Women’s Health Insurance Coverage

SOURCES OF HEALTH INSURANCE COVERAGE

EMPLOYER-SPONSORED INSURANCE:

Approximately 57.5 million women ages 19-64 (59%) received their health coverage from their own or their spouse’s employer in 2015 (Figure 1). Women are less likely than men to be insured through their own job (35% vs. 44% respectively) and more likely to be covered as a dependent (24% vs. 16%).¹

• Women in families with at least one full-time worker are more likely to have job-based coverage (68%) than women in families with only part-time workers (31%) or without any workers (15%).²
• Because women are more likely than men to be covered as dependents, a woman is at greater risk of losing her insurance if she becomes widowed or divorced, her spouse loses a job, or her spouse’s employer drops family coverage or increases premium and out-of-pocket costs to unaffordable levels. The ACA also requires employer plans that offer dependent coverage to give workers the option of keeping adult children up to age 26 enrolled as dependents. An estimated 39% of women between the ages of 19 and 25 are covered as dependents under a parent’s or a spouse’s plan.³
• In 2016, annual insurance premiums for employer sponsored insurance averaged $6,435 for individuals and $18,142 for families, increasing by 58% over the last decade. On average, workers paid 18% of premiums for individual coverage and 30% for family coverage with the employers picking up the balance.⁴

NON-GROUP INSURANCE:

The ACA expanded access to the non-group or individually purchased insurance market by offering premium tax credits to help individuals purchase coverage in state-based health insurance Marketplaces. It also included many insurance reforms to alleviate some of the long-standing barriers to coverage in the non-group insurance market, many disproportionately affecting women. In 2015, about 9% of non-elderly adult women (approximately 8.8 million women) purchased insurance on their own.⁵ This includes women who purchased private policies from the ACA Marketplace in their state, as well as from private insurers that operate outside of Marketplaces.

• Individuals who seek insurance policies in their state’s Marketplace may qualify for assistance with the costs of coverage. Those with incomes below 400% of the FPL can qualify for assistance in the form of federal tax credits which lower costs of premiums, and those with income below 250% FPL can purchase coverage that limits cost-sharing requirements. In a national survey conducted in Fall 2014, nearly all (94%) women in marketplace plans had household incomes below 400% FPL, the upper limit for premium credits and 75% had incomes below 250% FPL, the threshold for cost sharing reductions.⁶
• The ACA set new standards for all individually purchased plans, including new plans available through the Marketplace as well as those that existed prior to the ACA. Historically, insurance carriers selling plans on the individual insurance market adopted policies that specifically placed women at a disadvantage, either by charging them higher premiums than men for the same level of coverage (a practice called gender rating) or disqualifying them for coverage because they had certain pre-existing medical conditions, including pregnancy. The ACA bars plans from instituting these policies.
• Many of the pre-ACA individually purchased policies did not include coverage for services that are important to women, such as maternity care, prescription medications, or treatment for mental health conditions such as depression. As a result of the ACA, all direct purchase plans also must cover certain “essential health benefits” (EHBs) that fall under 10 different categories, including maternity and newborn care, mental health, and preventive care.

MEDICAID:

The state-federal program for low-income individuals, Medicaid, covered 17% of non-elderly adult women in 2015. Historically, to qualify for Medicaid, women had to have very low incomes and be in one of Medicaid’s eligibility categories: pregnant, mothers of children 18 and younger, disabled, or over 65. Women who didn’t fall into these categories typically were not eligible regardless of how poor they were. The ACA allowed states to eliminate these categorical requirements and broaden Medicaid eligibility to most individuals with incomes less than 138% of the Federal Poverty Level (FPL) regardless of their family or disability status or age, effective January 2014. However, not all states have taken up this option, as is discussed further below.

• Among all sources of coverage, Medicaid disproportionately carries the weight of covering the poorest and sickest population of women. Approximately 66% of non-elderly women with Medicaid had incomes below 200% of the FPL. More than one in four (27%) women covered by Medicaid rate their own health as fair or poor, compared to 6% of women covered by employer-sponsored insurance and 11% of uninsured women.⁷
• Medicaid finances nearly half of all births in the U.S.,⁸ accounts for 75% of all publicly-funded family planning services⁹ and half (51%) of all long-term care spending, which is critical for many frail elderly women.¹⁰
• Over half of the states (28 states) have established programs that use Medicaid funds to cover the costs of family planning services for low-income women and most states have limited scope Medicaid programs to pay for breast and cervical cancer treatment for certain low-income uninsured women.¹¹

