"@ ASPE ISSUE BRIEF
SS ASSISTANT SECRETARY FOR March 21, 2022

PLANNING AND EVALUATION

Health Coverage for Women Under
the Affordable Care Act

Sarah Sugar, Joel Ruhter, Sarah Gordon, Amelia Whitman,
Christie Peters, Nancy De Lew, and Benjamin D. Sommers

 

KEY POINTS

e Coverage expansions under the ACA decreased uninsured rates and improved stability of health
coverage for women. Over 10 million adult women (19-64) gained coverage between 2010 and
2019, as did over 7 million women of reproductive age (15-44).

e The ACA's coverage expansions have been associated with improved access to care, increased use
of health services, and better self-reported health among women of reproductive age.

e Despite the ACA's coverage gains, approximately 7.9 million women of reproductive age remain
uninsured.

e Adisproportionate share of uninsured women are Latino (40 percent), and nearly half reside in the
12 states that have not adopted the ACA Medicaid expansion (47 percent).

e Nearly 1.9 million uninsured adult women (19-64) who live in Medicaid non-expansion states would
be newly eligible for Medicaid if the remaining 12 states adopted the Medicaid expansion.

e Among women of reproductive age, an estimated 3.8 million have incomes at or below 138% FPL,
the ACA Medicaid expansion income eligibility limit. Over half of them - 1.9 million - live in
Medicaid non-expansion states and could fall in the coverage gap.

e Anestimated 4.1 million uninsured women of reproductive age are eligible for subsidized
Marketplace coverage under the tax credit provisions of the American Rescue Plan.

 

BACKGROUND

The Affordable Care Act (ACA) increased access to comprehensive health care coverage among women. Prior
to the ACA, nearly 22 million women under age 65 were uninsured,' and one-third of women who tried to buy
a health plan were either charged a higher premium, had specific services excluded from their plans, or were
turned down for coverage altogether.? For example, before the ACA's consumer protections took full effect,
only 12 percent of health plans in the individual market offered maternity coverage, and young women were
frequently charged higher premiums than their male counterparts .?*

The ACA prohibited plans from charging different premiums to women than men of the same age. In addition,
plans were required to cover maternity care and preventive services for women without cost-sharing, such as
breast and cervical cancer screenings, well-woman visits, birth control and related counseling, breastfeeding
supplies and supports, and sexually transmitted infection services.> The elimination of cost-sharing for
contraceptives in most private health insurance plans saved women an estimated $483 million to $1.4 billion in
out-of-pocket spending in 2013, and studies indicate this policy was associated with increased use of
prescription contraception.® A recent ASPE report estimated that 58 million women currently benefit from the
ACA's coverage of preventive services without cost-sharing in private plans.' Research also has found that

 

March 2022 ISSUE BRIEF 1
early detection of breast cancer improved post-ACA and the ACA's dependent coverage provision was
associated with higher early detection of cervical cancer in women ages 21 to 25.®°

The ACA's Medicaid expansion to low-income adults also significantly reduced disruptions in insurance
coverage over time ("churning"), which can lead to delayed care, less preventive care, and higher monthly
health care costs due to pent-up demand for health care services.?° Churning is especially common in
Medicaid during the perinatal period (pregnancy and the first year postpartum), as the pregnancy-related
eligibility pathway has a higher income threshold than other Medicaid eligibility pathways such as for parents
or low-income adults. The ACA's Medicaid expansion was associated with decreased postpartum churn,
including increased duration of postpartum enrollment and use of outpatient care in the 6 months
postpartum, particularly among women who experience significant maternal morbidity at delivery."
Medicaid expansion has also been associated with increased use of health services and better self-reported
health among women of reproductive age." For example, research has found that Medicaid expansion led to
increased rates of preconception health counseling, pre-pregnancy folic acid intake, and effective use of birth
control after pregnancy among low-income women, compared to their counterparts in non-expansion states.'
However, coverage disparities remain. Low-income women, women of color, and women who are non-
citizens are at greater risk of being uninsured."

Access to comprehensive and continuous health coverage for women, particularly those of reproductive age, is
critical to improving maternal and infant health, which is a key priority of the Biden Administration." This is
especially important for Black and American Indian/Alaska Native women, who experience far worse maternal
health outcomes.'® This brief presents estimates over time and characteristics of uninsured women (including
those of reproductive age), identifying those who are likely to be eligible for Medicaid coverage under the ACA
or qualify for subsidized Marketplace coverage.

