The New Republican Government

The new Republican Government: How Will an Obamacare Repeal Affect Family Planning in Colorado?

spotlight-image

 

Photo by osucoverde at morguefile.com

The upset victory of Donald Trump in November left many Americans in shock. Whether you are celebrating or dreading the next four years, no one can deny the political seismic shifts taking shape here in the US and around the world.

A big concern on the minds of those of us in the pro-choice community is the future of Roe v Wade, since Trump may have the chance to appoint as many as four supreme court justices. Trump said during the campaign that women should face punishment for having an abortion.

The new congress opened with another attempt to defund Planned Parenthood, a harbinger of what is predicted to be an unusually tough year for women’s rights around the world.

Another area of anxiety for many Americans – and one that will have significant repercussions on women’s healthcare access – is the Republicans’ promised repeal of the Affordable Care Act. Preliminary steps to dismantle ACA have begun in the Senate, and an amendment to preserve mandatory birth control insurance coverage was rejected.

Obamacare now covers about 20 million people nationwide. Coverage by ACA, plus shrinking unemployment, has helped put the uninsured rate in Colorado at historic lows – down to 6.7% in 2015. That translates to 419,000 people in Colorado who obtained insurance since the ACA was enacted in 2010, according to the US Department of Health and Human Services. December 2016 data released by Connect for Health Colorado, the healthcare exchange in our state, showed a 30% increase in enrollees from the previous year.

What’s more, every woman with health insurance – whether it’s through the healthcare exchange, Medicare or Medicaid, or private insurance through an employer – is guaranteed free preventive coverage including all FDA-approved contraceptive options like the pill, Plan B, and long-acting contraception like IUDs and female sterilization – even if they work for an organization that objects to contraception for religious reasons.

Vasectomies and other forms of male contraception, and abortions, are not required to be covered under ACA rules.

And ACA also bans gender discrimination in premiums: prior to the gender discrimination ban, women in some states could pay as much as 50% more than their age-matched male peers from some plans.

What will happen to women’s health choices in Colorado if ACA is repealed, in whole or in part?

Connect for Health Colorado (referred to as “the exchange” from now on) assures enrollees that changes to federal law can’t impact Colorado plans already sold for the 2017 calendar year, so there’s a year of breathing room for healthcare consumers who have insurance through the exchange. Yet there could be big changes to family planning coverage, even if there’s only a partial repeal of ACA.

Pregnancy – a pre-existing condition?

Some pundits are predicting a possible dip in births, as women wait to become pregnant to see how the healthcare situation develops.

Deyanna Lambert, a married mom of two in Broomfield county, says she and her husband were considering having a third child. “That is, until the results of the election gave me a firm shove the other way. The costs of healthcare, childbirth, and childcare are already ridiculous. I worry it will only get worse under the new administration.”

So while pregnancy is not traditionally thought of by some as part of family planning, many considerations including access to quality prenatal care, birth costs, and even political factors go into the decision to prevent or continue a pregnancy.

The cost of a pregnancy today in Colorado varies widely, even for women who have insurance. A cost estimator from Anthem Blue Cross Blue Shield in January 2017 found the negotiated cost of an uncomplicated vaginal birth was between just over $9000 to $15000 in the Denver metro area, with out-of-pocket costs as low as $300 for a low-deductible plan, and into the thousands for high deductible plans.

Yet half of all pregnancies are unplanned and poor women are five times more likely to have an unplanned pregnancy than affluent women. How would an unplanned pregnancy be likely to play out if parts of ACA or the Medicaid expansion are repealed?

Let’s start with some possible good news: a post-election analysis by Colorado’s state exchange suggested that the preexisting condition ban under ACA is unlikely to be repealed since it enjoys strong bipartisan and popular support. If true (and there are dissenters), that would mean women who are or may become pregnant could continue to be covered for prenatal care and delivery even if they have to change insurance providers during their pregnancy.

And it’s worth remembering that the pre-existing condition clause only applied to individual health insurance even before ACA, i.e., insurance you purchased out of pocket, not through an employer – so if you changed employers during your pregnancy, you were still covered. Cold comfort, but it’s something.

Now for the not-so-good news: Medicaid expansion is very vulnerable to changes in federal funding levels. Colorado has one of the largest state Medicaid expansions, enrolling almost 300,000 people in the first year and a half after the expansion was signed into law by Governor Hickenlooper in 2013.

The Medicaid expansion as it exists now increases the income cap for pregnant women to qualify from $48,000 to $64,000 per year for a family of four. Expectant families with income up to $97,200, or four times the poverty level, qualify for tax credits through the exchange. The federal government pays for most of the additional expenditures with these expanded income limits.

The impact of federal restructuring of Medicaid reimbursements to lower levels will mean that the state will have to cut services,make service more efficient, shrink the rolls to maintain services, or all three. This will hit the working poor and lower middle class women the hardest, as they’re the likeliest to have coverage under expanded Medicaid.

Contraceptive coverage

An unplanned pregnancy in Colorado is a lot less likely than it was even a few years ago. The decrease in unplanned pregnancies could be partly due to improved access – both because of the record numbers of women insured through the exchange and Medicaid expansion, and because ACA requires insurance plans to cover all eighteen FDA-approved forms of contraception including IUDs, which are highly effective but had very high out-of-pocket costs before ACA.

Just before the rollouts of ACA and Medicaid expansion, the state launched the Colorado Family Planning Initiative (CFPI) in 2008. Funded by a $27M anonymous donation and run by the Department of Public Health and Environment, the CFPI has been extremely successful, cutting the teen birth rate and abortion rates in half in just five years.CFPI provides funding to Title X clinics – a family planning program aimed the poor and uninsured enstated in 1970 by Nixon. The goal of CFPI was to increase access to the most effective forms of reversible birth control, long-acting contraception like IUDs. Insertion of IUDs quadrupled over the first six years of the program.Over the same period, revenue to participating Title X clinics became much more reliant on third party payers, flipping from 80% client paid to 75% third party payer paid, mostly from Medicaid which paid out $4M in 2015.

