Women’s Health Care: The Implications of the 

Affordable Care on Coverage and Access

Alina Salganicoff, Ph.D.

Vice President and Director, Women’s Health Policy 

Kaiser Family Foundation

for 

VA HSR&D CyberSeminars

October 3, 2013
Figure 1 

SOURCE: Kaiser Family Foundation Kaiser Health Tracking Poll Omnibus Supplement (conducted August 15-18, 2013)

Lots of Confusion about ACA: Over 4 in 10 Americans 

Unsure Whether ACA Remains Law

As you may know, a health care bill was signed into law in March 2010. As far as you know, which comes 

closest to describing the current status of the health care law?

Unaware of 

current status of 

health care law 

(NET)

44%
Figure 2 

Do you feel you have enough information about the 

health reform law to explain to a patient or a family 

member how it may affect them? 

– Yes, I have enough information

– No, I do not have enough information

Poll Question #1
Figure 3 

NOTE: Don’t know/Refused answers not shown.

SOURCE: Kaiser Family Foundation Health Tracking Poll (conducted August 13-19, 2013)

Majority of Uninsured, Low Income Don’t Know How Law Will Impact 

Their Family

"Do you feel you have enough information about the health reform law to understand how it 

will impact you and your family, or not?"
Figure 4 

• Status of implementation 3 years post enactment

• Major Issues Involved in the Coverage Expansion: 

Medicaid and the Exchanges

– Eligibility and Enrollment

– Benefits and Scope of Coverage

– Cost and Affordability

• Services of Importance to Women

• Considerations Looking Forward

ACA and Women’s Health
Figure 5 

 Already Implemented: Insurance Reforms 

Temporary high-risk pools

Dependent coverage extended to age 26

No lifetime limits and no rescissions; restricted annual 

limits

No pre-existing condition exclusions for children

Review of increases in health plan premiums 

Plan rebates

No cost-sharing for preventive services in private plans

ACA’s Impact on Access to and Affordability of Coverage
Figure 6 

Promoting Health Coverage through the ACA 

How will it work?

Medicaid Coverage For 

Low-Income 

Individuals 

Employer-Sponsored Coverage

Marketplaces With Subsidies 

for Moderate Income 

Individuals 

Individual

Mandate

Health Insurance 

Market Reforms

Universal Coverage
Figure 7 

Many Uninsured Will Be Newly Eligible for Coverage:

NOTE: Other includes programs such as Medicare and military-related coverage. 

The federal poverty level for a family of three in 2011 was $18,530. 

SOURCE: KFF/Urban Institute analysis of 2012 ASEC Supplement to the Current Population Survey, U.S. Census Bureau. 

98.2 million women ages 18-64 

≤138% FPL 

Income Levels of Uninsured 

Women

139-399% FPL

> 400% FPL

Health Insurance Coverage of Nonelderly Women, 

2011 
Figure 8 

Tremendous Geographic Variation in Who Potentially Benefits from 

ACA Coverage Expansions

Share of the Nonelderly Population with incomes under 400% 

FPL who were uninsured or purchasing individual coverage
Figure 9 

*138% FPL = $15,856 for an individual and $26,951 for a family of three in 2013.

ACA Medicaid Expansion Fills Current Gaps in Coverage

Adults

Elderly & 

Persons with 

Disabilities

Parents 

Pregnant

Women

Children

Extends to Adults 

≤138% FPL* 

Medicaid Eligibility Today Medicaid Eligibility 

in 2014 Limited to Specific Low-Income Groups Extends to Adults ≤138% FPL* 
Figure 10

Supreme Court Ruling Impact: 

Half of states will be expanding Medicaid eligibility

NOTE: *These states are exploring an approach to the Medicaid expansion that is likely to require waiver approval. 

SOURCE: Kaiser Family Foundation, State Health Facts, Status of State Action on the Medicaid Expansion Decision, October 1, 2013.

