Trump, the ACA, and Women’s Health

The health of women in the United States is in the hands of President Trump and the Republican-controlled Congress. On the campaign trail, Trump vowed to repeal and replace the Affordable Care Act (ACA) by partnering with Congress to “create a patient-centered health care system that promotes choice, quality, and affordability.” However, repealing the ACA poses a serious threat to the health care in America. As of 2016, the Health Insurance Marketplaces, Medicaid, and other ACA provisions expanded health insurance coverage to 20 million Americans, and a record number of Americans enrolled in health plans from Health Insurance Marketplaces for 2017. Women are particularly vulnerable to the effects of repeal.

One way the ACA is improving women’s health is through nondiscrimination policies and access to affordable, quality health plans. No woman can be denied health insurance because of her gender. In 2016, 6.8 million women and girls selected health plans from the Health Insurance Marketplaces. The uninsured rate among women aged 18 to 64 decreased by 44%. The ACA also extended preventive services without co-pays or deductibles to 55.6 million women, and 8.7 million women received insurance for maternity services. Another 65 million women are protected from discrimination or higher premiums because of pre-existing conditions. Despite these expansions in coverage, cases like Burwell v. Hobby Lobby, which allows family-owned corporations to cite religion to deny ACA-mandated contraception coverage, limit women’s access to health care.

Repeal

Repeal

Republicans have control of both chambers of Congress, but are eight seats shy of a filibuster-proof 60-vote majority in the Senate. As a result, Democrats will be able to stop Republicans from passing a law that fully repeals the ACA. But Republicans have already begun to lay the groundwork to use the budget reconciliation process to get rid of the ACA’s coverage expansions. This is a parliamentary tactic that allows bills with a clear budgetary impact to pass the Senate with a straight majority of 51 votes.

Only 20 budget reconciliation bills have become law since 1980, but they have included some of the most consequential legislation of the last 20 years, including Bill Clinton’s welfare reform and the George W. Bush tax cuts. Republicans have already used reconciliation to repeal parts of the ACA, though their bill did not become law because of President Obama’s veto last January. Democrats are not in a position to criticize Republicans for using reconciliation to repeal major parts of the ACA given that this is how they passed the law in the first place.

It is clear that Republicans can pass a bill repealing the ACA. It is far from clear, however, whether they can simultaneously pass a replacement. Many don’t think they need to because they can simply delay the date by which their repeal will go into effect. They hope that a compromise on what comes next will become possible in a few years because enough parts of the law will fall apart by that point and there will be intense pressure on Democrats to cooperate.

And Replace?

Repealing the ACA would increase the number of uninsured women, limiting access to quality, affordable health plans. The extent of the impact will depend on what is ultimately enacted. One approach Trump and Ryan have proposed is expanding the use of Health Savings Accounts (HSAs). According to Timothy Jost, HSAs would primarily benefit the wealthy because tax deductions do not proportionately benefit low-income families compared to high-income families. Jost also notes that Republicans have proposed replacing the ACA with fixed dollar tax credits, but these credits would not cover the cost of health care as much as the current ACA health plans. Replacing the ACA health plans with HSAs might disproportionately affect low-income women if this approach mostly benefits the wealthy.

Replacement proposals should continue non-discrimination policies that prohibit insurers from denying a woman coverage because of her gender, as well as ensure access to quality, affordable plans with preventive and maternity services.

Trump has shown a willingness to keep some parts of the ACA, like a provision extending coverage to individuals on their parents’ health plans until the age of 26 and a provision protecting individuals with pre-existing conditions. He should add women’s coverage to that list. Republicans are likely to target federal funding for Planned Parenthood. This would significantly decrease access to services like cervical cancer prevention, breast cancer screenings, pelvic exams, endometriosis treatment, and Pap and HPV tests, among others. But this does not mean Republicans cannot support parts of the ACA that maintain access for women. Pace and colleagues found that the ACA improved consistent use of the oral contraceptive pill among women because it eliminated cost sharing, which lowers rates of unintended pregnancy. Replacement proposals should continue non-discrimination policies that prohibit insurers from denying a woman coverage because of her gender, as well as ensure access to quality, affordable plans with preventive and maternity services.

Secretary Price & What Comes Next

The nomination of Georgia Congressman Tom Price to lead the Department of Health and Human Services has enormous implications. He is an avid opponent of the ACA, having introduced replacement plans to Congress each year since its enactment. Just as Kathleen Sebelius and Sylvia Burwell played major roles as HHS Secretary in defining what the ACA actually accomplishes, what the ACA’s repeal legislation actually means will in large part hinge on Price’s interpretation and influence.

Even before the ACA is repealed, Price could undercut major parts of the law by refusing to enforce regulatory requirements. The Obama administration is defending challenges to the ACA in court, but Price and the Trump administration could stop defending the lawsuits, allowing the plaintiffs to win. These include contraceptive cases like Zubik v. Burwell, which the Supreme Court recently returned to lower courts after religious groups challenged the ACA’s mandate to provide insurance coverage for contraception to employees.

Considering Price and Trump’s vow to dismantle the ACA, it is difficult to imagine “a patient-centered health care system” that serves women and “promotes choice, quality, and affordability” for women.

Featured Image: Gage Skidmore, Donald Trump speaking at CPAC 2011 in Washington, D.C., used under CC BY/cropped from original.