METHODS

We estimated the number of uninsured adult women (19-64) and women of reproductive age (15-44") using
the American Community Survey (ACS) Public Use Microdata Sample 1-Year Estimates from 2010 to 2019. We
then calculated the number of uninsured women ages 15-44 with family incomes' that would likely qualify for
Medicaid expansion coverage or subsidized Marketplace coverage in the 2019 ACS.'" We did not use 2020 ACS
data due to disruptions in data collection caused by the COVID-19 pandemic; as a result, the Census Bureau
does not recommend comparing the 2020 ACS 1-year experimental estimates with previous ACS estimates. 1*
Our analysis accounts for the American Rescue Plan's (ARP) premium tax credit (PTC) expansion, which
temporarily increases the PTC amount for those who are eligible and extends eligibility to individuals with
incomes above 400 percent of the federal poverty line (FPL) for the first time.*°

We also provide estimates of the number of uninsured women in the 12 states* that have not adopted the
Medicaid expansion, as of March 2022. These estimates are drawn from ASPE's Transfer Income Model
version 3 (TRIM3), which simulates major government tax, benefit, and health insurance programs in the
United States. TRIM3 estimates come from an analysis of the Census Bureau's Current Population Survey for
calendar year 2018, using each state's rules for Medicaid eligibility as of 2021.7

 

* While women aged 15-17 are minors, we define them as women because this is the standard language in demography about

reproductive age.

+ Family income is defined based on the health insurance unit, which consist of an adult, their spouse, and any dependent children.

+ The non-expansion states are Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota,
Tennessee, Texas, Wisconsin, and Wyoming.

 

March 2022 ISSUE BRIEF 2
In this report, we did not assess immigration status in the sample, which means our estimates of the uninsured
include some women who are not legally present and would not be eligible for Medicaid or Marketplace
subsidies.

RESULTS

Over 10 million adult women (ages 19-64) and over 7 million women of reproductive age (ages 15-44) gained
health insurance coverage between 2010 and 2019. During this period, the percent of uninsured adult women
decreased from 19 percent to 11 percent, and the percent of uninsured women of reproductive age decreased
from 21 percent to 12 percent (Figure 1).

Figure 1. Uninsured Adult Women (Ages 19-64) and Women of Reproductive Age (Ages 15-44), 2010-2019

25% 21%

20%
19%
15% 12%

10% 11%

|

5%

0%
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

=== Women of Reproductive Age (15-44) === Adult Women (19-64)

Source: ASPE analysis of 2019 ACS data

As of 2019, approximately 7.9 million women of reproductive age were uninsured. Of these women, 48
percent had incomes of 138% FPL or below, qualifying them for Medicaid in states that had expanded
Medicaid$, while 52 percent were likely eligible for PTCs for Marketplace coverage (Figure 2). In non-
expansion states, only pregnant women (through 60 days postpartum), low-income parents, and adults with
disabilities who have incomes below their states' income thresholds generally qualify for Medicaid. Overall, 36
percent of uninsured women of reproductive age had incomes below 100% FPL, meaning that if they lived in
one of the 12 non-expansion states, they could fall into the coverage gap if they have income too high to
qualify for Medicaid and too low to qualify for Marketplace subsidies. Most Marketplace subsidy-eligible
uninsured women (42 percent) had incomes between 139%-400% FPL, which is within the ACA's income-based
subsidy eligibility range of 100-400% FPL; an additional 10 percent (those with incomes above 400% FPL) may
be newly eligible for subsidies due to the ARP's subsidy expansion.

 

§ A proportion of these women live in non-expansion states and may not be eligible for Medicaid.

 

March 2022 ISSUE BRIEF 3
Figure 2. Income Distribution Among Uninsured Women of Reproductive Age (15-44)

40% 36%

35%

30% 27%
25%

20% 15%

15% 12% 10%
10%
: a in
0%
< 100% FPL 100-138% FPL 139-249% FPL 250-400% FPL > 400% FPL

Source: ASPE analysis of 2019 ACS data
A prior ASPE analysis estimated that 1.9 million low-income women in the remaining 12 non-expansion states
would be newly eligible for Medicaid if the states extended coverage to adults with income up to 138% FPL."*
Of these 1.9 million uninsured women, 47 percent are ages 19-34, most have incomes below the poverty level
(59 percent), 41 percent are White, 25 percent are Black, and 30 percent are Latino."

Table 1 shows the number of women in the 12 non-expansion states currently eligible for Medicaid, the
number who would be eligible for Medicaid if all non-expansion states were to adopt the Medicaid expansion,
and the number of women who would be newly eligible for Medicaid coverage after Medicaid expansion in
non-expansion states (i.e., the difference between the first two groups).

