Co-authored by Dr. Diana Taylor, professor emerita, University of California, San Francisco; Dr. Ellen F. Olshansky, women’s health nurse practitioner, and professor and chair, University of Southern California; Dr. Versie Johnson Mallard, women’s health nurse practitioner and Association of Reproductive Health board member; Dr. Nancy Fugate Woods, professor and dean emeritus, University of Washington; Dr. Monica R. McLemore, assistant professor, University of California, San Francisco, and research scientist with Advancing New Standards in Reproductive Health.
The Affordable Care Act (ACA) repeal is in the hands of the Senate in the form of recent ACA Repeal proposals (that started with the Better Care Reconciliation Act [BCRA]). Repealing the ACA would be devastating for the health and economic security of women and families, and will hinder the ability of the U.S. nursing workforce to provide quality care to our patients. As registered nurses, health care providers, researchers, and educators on women’s health, we are concerned that the Senate has little knowledge of (at best) or care for (at worst) the bill’s impact on women, their families or the health care system (much like the House of Representative’s bill to repeal the ACA, which was passed on May 4, 2017). Thus, the purpose of this post is to spell out what will happen to women, families, and health care providers, if the ACA is repealed.
Loss of Insurance
First and foremost, any ACA Repeal proposal would strip coverage from millions of women and families. The nonpartisan Congressional Budget Office (CBO) estimates that 22 million people would lose coverage over the next 10 years, if the ACA is repealed with the likes of the BCRA. By repealing the ACA’s premium and cost-sharing subsidies and imposing age-based tax credits, and dismantling the Medicaid program, the BCRA and other ACA-repeal bills would make it more difficult for low-income women and families to afford health coverage as well as for older women who would see rising costs.
In 2016, 6.8 million women and girls enrolled in health plans through the health insurance marketplaces created by the ACA. Because of the ACA, in the majority of states, more than 80% of women of color ages 18-64 are now insured. The BCRA would roll back these important advances, making it harder for women and their families – particularly low-income women and women of color – to afford necessary health coverage and get the care they need.
Decreased Access to Coordinated Care
The ACA also allowed for a greater number of nurses to enter the health care sector and provide higher quality care and better health outcomes for their patients through care coordination provisions that integrate care across health care settings and reduce costs. The BCRA would result in the loss of hundreds of thousands of RN/APRN jobs and compromise the remaining nursing workforce’s capacity to deliver the high quality, efficient care.
No Protections for Those with Preexisting Conditions
The BCRA also allows states to waive protections for people with preexisting conditions and exacerbates existing health inequalities. Under the ACA, health plans in the marketplace are prohibited from denying coverage or increasing premiums based on prior health conditions or medical history, including pregnancy and childbirth. An estimated 133 million Americans with preexisting conditions could be denied coverage or be subject to skyrocketing costs without the current ACA protections. Under the BCRA, states would be able to waive ACA protections that are crucial to people with preexisting conditions, which would give license to insurance companies to charge these individuals extremely high premiums in certain circumstances, thereby denying them access to affordable coverage.
No Guaranteed Maternity Coverage
In addition, the BCRA guts the Essential Health Benefits (EHB) provision, which ensures women have guaranteed access to 10 categories of coverage, including maternity care, mental health services, prescription drugs, and more. Universal access to essential health care services is fundamental to nurses’ and other frontline women’s health care providers’ ability to provide comprehensive care. Because of this ACA provision, now all women have guaranteed access to maternity coverage on the individual market. Prior to the ACA, only 12% of individual market plans covered this benefit. Under a similar provision in the House bill, according to the CBO, women could pay an additional $1000 per month for maternity care in states where EHBs are waived. By sanctioning states to repeal EHBs, the BCRA pushes women back to a time where they would be charged more for inadequate and uncomprehensive coverage. It would also compromise nurses’ capacity to deliver the high-quality care and full range of services their patients deserve.
Added Barriers to Birth Control
By stripping health coverage away from millions of women and families, the BCRA also creates new barriers to accessing important preventive services like birth control. Because of the ACA, 55 million women (and approximately 40 million people of color) now have access to preventive services with no cost-sharing. In 2013 alone, women saved more than $1.4 billion in out-of-pocket costs on oral contraceptives. Without health coverage, millions of women will be forced to pay out of pocket for contraception. Access to affordable preventive care allows women to choose if and when to have children, which in turn, allows for greater economic security and stability. To make matters worse, the BCRA also defunds Planned Parenthood, which provides millions of people with access to vital preventive services like contraception, STI testing, and breast and cervical cancer screenings. By undermining women’s access to preventive services in addition to blocking their ability to obtain necessary care at Planned Parenthood, the BCRA is putting women’s financial stability and health at risk.
Deep Cuts to Medicaid
Finally, the BCRA eviscerates Medicaid, slashing our nation’s health care safety net. By restructuring the Medicaid program into block grants or per capita caps and effectively ending the ACA’s Medicaid expansion, the BCRA is stripping away $772 billion in federal funding from states, making it harder for women and families on Medicaid to access necessary health care services, and reducing the ability of nurses to provide health care services to the most vulnerable populations. One in five women of reproductive age, nearly one-third of Black women of reproductive age, and more than one-quarter of Latina women of reproductive age are enrolled in Medicaid. Furthermore, Medicaid finances over half of all births in the US, and accounts for 75% of all public dollars spent on family planning. All of the ACA-repeal bills decimate the Medicaid program and will leave millions of women and families without health care coverage or access to necessary family planning services, increasing health and economic disparities for communities of color and low-income women. And this not only affects women of reproductive age but also older and aging women. In fact, AARP data show the majority of nursing home residents are women on Medicaid, which would mean dramatically reduced benefits for older women requiring nursing home placement.
All of these bills are an attack on women’s health and would have a disproportionate impact on low-income women and women of color. They would compromise America’s 3.6 million nurses’ ability to do their jobs and deliver high-quality, safe and efficient care. By stripping away health coverage from millions of people, rolling back protections for preexisting conditions, undermining preventive services and the Essential Health Benefits, defunding Planned Parenthood, and gutting Medicaid, ACA-repeal bills put women’s health and economic security on the line. We can’t allow Congress to discard the gains made by the ACA and endanger nurses, and women and their families.
Note: The authors acknowledge the American Nurses Association and the National Partnership for Women and Families for their assistance with this post. The authors are members of the Women’s Health Expert Panel of the American Academy of Nursing. Thoughts expressed here are ours alone and do not reflect those of the American Academy of Nursing.