WY

WI

WV

WA

VA

VT

UT

TX

TN*

SD

SC

RI

PA

OR

OK

OH

ND

NC

NY

NM

NJ

NH

NV

NE

MT

MO

MS

MN

MI*

MA

MD

ME

LA

KS KY

IA*

IL IN*

ID

HI

GA

FL

 DC 

DE 

CT

CO

CA

AR* AZ

AK

AL

Moving Forward at this Time (24 States and DC)

Not Moving Forward at this Time (26 States)
Figure 11

Medicaid Expansion Would Increase Access to Coverage for Many 

Low-income Adults, Especially Single Adults & Couples without Kids

138% 

NOTE: Ten states (CT, IL, ME, MA, MN, NJ, NY, RI, VT, WI) &DC already offer coverage to parents at or above 133% FPL; under the ACA an income 

disregard of 5 percentage points will be applied to this limit increasing the effective income limit to 138% FPL. 

SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown 

University Center for Children and Families, 2013.
Figure 12

However, Not All States are Participating, Creating Continued 

Coverage Challenges for Adults in Many States

138% 

NOTE: Ten states (CT, IL, ME, MA, MN, NJ, NY, RI, VT, WI) &DC already offer coverage to parents at or above 133% FPL; under the ACA an income 

disregard of 5 percentage points will be applied to this limit increasing the effective income limit to 138% FPL. 

SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown 

University Center for Children and Families, 2013.

No Medicaid

or Subsidies

Subsidies on 

Exchange Plans
Figure 13

States Have Made Their Decisions For Creating Health Insurance 

Marketplaces

State-based Marketplace (17 states including DC)

Partnership Marketplace (7 states)

Federally-facilitated Marketplace (27 states)

WA

OR

WY

UT*

TX

SD

OK

ND

NM**

NV

NE

MT

LA

KS

ID** 

HI

CO

CA

AR AZ

AK

WI

WV VA

TN

SC

OH

NC

MO

MS

MN

MI

KY

IA

IL IN

GA

FL

AL

VT

PA

NY

NJ

NH

MA

ME

CT

DE 

RI

MD

 DC 

NOTES: * In Utah, the federal government will operate the individual exchange while the state will run the SHOP exchange.

** Idaho and New Mexico received approval to operate state-based marketplaces; however, due to time constraints, the states will rely on the 

federal government for the IT infrastructure, but will perform most other functions.

SOURCE: Kaiser Family Foundation, State Health Facts, State Decisions for Creating Health Insurance Exchanges, as of May 28, 2013.
Figure 14

Have you seen or read ads or other 

materials that provide information about 

the health care marketplace in your 

state?

– Yes 

– No

Poll Question #2
Figure 15

SOURCE: Kaiser Family Foundation Health Tracking Polls

8 in 10 Adults Have Either Not Heard or Only Heard a Little about 

Health Insurance Marketplaces

As you may know, the health care law does create health insurance exchanges or marketplaces where people who don’t 

get coverage through their employers can shop for insurance and compare prices and benefits. How much, if anything, 

have you heard about this new health insurance marketplace, [also known as (STATE EXCHANGE NAME)] in your state?
Figure 16

Source: http://kaiserfamilyfoundation.files.wordpress.com/2013/09/8481-getting-into-gear-for-2014-an-early-look-at-brandingand-marketing.pdf

17 States Will Be Operating their Own Health Exchanges 
Figure 17

Health Insurance Marketplaces Will Facilitate Enrollment into 

Coverage by Individuals and Small Employers

Eligibility for Multiple 

Programs Determined in 

Real Time

Information Provided 

on Available Plans 

for Comparison

Enrollment Into 

Selected Plan

Plan 

A 

Plan 

B Plan C

 

  

 

  

John Doe

123 Main Street

12345

Medicaid/CHIP

Unsubsidized 

Exchange Coverage

Premium Tax 

Credits
Figure 18

Plan Type

“Actuarial 

Value” Typical Deductible Coinsurance

Maximum Out-ofPocket Cost

Bronze 60% $5,000 30% $6,350 

Silver 70% $2,000 20% $6,350 

Gold 80% $0 20% $6,350 

Platinum 90% $0 10% $6,350 

Catastrophic

(up to age 30) NA $6,350 0% $6,350 

Examples of Coverage Options for Individuals and Small Businesses

All figures are for single coverage. Amounts for families would be double.