Table 1. Demographic Characteristics of Uninsured Non-Elderly Women (Ages 19-64) Potentially Eligible for
Medicaid if All 12 Non-Expansion States Adopted Medicaid Expansion

Newly Eligible After

Before Expansion After Expansion Sena
# % # % # %
515,596 100.0 2,402,438 100.0 1,886,842 100.0
239,017 46.4 1,115,666 46.4 876,649 46.5
184,126 35.7 670,376 27.9 486,251 25.8
92,453 17.9 616,395 25.7 523,942 27.8

439,595 85.3 1,554,548 64.7 1,114,953 59.1

100%-138% 24,355 4.7 521,884 21.7 497,529 26.4
51,645 10.0 326,005 13.6 274,360 14.5
215,230 41.7 989,193 41.2 773,968 41.0

 

 

™ This brief uses the term "Latino" to refer to all individuals of Hispanic and Latino origin.

 

March 2022 ISSUE BRIEF 4
135,362 26.3 600,136 25.0 464,773 24.6

PSE wee eee ell

Pee Ree eae) 7,247 1.4 37,912 1.6 30,665 1.6
American Indian/Alaska Natives 9,385 1.8 28,257 1.2 18,872 1.0
Other Races (NL) 9,081 1.8 41,143 1.7 32,062 1.7

139,291 27.0 705,792 29.4 566,501 30.0

  

 

Source: HHS/ASPE TRIM3 model applied to March 2019 / CY 2018 CPS data combined with TRIM3 imputations.

Notes: The estimates compare simulated eligibility data without and then with the Medicaid expansion.

* These persons have monthly MAGI below 138 in at least one month.

** "Latino" includes all people reporting Latino ethnicity, regardless of race(s). Non-Latino individuals were categorized as White, Black,
or Asian American, Native Hawaiian, or Pacific Islander only if they reported a single race.

Figures 3 and 4 describe demographic factors among uninsured women of reproductive age, across all states.
Most uninsured women of reproductive age are between the ages of 19-34 and are Latino (40 percent), White
(38 percent), or Black (14 percent). Table 2 shows language spoken and education among the same population;
15 percent live in households with no English-speaking adults, and 20 percent have less than a high school
education.

Figure 3. Age Distribution Among Uninsured Women of Reproductive Age (15-44)
10% 63%
60%
50%
40% 33%
30%

20%
0,
10% 8%

ov [_

  

Age 15-18 Age 19-34 Age 35-44

Source: ASPE analysis of 2019 ACS data

Figure 4, Race and Ethnicity Among Uninsured Women of Reproductive Age (15-44)

Multi-racial or Other J 3%
American Indian / Alaska Native Jj 1%
Asian / Native-Hawaiian / Paclslander - 4%
Black Non-Latino x 14%
White Non-Latino ee 38%
cpp ee 40%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

Source: ASPE analysis of 2019 ACS data

 

March 2022 ISSUE BRIEF 5
Table 2. Language Spoken and Education Among Uninsured Women of Reproductive Age (15-44)

Demographic

  

Vue
No English Speaking Adults in Household 15%
English Spoken in Household 78%
Spanish Spoken in Household 18%

  

Educational Attainment
Less than High School 20%
High School Diploma 65%
College Grad 15%

Notes: ASPE analysis of 2019 ACS data. Language categories sum to more than 100 percent because
they are not mutually exclusive.

There is significant variation in the number of uninsured women of reproductive age at the state level
(Appendix Table A). Of the five states with the largest number of uninsured women of reproductive age, four
are Medicaid non-expansion states (Texas, California, Florida, Georgia, and North Carolina). Forty-seven
percent of all uninsured women of reproductive age reside in the 12 states that have not adopted the
Medicaid expansion. Among women of reproductive age with incomes at or below 138% FPL, over 50 percent
live in Medicaid non-expansion states and could fall in the coverage gap.

Given the large disparities in maternal health outcomes for Black women, we also assessed the share among
uninsured women of reproductive age who are Black by state (Figure 5). On average, non-expansion states
have a higher proportion of Black women among this population compared to states that have adopted the
Medicaid expansion.

 

March 2022 ISSUE BRIEF 6
Figure 5. Share of Uninsured Women of Reproductive Age who are Black, in Medicaid Non-Expansion States
vs. All Expansion States

Mississippi es 2%
Georgio as 34%
Acbono es 32°

South Carino es 20°
North Carlin, i 23°
(lords I 33;
Tennessee Po 18%
All Expansion States Re 11%
Texas Po 10%
Wisconsin Po 9%
South Dakota [A 7%
Kansas Po 7%
Wyoming i 2%

Source: ASPE analysis of 2019 ACS data

DISCUSSION

Under the ACA, the U.S. has made significant strides in improving women's access to comprehensive health
coverage. After implementation of ACA Medicaid and Marketplace coverage provisions, the proportion of
women of reproductive age who were uninsured dropped from 21 percent in 2010 to 12 percent in 2017. This
decline was pronounced in states that extended Medicaid to low-income adults with incomes up to 138
percent of the federal poverty level (FPL): ACA expansion states saw their uninsured rates drop by more than
half among women of reproductive age (19-44), while non-ACA expansion states experienced only a 28
percent decrease. Further, most women can now obtain coverage that provides a wide range of
recommended preventive services at no-cost and includes essential services such as maternity care and
contraception." The ARP's enhanced Marketplace subsidies and state option for extended postpartum
coverage in Medicaid are critical tools in helping expand coverage in this population.