UNINSURED WOMEN

Approximately 11% of women ages 19 to 64 (approximately 11.2 million women) were uninsured in 2015, a decline from a rate of 17% in 2013. Uninsured women often have inadequate access to care, get a lower standard of care when they are in the health system, and have poorer health outcomes.¹² Compared to women with insurance, uninsured women have lower use of important preventive services such as mammograms and Pap tests and are more likely to forgo medical services due to cost.¹³ In a survey conducted in Fall 2014, uninsured women were less likely to have a regular source of care compared to women with any form of insurance.¹⁴

PROFILE OF UNINSURED

• Low-income women, women of color, and immigrant women are at greater risk of being uninsured (Figure 2). Single mothers are more likely to be uninsured (16%) than women in two-parent households (9%).
• The majority of uninsured women live in a household where someone is working: 68% are in families with at least one adult working full-time and 82% are in families with at least one part-time or full-time worker.¹⁵
• There is considerable state-level variation in uninsured rates across the nation, ranging from 21% of women in Texas to 4% of women in Washington DC (Table 1).

LOOKING FORWARD

As the ACA enters the fourth full year of implementation, policymakers face a number of issues in achieving the law’s main goal of expanding coverage.

REMAINING UNINSURED:

Since the ACA went into effect there has been a sharp drop in the number of uninsured women. Yet, many women remain uninsured for a variety of reasons. In 2016, this includes an estimated 1.3 million poor women in the so-called “Medicaid coverage gap” who live in states that have not expanded their Medicaid programs but who would qualify for Medicaid if their states expanded eligibility under the ACA. A 2012 Supreme Court ruling effectively made Medicaid expansion optional for states and, as of October 2016, 31 states and the District of Columbia have decided to expand their state Medicaid programs but 19 states have not (Figure 3).

In addition, a portion of uninsured women are also eligible for full scope traditional Medicaid (1.9 million) but are not enrolled and 2.3 million are income eligible for a subsidized Marketplace plan. Around 2.9 million are still uninsured but have an offer of employer-based insurance or are not eligible for subsidy assistance under the ACA because their income is too high. Approximately 2.3 million undocumented individuals are ineligible for Medicaid and, in nearly all states, are prohibited from purchasing insurance on the Marketplaces (Figure 4).

SCOPE OF COVERAGE:

The ACA set new standards for the scope of benefits offered in private plans. In addition to the broad categories of essential health benefits (EHBs) offered by state-based marketplace plans, the law also requires that new private plans cover preventive services without co-payments or other cost sharing. This includes pap tests, mammograms, bone density tests, as well as the HPV vaccine. Starting in August 2012, new private plans were also required to cover an additional set of preventive services for women, including prescribed contraceptives, breastfeeding supplies and supports such as breast pumps, screening for domestic violence, well woman visits, and several counseling and screening services.¹⁶ This set of women’s services is to be updated by the end of 2016. Abortion services are explicitly prohibited from being included as EHBs and 25 states have laws banning coverage of most abortions from the plans available through the state Marketplaces, and an additional 7 states did not include abortion coverage in 2015 even though they had no bans. As a result, in 2015, women enrolled in Marketplace plans in 32 states lacked abortion coverage in their new policies.¹⁷

AFFORDABILITY AND ACCESS:

Affordability of coverage and care continues to be a significant concern for many women, both for those who are uninsured as well as those with coverage. The leading reason why uninsured women report that they haven’t obtained coverage is that it is too expensive. Under employer-sponsored insurance, the major source of coverage for women, half of all covered workers have deductibles of at least $1,000.¹⁸ Similar affordability challenges exist in the non-group market, which includes the ACA Marketplaces. Forty-seven percent report dissatisfaction with their plan’s annual deductible, and 43% are dissatisfied with their monthly premium.¹⁹ The ACA includes some measures directed at making care more affordable, such as caps on out-of-pocket spending for some low-income individuals who obtain Marketplace coverage and no cost coverage for recommended preventive services for all those with private insurance. Assuring access to care remains a priority.  There has been some concern that the narrower networks offered by some Marketplace plans may not be able to meet the needs of enrollees, especially when it comes to specialty care. In Fall 2014, one in five women with Marketplace coverage reported that they could not get an appointment because the provider didn’t accept their insurance. ²⁰