All plans have to cover a wide range of benefits.
Figure 19

Single 25 year old making $20,000

Unsubsidized silver premium = $2,772

Individual contribution = $1,021

Tax credit (federal subsidy) = $1,751

40 year old parents with two kids making $50,000

Unsubsidized silver premium = $10,563

Family contribution = $3,365

Tax credit (federal subsidy) = $7,198

60 year old couple making $50,000

Unsubsidized silver premium = $14,986

Family contribution = $4,750

Tax credit (federal subsidy) = $10,236

Annual Premium Subsidy Examples (California Average)

http://www.kff.org/interactive/subsidy-calculator/
Figure 20

What Will the New Plans Cover? Essential Health Benefits

• Insurance Plans are required to cover 10 categories of benefits

 Ambulatory patient services

 Emergency services

 Hospitalization

 Maternity and newborn care

 Mental Health and substance use disorder services, including behavioral health 

treatments

 Prescription drugs

 Rehabilitative and habilitative services and devices

 Laboratory services

 Pediatric services including dental care

 Preventive and wellness services and chronic disease management

• The Medicaid expansion group will have benchmark benefits that 

include these benefits, BUT may differ than benefits offered under 

the traditional program 
Figure 21

New plans must cover without cost-sharing:

• U.S. Preventive Services Task Force (USPSTF) Recommendations rated A or B

• ACIP recommended immunizations

• Bright Futures guidelines for preventive care and screenings

• “With respect to women,” evidence-informed preventive care and 

screenings not otherwise addressed by USPSTF recommendations

• Services recommended by IOM committee and adopted by HHS

ACA Preventive Services for Private Plans

SOURCE: Patient Protection and Affordable Care Act. Public Law 111–148, AND HRSA Women’s Preventive Services Guidelines, 2012.

•Well-woman visits 

•Gestational diabetes, HIV, and STI 

screening and counseling

•HPV testing

•FDA-approved contraceptives

•Breastfeeding support, supplies, and 

counseling

•Interpersonal and domestic screening 

and counseling
Figure 22

Cancer Chronic Conditions Immunizations Healthy Behaviors Pregnancy-Related** Reproductive Health

Breast Cancer

– Mammography for 

women 40+*

– Genetic (BRCA) 

screening and 

counseling

– Preventive medication 

counseling

Cervical Cancer

‒ Pap testing (women 

21+ )

‒ High-risk HPV DNA 

testing 

Colorectal Cancer

− One of following: fecal 

occult blood testing, 

colonoscopy, 

sigmoidoscopy 

Cardiovascular health

− Hypertension screening

− Lipid disorders 

screenings 

− Aspirin 

Type 2 Diabetes 

screening (adults w/ 

elevated blood 

pressure)

Depression screening 

(adults, when follow up 

supports available)

Osteoporosis screening 

(all women 65+, 

women 60+ at high 

risk)

Obesity 

Screening (all adults)

Counseling and 

behavioral 

interventions (obese 

adults)

Td booster, Tdap

MMR 

Meningococcal

 Hepatitis A, B

Pneumococcal

Zoster 

Influenza, 

Varicella 

HPV (women and 

men 19-26)

Alcohol misuse 

screening and 

counseling (all adults)

Intensive healthy diet 

counseling (adults 

w/high cholesterol, 

CVD risk factors, dietrelated chronic 

disease)

Tobacco counseling 

and cessation 

interventions (all 

adults)

Interpersonal and 

domestic violence 

screening and 

counseling (women 

18-64)♀

Well-woman visits 

(women 18-64) 

Tobacco and cessation 

interventions

Alcohol misuse 

screening/counseling 

Rh incompatibility screening 

Gestational diabetes 

screenings♀ 

− 24-28 weeks gestation 

− First prenatal visit (women at 

high risk for diabetes) 

Screenings

− Hepatitis B

− Chlamydia (<24, hi risk)

− Gonorrhea

− Syphilis

− Bacteriurea 

Folic acid supplements 

(women w/repro capacity)

Iron deficiency anemia 

screening 

Breastfeeding Supports

− Counseling

− Consultations with trained 

provider

− Equipment rental

STI and HIV counseling 

(adults at high risk; all 

sexually-active women ) 

Screenings: 

− Chlamydia (sexually 

active women <24y/o, 

older women at high 

risk)

− Gonorrhea (sexually 

active women at high 

risk)

− Syphilis (adults at high 

risk)

− HIV (adults at high risk; 

all sexually active 

women ) 

Contraception (women 

w/repro capacity) 

− All FDA approved 

methods as prescribed,

− Sterilization procedures

− Patient education and 

counseling 

Adult Preventive Services to be Covered by Private Plans Without Cost Sharing 

SOURCE:U.S. DHHS, “Recommended Preventive Services.” Available at http://www.healthcare.gov/center/regulations/prevention/recommendations.html. 

