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What Women Have to Gain (or Lose) In the Battle Over Health Reform

May 1, 2012

By Maggie Mahar

(This post is excerpted from a series that originally appeared on Healthinsurance.org)

When Vice President Joe Biden told President Barack Obama that health reform is a BFD, he wasn’t kidding—especially for women. Currently, state law decides what insurers have to cover. Under the Affordable Care Act, federal law will call for equal benefits in all states.

The male body has long been considered the “standard” for health care coverage. Having a woman’s body is seen as an expensive anomaly, and women pay dearly for being different. When they buy their own health insurance in the individual market, women must lay out an extra $1 billion a year, simply because they are women.

Take maternity care: In the 41 states where such benefits are not mandated, a 30-year-old woman will find that only 6 percent of plans in the individual market now offer coverage. Guess how expensive those plans are? Under the ACA, maternity care will be considered an “essential benefit” that all insurers selling policies to individuals and small businesses must cover, without charging extra, beginning in 2014.

Some argue that charging women more for insurance is only fair: after all, a woman could become pregnant, and labor and delivery are costly.

But the truth is that, even when maternity benefits are excluded, one-third of all health plans charge women at least 30 percent more, according to a report released last month by the National Women’s Law Center. In 36 states, “92 percent of best-selling plans charge 40-year-old women more than 40-year-old men,” the Center reports, and “only 3 percent of these plans cover maternity services … One plan in South Dakota charges a woman $1252.80 more a year than a 40-year-old man for the same coverage.”

Today, less than half of American women can obtain affordable insurance through a job, which explains why millions buy their own insurance in the individual market. In that market, just 14 states ban gender rating:  California, Colorado, Maine, Massachusetts, Minnesota, Montana, New Hampshire, New Mexico, New Jersey, New York, North Dakota, Oregon, Vermont, and Washington.

Pricing based on gender also plagues the small group market, where insurers frequently jack up premiums if a small or mid-size business employs too many women. This means that many of these employers just cannot afford to offer insurance. Only 17 states address the problem.

Insurers explain that women cost them more, even if policies don’t cover maternity, because “they are more likely to visit doctors, get regular check-ups, take prescription drugs, and have certain chronic illnesses.” In other words, women are penalized for taking care of themselves. As for those “female chronic ailments,” men also are more vulnerable to certain diseases – including many caused by smoking (23 percent smoke vs. 17 percent of women). But insurers ignore male vulnerabilities. As Soraya Chemaly points out on BlogHer: “In most markets if you are a non-smoking female you will pay more than a smoking male of the same age because you possess ovaries and not testes.”

And that is if you can get insurance.

All too often, women are closed out of the individual health insurance market because their medical history reveals a pre-existing condition. Rules discriminate against millions of women for a long list of commonplace reasons including:

In 45 states, insurers can reject a woman because she has had a C-section – even if it was medically mandated.

  • If a woman has survived breast cancer, this is a pre-existing condition
  • If she is pregnant when she applies, this also is considered a pre-existing condition, just like cancer.  Most likely, she will be turned down.
  • If she is of child-bearing age and has children, this may well viewed as a pre-existing condition, leading to higher premiums
  • On the other hand, if she is infertile, this too, can be labeled a pre-existing condition.

Not long ago, House Minority Speaker Nancy Pelosi summed up the hurdles: “If you’re a woman, it’s a pre-existing condition.”

The Affordable Care Act (ACA) would help fill many of the coverage gaps we currently experience in women’s health care. Important provisions include:

Preventive services with no co-pays or deductibles: New Policies (issued or renewed on or after September 23, 2010) are required to cover services that many women need  – mammograms, Pap smears, at least one well-woman care visit a year, contraceptive products and counseling, and screening and counseling for interpersonal and domestic violence. In 2018, these requirements will apply to all plans.