CONCLUSION

Health coverage matters for women. Those with health coverage are more likely to obtain needed preventive, primary, and specialty care services, and have better access to new advances in women’s health. The ACA has made major changes to the health insurance market and millions of women have gained coverage in the first three full years of implementation. Millions more have gained no-cost coverage to recommended preventive care and access to a more robust benefit package that includes maternity care and mental health. As the fourth year of the ACA expansion gets underway, the issue of affordability and availability of plans is getting considerable attention. Costs and reductions in the number of plans participating in the marketplace may make it more challenging to make inroads in reducing the number of uninsured through Marketplace plans. Affordability concerns are also affecting women with employer coverage, who shoulder a significant share of premium costs and have enrolled in high-deductible plans in increasing numbers. For low-income women, participation and eligibility for Medicaid continues to be a challenge. Many women still lack a pathway to affordable coverage because their state is not expanding Medicaid or they are undocumented immigrants, and others are eligible but not enrolled in their state programs. While there has been much progress in expanding coverage and reducing the number of uninsured since the passage of the ACA, access to affordable coverage and care continues to be concern for many women across the nation.

Table 1: Health Insurance Coverage of Women Ages 19-64 in 2015, by State
	Estimated Number of Women (Thousands)	Percent Distribution by Coverage Type
		Employer Sponsored	Direct Purchase	Medicaid	Other	Uninsured
United States	98,012	59%	9%	17%	4%	11%
Alabama	1,508	56%	9%	13%	9%	14%
Alaska	210	58%	4%	15%	8%	14%
Arizona	2,052	52%	5%	23%	6%	14%
Arkansas	880	55%	10%	16%	7%	12%
California	12,194	52%	12%	24%	3%	9%
Colorado	1,683	61%	8%	15%	4%	11%
Connecticut	1,123	61%	11%	15%	3%	10%
Delaware	300	65%	6%	16%	5%	7%
DC	242	61%	9%	25%	1%	4%
Florida	6,107	51%	13%	14%	6%	16%
Georgia	3,232	55%	8%	13%	5%	19%
Hawaii	411	64%	4%	18%	9%	6%
Idaho	469	61%	9%	11%	3%	15%
Illinois	3,869	62%	9%	17%	4%	8%
Indiana	1,954	63%	7%	16%	3%	11%
Iowa	925	65%	10%	14%	3%	8%
Kansas	813	68%	9%	7%	4%	13%
Kentucky	1,329	58%	11%	20%	5%	6%
Louisiana	1,460	55%	9%	16%	7%	14%
Maine	396	61%	7%	21%	N/A	6%
Maryland	1,953	66%	8%	13%	5%	8%
Massachusetts	2,150	62%	6%	24%	2%	6%
Michigan	2,986	65%	6%	17%	4%	7%
Minnesota	1,586	68%	9%	15%	2%	6%
Mississippi	915	51%	9%	16%	8%	16%
Missouri	1,827	64%	10%	9%	4%	13%
Montana	296	58%	9%	12%	7%	14%
Nebraska	555	65%	10%	11%	N/A	11%
Nevada	857	56%	8%	16%	8%	12%
New Hampshire	420	71%	7%	12%	4%	6%
New Jersey	2,762	64%	7%	16%	3%	10%
New Mexico	593	49%	6%	24%	6%	15%
New York	6,160	58%	9%	22%	3%	8%
North Carolina	3,144	57%	10%	13%	5%	15%
North Dakota	220	69%	9%	10%	3%	10%
Ohio	3,572	62%	7%	20%	4%	7%
Oklahoma	1,159	58%	8%	12%	6%	16%
Oregon	1,252	54%	10%	23%	5%	8%
Pennsylvania	3,823	67%	8%	16%	2%	7%
Rhode Island	330	65%	8%	18%	3%	5%
South Carolina	1,520	56%	9%	15%	6%	14%
South Dakota	239	66%	11%	11%	N/A	10%
Tennessee	2,021	56%	8%	16%	7%	13%
Texas	8,338	57%	8%	8%	5%	21%
Utah	844	66%	8%	11%	4%	12%
Vermont	193	62%	10%	16%	4%	7%
Virginia	2,559	63%	11%	7%	8%	10%
Washington	2,145	62%	7%	19%	3%	8%
West Virginia	531	51%	6%	30%	5%	8%
Wisconsin	1,740	66%	8%	16%	3%	7%
Wyoming	166	65%	9%	8%	7%	12%
NOTES: Other category includes: Medicare coverage and military-related coverage. Percentages may not sum to 100% due to rounding. Some estimates are “N/A” because point estimates do not meet the minimum standards for statistical reliability. SOURCE: Kaiser Family Foundation analysis of 2016 ASEC Supplement to the Current Population Survey, U.S. Census Bureau.