The failure last week of U.S. Republican leadership to repeal and replace the Affordable Care Act (ACA), also known as “Obamacare,” is an example of just how hard it is to design and implement health care reform. President Donald Trump himself told reporters: “Nobody knew health care could be so complicated.”
After two decades of working on health care reform in the U.S. and supporting countries around the world with their reform efforts, I have seen just how complicated it can be to design workable health policy and then build political consensus to put it in place.
What I’ve learned: We can’t give up on the goal of building strong health systems that work for everyone — rich or poor, young or old, healthy or sick, man or woman. Healthy people who are not hamstrung by medical costs are the foundation of thriving, prosperous economies.
We need to find a fair and affordable way for everyone to pay over the course of their lives and then draw from the system when they need it…recognizing that some people are unluckier when it comes to their health. If we all contribute some resources — through taxes or premiums — everyone benefits. People who are not sick now may be in 20 years. A man who doesn’t need prenatal care for himself is the product of maternity care and may father children who require it.
This premise appears to be lost on some U.S. lawmakers who wanted to eliminate ACA requirements that health plans cover essential services. This is a particularly dangerous notion for women.
We must design health systems that work for women — supporting both their health needs and their economic independence. Societies are stronger when women can get affordable family planning, prenatal care, childbirth services and care for their newborns and children.
Women need comprehensive coverage, and they shouldn’t have to pay higher prices just because they are women
Over the course of our lives, women on average require more contact with the health system and incur more health care costs than men.
When I compare how much health care I have consumed over the past 15 years versus my husband, there is a huge difference. I’ve had two pregnancies, two cesarean sections, and I get frequent mammograms because of my family history. My husband, on the other hand, basically goes for an annual checkup.
In the past, American women were frequently discriminated against in the insurance market. Insurance companies charged higher premiums for women than for men with similar ages and risk profiles. But the passage and enactment of the ACA changed all of this. In particular, it required plans to cover key preventive services, including family-planning and reproductive health. And it made it illegal for insurers to differentiate prices based on gender.
Thankfully, last week, a bill that could’ve rolled back these gains did not advance past the U.S. House of Representatives.
Systems that offer health coverage based on employment status reduce women’s personal and professional options
American women also dodged a different kind of bullet last week. They will maintain personal and professional options.
The ACA makes it much easier for people who don’t receive health coverage from an employer to get health insurance as an individual. (Most working-aged Americans get health insurance through a private employer-sponsored plan.) Today, approximately 11.5 million people are receiving coverage through the ACA individual insurance marketplace.
It’s a win for women when they don’t have to work for a large traditional employer to get access to the care they need, or rely on their husband’s employer-sponsored health coverage.
Imagine a woman who is not in the paid labor force. She is working at home, taking care of a family, but her domestic situation is violent or otherwise bad. She gets her health coverage as a result of her husband’s employment. Maybe she is currently pregnant or she or one of her children has a chronic health condition. She may feel like she can’t remove herself and her children from a bad situation, in part because she will lose health coverage.
Now let’s imagine a different woman — she currently has a decent job that pays her bills and ensures health coverage, but she has a dream to strike out on her own and start a business or maybe quit her job to run for public office. She may decide not to pursue these opportunities for fear of losing health coverage. This applies to men as well, but with more limited health costs during their working years, they may be more willing than women to take a professional risk and forgo health coverage.
Tying coverage to employment may put women in positions of dependency or limit their professional options.
The best health systems offer high-quality, affordable coverage for all
Here in the U.S., lawmakers will continue to debate whether to repeal and replace or improve upon the ACA. Meanwhile, the rest of the world can learn from our health care reform challenges. For instance, other countries should ensure that all forms of health coverage include essential benefits, such as primary and preventive health care and women’s health services. They should create systems where access to health coverage is not tied to employment status, which presents particular challenges for women. Ideally, everyone should get the same high quality coverage, where the risks and the costs are shared across the population.
The good news is that a number lower and middle-income countries that are working to create health coverage systems. Countries like Ghana, the Philippines, Indonesia and Vietnam are moving toward single-coverage programs instead of separate programs for different populations. These countries have a long road ahead of them, but they are on a good path to health systems that are designed efficiently and effectively. These programs receive strong political support across the spectrum because they cover everyone.
The U.S. could learn a few lessons from these countries, too. Just last week, calls for one system of health coverage for all began to emerge. This would be an improvement over our current fragmented system. But for now, I am pleased that American women will, at least for the moment, keep the gains they won seven years ago.