We already know that the Republican plan to replace the Affordable Care Act will have a disproportionate impact on the poor, the elderly, and those living in high-cost healthcare areas. But the biggest losers under the Republican plan may be rural women.
Women’s health advocates say that, under the new proposal, unintended pregnancies and abortions would go up, the quality of pre-natal care would decline, fewer low-income women would be eligible for Medicaid, and the personal cost of individual health insurance would climb, especially for those in lower income brackets.
Rural residents are more likely to be low-income, less likely than urban people to get insurance coverage through a job, and more likely to live in a state that did not expand Medicaid. Rural areas have fewer (and thus more expensive) coverage options from the private market. Rural America will be hit hard by the new plan. Rural women will be hit harder.
Rural women already experience higher rates of unintended pregnancy in general because of less contraceptive use, so we will likely see a disproportionate increase in unintended pregnancy among rural women if contraceptive coverage suffers. And in more rural states, where there are fewer abortion providers, getting an abortion entails driving long distances and increased child care costs.
In the summer of 2012, the Affordable Care Act mandated that insurance plans cover all forms of contraception — from birth control pills to IUDs and implants to Depo-Provera shots and sterilization — at no cost to the consumer. Because of this, American women have been using contraception at a higher rate, which has led to all kinds of positive ripple effects, including the lower rate of unintended pregnancy and abortion. The drop in unintended pregnancies also means women have a better chance of achieving higher levels of education and career advancement (particularly important for rural states, which consistently lag behind in women’s educational attainment and pay equality).
The Trump administration could unilaterally remove birth control as an “essential” service, meaning it would no longer have to be covered. Further, the proposed health-care law, unlike the ACA, does not promise that women receiving coverage under the Medicaid expansion will receive no-cost contraception.
The current Republican proposal to replace Obamacare is requiring private insurers to cover contraception and maternity services at no cost. But the future remains uncertain. The Trump administration could unilaterally remove birth control as an “essential” service, meaning it would no longer have to be covered. Further, the proposed health-care law, unlike the ACA, does not promise that women receiving coverage under Medicaid expansion will receive no-cost contraception.
The new plan will also make insurance more expensive overall for many groups, meaning fewer rural women would be able to afford coverage. The new plan is largely based on providing Americans with tax-credits to help them buy insurance from private companies. But the new proposal will provide smaller subsidies for some groups, especially those who are poor or older. The subsidy would not be adaptable based on differences in income below $75,000. And, unlike the current law, the subsidy won’t vary based on regional variations in health-care costs. These changes mean consumers would get the same subsidy if they make $20,000 a year or $70,000. The subsidy also wouldn’t vary if you lived in a low-cost service area like Massachusetts or a high-cost area like Alaska.
Under the proposed law, funding for expanded Medicaid will end in 2020, pushing working-poor women off the rolls and resulting in vast inequalities between individual states.
Because the proposed healthcare law would make coverage so much more variable state by state, contraceptive coverage might be covered in some states, but not in others, as some states have passed their own “contraceptive equity” laws requiring insurance to cover birth control, but not at no cost. Of the 10 “most rural” states — Maine, Vermont, West Virginia, Mississippi, Montana, Arkansas, South Dakota, Kentucky, Alabama, and North Dakota — only four have such contraceptive equity provisions. Even in West Virginia, one of the states with such a law, women will still feel the effects of the change.
“Thanks to lobbying efforts of reproductive rights and justice advocates in 2005, West Virginia passed its own contraceptive coverage mandate known as the Prescription Fairness Act,” said Margaret Pomponio, director of nonprofit WV Free. “We are relieved that this law that brought vital coverage to thousands of West Virginia women will still be intact if and when the ACA is repealed.”
The West Virginia act helped to establish more than 170 Title X family planning sites around the state. Most of the sites are in rural areas. They provide contraceptives on a sliding scale. If Congress eliminates the ACA, however, more women would need to use the Title X sites for family planning, which could cause a backup and longer wait times for contraception. Further, due to limited funds, many of the clinics offer birth-control services only on particular days.
Rural healthcare access could decline in other ways. Loss of either private insurance or Medicaid means women will lose the transportation help they currently receive under those programs. Rural women disproportionately favor sterilization, but this means of contraception is more expensive upfront and would be dramatically more expensive for those who lose insurance.
Under the ACA, women also get 100% coverage for annual gynecological exams, including breast exams and cancer screening.
“This has been a huge benefit for the women we see,” said Linda Griebsch, of the Joan G. Lovering Health Center in rural Greenland, New Hampshire. Before the ACA, private insurers didn’t cover preventative care and even good plans required a co-pay, she said. The ACA also prevents insurers from charging women higher premiums for basic reproductive health services. In some rural states before the ACA became law, women were charged as much as 34 percent more than men for health insurance coverage.
So far, the Republican proposal has kept no-cost preventative services as well as no-cost basic maternity services. But the advocates I spoke with fear that the reality of life for women under the AHCA may be significantly different. Smaller subsidies for private insurance and tighter eligibility requirements for Medicaid will mean fewer rural women would receive pre-natal care. Less care can lead to more birth complications more health problems for infants.
“Rural hospitals will have to pick up the costs,” said Griebsch, “which benefits no one in a rural area. The women will be in debt for a very long time, as they will be unable to pay. This will lead to large amounts of stress, health issues, and homelessness. You get the picture.”
Advocates also worry about the large scale pressures that will hit healthcare providers and states governments when Medicaid is eliminated in 2020. Even under the current healthcare plan, research sponsored by the National Rural Health Association estimates that 673 rural hospitals are at risk of closing over the next decade.
“Our entire state economy would be affected,” says Pomponio of WV Free, “due to the fact that we would lose millions in Medicaid dollars. We would lose 755 million federal dollars into the state economy — this will affect everyone in the hospital profession as well as the [overall] state economy.”
Griebsch, of New Hampshire, agrees, saying the rural hospital leaders she knows are in favor of affordable universal healthcare because it means they see fewer uninsured patients who will leave hospitals footing the bill.
“We have benefited from expanded Medicaid and other ACA coverage,” Griebsch said. “We are now being paid for things we often ended up doing for free because patients could not afford the needed tests. That does have a consequence of raising costs for everyone and keeping the healthcare staff underpaid.”
Emma Eisenberg writes about Appalachia, queerness, and feminism for Salon, Slate, The New Republic, Fusion, and others. She lives in West Philadelphia. Her Twitter handle is @EmmaEisenberg.