More information about each of the services in this table, including details on periodicity, risk factors, and specific test and procedures are available at the following websites: 

USPSTF: http://www.uspreventiveservicestaskforce.org/recommendations.htm

ACIP: http://www.cdc.gov/vaccines/pubs/ACIP-list.htm#comp HRSA Women’s Preventive Services: http://www.hrsa.gov/womensguidelines/
Figure 23

• HRSA Guidelines apply to full range of FDA-approved contraceptive methods 

“as prescribed” for women including:

– barrier methods (diaphragm, sponge, spermicide, cervical cap)

– hormonal methods (OCs, Patch, Ring, shots)

– Emergency contraception (Plan B, One Step, Next Choice, Ella)

– implanted devices, (IUDs, implantable rods)

– sterilization (surgery or implants) 

• Also includes counseling and insertion as well as services related to follow-up 

and management of side effects, counseling for continued adherence, and 

device removal

• HHS Clarification: 

– If the generic drug (or a brand name drug) would be medically inappropriate, plan must waive 

cost-sharing for the provider-recommended branded or non-preferred brand version 

– If generic is not available or it would be medically inappropriate, then plan must cover the brand 

name drug “without cost-sharing, subject to reasonable medical management” 

Contraceptive Coverage: What does it include?
Figure 24

• All “houses of worship” exempt from ONLY the contraceptive coverage 

requirement if they wish.

• An HHS regulation for religiously affiliated non-profits that object. In 

those cases, the insurer/TPA is required to cover the contraceptive 

services and supplies, NOT the employer.

• More than 60 lawsuits have been filed against HHS, DOL and Treasury to 

block implementation.

– Non-profits, for-profits, individuals, and corporations are among the 

filers. Some object to all contraceptive coverage and some focus on 

EC. Lawsuits expected to reach Supreme Court.

What About Religious Exemptions for Contraceptive Coverage?
Figure 25

• Abortion explicitly banned as an essential benefit

• Medicaid: 

– Hyde limitations still apply, no federal funds, tax credits or subsidies may 

be used for abortion coverage except in rape, incest, life endangerment 

– States may use state funds to cover other “medically necessary” 

abortions 

• State Exchanges:

– States can ban coverage in Exchanges; 23 states have done so

– If there is a plan with abortion coverage, the state must also offer at least 

one plan that limits abortion coverage to Hyde rules 

– Plans that offer abortion coverage beyond Hyde limits must segregate 

premium payments for coverage of abortion; Abortion coverage 

separated from all else

Access to Coverage for Abortions Explicitly Addressed
Figure 26

• Pregnancy can no longer be defined as a pre-existing condition

• Maternity and newborn care defined as essential benefit in plans, 

details will vary by state

• Prenatal care and screening services, and breastfeeding support are 

covered without cost-sharing in new private plans

• Medicaid 

– Covers 41% births nationally

– Mandatory coverage of tobacco cessation programs for pregnant women

– Optional coverage for freestanding birth centers

– Medicaid coverage for all newborns who lack acceptable coverage

• Grants to states for home visiting and postpartum depression 

services

• Workplace breastfeeding protections for nursing mothers

Maternity Care
Figure 27

Alcohol misuse 

counseling

Blood pressure 

screening 

BRCA screening, 

counseling about

Breast cancer 

preventive medication

Breast cancer 

screening

Breastfeeding 

counseling

Cervical cancer 

screening

Chlamydia infection 

screening

Cholesterol 

abnormalities 

screening

Colorectal cancer 

screening

Depression screening

Diabetes screening

Folic acid 

supplementation

Gonorrhea screening: 

