Stacy Collins
Associate Director, Health Systems Transformation
No longer considered a high-stakes experiment, the 10-year-old Affordable Care Act (ACA) is now well established in the U.S. health care system. Few health care laws have been as politically polarizing and controversial as the ACA. However, 10 years after passage, the law’s positive impact on the health and well-being of the nation’s women, children, and families is undeniable. The maternal and child health (MCH) community celebrates the following achievements.
More people are covered across all ages
By the end of 2016, the U.S. uninsured rate stood at its lowest recorded level. In 2010, nearly 49 million Americans (18 to 64 years of age) lacked health insurance; the current number is 30 million. This historic improvement is mostly due to expansion of Medicaid and subsidized coverage through the Health Insurance Marketplace.
Women of reproductive age: Higher rates of insured women, more services covered, and improved continuity of care
Women of reproductive age (19 to 44 years of age) are covered in significantly higher numbers; approximately 5 million women in this category gained coverage from 2010 to 2015. The ACA requirements to improve coverage for preventive services is correlated with a rise in the number of mammograms and well-woman visits; inter-conception, pre-conception, and prenatal care; and improved neonatal outcomes, including reduced probability of preterm birth. Another hallmark of the ACA is continuity of coverage and care in the postpartum period. Prior to the ACA passage, pregnant women on Medicaid typically lost coverage at six weeks postpartum, due to severe restrictions on Medicaid eligibility for non-pregnant women in most states. In states that expanded their Medicaid programs, postpartum women with incomes below 133 percent of the federal poverty line are now offered continuous coverage. Women with subsidized Health Insurance Marketplace plans similarly benefit from continuity of care.
Children
Although children have had traditionally high rates of insurance coverage, an estimated 2.8 million children from birth to age 18 have gained coverage since passage of the ACA. Several ACA-related measures contributed to these gains: streamlining Medicaid and Children’s Health Insurance Program (CHIP) enrollment processes, enhancing outreach and enrollment efforts, and providing affordable coverage to more parents, which increased children’s coverage. In addition, the ACA deemed all children up to age 19 with family incomes below 133 percent of the federal poverty line eligible for Medicaid. As a result, 21 states raised their Medicaid eligibility levels for children to meet the new requirement.
Medicaid coverage guarantees access to Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT). This broad array of preventive and treatment services is often more comprehensive than commercial insurance plans. Prior to the ACA, many state Title V programs funded health care services for older teens who were not Medicaid-eligible. The expansion of Medicaid coverage for this population has thus freed up funds that Title V programs can now devote to other health care priorities in their states. The ACA also established the “Health Home” program, which provides federal funding for care coordination for individuals with complex medical and behavioral health needs. Of the 20 states that have received health home planning funds as of 2019, at least eight serve children.
For teens and young adults
One of the most popular provisions of the ACA is the opportunity for adult children to keep their coverage on their parents’ health insurance plans up to age 26. As a result of this provision, about 2.3 million young adults gained health insurance coverage. Expanding dependent coverage has also been associated with increased access to mental health treatment and to early-stage cervical cancer diagnosis for young adult women. The ACA also requires states to extend Medicaid coverage to former foster care youth until they reach age 26. This eligibility change is significant because former foster care youth are more likely to be uninsured and to have more complex medical needs than other young adults.
Preexisting condition exclusions
Fifty four million people in the United States (27 percent of the non-elderly population) have a pre-existing condition; in the pre-ACA individual market, individuals were denied coverage for certain preexisting conditions. In addition, before the ACA essential health benefits (EHB) requirement took effect, non-group health plans routinely excluded important benefits for women, including the following:
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Maternity care (75 percent of plans did not cover)
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Substance use disorder treatment (45 percent did not cover)
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Mental health services (38 percent did not cover).
All ACA-compliant health plans in the individual and small group market must now cover all preexisting conditions. Plans must also offer 10 EHB benefit categories, including hospitalization, outpatient medical care, maternity care, mental health and substance use disorders treatment, prescription drugs, habilitative and rehabilitative services, and pediatric dental and vision services.
Support for expectant and postpartum women
The ACA also established the highly successful Maternal, Infant and Early Childhood Home Visiting (MIECHV) program. MIECHV brought national attention to the value of home visiting as a tool for improving the health and well-being of at-risk pregnant women, infants, and young children. The MIECHV program funds state efforts to pair new or expectant parents with professionals, using approved evidence-based interventions. In fiscal year 2018, MIECHV-funded home visiting programs provided more than 900,000 home visits nationwide and served more than 150,000 parents and children.
The ACA workplace breastfeeding provision has been a significant investment in breastfeeding promotion nationally. The law requires ACA health plans to provide women with electric breast pumps upon request.
Additionally, employers with 50 or more employees must provide break time and a private space to express breast milk (other than a bathroom). However, more must be done to ensure that single mothers and women with low-paying jobs, who are more likely to have less break time and/or work for exempt employers, benefit from this important provision, which is often difficult to enforce.
Addressing racial disparities and social determinants of health
The ACA has advanced health equity by reducing racial and ethnic disparities in access to care and levels of coverage. Before the ACA was implemented, nearly 25 percent of black women and 36 percent of Hispanic women were uninsured. Research has demonstrated that with ACA coverage expansions, fewer black women and Hispanic women, as well as young women of all races and ethnicities, delayed medical care. Research has also shown that the Medicaid expansion has been a key tool for addressing persistent racial disparities in maternal health. Although maternal mortality continues to rise in the United States, states that have expanded their Medicaid programs have seen a slower rate of increase compared to states that have not expanded Medicaid. The Medicaid expansion has also had a positive effect on social determinants of health. For example, research shows that states that implemented the Medicaid expansion had higher rates of parental financial stability and significant reductions in eviction rates.
Challenges ahead
Polling data indicate that the ACA is now more popular than at any other point in its 10-year history, and major provisions continue to be viewed positively. The ACA is far-reaching and complex and affects nearly every American in some way. However, significant challenges remain.
In 2020, the Supreme Court will hear Texas vs United States, which seeks to invalidate the entire ACA based upon Congress’ repeal of the individual mandate. A court decision to invalidate the entire law could have a devastating impact on MCH populations and the U.S. health care system as a whole.
Health disparities between MCH populations living in expansion and non-expansion states continue to widen. Barriers to coverage, access, and affordability in all states pose serious threats to the health of low-income women and children.
In short, more needs to be done to provide coverage to the remaining 30 million uninsured in the United States. All stakeholders need to work together to devise innovative policy solutions to help those groups who continue to be uninsured at high rates as well as those who do not qualify for subsidized marketplace coverage. These people include those in the “coverage gap” (in states where Medicaid was not expanded) and undocumented immigrants.
Despite the ACA’s challenges and shortcomings, the nation’s women and children have been among its greatest beneficiaries. Strengthening the law for the benefit of future generations should be an MCH priority.
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