Our Bodies, Ourselves (164 page)

The PPACA proposes to make insurance affordable through a combination of cost controls, subsidies, and mandates. It is estimated to cost $848 billion over a ten-year period, but the cost would be fully offset by new taxes and revenues and was projected on signing to actually reduce
the U.S. budget deficit by $131 billion over the same period. It also has separate provisions intended to stabilize and improve the federal Medicare program for seniors and people with disabilities. Some of the provisions are of particular importance to women. The program is being challenged by the Republican majority in the House of Representatives and in the courts. The following describes the law as enacted.

Three provisions on coverage went into effect immediately in 2010: Small employers can get tax credits for providing insurance to their employees; young adults can remain covered on their parents' plans until age twenty-six if they are not covered through their own jobs; and new, temporary “high risk pool” plans, called the Pre-Existing Condition Insurance Plan (PCIP), became available for people who have been uninsured for at least six months owing to a preexisting condition (this plan will close when the health insurance exchanges open in 2014). Other provisions are outlined below.

Insurance exchanges for individuals and small employers:
Beginning in 2014, new state-run health insurance exchanges will be available to individuals and employees of small businesses. (People already covered by Medicare or other insurance will not be affected.) The exchanges will offer choices of insurance plans with regulated benefits and premiums. Most uninsured individuals and some businesses will be mandated to pay into the exchanges; people earning up to 400 percent of the poverty limit will get subsidies. Members of Congress and their staffs will be required to obtain their insurance through the exchanges.

Medicaid and the Children's Health Insurance Program:
The act maintains current funding levels for the Children's Health Insurance Program (CHIP) through fiscal year 2015. It also expands eligibility for Medicaid to include everyone with an income below 133 percent of the federal poverty level and increases assistance to states to help cover the costs of adding people under Medicaid, as of 2014. The majority (69 percent) of adult beneficiaries of Medicaid are female.

This expansion removes two present barriers to Medicaid eligibility: First, some states cover only people with much lower incomes, such as by cutting off eligibility at 50 percent of the federal poverty level. Second, some states require “categorical eligibility,” meaning that in addition to having low income, people must fall into certain categories of need—have young children, for example, or certain serious health conditions.

Medicaid is the largest source of public funding for family planning services for low-income women, as well as the largest funder of maternity services. Twelve percent of women of reproductive age rely on Medicaid for their care; the percentage ranges from 6 percent of women in Nevada and New Hampshire to 24 percent of women in Maine.
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Expansion of Medicaid services means an expansion of critical family planning and contraceptive services for women, one reason that increased access to health care helps reduce the number of unintended and unwanted
pregnancies. Expanding access to these services and to community health centers generally will also dramatically increase access to testing and treatment for sexually transmitted infections.

Preexisting conditions:
The act prohibits insurance companies from denying coverage to people because of preexisting conditions. The prohibition applied immediately to children; adults will be protected starting in 2014.
Elimination of annual and lifetime limits:
A key cause of bankruptcy by individuals even though they have insurance is the annual and lifetime limits some plans imposed on how much insurers would pay. The lifetime limits were eliminated in 2010; annual limits will be eliminated in 2014.

Elimination of gender rating:
Many individual and small group insurance plans charge women more for insurance coverage than men of the same age and health status. The act eliminates this practice for plans offered through the exchanges.
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Limits on age rating:
Plans in the exchanges will be able to charge older people only three times more than younger ones; there is currently no limit, and many individual plans charge older enrollees up to seven times more. This does not apply to Medicare, which does not use age rating.

No referrals for ob-gyn and midwifery care:
Plans can no longer require preauthorization or referrals for ob-gyn care.

To improve quality and lower costs, the law mandates the following:

Free preventive care:
The act requires new private plans and Medicare to cover preventive services with no co-payments or deductibles. This dramatically expands women's access to screening for cervical and breast cancer and other forms of preventive reproductive and sexual health care.

Increased funding for community health centers and primary health care:
The act increases funding by $11 billion over five years to these partly publicly supported neighborhood clinics in underserved areas, known to offer high-quality primary care and often dental and other services. This will allow for nearly double the number of patient visits over the next five years. This funding went into effect in fiscal year 2010 and is an essential aspect of health care, particularly for low-income women and their families.

Improvements to Medicare, long-term care:
The law creates a number of programs critical for older women. Several initiatives will explore and evaluate programs to improve the quality of care through Medicare. One goal is to ensure that health care professionals and systems will have the evidence about the best medical treatments and incentives to practice accordingly.

The law also expands community-based options for long-term care. These programs are especially important for women, as they live longer than men. There are also improvements to the prescription drug program (Medicare Part D), including phasing out of the gap in coverage known as the “donut hole.” For more information, see
“Medicare Basics,”.

Time for mothers to express breast milk:
The act amended the Fair Labor Standards Act (FLSA), giving breastfeeding mothers in all fifty states the right to pump at work. The act requires that employers provide a reasonable—though unpaid—break time for an employee to express breast milk for her nursing child for up
to one year after the child's birth, whenever the employee has need to express milk.

