Reena Aggarwal: What does the failure of AHCA mean for women’s healthcare?

Despite the AHCA failing, plans to defund Planned Parenthood in the US will damage women’s healthcare choices, says Reena Aggarwal

reena_aggarwalThe Affordable Care Act (ACA) was a game changer for women’s health. Prior to the ACA, 1 in 6 Americans were uninsured—non pregnant women were twice as likely to be uninsured compared to pregnant women, and 25% of women of reproductive age were uninsured at some point over the course of one year. [1,2] The ACA expanded federal funding to increase Medicaid eligibility which  resulted in 20 million previously uninsured individuals gaining coverage, and women of reproductive age who did not have health insurance dropping by a third. [3]

During the Republican Party’s recent failed attempt to “repeal and replace” the ACA, women’s healthcare came under fire. One element of the ACA was the requirement that all insurers cover an array of ten “essential health benefits” which spanned maternity care and preventive services (vaccinations, screening, and contraceptive coverage) at no extra cost. In order to make the American Health Care Act (AHCA) more palatable to the House Freedom Caucus (a group of strict fiscal Conservatives in the Republican Party), these essential benefits were taken away to allow individual states to decide what counted as “essential.” It is worth remembering that prior to ACA, the majority of insurers either had no maternity benefit, or it was prohibitively expensive (high deductibles and co-pays). If a woman became unexpectedly pregnant and discovered her plan did not cover maternity, and then tried to change plans, pregnancy would be a considered a pre-existing condition and she could therefore be denied coverage. Adding a maternity benefit to all health insurance policies prevented discrimination and also prevented women paying more for health insurance. Without health insurance, childbirth can cost anything up to $20,000 in the USA, but whilst the maternity benefit has raised premiums overall, it made childbirth affordable for millions of families. However, now that President Trump has said he will allow “Obamacare to explode” due to the instability of insurance markets, there is legitimate concern that with no federal oversight private insurers may remove essential benefits from their plans, which could leave millions of women without maternity coverage.

Additionally, in an effort to appease the pro-life agenda of more Conservative Republicans, the AHCA had proposed defunding Planned Parenthood by removing federal funding. From the creation of Margaret Sanger’s birth control organization in 1916, Planned Parenthood has grown into a global not for profit organization providing comprehensive family planning and related reproductive health services. It has received federal funding since 1970 when President Nixon wrote that, “no American woman should be denied access to family planning assistance because of her economic condition” and brought into being the Title X Family Planning Program with broad bipartisan support. The purpose was to ensure all people, not just the wealthy, could plan their families. The 1976 Hyde Amendment banned federal funding for abortions, so despite receiving Title X funding and being reimbursed by Medicaid for providing services, Planned Parenthood cannot use these funds to pay for abortions. Opponents of abortion attest that by allocating money to Planned Parenthood for the provision of other medical services allows other funds from philanthropic organizations to be re-allocated for abortions.

The Congressional Budget Office (CBO) predicted that by removing federal funding from Planned Parenthood about 15% of women in low income areas would lose care by affecting “services that help women avert pregnancies” and the additional births “stemming from the reduced access” would add to federal Medicaid spending. This is because Planned Parenthood is the sole source of publicly funded contraceptive care in the United States offering comprehensive methods including more expensive (but reliable) long acting reversible contraception (LARCs), alongside STI testing, mammograms and cancer screening. Abortion care accounts for only 3% of services. Many of their clients are young, immigrant, low income women whose only source of care are their services as clinics often operate medically underserved areas making it the “safety net” for marginalized women. [4]

President Trump blamed the House Freedom Caucus (vehemently pro-life) for helping to save Planned Parenthood by opposing the AHCA. At the end of April, the US government faces an expiration of their spending bill to fund federal government and in order to pass a new resolution, calls to deny federal funding to Planned Parenthood may become a non-negotiable condition. President Trump needs the funding bill to pass as many of his policies hinge upon this—for example, increasing defence spending and funds to build a border wall between Mexico and the United States. Despite failing to pass AHCA, last week, Vice President Pence cast a tie-breaking senate vote to pass legislation allowing states to withhold federal funds from Planned Parenthood and other providers performing abortions.

By resuscitating these measures, women covered by Medicaid will no longer be able to choose Planned Parenthood clinics for their care. Unless alternative services are provided, this would be catastrophic for women’s reproductive choices and health needs. The US abortion rate has declined 14% between 2011-14 and in 2014 was at the lowest rate since 1973 when abortion was legalized. This is attributed to education and contraception coverage. [5] Without publicly funded family planning care, it is predicted that US teen pregnancies could be 73% higher than they are now. [6] Some commentators have suggested that women look for other providers or even move states. Lest we forget restriction of contraception and abortion services in Romania led to one of the highest maternal mortality rates in Europe.

Removing federal funding from Planned Parenthood doesn’t prevent abortions—it hurts women’s choices by denying them access to affordable contraception or screening services. Removing maternity care from the essential health benefits in insurance policies means it will cost women more to have coverage. Both of these are unconscionable. Sean Spicer, suggested “men and women beyond maternity age and young people paying for end of life care” did not make “sense.” This exposes a lack of understanding about health insurance and the role of essential health benefits. Despite AHCA failing, there is a very real danger that the hostility toward abortion will roll the clock back to the discriminatory policies before the ACA was implemented, and make it harder for women to prevent an unintended pregnancy (already 1 in 2 pregnancies is unplanned), have care throughout their pregnancy, and maintain their health needs. President Trump once espoused that his healthcare plans would cover “everyone”—let’s hope he remembers to do just that for the 50.8% of the American population who are women.

Reena Aggarwal is a specialist registrar in Obstetrics and Gynaecology and a research fellow at Ariadne Labs in Boston. Twitter @drraggarwal

Competing interests: None declared. 

  1. Institute of Medicine. America’s Uninsured Crisis: Consequences for Health and Health Care. Washington DC; 2009.
  2. Kozhimannil KB, Abraham JM, Virnig BA. National Trends in Health Insurance Coverage of Pregnant and Reproductive-Age Women, 2000 to 2009. Women’s Heal Issues. 2012;22(2):e135-e141. doi:10.1016/j.whi.2011.12.002.
  3. Gold RB, Starrs AM. US reproductive health and rights: beyond the global gag rule. Lancet Public Heal. 2017;2(3):e122-e123. doi:10.1016/S2468-2667(17)30035-X.
  4. Understanding Planned Parenthood’s Critical Role in the Nation’s Family Planning Safety Net | Guttmacher Institute.
  5. Behind the Declines. Guttmacher Policy Rev. 2017;20.
  6. Teen Pregnancy | Guttmacher Institute. https://www.guttmacher.org/united-states/teens/teen-pregnancy. Accessed March 31, 2017.
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