of the literature.   Health Aff (Millwood). 2020;39(3):387-394. doi:10.1377/hlthaff.2019.01361 PubMedGoogle ScholarCrossref
Lee  LK, Monuteaux  MC, Galbraith  AA.  Women and healthcare affordability after the ACA.   J Gen Intern Med. 2020;35(3):959-960. doi:10.1007/s11606-019-05248-4 PubMedGoogle ScholarCrossref
Johnston  EM, Strahan  AE, Joski  P, Dunlop  AL, Adams  EK.  Impacts of the Affordable Care Act’s Medicaid expansion on women of reproductive age: differences by parental status and state policies.   Womens Health Issues. 2018;28(2):122-129. doi:10.1016/j.whi.2017.11.005 PubMedGoogle ScholarCrossref
Dalton  VK, Carlos  RC, Kolenic  GE,  et al.  The impact of cost sharing on women’s use of annual examinations and effective contraception.   Am J Obstet Gynecol. 2018;219(1):93.e1-93.e13. doi:10.1016/j.ajog.2018.04.051PubMedGoogle ScholarCrossref
Soni  A, Wherry  LR, Simon  KI.  How have ACA insurance expansions affected health outcomes? findings from the literature.   Health Aff (Millwood). 2020;39(3):371-378. doi:10.1377/hlthaff.2019.01436 PubMedGoogle ScholarCrossref
Moniz  MH, Fendrick  AM, Kolenic  GE, Tilea  A, Admon  LK, Dalton  VK.  Out-of-pocket spending for maternity care among women with employer-based insurance, 2008-15.   Health Aff (Millwood). 2020;39(1):18-23. doi:10.1377/hlthaff.2019.00296 PubMedGoogle ScholarCrossref
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