Essential benefits: In 2014, both all plans sold inside the new state-run health insurance exchanges and all new plans sold outside of the exchanges will be required to cover a specific set of essential health benefits. For women, these include maternity and newborn care; mental health services (including counseling for post-partum depression); preventative and wellness services; contraception; chronic disease management; and pediatric services for her children, including dental and vision care.

At the same time, the legislation bans:

Gender rating: In 2014, charging women more because they don’t have a Y chromosome will be outlawed both in individual and small employer markets. After 2017, if a state lets large employers into its exchange (and many will), the rule will apply to all large-employer coverage in the state.

Charging more for pre-existing conditions: Starting in 2014, insurers cannot charge higher premiums, or deny coverage due to a person’s pre-existing conditions.

The bottom line: Under the Affordable Care Act, women’s bodies will no longer be viewed as exotic, costly deviations from the norm that just don’t fit into a health care system designed by, and for, men.

What happens if the Supreme Court overturns the individual mandate?

The Court might rule that if everyone is not forced to buy coverage, insurers shouldn’t be forced to cover everyone—especially if they are suffering from pre-existing conditions. (Without a mandate, the reasoning goes, many Americans will wait until they fall ill, and only then purchase coverage, secure in the knowledge that insurers will have to cover them, and can’t charge them more).

Even if you don’t like the mandate, you should consider what it would mean for women if insurers can charge patients suffering from a “pre-existing condition” whatever they like.

For example, a recently divorced 62-year-old woman who is no longer covered by her husband’s insurance may find that she is closed out of the insurance market because she is a breast cancer survivor. Even if she can find an insurer who will take her, the penalty for having a pre-existing condition may well be more than she can afford. In insurance parlance, she will have to “go naked” until she is eligible for Medicare, keeping her fingers and toes crossed that her cancer does not recur or spread over the next three years. (If it does, she will have to spend down whatever savings she has, and perhaps sell her home, before she will be eligible for Medicaid.)

Or consider the case of a young woman who discovers that she is pregnant. She and her husband were not planning on having a child so soon. Suddenly, they find themselves facing thousands of dollars in medical bills. If the woman needs a C-section they may wind up owing as much as $24,400. (Five percent of U.S. hospitals actually charge more.) And that is if there are no serious complications.

It is extremely unlikely that the Supreme Court will declare the entire Patient Protection and Affordable Care Act unconstitutional. Whatever the Court decides in June, women will retain protection against much of the sexual discrimination embedded in our current health care system – unless lawmakers set out to eviscerate the ACA.

As Chemaly points out on BlogHer: “The openly stated primary priority of the Republican Party is to overturn this law.” If that happens, “these discriminatory practices will continue and women will pay in complex ways.”

Even if President Obama is re-elected, Republicans and Democrats who oppose reform could constitute a majority in both houses, and might even have enough votes to overturn a veto on certain controversial issues—such as gender rating, or essential benefits. Many men believe that women should pay more. And they are not happy about covering maternity benefits, contraception, or post-partum depression.

Meanwhile, without the Affordable Care Act, we cannot count on insurers to mend their misogynistic ways. Four years ago, the Women’s Law Center issued a national report titled “Nowhere to Turn: Insurance Companies Treat Women like a Pre-Existing Condition.”

Back then, the Center reached conclusions very similar to what it said in the report released last month. In 2008, “Some insurance executives ‘expressed surprise at the size and prevalence of the disparities,’” Chemaly notes, but “apparently these executives weren’t surprised enough to do anything about it. . . By failing to rectify clearly discriminatory policies despite years of awareness, they continue to demonstrate their untrustworthiness.”

This is why, in the run-up to this fall’s election, voters should take a close look at their Senators’ and Representatives’ records when voting on major health legislation. Not only women—but the many men who care deeply about their daughters, wives, mothers, and sisters—should think carefully about what repeal could mean for those they love.

Maggie Mahar is a notable health care policy blogger as well as the former Health Fellow at The Century Foundation where she was editor of HealthBeat. She is the author of  “Money-Driven Medicine: The Real Reason Health Care Costs So Much” (Harper Collins 2006)

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