Healthy diet 

counseling

HIV screening

Obesity screening and 

counseling

Osteoporosis 

screening

STIs counseling

Tobacco use 

counseling and 

interventions 

Syphilis screening 

Diet and Physical 

Activity

Establishing Pregnancy 

History of CVD-related 

Conditions

Mental health

Metabolic Syndrome 

Preconception health

Prenatal Care

STIs: Screening for 

Chlamydia and 

gonorrhea 

IOM Services Recommended for Potential Inclusion in 

Well Woman Visit

At least one annual well-woman visit is covered... but who should do 

it? How do we create a medical home for women?
Figure 28

• More patients will have 

coverage – Exchange Plans 

and Medicaid will increase 

access to and affordability of 

coverage for millions

• Floor on scope of 

coverage- Essential Health 

Benefits 

• Comprehensive coverage 

for preventive care – 63 

preventive services now covered 

without cost sharing

• Incentives for primary care 

– higher reimbursements for 

Medicaid and Medicare

Impacts of ACA on Practice: The Good News
Figure 29

• Coverage Challenges

– Coinsurance and deductibles could be high

– “Reasonable Medical Management”

• Primary care 

– Concerns about size workforce 

• Medicaid

– Low reimbursement rates; 

– Limited provider participation

• Private Plans

– Most enrolling in Medicaid and Exchange will be in private plans

– To keep premiums low, will provider reimbursements be low?

• Provider Networks

– Extent of involvement of Essential Community Providers (e.g. CHC and Family 

Planning Clinics) could be limited

– Adequacy of networks... TBD

A Few Considerations for Providers: Much is still unknown
Figure 30

NA = Item not asked for this question.

*The news media includes cable TV news, national or local TV news, radio news or talk radio, online news sources, and newspapers/magazines.

NOTE: Wording for some items abbreviated; item wording between questions varies. For full question wording see topline: 

http://www.kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-august-2013/ 

SOURCE: Kaiser Family Foundation Health Tracking Poll (conducted August 13-19, 2013)

Most Trusted on ACA: Doctors and Nurses, Federal and State 

Agencies, Pharmacists

Percent who say they have heard something about the 

law from each of the following in the past 30 days:

Percent who say they would trust information about the 

health care law from each of the following ‘a lot’:
Figure 31

• Estimates that in 2019 -- 23 million 

uninsured nationally

• Who are they?

– Undocumented residents

– Eligible for Medicaid but not enrolled

– Exempt from mandate (most because 

can’t find affordable coverage)

– Choose to pay penalty in lieu of 

getting coverage

• Many (most?) remaining uninsured 

will be low-income

AND Not All Will Be Covered ...

Will the Uninsured Have Access to Care?

Percent of women reporting they have 

received screening test in past two years:

NOTE: Colon cancer screening among women 50 and older; 

SOURCE: 2008 Kaiser Women’s Health Survey; Congressional Budget Office, 2013.
Figure 32

• Open enrollment for coverage through Marketplaces runs for 6 months 

(October 1, 2013- March 31, 2014). Coverage begins January 1, 2014 and much work 

is still being done by states and the federal government to ensure Marketplaces are fully 

functional.

• There are many important elements of the ACA that promote access to 

coverage and care for women. Elimination of gender rating, subsidies, and new 

requirements for coverage of services such as maternity care, contraception, 

breastfeeding support, and other preventive services represent major advances in scope 

of coverage. 

• ACA coverage expansions offer an important opportunity to significantly reduce 

disparities in coverage, but coverage gaps will remain. Many poor adults in states 

that don’t expand Medicaid, as well as undocumented immigrants, will remain uninsured. 

Lack of access to affordable coverage may leave others out. A robust safety net will still 

be critical.

• Consumer assistance will be essential to ensure people get enrolled into 

coverage. Patients will look to and trust their providers for information about 

enrollment and coverage options. Women will play a critical role in this effort. 

• 2014 is not the end, it is the beginning. Reform will keep getting reformed.

Looking Ahead
Figure 33

• Check out the following resources: 

• HHS site: healthcare.gov

• Kaiser Family Foundation: kff.org

• Women’s Health Policy

• Health Reform

• Consumer Information

 Thank You!

 Alina Salganicoff (alinas@kff.org)

Want to learn more about the ACA?