A January 2017 report on CFPI by the state public health department cited revenue from public and private insurance claims under ACA and new state funding as part of its financial sustainability model. Public records in 2015 indicate that the state would have to pick up a $3M shortfall if federal funding for expanded Medicaid and ACA dry up, but it is unclear at this time how deeply affected the program will be with cuts in federal funding. The Family Planning Program office declined to comment on possible impacts from federal cuts.

Planned Parenthood of the Rocky Mountains (PPRM) is another of the biggest providers of women’s healthcare in the state, serving 72,000 women per year. PPRM does not receive Title X funding in Colorado. About 30% of PPRM clients are Medicaid recipients, roughly double the percentage prior to Medicaid expansion. Rolling back Medicaid coverage to pre-expansion limits would cut off over eleven thousand PPRM clients from care.If congressional Republicans succeed in halting reimbursements to Planned Parenthood by Medicaid – they tried to again in early January – that’s an estimated 22,000 women in Colorado who would lose their provider. In some rural counties of Colorado where Planned Parenthood is the only provider for low income women, that could mean women going without necessary preventive care.

Thinking about the big picture, there are 650,000 women of childbearing age in Colorado who require family planning services. As is often the case, the most vulnerable women are the ones who are likeliest to have their access to family planning threatened. Women who are at risk fall into three main categories:

  • Lower income women who stand to lose their coverage, if they are currently covered through expanded Medicaid.
  • The uninsured – or women who feel they can’t use their insurance for family planning services – who may face reduced access to services due to decreased funding.
  • Those whose private insurance companies may choose to rescind or reduce contraceptive coverage when no longer required to by law.

Federal changes to ACA and expanded Medicaid have the potential to directly impact many women in Colorado and their families. Michelle Lueck, CEO of the Colorado Health Institute issued a challenge last month at the annual Hot Issues in Healthcare 2016 conference, “How can we sharpen our gaze, find a way forward, and wisely choose our battles – for the things that matter most?”

As we Coloradans chart our course through this tumultuous time in history and an uncertain healthcare future, it’s important to keep our focus on what matters most: the tenacious women, men, and children who are at the beating heart of this state.

What will we be doing, as pro-choice women and men of faith, to help chart a caring and compassionate course that provides healthcare and family planning for all?

 

Ways you can help

 

  1. Attend a Women’s March! The Women’s March on Denver starts at 9:30 am on Saturday, January 21 in Civic Center Park. Visit the website for updates and schedule of speakers. If you’re not in town, attend a sister march in one of the many around the country. At time of writing there were 281 scheduled solidarity marches around the world!

 

  1. Watch the “anti-inauguration” Love-a-thon, a facebook live stream event, with proceeds benefiting Planned Parenthood, the ACLU, and other progressive organizations. Read more: http://money.cnn.com/2017/01/04/technology/loveathon-facebook-live/

 

  1. Make a donation to Planned Parenthood of the Rocky Mountains, or the Colorado Religious Coalition for Reproductive Choice.

 

  1. Write a letter to the editor. These DO make a difference!

 

Don’t see your local paper? Check here for a full list.

 

  1. Post a comment below in the comments section of this article with YOUR ideas of how to impact choice in this difficult time.

 

Sources/Further Reading

Adamczyk, A. (2017, January 13). Obamacare Repeal: What Happens to Birth Control Coverage? Money Magazine.

Assistant Secretary of Public Affairs. (2016, December 16). Impact of the Affordable Care Act in Colorado.

CDPHE Title X and Medicaid / Insurance Reimbursement (2011-2014). (2015, March 4).

Cohen, C. (2016, November 9). Donald Trump sexism tracker: Every offensive comment in one place. The Telegraph.

Colorado Department of Public Health and Environment (2017, January). Taking the Unintended Out of

Pregnancy: Colorado’s Success with Long-Acting Reversible Contraception.

Connect for Health Colorado Metrics. (n.d.) http://connectforhealthco.com/resources/stay-informed/metrics/

Healthcare.gov staff. (n.d.) Health Care Benefits: Birth Control Benefits.

Johnson, E., Brooks, R. (2016, December 22). Medicaid Midstream – The Impact of Expansion So Far and Options for the Future. Colorado Health Institute 2016 Hot Issues in Healthcare.

Kaplan, T., Thrushjan, G. (2017, January 4). Senate Republicans Open Fight Over Obama Health Law. The New York Times.

Liptak, A. (2016, November 9). What the Trump Presidency Means for the Supreme Court. The New York Times.

Laliberté F, Lefebvre P, Law A, Duh MS, Pocoski J, Lynen R, Darney P. Medicaid spending on contraceptive coverage and pregnancy-related care. Reprod Health. 2014 Mar 3;11(1):20.

Norris, L. (2017, January 10). Colorado health insurance exchange / marketplace.

Pear, R. (2017, January 4). Republicans’ 4-Step Plan to Repeal the Affordable Care Act. The New York Times.

Pollack, H., Jost T. (2017, January 10). Seven Questions about Health Reform. The New York Times.

Stein, P and Somashekhar, S. (2017, January 4). It started with a retiree. Now the Women’s March could be the biggest inauguration demonstration. The Washington Post. Retrieved on 1/4/2017 from http://www.chron.com/national/article/Women-s-March-on-Washington-is-poised-to-be-the-10833059.php

The Associated Press. (2017, January 4). GOP House Panel: Halt Federal Money for Planned Parenthood. The New York Times.