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The Architecture of Health Reform:
Building Access to Reproductive Health
Susan Berke Fogel JDLA County Coalition for Women and Health Care Reform
September 1, 2011“Securing Health Rights for Those in Need”
NHeLP
• National public interest law firm working to advance access to quality health care and protect the legal rights of low-income and underserved people
• Offices in Washington D.C., Los Angeles, and North Carolina
• Comprehensive analysis of health care reform law; ongoing updates
• Visit our website at: www.healthlaw.org
Two Roads at Once•State and Federal Cutbacks•Anti-Reform Litigation•De-funding the ACA
•State Exchanges•ACA Implementation•Family Planning Expansions
Goals and Ideals
* “everyone” excludes undocumented immigrants; coverage excludes abortion
The current system
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The current system
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What Will we Build?
Uninsured in California
• 7 million uninsured (2009)– 4.7 million non-elderly will be eligible for exchange– 3.1 million remain uninsured• Undocumented• Exempt from individual mandate• Won’t/can’t participate
• Source: Unsure the Uninsured Project
Insurance Status of Non-elderly Women in California
Uninsured by Income*
Women ages 18-64Kaiser Family FoundationInsurance Data 2008-2009*Income Data 2007
Total: ~2.6 M
Insurance and income – LA County
Insurance status• 21.3% of women (18-64) in LAC are uninsured• 20.4 % are enrolled in Medicaid• 57.1 % have private insuranceEconomic status• 39.7% of uninsured women <100% FPL• 30% of uninsured women 100-199% FPL
Health disparities and reproductive health
Women of color of child bearing age are disproportionately poor– 10.7% non-Hispanic white– 11.1% Asian Pacific Islander– 25.5% African American– 22.4% Latina– 24.2% Native American/Alaska Natives
• People of color are the majority of individuals enrolled in Medicaid
Health Disparities and Pregnancy
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Unintended pregnancy Abortion % of all abortions
Prenatal care in 1st trimester
African American 69% of pregnancies 30% 73%
Latina 54% of pregnancies 25% 74%
White 40% of pregnancies 36% 85%
How Will We Get Insurance?
Medicaid Eligibility: Overview
What does this mean for women?
20% of women are uninsured 28% of women of color are uninsured
37% Latinas 23% African Americans 18% API
54% of uninsured women eligible for Medicaid “Newly eligible” include childless lesbians,
young adults, older women under age 65, women with disabilities, women with HIV
Source: Kaiser Family Foundation
Who is left out?
• Undocumented immigrants– Do not qualify for Medicaid• Can access emergency care, pregnancy, family planning
– Cannot buy insurance in the exchange with their own money
• People above 133% FPL who can’t afford premiums• People exempt from mandate• People who can’t navigate the system– Homeless, mental disabilities, can’t prove citizenship, LEP,
disaster victims, DV survivors
What’s Covered?
Delivery Systems
Preventive Screening ServicesU.S. Preventive Taskforce A and B Level Recommendations
Lifestyle/Healthy Behaviors
Cancer STI/STDs Chronic Conditions Pregnancy
Alcohol Screening Colorectal HIV Hypertension Tobacco
Depression Screening
Breast Screening Gonorrhea Diabetes Rh Incompatibility Screening
Healthy Diet Counseling
Breast Chemoprevention
Chlamydia Obesity Screening Hepatitis B Screening
Tobacco Breast/Ovarian High Risk/BRCA
Syphilis Osteoporosis Iron Deficiency Anemia Screening
Immunizations Cervical Cancer Lipid Disorders Bacteriurea Screening
Publicly-funded family planning
Pregnancy care
• Insurers must cover maternity care• Funding for research and treatment of post-
partum depression• Pregnancy supports – especially educational
support for pregnant and parenting teens and young adults
• Medicaid coverage of birthing centers
Abortion restrictions in Exchanges: Nelson Amendment
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The Exchange
Systems Issues
• Qualified Health Plans must include Essential Community Providers (ECP) “such as”– Community clinics (FQHC and others)– Title X and other family planning clinics
• Implementation issues– Contracting– Recognizing ECPs as medical homes
• Network adequacy: access to all covered services; religiously-controlled health systems
Impact of Religiously-controlled Health Systems
• Ethical and Religious Directives for Catholic Health Care Services – US Conference of Catholic Bishops– Absolute bans on abortion, sterilization, family planning– Limits on treatment miscarriage mgmt, ectopic pregnancy
care, EC, end of life care– No health or life exception– May refuse some services to LGBT communities– Refusal to provide referrals = barrier in managed care
• Some California Catholic hospitals allow some limited services under limited circumstances
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Refusal Clauses Exempt Providers from Meeting the Standard of Care
• Refusal clauses shield individual providers and institutions from liability for their failure to deliver care that would otherwise be required– accepted medical standards of care– legal requirements for care
• Refusal clauses allow institutions to prevent providers from meeting the standard of care
• Regardless of health outcome
The California Exchange Board
• 5 member board:– Kimberly Belshe, Diana Dooley, Paul Fearer, Susan
Kennedy, Robert Ross• Executive Director: Peter Lee• Responsibilities:– Determine structure of Exchange– Determine criteria for participation in Exchange – selective
contracting– Stakeholder input– Accountability
Access and affordability“No Wrong Door”
• Web Portal– Eligibility and enrollment– Language access
• Toll-free hotline• Navigators– Assist with outreach and enrollment– New proposed rules – open comment period
• Affordability– Subsidies– Cost-sharing
Low Income Health Program
• ACA allow states to begin Medicaid expansion• CA waiver: county option (LAC is up and
running)– <133% FPL; resident; citizen or lawful immigrant 5
yrs+–Medical home– No categorical eligibility– No cost– Preventive, mental health, specialty care
Other options on the horizon
• Basic Health Plan (SB 703)• State option• 134 – 200% FPL• Enrollees don’t get subsidies or tax credits, but
premiums cannot be higher than in exchange• State gets 95% of federal share of subsidies and tax
credits• Managed care• Essential health benefits• Lower cost-sharing
A few of the many remaining questions
• Transitions between Medi-Cal and Exchange– Fluctuations in income– Pregnant women above 133% FPL
• Family planning expansions post 2014?• Breast and Cervical Cancer Treatment• Title X, Ryan White, etc – what will happen to targeted funding?• Refusal Clauses?• Citizenship documentation• How much “flexibility to the states” is good for consumers?
Stakeholder Input
Comment on federal regulations www.healthcare.gov– Exchanges– Medicaid eligibility and enrollment– Women’s health preventive services– Essential Health Benefits
Participate in California Exchange Board meetings www.healthexchange.ca.gov– In person meetings in Sacramento– Web-cast
