For the nation’s consumers and providers of reproductive health care, and for advocates of reproductive health and rights, the healthcare reform legislation just enacted is something of a mixed bag. The bill’s onerous abortion restrictions have been rightly denounced by reproductive rights supporters. New funding for evidence-based sex education was regrettably paired with the retention of a failed and discredited abstinence-only program. But, taken together, a number of other provisions in this sweeping measure constitute a clear and significant step forward for the reproductive health of America’s women and men.
Abortion: Insurance Coverage Now an Endangered Species
The bill’s restrictive abortion provision is putatively designed to uphold the status quo on the question of federal funding. Accordingly, federal funds—in this case, subsidy dollars for individuals purchasing insurance plans on the new health care “exchanges” that are slated to become operational in 2014—may not be used to pay for abortion coverage (except in extreme cases), but individuals, at least in theory, may purchase a plan that includes abortion coverage so long as the abortion coverage itself is paid for with their own money. (This mirrors the Hyde Amendment, under which federal Medicaid dollars may not be used to pay for most abortions, but states may cover the procedure for their Medicaid recipients using their own funds.)
In practice, however, the complex, politicized arrangements the legislation necessitates militate heavily against the likelihood that many such plans will be purchased—or even offered. Consumers purchasing exchange plans that include abortion coverage would have to make two separate premium payments—one to cover abortion services and one to cover everything else. Insurance companies would have to jump through numerous, unprecedented hoops to estimate the cost of abortion coverage and ensure that the abortion payments never mix with other funds; they also are likely to face extensive public scrutiny and protest around their action. All told, according to an analysis by George Washington University’s Sara Rosenbaum, “the more logical response” for private insurers marketing plans within the exchanges—and eventually in the broader market as well—“would be not to sell products that cover abortion services.”
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Sex Education: One Step Forward, One Step Back
The legislation provides $75 million per year over five years for a new “personal responsibility education program,” most of it in grants to states for programs that educate adolescents about both abstinence and contraception for the prevention of pregnancy and sexually transmitted infections. Similar to the $114.5 million teen pregnancy prevention initiative signed into law by President Obama in December 2009, this new funding stream will focus on programs that are evidence-based, age-appropriate and medically accurate.
At the same time, the recently lapsed Title V abstinence-only-until-marriage education program was resuscitated for five years, making $50 million annually available to the states for programs that have nonmarital abstinence promotion as their “exclusive purpose” and accordingly are prohibited from discussing the benefits of contraception or any safer sex behaviors. Going forward, this means that a total of about $190 million in federal funding will be granted to states and community-based organizations for evidence-based programs, while $50 million will be offered to states for rigid abstinence-only programs (although, notably, roughly half the states have rejected their grant offers in the past).
Medicaid: A Huge Advance for Lower-Income Americans’ Reproductive Health
According to the Congressional Budget Office, a provision expanding eligibility to all Americans with a family income below 133 percent of the federal poverty level will allow 16 million more Americans to join Medicaid by 2019 than would otherwise be the case. All Medicaid recipients receive the program’s guarantee of family planning services without cost sharing, along with coverage for its comprehensive package of reproductive health services beyond family planning. (The major exception, of course, is abortion; however, this provision effectively would expand abortion coverage in the 17 states that fund abortions for their Medicaid recipients with state dollars.) The legislation, moreover, goes one step further: It allows states to expand Medicaid coverage solely for family planning services to the same income eligibility levels they use for pregnancy-related care, typically around 200 percent of poverty.
Private Insurance: Real Improvements on the Horizon
Under the legislation, currently uninsured individuals with incomes above 133 percent of poverty will be able to purchase private insurance coverage through the new health care exchanges, almost all of them with the help of a federal subsidy. Most of the plans offered on the exchanges will be required to offer a similar package of core services. The deliberately sketchy package described in the legislation specifies maternity care, closing a major coverage gap in the individual and small group market, but the final package is expected to also include coverage of a broad package of reproductive health services, including contraceptive services and supplies, as is typically the case in private-sector plans today. Insurance plans participating in the exchanges also will be required to contract with essential community providers, defined to include family planning centers, community health centers, public hospitals and HIV/AIDS clinics.
Meanwhile, all private insurance plans, both inside and outside the exchanges, will be required to cover, without cost sharing, a package of preventive and screening services for women. The exact package will be defined by the federal government, following a study to be conducted by the Health Resources and Services Administration. Similarly, all private plans that provide dependent coverage will be required to make it available for unmarried adult children younger than age 26. This provision, which goes into effect later this year, represents another important avenue for young adults to receive reproductive healthcare coverage.
Public Health: New Money for Struggling Safety-Net Providers
Finally, although strengthening the healthcare provider network was rarely mentioned as a core goal of the health care reform legislation, the law includes a vast array of new grants and programs to that end. It includes $1.5 billion over five years to support maternal, infant and early childhood home visiting programs, with a focus on high-risk families. It provides a significant increase in the rebates pharmaceutical manufacturers must offer to state Medicaid programs for both brand-name and generic drugs and in the discounts offered to safety-net providers, including Title X–supported family planning centers, under the 340B Drug Discount Program. It includes many billions of dollars in new funding for community health centers, which provide family planning services and other basic reproductive healthcare to their clients, and establishes a dedicated $50 million yearly funding stream for school-based health centers, many of which provide contraceptive care to students in need. The legislation also includes several dozen programs designed to bolster the healthcare workforce through loan forgiveness and provider training programs, some of which are relevant for family planning providers.
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