The law is under attack from the U.S. Chamber of Commerce and parts of the insurance industry that oppose expanding population-wide benefits and oppose almost all forms of government involvement and oversight. Congress is proposing to reverse or at least chip away at elements of the reform.

In addition, there are concerns about whether the combination of regulations and delivery system reforms will effectively control costs. State and federal regulators have some new powers to control health insurance premiums. The law did not adopt popular proposals to offer a public option through the insurance exchanges. Our Bodies Ourselves has long supported proposals for publicly financed systems such as H.R. 3000, sponsored by U.S. Representative Barbara Lee (D-Calif.), which would provide affordable care to every resident and could effectively use the public sector's bargaining power to control health care prices. (See
the sidebar on single-payer proposals,.
)

Two explicit exclusions are additionally significant for women: the exclusion of some immigrants, and restrictions on abortion and contraceptives.

Coverage for immigrant women:
According to the National Latina Institute for Reproductive Health (NLIRH), the Patient Protection and Affordable Care Act “will cover an estimated 9 million uninsured Latinos and increase funding for community health centers, which is a lifeline for many in our neighborhoods. In addition, 4.4 million Americans in Puerto Rico and territories will receive $6.3 billion in new Medicaid funding, increased flexibility in how to use federal funding, access to the Exchange and $1 billion in subsidies for low-income residents.”
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At the same time, immigrant women, a highly vulnerable population, will continue to face high barriers to accessing basic health care. The act bars undocumented immigrants from receiving Medicaid or from enrolling in health insurance exchanges. About half of the nation's 12 million immigrants would be excluded. This is a human rights violation and bad public health policy.

The bill also imposes a five-year waiting period on permanent, legal residents before they are eligible for assistance such as Medicaid or subsidies for purchasing insurance through the exchange.

Threats to abortion and contraception care:
The law took several significant swipes at reproductive health care. Advocates are exploring options to ameliorate the impact of each provision, while opponents seek to tighten these limits. The main provisions, which concern limits on access to abortion and prescription contraceptive services, are covered in more detail below.

Owing to the combination of well-funded and sometimes violent opposition and a diffuse political defense, the issue of abortion has become increasingly stigmatized over the past several decades. As a result, women's health in general—an issue relevant to more than half the population—has become a hot-button issue.

During the 1980s, conservatives focused their efforts on a crusade to limit and ultimately strip women of their rights to sexual and reproductive health services both at home and abroad. This agenda has been used to win support for conservative, pro-corporate political candidates, whose economic and financial interests
otherwise have little in common with many of the voters who elect them. President Reagan (who, as governor of California, approved a law in 1967 liberalizing access to abortion
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) instituted the so-called global gag rule, which mandates that no U.S. family planning assistance can be provided to nongovernmental organizations that use funding from other sources to perform abortions in cases other than when a pregnancy poses a threat to the woman's life or is a result of rape or incest; or that use other funding to provide counseling and referral for abortion; or that lobby to make abortion legal or more available in their country. (See for more on the
global gag rule
.)

This battle continued during the 1990s, with court challenges and local and state initiatives. However, the Clinton administration did not support restraints on reproductive health and promptly overturned the global gag rule. Then came the administration of George W. Bush, which cooperated with strategies of the far right to support candidates at the local, state, and national levels representing extreme anti–abortion rights agendas. Antichoice advocates aimed to control the public dialogue around sex and reproduction through aggressive messaging strategies based on the spread of misinformation while continuing efforts through the executive branch, federal and state legislatures, and the courts to hinder gains in reproductive and sexual health policies and programs.

One legislative legacy that has had far-reaching implications is the Hyde Amendment. First adopted in 1976, it prohibits using U.S. federal funds to pay for abortions in programs administered through the Departments of Labor and Health and Human Services, including Medicaid. Exceptions are granted in cases of rape or incest, or a threat to the woman's life. The Hyde Amendment is not permanent law; it is an amendment to a federal appropriations bill specific to those two federal departments, and it must be reintroduced for consideration during every two-year session of Congress. Yet over the years, the Hyde Amendment's restrictions have been included in an ever-wider range of programs—for instance, abortions are no longer covered for any federal employee or members of the military. This is exceptional treatment of a legal and common medical procedure.

The ongoing debate over the health care reform law underscores the formidable political obstacles to women's health and equality in the United States. In 2009, President Obama and the Democratic-controlled Congress increased funding for evidence-based teen pregnancy prevention programs. They also revived a long-stalled authorization for the State Children's Health Insurance Program. The Justice Department awarded $127 million to Native American and Alaskan Native communities, in part to enhance law enforcement and better serve women who have been sexually assaulted. Benefits were extended to same-sex partners of federal employees, and restrictions were lifted on federal funding for embryonic stem cell research. And President Obama overturned the global gag rule, yet again. The pro–reproductive rights public was optimistic that its champions had regained legitimacy.

But the far right engaged in a sustained and angry assault on Democrats generally—and the president in particular—throughout efforts to pass health care reform, extend unemployment benefits, and bolster the economy. These attacks escalated the war on women at both the state and the federal levels, posing the greatest threats to our reproductive and sexual rights since before the Supreme Court decision on
Roe v. Wade
legalized abortion in 1973.