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Human Rights

The Impact Poverty Has on Women’s Health

by Gretchen Borchelt

Imagine being forced to choose between paying for necessary health care and paying for food, rent, or your child’s school supplies. This is the untenable situation in which many poor women find themselves. Despite the Affordable Care Act’s advancements in making health care more available and affordable for millions of women across the country, poor women still face significant challenges when it comes to getting the care they need, including abortion. Court decisions, politicians, and policies of the Trump administration are pushing poor women and families deeper into poor health, and deeper into poverty.

Women Face Higher Health Care Costs

Women need more health care, but also are more likely to be poor. Health care costs threaten their health and economic security. Women are more likely than men to require health care throughout their lives. They are more likely to have chronic conditions that require ongoing medical treatment. They are more likely, on average, to use prescription drugs. Certain mental health problems, like depression, affect twice as many women as men. Throughout their reproductive years, regardless of whether they have children, women require substantially more contact with medical providers than men their age.

This means women face more costs. Indeed, a greater share of women’s income is consumed by out-of-pocket health care costs. But on average, women have lower incomes than men—in part due to pay inequities—and are more likely to live in poverty or extreme poverty than men. More than 16 million women lived in poverty in 2016; 21.4 percent of black women, 22.8 percent of Native women, 18.7 percent of Latina women, and 10.7 percent of Asian women. The poverty rate for families with children headed by women is higher than those headed by men or those headed by married couples.

This makes women particularly vulnerable to health care costs. To stay financially secure, women routinely forgo needed care. Roughly 1 in 4 women reported in 2017 that they delayed or went without care due to costs. Low-income women are also more likely to cite problems taking time off work, childcare, or transportation as reasons for not obtaining care. 

When women forgo care because of cost or other barriers, they may postpone diagnosis of a serious health problem or go without needed treatment, which can leave them in poor health. Cost as a barrier can be particularly harmful to certain groups of women, like black women who are more likely than white women to be diagnosed with chronic conditions like diabetes and hypertension.

Health care costs lead to financial insecurity. Women—especially those in low-wage jobs without schedule flexibility—may not be able to take time off to receive medical care and may lack paid sick time. They will suffer financial losses—or lose their job—if they miss work for medical treatment or illness. Women are also more likely to struggle with medical debt or bills, with 1 in 4 women reporting trouble paying medical bills in 2016, and reporting they used most of their savings or borrowed money. 

Affordable Care Act’s Expansion of Health Insurance

Insurance coverage matters for poorwomen, and the Affordable Care Act (ACA) made great strides in expanding coverage, improving women’s health and financial security. Health insurance is critically important for poor women because it helps make health care accessible, keeps people healthy, and covers health care costs. But low-income women remain at a greater risk of being uninsured. Half of uninsured women reported going without health care in 2016 because of cost. Uninsured women generally receive less preventive care, such as pap smears and mammograms. Lack of insurance often leads to poorer health outcomes. Uninsured individuals are diagnosed at more advanced disease stages than the insured. The uninsured also have higher mortality rates. 

Fortunately, almost 90 percent of women in this country now have health insurance coverage. This includes over 33 million women of color, who historically have been more likely to be uninsured, be poor, and go without health care because of cost. These coverage gains are due in large part to the landmark ACA. The ACA reforms the private insurance industry, helps individuals afford health coverage, and expands Medicaid eligibility, all of which are critically important for women struggling to make ends meet.

The ACA addresses the discrimination women face in the individual market, which often cause women to bear significant costs or go without health care. For example, the ACA remedies the long-standing practice of refusing to sell insurance to women with so-called “pre-existing conditions” unique to them, such as prior pregnancy or having had a Cesarean delivery. It also targets practices unfair to women, such as charging women more than men for the same coverage, which cost women $1 billion a year pre-ACA. And insurance now covers most ofwomen’s major health needs, including maternity care, prescription drugs, substance abuse and mental health services, and preventive care.

The ACA helps individuals afford health insurance. It creates a system of tax credits designed to ease the cost burden; as of 2014, 9 million women who would otherwise have gone without affordable health insurance were eligible for the tax credits, including a disproportionate number of women of color. The ACA also contains additional “cost-sharing reductions” available to low- and moderate-income families, which effectively buy down the enrollee’s cost-sharing obligations. These forms of financial assistance are critical to low-income women’s ability to get health insurance—and health care.

To stay financially secure, women routinely forgo needed care.

The ACA expands eligibility for public insurance by allowing states to cover low-income individuals in Medicaid regardless of family structure or health status. Medicaid expansion is enormously important to women. Medicaid covers a range of services, including birth control, maternity care, prescription drugs, and hospitalization, addressing most of women’s major health needs throughout their lives. A growing body of research has demonstrated how important Medicaid coverage is to enrollees’ access to care, overall health, and mortality rates.