 

March 2022 ISSUE BRIEF 7
Despite these gains, approximately 11 million women under age 65 remained uninsured in 2019. Most of
these women (approximately 7.9 million) are of reproductive age and are eligible for subsidized Marketplace
coverage or would be eligible for Medicaid if all states adopted the Medicaid expansion. Health coverage for
women of reproductive age is critical to improving maternal and infant health, especially for Black and
American Indian/Alaska Native women, who experience far worse outcomes." Closing the coverage gap in the
12 remaining non-expansion states would be an important step in improving access to coverage and continuity
of coverage among women of reproductive age. Currently, nearly 1.5 million women of reproductive age in
non-expansion states have incomes below 100% FPL and could fall in the coverage gap. Medicaid expansion
would provide this population with a pathway to coverage and, for women who become pregnant, promote
continuity of coverage prior to pregnancy, throughout pregnancy and postpartum, and beyond.

The ARP included a temporary state option to extend continuous Medicaid and Children's Health Insurance
Program (CHIP) eligibility for pregnant individuals from 60 days up to 12 months postpartum. Previous ASPE
research found that if all states extended pregnancy-related Medicaid eligibility to 12 months postpartum,
approximately 720,000 women annually would be eligible for expanded postpartum coverage."*

Outreach and enrollment efforts could also help boost coverage rates among the remaining uninsured women
of reproductive age. Research has found that many uninsured individuals are not aware of their coverage
options and cite cost and difficulty with the enrollment process as barriers to enrolling in coverage. Enrollment
strategies such as public information campaigns, individual assistance, and community outreach efforts can be
effective at reaching targeted populations, improving consumers' understanding of plans, and increasing
enrollment."> To support this effort, the Centers for Medicare and Medicaid Services (CMS) awarded $80
million in grant awards for the 2022 plan year and another almost $11.5 million in additional funding to
support outreach and enrollment efforts.?°

CONCLUSION

The ACA has produced major gains in coverage among women since 2010. Early evidence indicates that efforts
to expand coverage by the Biden-Harris administration, including enhanced outreach efforts, the ARP's
expanded Marketplace subsidies, and efforts to boost postpartum coverage in Medicaid, have produced
further reductions in the uninsured rate in 2021." Future efforts to build on these coverage gains can help
improve health care access and health outcomes for women in the U.S.

 

March 2022 ISSUE BRIEF 8
APPENDIX

Table A. Number of Uninsured Women of Reproductive Age (15-44), by State

State

U.S. Total

Alabama*

Ee) mM Olivia -ye|
Women (Ages 15-44)

7,872,202

132,237

 

NK] # of Uninsured
Women (Ages 15-44)
WTSXelO aT 170,220

 

[eee |
15,283 N ar 319,600
Mississippi* 116,917 Wyoming* 20,656
Source: ASPE analysis of 2019 ACS data
* States that have not expanded Medicaid under the ACA, as of March 2022.
March 2022 ISSUE BRIEF 9
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2021-uninsured.pdf

 

 

March 2022 ISSUE BRIEF 11
alae 477 8)

 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Office of the Assistant Secretary for Planning and Evaluation

200 Independence Avenue SW, Mailstop 447D
Washington, D.C. 20201

For more ASPE briefs and other publications, visit:
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=]

ABOUT THE AUTHORS

Sarah Sugar is an Analyst in the Office of Health Policy in ASPE.
Joel Ruhter is an Analyst in the Office of Health Policy in ASPE.
Sarah Gordon is a Senior Advisor in the Office of Health Policy in
ASPE

Amelia Whitman is an Analyst in the Office of Health Policy in
ASPE.

Christie Peters is the Director of the Division of Health Care
Access and Coverage for the Office of Health Policy in ASPE.
Nancy De Lew is the Associate Deputy Assistant Secretary for the
Office of Health Policy in ASPE.

Benjamin D. Sommers is the Deputy Assistant Secretary for the
Office of Health Policy in ASPE.

SUGGESTED CITATION

Sugar S, Ruhter J, Gordon S, Whitman A, Peters C, De Lew N, and
Sommers BD. Health Coverage for Women Under the Affordable
Care Act. (Issue Brief No. HP-2022-09). Office of the Assistant
Secretary for Planning and Evaluation, U.S. Department of Health
and Human Services. March 21, 2022.

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may be reproduced or copied without permission; citation as to
source, however, is appreciated.

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