Seeking Access: Low-Income Women Access to Healthcare

1. Seeking Access: Low-Income Women Access to Healthcare By: Jamille Fields, J.D., M.P.H. Reproductive Justice Fellow June 13, 2014

2. The National Health Law Program National non-profit law firm committed to improving health care access and quality for low and limited-income individuals and underserved populations Offices in Washington, D.C., Los Angeles, and North Carolina. Seeking Access: Low-Income Women Access to Health Care

3. Overview • The Healthcare World Pre-ACA • The Healthcare World Post-ACA • How this affects different Populations • Women of Reproductive Age • Pregnant Women • Women Living with HIV/AIDs • Women with Disabilities • Women of Color Seeking Access: Low-Income Women Access to Health Care

4. The World Pre-ACA • Employer-Sponsored Insurance • In 2010, 56% of Americans had ESI • 92% of Americans under 65 with private insurance were insured through their employer • Medicaid for somelow-income individuals • Seven of ten Medicaid enrollees over 14 are women • Medicaid is the single-largest source of public funding for family-planning services and supplies • In 2010, 9.4 million women of reproductive age covered under Medicaid • Medicaid covers around 40% of births Seeking Access: Low-Income Women Access to Health Care

5. Medicaid Eligibility: “Worthy Poor” Requirements for Eligibility Personal Characteristics Financial Conditions Person Characteristics Financial Condition Citizenship or Immigration Status Limited Resources State Residency Categories Low Income State Residency Low Income Category of “Worthiness” Seeking Access: Low-Income Women Access to Health Care

6. Traditional Medicaid Benefits: • Traditionally, Medicaid requires states to cover broad categories of services • States help define what is covered in each category • Existing Buckets (list not exhaustive) • Inpatient hospital services (other than services in an institution for mental diseases) • Outpatient hospital services • Laboratory and X-ray services • Early and periodic screening, diagnostic, and treatment (EPSDT) services for recipients under age 21 • Pregnancy-related services and services for conditions that might complicate pregnancy • Family planning services and supplies • Physician services Seeking Access: Low-Income Women Access to Health Care

7. The World Post- ACA Seeking Access: Low-Income Women Access to Health Care

8. Marketplace Coverage Name of presentation goes in footer

9. 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 Name of presentation goes in footer

10. Consequences of Failure to Expand http://kff.org/interactive/uninsured-gap/ Seeking Access:: Low-Income Women Access to Health Care

11. Family Planning “Expansion” Option • Family Planning “waiver” programs • 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 • Family planning “SPA” option • 29 states have expanded family planning services to otherwise ineligible individuals Seeking Access: Low-Income Women Access to Health Care

12. ACA Required Benefits • Essential Health Benefits • Again, Big Buckets: • 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 Name of presentation goes in footer

13. What this all Means for WOMEN

14. Women of Reproductive Age • “Reasonable medical management” allowed • Women’s preventive services reqare gender-specific • Contraceptive reqincludes “as prescribed” frequency Seeking Access: Low-income Women Access to Health Care

15. Women Living with HIV/AIDS • Traditional Medicaid – “Catch 22” • Categories remain • Childless adults need AIDS diagnosis to qualify • Medicaid Expansion States • New eligibility paths for • childless adults • Nearly 60,000 uninsured • persons with HIV • living in states not • expanding Medicaid • Out of 10 states with • highest HIV diagnosis, • 5 have not expanded Seeking Access: Low-Income Women Access to Health Care

16. Pregnant Women • Abortion Coverage • Restrictions in the Marketplace – Nelson Amendment • States can ban abortion outright • No “subsidy” funds can be used for abortion except for Hyde permitted • Medicaid Restrictions Remain - • Hyde Amendment • Rape, Incest or Life Endangerment Name of presentation goes in footer

17. Pregnant Women:Maternity Care • Full-Scope Medicaid Coverage • Meets state income threshold • Pregnancy-Related Coverage • Exceeds threshold, but below 133% of the FPL • Medicaid Expansion • Not if pregnant at time of • application • Children’s Health Insurance Plan • State Option, State Discretion on upper-income threshold • Health Insurance Marketplaces • Qualified Health Plans must include maternity coverage Seeking Access: Low-Income Women Access to Health Care

18. ACA & Women with Disabilities • Pre-existing condition exclusions prohibited • Medicaid Community First Choice Options • State option to cover HCBS for people up to 150% FPL or requiring institutional care • Medicaid Removal of Barriers • State option to provide HCBS to people up to 3X the SSI rate who are in waiver programs (currently only up to 150% FPL) Name of presentation goes in footer

19. Women of Color: Medicaid Seeking Access: Low-Income Women Access to Health Care

20. 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

21. ACA Non-Discrimination: Sec. 1557 • Prohibits discrimination on basis of race, color, sex, national origin and disability in: • any health program or activity receiving Federal financial assistance; • any program or activity administered by a federal Executive agency; and • 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 Name of presentation goes in footer

22. 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 fields@healthlaw.org Name of presentation goes in footer

23. THANK YOU