But lawsuits shortly after the ACA’s passage challenged the constitutionality of the individual responsibility provision, which requires individuals (unless exempt) to obtain health insurance or pay a penalty. The challengers argued that Congress’s power to regulate interstate commerce did not allow it to require people to obtain health insurance. Several states also brought a lawsuit challenging the requirement that states expand Medicaid eligibility as a condition of future receipt of Medicaid funding, arguing it was an unconstitutionally coercive exercise of Congress’s spending power. 

In 2012, the Supreme Court decided National Federation of Independent Business, et al. v. Sebelius, holding that the individual responsibility provision was a valid exercise of Congress’s constitutional authority to tax. The Court upheld the Medicaid expansion as constitutional, but ruled that the federal government could not penalize states’ failure to expand Medicaid coverage by withholding states’ existing Medicaid funding.

The ACA came before the Supreme Court again in 2015, in a case challenging the tax credits provided to help purchase health insurance. King v. Burwell considered whether the ACA allows the Internal Revenue Service  to provide these subsidies to those in the federally facilitated marketplaces (as opposed to those that are state-run). The Supreme Court determined that, when reading the law in its entirety, Congress’s clear intent was to provide tax credits for all marketplaces. 

In upholding these key pieces of the ACA, the Supreme Court helped poor women who need the ACA’s protections against sex discrimination in health care, financial assistance to afford health insurance, and coverage of their major health needs. 

Simply by providing people with health insurance and placing limits on patient co-payments and co-insurance, the ACA protects women from the financial risk that accompanies poor health. This adds up to considerable protection for those struggling to make ends meet. Research has shown a significant relationship between Medicaid coverage and reduced likelihood of personal bankruptcy related to out-of-pocket health care spending. 

Some of the particular coverage requirements are making a real difference to women’s financial security. Before the ACA, only 12 percent of individual plans covered maternity care, saddling women with huge bills because hospitals charge an average of $32,000 to $51,000 for births. Now, most plans are required to cover it. The required coverage of women’s preventive services without cost-sharing—which 62.4 million women now have—has also made a difference; the birth control benefit alone saved women $1.4 billion in one year just on oral contraception.

By providing health coverage not tied to employment, the ACA is allowing women to seek positions that may offer higher wages or better opportunities. Its coverage of birth control, in particular, allows women to determine whether and when to start a family, expanding their educational and career opportunities. Medicaid payments to health care providers also directly support women’s jobs: Women workers comprise approximately 80 percent of the workers who fill Medicaid-supported jobs.

Having insurance also makes it more likely that individuals will obtain health care services. A study conducted after the ACA’s first open enrollment found that 60 percent of the newly insured reported they visited a health care provider or paid for a prescription. Of those, 62 percent said they could not have accessed or afforded this care previously. Studies have shown that the ACA’s birth control benefit has corresponded with an increase in use of contraception, particularly the most effective methods.

Despite the ACA’s advances, challenges remain for poor women trying to access needed health insurance and health care services, especially abortion. One in 10 women remains uninsured, with higher rates among low-income women and women of color. This is due in part to the Court’s decision to give states the choice to opt out of covering more people through Medicaid. Thirty-three states and Washington, D.C., have moved forward with Medicaid expansion, but in the other states, low-income individuals—the majority of whom in those states are women—are left without the coverage they need. Additionally, lawfully present immigrants are barred from participating in Medicaid for the first five years, and the ACA prohibits undocumented immigrants from purchasing private coverage in the marketplaces. 

The Impact of Undermining the ACA

The Trump administration has taken a number of steps to undermine the ACA that will harm women’s health and financial security. For example, it cut off the cost-sharing reduction payments to insurers that are so vital to helping low-income women afford health insurance. It issued rules (currently blocked by courts) allowing virtually any employer to refuse to cover birth control without out-of-pocket costs as required by the ACA, and it recently proposed rules to expand the sale of junk plans that discriminate against women. 

Harmful Changes to Medicaid

The Trump administration is putting into place a series of harmful “reforms” to Medicaid, the most pernicious being its decision to allow states to establish work requirements. The idea that Medicaid enrollees need an incentive to work—Medicaid coverage—or should be punished if they don’t work—through loss of coverage—is based on the false narrative that Medicaid enrollees are taking advantage. This false narrative is largely based on and perpetuates harmful racist stereotypes about women of color. 

The reality is that most Medicaid enrollees are working if they are able, which means work requirements would not actually increase employment. Instead, work requirements endanger individuals’ health and economic security, particularly women. These are women who are providing care to relatives, furthering their education, or managing chronic conditions. Forcing them to work to get the coverage they need could mean the loss of vital health services. This will threaten poor women’s health and also their economic security. Studies have shown that work requirements in other programs increased the share of families living in deep poverty. So far, the Trump administration has approved Medicaid work requirements in four states, and at least two lawsuits have been brought to stop them, with a federal court recently blocking Kentucky’s attempt to impose a Medicaid work requirement.

