The Impact of Medicaid on Women's Healthcare Coverage, Explained
- Sophia Steinhorn
- May 9, 2020
- 8 min read
Over the last decade, conversations about healthcare have dominated political and social discourse. Words like Medicare, Medicaid, and Obamacare have become colloquial, and sometimes incorrectly interchangeable, ways to refer to federal health programs. When President Obama passed the Affordable Care Act (ACA) in 2010, he intended to re-shape the American healthcare system entirely, but the volume of current discussions surrounding public and private systems has blurred the actual impact of these federal expansions. For women, the ACA meant increased coverage and greater access to reproductive services like family planning, preventive care, and contraceptive education. With the current administration’s intent to dismantle public insurance, the longevity of this access has been called into question. But what are the actual impacts of programs like Medicaid on women’s care across the country? And how are these impacts threatened by recent legislative challenges?
Why was the Medicaid program established?
In 1965, the federal government established Medicaid to increase public healthcare coverage for low-income individuals and families. It was developed alongside its partner program, Medicare, which primarily provides services to retirees, disabled workers, and their spouses or dependents. Prior to Medicaid’s implementation, healthcare for federally recognized vulnerable populations was rarely supplemented with federal funding, and states had to manage these public assistance programs without much oversight.
Unlike Medicare, which is federally funded and administered, Medicaid was created as a joint federal-state program and still left significant agency up to individual states in terms of what medical services they offer and how much federal funding they receive. Throughout the 1980s and 90s, Medicaid expanded their eligibility categories to include low-income pregnant women and children via the State Children’s Health Insurance Program (SCHIP). Under changing Medicaid requirements, low-income women qualified for enrollment if they were seniors, pregnant, disabled, or had dependents. Despite these increased federal mandates, primary jurisdiction over the implementation of Medicaid-covered healthcare services has consistently remained with the states.
How has Medicaid coverage changed under the Affordable Care Act (ACA)?
The Affordable Care Act (ACA) is the most recent expansion to Medicaid that eliminates eligibility categories and extends coverage to all individuals whose income is 138% of the federal poverty line (about $17,000 in 2020). While President Obama intended to move towards an increase in affordable healthcare services nationally, strong opposition to the ACA has preserved the original federal-state structure of the program. In its original verbiage, the ACA outlined that states had to either adopt the expansion or forfeit their Medicaid funding entirely, but the Supreme Court ruled in National Federation of Independent Business v. Sebelius that it was unconstitutional to impose this severe punishment on the states. With this optional adoption policy, Medicaid coverage throughout the United States is severely inconsistent. However, the courts did approve an individual mandate that requires individuals to enroll in health insurance or pay a penalty, deeming this requirement within Congress’s ability to impose taxes. Ideally, this mandate would generate the funds to improve the Medicaid program and provide health insurance for a greater number of low-income people across the country.
Since the first ACA expansions were implemented, the number of uninsured women declined from 18% in 2013 to 12% in 2017. The enrollment statistics gathered in 2014 found that 25 million women were enrolled in Medicaid, and 67% were between the ages of 19 and 49 years old. Because women belonged to the previously required eligibility groups (i.e. pregnant, parent of a dependent child, disabled) at higher rates, they have historically comprised a majority of Medicaid recipients. Additionally, 41% of the women on Medicaid have incomes less than 200% the federal poverty line, indicating that the program still mainly services financially struggling or impoverished individuals.
How does the Medicaid expansion differ state by state?
Because states do not have to adopt the Affordable Care Act to continue receiving Medicaid funding, eligibility requirements and women’s coverage vary drastically between states. Washington DC and thirty-six states have implemented the expansion, allowing individuals at or below 138% the federal poverty line to qualify for Medicaid. Some states like California and New York implemented the ACA as early as January 2014, while others have endured a more tumultuous road towards expanding coverage. For example, voters in Utah approved the expansion via ballot measure in November 2018, but didn’t achieve full implementation until January 2020 due to push back from the state legislature. Similarly, Nebraska also approved the Medicaid expansion in November 2018, but the state delayed the full enactment until October 2020 in order to submit amendments to the program.
The 14 states that have not adopted the ACA still require Medicaid recipients to belong to the traditional eligibility groups, and some have implemented significantly lower income thresholds. For example, in Texas parents must either belong to federally-specified vulnerable groups or make a mere 17% of the federal poverty line to qualify for Medicaid coverage. In this way, Texas has rejected the ACA expansion altogether. Likewise, recently elected Republican conservatives in the Mississippi state legislature have taken a staunch opposition towards broadening the eligibility requirements for Medicaid, making it highly unlikely that the state will adopt any expansive measures in the near future. Wyoming has attempted to move forward with approving the Medicaid expansion via bill, but the House voted in February 2020 against adding the bill to its consent agenda and against including the expansion on the November 2020 ballot.
This variability in Medicaid coverage nation-wide has also resulted in sporadic services for women ages 19-64. ACA states like California, New York, and New Mexico cover 24-31% of women, whereas Mississippi covers 16%, Texas covers 9%, and Wyoming covers 8%. With these coverage disparities, access to affordable medical services for women is almost entirely dependent on the state they live in.
