Graham-Cassidy has been deemed “far-reaching” because it would end both the Affordable Care Act’s Medicaid expansion and its system of tax credits to help people buy personal insurance plans. Instead, it would give that money back to the states in a big chunk to create various types of health programs as they see fit—though they don’t necessarily have to be programs for the poor, under the law. By 2026, the size of this chunk is estimated to be about 9 percent smaller than the money provided by Obamacare’s subsidies and Medicaid expansion funds.
Because the bill would redistribute funds among the states according to a new formula, certain states—mostly Democratic ones that expanded Medicaid under Obamacare—would see cuts to the overall amount of federal funds they receive, while others would get a boost. According to the Kaiser Family Foundation, Medicaid-expansion states would lose 11 percent, compared to how much they receive now, and states that have not expanded Medicaid would gain about 12 percent on average by 2026. The bill would also slow Medicaid spending by capping it. After 2026, the chunk of money states receive would expire entirely, unless Congress decided to renew it.
What’s more, private insurers could once again charge people more based on their health status, and they would not be required to cover 10 essential health benefits, like maternity or mental-health care, as they are under Obamacare.
It’s here that women—no matter their income level, age, or childbearing preferences—would really feel the effects of Graham-Cassidy. Currently, contraceptives are required to be covered without a co-pay under Obamacare, but the bill would allow states to waive that requirement, which also covers other types of preventive services. That means birth control might no longer be free for women who buy their health insurance on the individual market. Women on Medicaid would not be able to use their Medicaid plans to visit Planned Parenthood clinics for birth control and other services for one year, potentially resulting in the closure of Planned Parenthood clinics.
“For pregnant women, there are a lot of screening services that are covered as part of preventive services—anemia screening, breastfeeding-support services, depression screening, folic acid, screening for gestational diabetes,” said Alina Salganicoff, the director of women’s health policy at the Kaiser Family Foundation. “All of those are covered without cost sharing. If a state chooses, that could also go away in the individual insurance market.”
If a woman on the individual market got pregnant and didn’t wish to be, Graham-Cassidy would ban her plan from covering abortion. If she worked for a small business, her company would no longer receive tax credits if their plan covered abortion.
Under the bill, states could also waive the requirement that maternity care be covered on individual plans. Before Obamacare, 75 percent of plans on the individual market excluded maternity coverage, 45 percent excluded substance-use treatment, and 38 percent excluded mental-health care, according to the Kaiser Family Foundation. In those states, women who were pregnant or planned to get pregnant could buy expensive riders to have their prenatal care and deliveries covered. Women suffering from postpartum depression, meanwhile, sometimes needed an extra mental-health rider on their plan, in states that didn’t require mental-health benefits. Graham-Cassidy would bring back this reality.
“The states might be looking for ways to scale back coverage and give insurers flexibility,” Salganicoff said. “The goal of Republican plans is to make insurance more affordable and allow people to tailor their benefits. But if you tailor this in this way, it’s antithetical to insurance. The people who buy maternity coverage are the ones who are going to use it.” So insurers know to charge a lot for it.
Though Graham-Cassidy’s waivers would only apply to individual-market plans, a state’s decision to tweak its essential health benefits could affect employer plans, as well. Under Obamacare, out-of-pocket medical expenses are capped and there are no annual or lifetime limits on the medical expenses insurers are required to cover.
But as an earlier analysis from Brookings explained, “the ACA’s ban on annual and lifetime limits only applies with respect to care that is considered essential health benefits. Similarly, the ACA only requires that plans cap enrollees’ annual out-of-pocket spending on care that is considered essential health benefits. Thus, as the definition of essential health benefits narrows, the scope of these requirements narrows as well.”
In other words, if maternity care is no longer considered an “essential health benefit,” and a woman insured through her employer has a very complicated delivery, her out-of-pocket spending might no longer be capped, as it is through Obamacare. (Before Obamacare, most employer plans imposed lifetime limits, and more than one-sixth didn’t limit out-of-pocket spending, according to Brookings.)
Women who deliver via C-section or who have even simply been pregnant in the past might face higher insurance rates for life. Graham-Cassidy would allow insurers to once again charge people different amounts based on their preexisting conditions, which can include things like pregnancy or depression.
Finally, according to the Kaiser Family Foundation, the reduced Medicaid funding might require states to return to a stricter standard for determining who qualifies for Medicaid. New mothers might lose their Medicaid coverage 60 days after giving birth. Or, they could face strict eligibility limits like those in Arkansas before the state expanded Medicaid, where mothers only qualified if they made about 16 percent of the federal poverty level, or $2,600 a year.
“What the ACA did was it really fixed a discriminatory practice that individual insurance plans had against pregnant women,” Salganicoff explained. It “leveled the playing field for all insurance plans so women didn’t have to worry about that anymore. This would take that away.”