Seeking Access:
Low-Income Women
Access to Healthcare
By: Jamille Fields, J.D., M.P.H. Reproductive Justice
Fellow
June 13, 2014
The National Health Law Program
• National non-profit law firm committed to improving
health care access and quality for low and limitedincome individuals and underserved populations
• Offices in Washington, D.C., Los Angeles, and North
Carolina.
Seeking Access: Low-Income Women Access to Health Care
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Overview
• The Healthcare World Pre-ACA
• The Healthcare World Post-ACA
• How this affects different Populations
o Women of Reproductive Age
o
o
o
o
Pregnant Women
Women Living with HIV/AIDs
Women with Disabilities
Women of Color
Seeking Access: Low-Income Women Access to Health Care
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The World Pre-ACA
• Employer-Sponsored Insurance
o In 2010, 56% of Americans had ESI
o 92% of Americans under 65 with private insurance were
insured through their employer
• Medicaid for some low-income individuals
o Seven of ten Medicaid enrollees over 14 are women
o Medicaid is the single-largest source of public funding for
family-planning services and supplies
o In 2010, 9.4 million women of reproductive age covered
under Medicaid
o Medicaid covers around 40% of births
Seeking Access: Low-Income Women Access to Health Care
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Medicaid Eligibility: “Worthy Poor”
Requirements for Eligibility
Personal
Characteristics
Person
Financial
Conditions
Financial
Characteristics
Citizenship or
Immigration
Categories
Category of Status
“Worthiness”
Condition
State
Residency
State
Residency
Low
Income
Low
Limited
Resources
Income
Seeking Access: Low-Income Women Access to Health Care
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Traditional Medicaid Benefits:
• Traditionally, Medicaid requires states to cover
broad categories of services
o States help define what is covered in each
category
• Existing Buckets (list not exhaustive)
o Inpatient hospital services (other than services in an
institution for mental diseases)
o Outpatient hospital services
o Laboratory and X-ray services
o Early and periodic screening, diagnostic, and treatment
(EPSDT) services for recipients under age 21
o Pregnancy-related services and services for conditions
that might complicate pregnancy
o Family planning services and supplies
o Physician services
Seeking Access: Low-Income Women Access to Health Care
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The World Post- ACA
Seeking Access: Low-Income Women Access to Health Care
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Marketplace Coverage
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U.S. Supreme Court:
An Option Created
• Federal government
cannot terminate a
state’s Medicaid
funding for not
expanding
• 27 states, including
the District of
Columbia, have
decided to expand
Medicaid
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Consequences of Failure to Expand
http://kff.org/interactive/uninsured-gap/
Seeking Access:: Low-Income Women Access to Health Care
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Family Planning “Expansion” Option
• Family Planning “waiver” programs
o States option to provide family planning
services to women (and men if the state
chooses) who would otherwise be ineligible for
Medicaid
• ACA created a new optional category of eligibility
for states to cover women and men in need of
family planning and related services
o Family planning “SPA” option
• 29 states have expanded family planning services
to otherwise ineligible individuals
Seeking Access: Low-Income Women Access to Health Care
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ACA Required Benefits
• Essential Health Benefits
• Again, Big Buckets:
o
o
o
o
o
o
o
o
o
o
Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance abuse services, including
behavioral health treatment
Prescription drugs
Rehabilitative and habilitative services and devices
Laboratory services
Preventive and wellness services and chronic disease
management (more on this later)
Pediatric services, including oral and vision care
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WHAT THIS ALL MEANS FOR
WOMEN
Women of Reproductive Age
• “Reasonable
medical
management”
allowed
• Women’s
preventive
services req are
gender-specific
Seeking Access: Low-income Women Access to Health Care
• Contraceptive
req includes “as
prescribed”
frequency
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Women Living with HIV/AIDS
• Traditional Medicaid – “Catch 22”
o Categories remain
o Childless adults need AIDS diagnosis to qualify
• Medicaid Expansion States
o New eligibility paths for
childless adults
o Nearly 60,000 uninsured
persons with HIV
living in states not
expanding Medicaid
o Out of 10 states with
highest HIV diagnosis,
5 have not expanded
Seeking Access: Low-Income Women Access to Health Care
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Pregnant Women
• Abortion Coverage
• Restrictions in the Marketplace
– Nelson Amendment
o States can ban abortion
outright
o No “subsidy” funds can be
used for abortion except for
Hyde permitted
• Medicaid Restrictions Remain Hyde Amendment
o Rape, Incest or Life
Endangerment
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Pregnant Women: •
Maternity Care
•
Full-Scope Medicaid Coverage
o Meets state income threshold
Pregnancy-Related Coverage
o Exceeds threshold, but below
133% of the FPL
• Medicaid Expansion
o Not if pregnant at time of
application
• Children’s Health Insurance Plan
o State Option, State Discretion on
upper-income threshold
• Health Insurance Marketplaces
o Qualified Health Plans must
include maternity coverage
Seeking Access: Low-Income Women Access to Health Care
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ACA & Women with Disabilities
• Pre-existing condition exclusions prohibited
• Medicaid Community First Choice Options
o State option to cover HCBS for people up to
150% FPL or requiring institutional care
• Medicaid Removal of Barriers
o State option to provide HCBS to people up
to 3X the SSI rate who are in waiver
programs (currently only up to 150% FPL)
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Women of Color: Medicaid
Seeking Access: Low-Income Women Access to Health Care
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Women of Color: Marketplace
Marketplace Enrollment -- Distribution by Race/Ethnicity of
Marketplace Plan Selections and the QHP Eligible
Population in the 36 FFM States
Dep’t of Health and Human Servs.,Office of Assistant Secretary for Planning and Evaluation, Health Insurance Marketplace: Summary
Enrollment Report For the Initial Annual Open Enrollment Period, For the period: October 1, 2013 – March 31, 2014 (May 1, 2014)
Seeking Access: Low-Income Women Access to Health Care
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ACA Non-Discrimination: Sec. 1557
• Prohibits discrimination on basis of race, color, sex,
national origin and disability in:
o any health program or activity receiving Federal
financial assistance;
o any program or activity administered by a federal
Executive agency; and
o any entity established under Title 1 of ACA (e.g.
Marketplaces)
• HHS clarified that discrimination based on sex includes
discrimination based on gender-identity or sex
stereotypes
• Based on existing federal civil rights laws
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Conclusion
• ACA has brought many changes, but gaps still remain
• How implementation handled will make the difference
• Please feel free to use me as a resource throughout your
summer
Jamille Fields
[email protected]
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THANK YOU
Washington DC Office
Los Angeles Office
North Carolina Office
1444 I Street NW, Suite 1105
Washington, DC 20005
ph: (202) 289-7661
fx: (202) 289-7724
[email protected]
3701 Wilshire Blvd, Suite #750
Los Angeles, CA 90010
ph: (310) 204-6010
fx: (213) 368-0774
[email protected]
101 East Weaver Street, Suite G-7
Carrboro, NC 27510
ph: (919) 968-6308
fx: (919) 968-8855
[email protected]
www.healthlaw.org