Damaging Changes to the Title X Program

The Trump administration is proposing fundamental changes to the nation’s family planning program, Title X, a vital source of birth control and other preventive services for poor women. The administration recently released a draft proposed rule designed to bar patients from going to Planned Parenthood health centers and making other harmful changes. The Title X program serves 4 million individuals a year—who are disproportionately low-income and women of color—and Planned Parenthood health centers serve 41 percent of them. Preventing those patients from going to Planned Parenthood health centers would leave many with nowhere else to turn for critical preventive health care because other providers cannot fill the gap. 

Lack of Access to Abortion

Abortion is an essential part of comprehensive reproductive health care. Yet, poor women have trouble accessing abortion. This is due to other barriers that compound in their lives and that are exacerbated by abortion restrictions being imposed by politicians. 

Between 2011 and 2015, state legislatures enacted 288 abortion restrictions. Many of these restrictions—such as mandatory delays and forced ultrasounds—are meant to dissuade women from having an abortion. Other unnecessary and burdensome restrictions on abortion providers are intended to shut down abortion clinics. 

These restrictions affect poor women’s ability to obtain an abortion, putting additional obstacles in their path and increasing costs and delays. For example, the restrictions included as part of Texas’s anti-abortion law—which the Supreme Court struck down as an unconstitutional undue burden in 2016 in Whole Woman’s Health v. Hellerstedt—would have closed the vast majority of Texas abortion clinics, leaving at most 10 clinics in the entire state. Those clinic closures would have forced women to travel much farther—sometimes hundreds of miles—to a clinic. For poor women—who often depend on public transportation—long-distance travel is a grave burden. And transportation is not the only cost; many will also need to cover hotel expenses and childcare costs because 6 in 10 women having an abortion are already mothers. Fortunately, the Court in Whole Woman’s Health clarified that the undue burden inquiry should consider the cumulative impact of abortion restrictions on a woman’s experience exercising her constitutional right.

This is critical because these cumulative costs can push poor women later into pregnancy. Poor women already have abortions later than they would prefer because of the time needed to raise money for the procedure and related travel. Abortion is a safe procedure, but the risk of medical complications increases with time, and so does the cost. 

Unfortunately, most poor women are prohibited from using insurance coverage for abortion. Federal law continues to withhold coverage of abortion from Medicaid enrollees. This exclusion—known as the Hyde Amendment—was upheld in a 1980 U.S. Supreme Court decision, Harris v. McRae, against statutory and constitutional challenges. Particularly troubling was the Court’s holding that the Hyde Amendment did not impinge on the liberty protected by the Fifth Amendment’s Due Process Clause because it is a woman’s “indigency”—not a government-imposed obstacle—that is keeping her from being able to exercise the right to abortion. This view reflects a fundamental misunderstanding of poor women’s lives. As Justice Thurgood Marshall said in dissent: “The Court’s opinion studiously avoids recognizing the undeniable fact that, for women eligible for Medicaid—poor women—denial of a Medicaid-funded abortion is equivalent to denial of legal abortion altogether.”

Many women with private insurance also cannot get abortion coverage. The ACA treats abortion differently. It explicitly prohibits abortion from being considered one of the “essential health benefits” that certain plans must cover. And it allows states to pass laws prohibiting issuers from covering abortion. Twenty-six states have laws prohibiting private insurance plans from offering coverage of abortion as part of a comprehensive health care plan.

Women struggling to make ends meet who are denied abortion coverage and are also forced to confront additional costs imposed by abortion restrictions are left with few options. They may have to postpone paying for other basic needs like food, rent, heating, and utilities to save the money for an abortion. In one study, more than one-third of women who had an abortion in the second trimester stated that they would have preferred to have the procedure earlier but could not because they needed to raise money. The greater the delay in obtaining an abortion, the more expensive the procedure becomes, catching poor women in a vicious cycle. 

Other poor women may be forced to carry an unwanted pregnancy to term, which could harm their future well-being. A study comparing women who terminated a pregnancy to those who wanted but were unable to obtain an abortion found that women denied an abortion were more likely to be in poverty, less likely to be employed in a full-time job, and more likely to be receiving public assistance for four years afterward. Being forced to forgo an abortion could push more women and their families closer to poverty and others deeper into the poverty they endure.

Our laws, policies, and courts need to recognize the reality of poor women’s lives. Poor women need access to quality, affordable comprehensive health care that includes reproductive health care. Their lives and financial security depend on it. While the Affordable Care Act has made great strides, there are still far too many women who face ongoing barriers and are left without the care they need.

But health insurance and health care by themselves are not enough to help poor women out of poverty and secure their health. Health is intricately connected to other parts of a woman’s life—from housing to working conditions to food security to systemic racism. All of these things must be addressed to ensure that women are in good health in this country. 

Gretchen Borchelt is vice president for reproductive rights and health at the National Women’s Law Center. She oversees the center’s advocacy, policy, and education strategies to promote the quality and availability of health care, especially reproductive health care.