Were you born female? If so, do you want to conceive, need birth control, a mammogram, or an annual exam? Gender aside, do you have any underlying health problems? Do you lack employer-sponsored insurance but do not qualify for Medicare or Medicaid? If so, you benefit from the protections established in the Affordable Care Act.
Prior to the implementation of the ACA, unless you were a healthy young man, individual or small business health insurance policies were costly or even unobtainable. If you had underlying health issues, known in insurance parlance as “pre-existing conditions,” such as hypertension, diabetes, or cancer, even if they had resolved, or if you had had prior surgery, such as a Cesarean section, you could be penalized with astronomically high rates. Even worse, about 20 percent of the time, your insurance application was denied. Yet, you still needed care. Since the passage of the ACA, the number of uninsured Americans decreased from 46.5 million in 2010 to under 27 million in 2016. Although the number of uninsured has risen some since then (to 33 million in 2019), a situation worsened by the rise in unemployment secondary to the COVID epidemic, the number of uninsured persons remains significantly lower than the pre-ACA state.
Did you realize that the ACA dictates that insurers cover well-woman care? This means pap smears, mammograms, screening for domestic violence, contraceptive counseling, exploring how to stay healthy. It may mean a routine exam that discovers thyroid or rectal cancer, or breast cancer not seen on mammogram, as my patients can attest. An annual exam is an opportunity to ask a question and receive a reassuring response, “no, you don’t have to worry; it’s nothing.” Other times, the question may prompt further investigation, leading to a better and longer life.
Another provision of the ACA requires insurance coverage of maternity care. Uninsured women are more likely to receive less care, have worse pregnancy outcomes, and their newborns are more likely to be of low birth weight, and are more likely to die. Without regular obstetrical care, there is a greater chance that your gestational diabetes, high blood pressure, or bladder infection will not be diagnosed, to the detriment of you and your baby. All moms, both new and experienced, have questions and concerns. OB visits are opportunities to make sure that you have what you need to care for yourself and your child.
The Affordable Care Act mandates that insurance companies cover all FDA approved contraceptives. While there were already religious exemptions to this rule, this imperative was further compromised by a 2017 presidential executive order, allowing any employer who does not wish to provide contraceptive coverage to refuse to do so. Access to affordable contraception is critical for women to build their lives and their families on their timetable, when they feel emotionally and financially ready. Decreasing access to contraception is counter-intuitive to an objective to reduce the number of unplanned pregnancies and abortions. Since sex can produce unwanted pregnancies, which can lead to abortions, it stands to reason that the way to reduce the number of abortions is to make contraception easy to access, safe, and cheap.
The goal of all the parents I know is to raise healthy, happy children who grow up to have fulfilling, independent lives. However, finding a job is particularly difficult now, and many starter jobs may not provide insurance benefits. The ACA allows children up to age 26 to remain on their parents’ health insurance, protecting them from catastrophic financial debt in the event of a major illness or accident.
What about mental health? We all want it, and the COVID pandemic is challenging our ability to hold on to it. Counseling helps. We might also need medication for anxiety, depression, bipolar disorder, or other mental health diagnoses. The ACA requires small and individual group plans, as well as Medicaid expansion plans, to cover mental health services at the same level that they cover medical and surgical services. Even if we cannot imagine that we’ll need mental health coverage, life has a funny way of changing our expectations-an unexpected loss of a loved one, divorce, serious illness. Having available, affordable access to professional mental health experts can have a profound effect on the quality of our lives and the quantity of our days.
Prior to the ACA, insurance underwriters could charge more for females than males, older compared to younger patients, and sicker vs. healthier patients. The ACA eliminates premium pricing discrimination based on gender and pre-existing conditions and limits the amount that older patients can be charged relative to younger patients to a 3:1 ratio. Yes, it may make premiums higher for young males than they would have been before, but this helps make it possible for older, sicker people to be able to obtain and afford insurance. Unfortunately, the effectiveness of this cost control measure was undermined by the loss of the individual mandate, which required everyone to have insurance or pay the penalty, as well as by the approval of low cost, low benefit non-ACA compliant plans. The net effect was to take younger, healthier people out of the marketplace and drive up rates for the remainder.
Is the ACA perfect? Not by a long shot. In Kentucky, where I live, there are only 2 insurers selling individual policies on the exchange. A Silver plan for my husband and myself costs $1,800 per month in premiums, with a $13,600 deductible and an out-of-pocket maximum of $14,600. Therefore, the total exposure every year is over $36,000! Furthermore, there are no alternatives for individual coverage other than the exchange. However, without the ACA protections, we might not be able to buy health insurance at all. The best solution? The U.S. must join all the other developed countries around the globe and implement universal health coverage. Make health care affordable and accessible for everyone. It should be the American way.
Susan G. Bornstein is an obstetrician-gynecologist.
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