In August this year, the infamous "Harry and Louise" ads of
1993 returned. This time, Harry and Louise weren’t complaining that the government would take away
their options on health care. Instead, they called for health care reform and
worried about skyrocketing costs. Health care reform remains a top domestic
concern, and the candidates for president have proposed very different ideas
of how to correct rising medical costs. The two different plans would affect
women in very different ways.
Push Toward the Individual Market vs. Expansion of Federal Benefits
Republican presidential nominee Sen. John McCain’s plan
promotes the individual health care market. Currently, Americans pay for
employer-sponsored health care premiums with pre-tax income. McCain’s plan
would require workers to pay for insurance out of post-tax income; his plan
would offset this by extending a tax credit of $2,500 for individuals and
$5,000 for families. This tax credit can either be applied to a person’s
employer-sponsored plan or to one on the individual market. Additionally,
McCain calls for opening up options by allowing people to purchase health care
plans from providers in other states.
But this push to the individual market isn’t optimal for
women. According to a report
recently released by the National Women’s Law Center,
women have a hard time finding equitable coverage on the individual market,
often paying more and getting less. Right now about two-thirds of women get
coverage though an employer, 16 percent of women get coverage through public
programs like Medicaid, and just 7 percent of women currently get coverage
through the individual market.
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Of women who bought insurance on the individual market, the
NWLC report found that they pay more in monthly premiums at almost every age
than men–6 to 45 percent more for women aged 25 and 4 to 48 percent more at age
40. How can this be legal in the individual market and not in employer-sponsored
coverage? Courts have ruled that Title VII of Civil Rights Act applies to
employer insurance coverage. Only ten states prohibit such discrepancies in
individual market premiums, and two states limit it.
McCain’s plan to allow the purchase of insurance across
state lines could allow some women to purchase coverage in a state where the
insurance industry is regulated against discrimination by gender on the individual
market. However, this is unlikely to happen in practice, since insurance plans
in states with non-discrimination policies are likely to be far more expensive,
and many health policy experts believe that if insurance companies can insure
individuals regardless of their state of residence, the companies would
relocate to the least regulated states, much like the lax financial regulations
in South Dakota and Delaware are magnets for credit card companies.
Frighteningly, too, for women the list of pre-existing
conditions that can lead to a legal denial of health care coverage is
long. Insurers in nine states and the District of Columbia are
legally allowed to deny coverage to survivors of domestic violence. Insurers
can classify it as a pre-existing condition and deny coverage; other such
conditions include diabetes, a family history of breast cancer, or even
pregnancy. Recent research
even shows that some women can be denied coverage for having had a c-section.
This is largely exclusive to the individual market because the Health Insurance
Portability and Accountability Act (HIPAA), which was enacted by Congress in
1996, prevents employers from denying coverage for pre-existing conditions for
more than 12 months. No such limit exists on the individual market.
On the individual market, women also often struggle to
obtain coverage for maternity care, which often includes prenatal care, the
costs associated with childbirth, and even infant care. Many individual plans
simply do not offer maternity coverage; if they do, maternity care is often
covered as an optional extension to a plan called a rider. A rider often
requires a woman to pay a higher premium for an average of 12 months before she
gets covered for maternity care. The plans often only offer a benefit of a few
thousand dollars–often much less than total maternity care costs.
The NWLC report concludes that riders often end up being a
bad deal for women. Judy Waxman, Vice President and Director of Health and
Reproductive Rights at the NWLC, notes, "Nobody knows that the [individual
market] plans out there don’t cover maternity [care] and the benefits are
Employers, meanwhile, are required to cover maternity care
because courts determined it falls under the Pregnancy Discrimination Act of
McCain has appended a Guaranteed Access Plan to his larger
plan on health care reform, which is a state-by-state strategy for mandating
that those with pre-existing conditions are not denied coverage. The plan
offers little in the way of what conditions qualify as pre-existing and which
states should be targeted first. Some have called this component of his reform
In contrast, Democratic presidential nominee Sen. Barack
Obama’s plan to reform the health care system sets up a very different set of
incentives. Obama’s plan maintains current employer-based health coverage but
would also open up the purchase of federal employees’ plans to the general
public. Additionally, Obama’s proposed plan would prevent insurance companies
from denying coverage for pre-existing conditions. Though the plan raises a lot
of questions about who would be covered–for instance, would the plan be
available only to U.S. citizens or those with legal documents?–and how to make
such wide access to coverage affordable, the plan ultimately seeks to make
plans accessible and affordable to anyone wanting to purchase health insurance.
Will Reproductive Health Care Be Covered?
Women need coverage for maternity care, access to insurance
without pre-existing condition exclusions, and fair premiums, but they also
need comprehensive reproductive health care coverage. Moving forward with
health care reform makes many health policy officials that are concerned with
women’s health nervous that services like abortion, perhaps even birth control,
might be eliminated from publicly subsidized plans.
"One of the critical elements of the benefits package has
got to address the reproductive health care needs of women. That to me is not negotiable," said Kathleen
Stoll, director of health policy at Families USA.
The expansion of the Federal Employees Health Benefits
package, which Obama’s plan calls for, is unlikely to include abortion coverage
because the package currently has a ban
on abortion services (PDF). Congress briefly reversed this ban on coverage
for abortion for federal employees in 1993, only to have the ban reinstated by
Congress two years later.
"The problem with the choice issue is that it can derail
some things. And we want to get health care reform and we want to make it
happen," Stoll said. "But it’s hard for me to imagine how you can take one
finite reproductive service off the table out of the many that women need and
call that comprehensive reproductive service."
How low-income people are covered tends also to
disproportionately affect women, because women tend to be
poorer than men in every racial and ethnic group. "Medicaid is sort of the
major option for low-income people," said Usha Ranji, a senior policy analyst
at the Kaiser Family Foundation.
Currently public programs such as Medicaid don’t cover the
individual service of abortion in most states, except in very rare
circumstances when the procedure might save the life of the mother. But except
for its ban on abortion, Medicaid tends to have much better coverage than the
individual market for reproductive services like annual exams, prescription
drug benefits for birth control, and testing for sexually transmitted
infections than the individual market does.
changes to Medicaid differ slightly between the two candidates. Obama
proposes expanding eligibility for Medicaid and the State Health Insurance
Program (SCHIP), which is a program designed for low-income children. He also
proposes states to have flexibility for implementing the plan, but would
require a federal list of clinical preventative services, like cancer
screenings, be covered under Medicaid. Again, McCain’s plan advocates the
individual market by allowing funds originally dedicated to Medicaid and SCHIP
to be used for individual insurance plans and opposes expansion of eligibility
for these public plans.
Although health care reform for women, who tend to be
getting poorer care on the individual market and are more likely to be living
in poverty than men, will be an uphill battle, there is some room for optimism.
There are a number of women’s organizations fighting to ensure comprehensive
reproductive health care coverage in any upcoming health care reform. Raising Women’s Voices has been gathering stories and
using grassroots tactics to mobilize women immigrants,
women of color, and the most impoverished. They hope that by collecting the
stories of these women’s experiences with the health care system, they can
begin to call for appropriate policy action. "Once [women] hear that they’re not
alone with these problems then they’re willing to speak out about it," said
Lois Uttley, the organization’s director. "[Health care is] getting costly and
the coverage is getting worse."
Women’s health care is an critical component
of any future health care reform. Women need to make their reproductive needs a
priority in the upcoming health care debate. But the type of plans
that we shift toward will be just as important as making sure reproductive
services are covered.