Guest post by Fabiola Carrión, J.D., Senior Attorney and Director of the Data and Accountability Project, National Health Law Program.
(Note: Latin@ is a gender-neutral way to refer to people with Latin American roots.)
Latin@s gained a lot from the Affordable Care Act (ACA). Thanks to this landmark law, more than four million Latin@s who were previously uninsured now have access to health care that includes comprehensive access to reproductive health services. One of the ACA’s biggest accomplishments was a requirement that most health insurance plans cover all forms of contraceptive methods and counseling without cost sharing. With the majority of Latin@s being of reproductive age, this is a provision that benefits us profoundly.
Yet, we know that we are nowhere close to achieving universal health care coverage. Twenty-four million people in the United States remain uninsured, and that especially includes the Latin@ population and people of childbearing age. It is also important to keep in mind the issue of under-insurance, when coverage does not protect the full amalgam of needed services or when patients cannot pay their share of the cost. A Commonwealth Fund Study indicated that 23 percent of 19-64 adults or 31 million people were underinsured, with Latin@s representing the largest underinsured ethnic group.
Access to family planning and abortion services involves additional barriers. A federal appropriations rider called the Hyde Amendment only allows Medicaid funding for abortion when the woman’s life is in danger or when she becomes pregnant as a result of rape or incest. Such restrictions are cumbersome for low-income women because Medicaid is their primary funding source for family planning, and even more so for Latin@s who comprise 21 percent of the low-income population in the United States. Moreover, several state laws prevent state-based abortion coverage: 25 states ban abortion in plans offered through insurance exchanges, and ten states prohibit private insurance plans from covering abortion services. Consequently employed Latin@s who have private insurance also bear a major brunt of those restrictions, since on average they earn 55 cents to a dollar earned by white men which makes it more difficult to afford these services.
And even when there are no prohibitions, other de facto barriers in insurance plans prevent people from accessing family planning and abortion care. These are the barriers that my organization, the National Health Law Program (NHeLP), is trying to document through its Reproductive Health Data and Accountability Project (Data Project). We have observed that in addition to the bans on public funding for abortion, private as well as public insurance plans place obstacles that prevent people from obtaining the services and supplies needed to achieve their reproductive life goals with dignity.
The Data Project collects and analyzes data regarding barriers to contraception and abortion care in private health insurance and public programs. In order to identify these issues, NHeLP has partnered with providers and consumer advocates in more than 30 states. We are hoping that this information can inform our advocacy strategies both at the national and the state level.
In the 16 months that we have been collecting data, we have found cases that confirm the issues identified by the Guttmacher Institute and the Health Research and Educational Trust: primarily that medical providers are receiving little to no reimbursement when it comes to reproductive health care coverage, subsequently decreasing their ability to provide needed care.
In particular, as explained below, we have found three main obstacles: (1) private insurance plans are making management decisions that curtail access to reproductive health care services; (2) states are not complying with the limited services that the Hyde Amendment allows, and (3) deductibles are too high for women to pay when they seek reproductive health care.
Harmful Management Decisions
The ACA allows insurance plans to engage in “reasonable medical management techniques” in order “to control costs and promote efficient delivery of care.” While this provision seems to make sense for insurance companies, we are finding that in practice the insurers’ decisions are delaying access to family planning services or halting reproductive health care all together.
For example, research conducted by the Data Project has found that even when there are no state restrictions for abortion coverage, private insurance plans decide to only cover abortions that they deem to be “medically necessary.” Hence, if a woman wants to terminate her pregnancy, the procedure can only be covered when a stranger who is not her physician makes a determination that she needs it to preserve her health.
Another medical management technique is prior authorization, a process by which the insurer needs to approve coverage before the patient acquires the services. Various patients who are seeking a specific type of contraception are required to submit prior authorization forms to their insurance company before receiving theprescribed contraception. As they wait for approval, sometimes they opt to take a different, and not as effective, method of family planning. This could be potentially harmful for this person who may not react well to the second choice. Our research also reveals that private insurance plans are not covering all types of contraception. The process of prior authorization becomes even more difficult when a woman is seeking to obtain abortion care. The longer she waits, the more difficult the procedure can be.
Furthermore, when someone who does not know us makes a decision that is important, private, and sensitive, it can be particularly damaging. Paying special attention to our cultural and linguistic needs as a community, we cannot let insurance plans make decisions that disregard our particular needs. Taking into account our circumstances, we should be able to choose any family planning method or provider of our convenience without having to first ask for permission.
Lack of Compliance with Current Abortion Coverage
After 40 years of denying abortion coverage to Medicaid recipients, there is no doubt that the Hyde Amendment creates barriers that may be harmful for low-income women. But the Data Project’s research so far has demonstrated that even with the little that Hyde allows, we are still seeing how states are not complying with its provisions. Medicaid State Directors should be accountable for ensuring that abortion services are provided to the full extent allowed for under the Hyde Amendment.
Our research shows that in a state that does not afford more coverage than allowed by Hyde, a woman who endured severe hyperemesis every time she got pregnant had such severe vomiting and nausea that it was difficult to keep her conscious. Although the doctor advised her that it would be dangerous for her to continue her pregnancy, the Medicaid state agency denied her coverage for the abortion procedure. Another woman suffered a stroke after blood clots had traveled to her brain from her uterus. In this scenario, the doctor also advised the woman that being pregnant could be deadly for her, and still Medicaid would not cover the abortion procedure.
The Data Project has also found that the rape provision is difficult to meet for various reasons: (1) few rape survivors want to talk about their rape with their provider, and (2) even when they are willing to talk about it, they are afraid to report it because the abuser is often their partner, a relative, or someone close to them. Federal law does allow any doctor to waive this requirement when the reporting may endanger the patient’s physical or emotional health, but this is often not known by providers and states have not taken the time to instruct them.
Cost-Sharing and Deductibles that are Too High to Meet
Perhaps the biggest issue the Data Project has identified is the high-deductible fees that patients cannot meet, prohibiting them from getting the services they need. It is important to note that deductibles are usually higher for insurance plans that are covered by smaller businesses or organizations. Latin@s are increasingly joining the small business workforce are the most likely to not be able to complete their share of the payment. These are the underinsured that are still not getting adequate health care.
While certain women end up receiving support from abortion funds provided by grassroots organizations, these funds have limited capacity. For Latin@s, who are low-income, not fully proficient in the English language, or who do not know about these support mechanisms, they are not going to be able to depend on them.
There is much work to be done to achieve universal access to health care for Latin@s. Our research so far demonstrates that reproductive health involves added barriers.
The Network for Public Health Law provides information and technical assistance on issues related to public health. The legal information and assistance provided in this document does not constitute legal advice or legal representation. For legal advice, readers should consult a lawyer in their state.
Support for the Network is provided by the Robert Wood Johnson Foundation (RWJF). The views expressed in this post do not necessarily represent the views of, and should not be attributed to, RWJF.