What types of reproductive healthcare services are covered by Medicaid?
Medicaid programs must offer certain family planning services to comply with federal guidelines, but some agency is left up to the states in terms of what benefits are covered. Women of reproductive age (19-49) make up a majority of female Medicaid recipients, making access to and quality of reproductive care counseling and contraceptives imperative.
In terms of changes to women’s preventive care, the ACA increased access and significantly lowered out-of-pockets costs. The expansion requires health plans to cover the cost of birth control, saving women more than $1.4 million per year in costs. Moreover, women on Medicaid pay out-of-pocket costs for preventative services like pap tests, mammograms, and colon cancer screenings at much lower rates than those covered under private insurance or uninsured.
Currently, Medicaid is responsible for paying 75% of all public funds for family planning services. Significantly, Medicaid also covers 42% of people giving birth, though some states operating under previous requirements limit maternity coverage to 60 days postpartum if the woman is not income-eligible. In states where the ACA expansion was adopted and implemented, women are likely to still qualify for Medicaid coverage and thus have a greater ability to seek postpartum care and support. Some states have even individually expanded their family planning coverage via permanent State Plan Amendment (SPA). For example, women in California whose income is 200% of the federal poverty line still qualify for Medicaid family planning services, as do women in Wisconsin whose income is 306% of the federal poverty line. In Wyoming and Rhode Island, women can continue using Medicaid family planning services postpartum if they would no longer qualify based on their income level, but both of these provisions are approved by waivers from the Centers for Medicaid and Medicare Services (CMS) and must be renewed in the coming years.
Abortion coverage under Medicaid is hotly contested. Because the Hyde Amendment prohibits the federal funding of abortion except in cases of rape, incest, or when a woman’s life is in danger, other circumstance abortions are not technically covered under Medicaid. However, 15 states have allocated state funds to other abortion cases, and California, Oregon, Washington, New York, Maine, and Illinois all require abortion to be covered under both Medicaid and private insurance plans. On the other end of the spectrum, some states have been found guilty of not complying with the federal allowances of the Hyde Amendment. Specifically, a January 2019 Government Accountability Report found that the South Dakota state plan only allowed Medicaid coverage for abortions when the woman’s life was endangered, and they had failed to provide services in the case of rape and incest for over 25 years. The CMS has not pressured South Dakota to comply with federal law thus far and officials say they don’t plan to anytime soon.
Although the ACA broadens the number of women who qualify for Medicaid’s family planning services, states ultimately have the final say over whether low-income women on a federal plan can access quality and affordable maternity care and abortion services. Again, location significantly dictates access, and a certain standard of care is not distributed equally throughout the country.
How will the Trump administration’s Medicaid reforms affect access for women?
Trump has been hard-pressed to dismantle the ACA since his first day in office. Since the ACA primarily increased the percentage of low-income women who qualified for public health insurance, rollbacks on this landmark Obama policy are disproportionately affecting their ability to seek medical care. Almost immediately after he was sworn in, Trump eliminated the individual mandate via Republican-backed tax legislation in 2017, thus raising premiums for ACA recipients that were previously controlled by the penalty revenue.
Trump has also instituted even more flexibility for states in terms of their Medicaid implementation. Recently, the administration gave states the option to add work requirements to Medicaid benefits, which could cause a significant number of current recipients to lose their coverage. Under these new standards, individuals seeking public healthcare coverage would have to show proof of work, volunteer experience, and job training. Of those that would lose Medicaid benefits under a work requirement, two-thirds would be women because they are more likely to have informal caregiving positions or low-paying jobs that do not offer health insurance. However, the Appeals Court recently rejected these work requirements in Arkansas, and other states that have approved similar requirements are waiting to implement them until subsequent court battles play out.
Perhaps one of the most significant new leniencies under the Trump administration is their changes regarding the federal free choice of provider allowance. Historically, the federal government has allowed Medicaid recipients to seek healthcare services at any reputable provider. This allowance was particularly important for low-income women in terms of family planning or reproductive services because it prevented states from restricting the use of certain clinics because they offered abortion services. However, Trump has recently made exceptions to this standard by approving Texas’s Medicaid waiver which excludes Planned Parenthood as a provider. With this exclusion, Texas has greatly reduced women’s access to contraception services and critical cancer screenings. Moreover, the state has attempted to fill the clinic loss by diverting funds to an anti-abortion organization called the Heidi Group with no prior family planning experience. Although Texas proposed that this organization could serve around 50,000 clients in 2017, they only provided public care for only 2,300 individuals. With the federal government approving these types of waivers, other states are likely to follow suit and low-income women will have a greater difficulty accessing essential family planning services.
Between cutting individual mandates and making federal guidelines more lenient, the Trump administration is overwhelmingly threatening the healthcare coverage of millions of women in the United States. Certain states will continue to serve as a type of safe haven for low-income women, but for women in areas that have not adopted the ACA expansion, access to affordable contraceptives, maternity care, family planning, and abortion is scarce and dwindling.
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