In Knots

The old adage “Be careful what you wish for” seems to apply to Republicans who finally have their chance to repeal the much-maligned Affordable Care Act (ACA) and replace it with what they claim will be a far better and cheaper option. Despite enthusiasm on their part, Republicans are now faced with unanswered questions about substantial aspects of repeal/replace. For example, how will Republicans protect popular options like the ban on preexisting conditions exclusions without flooding plans with sick people and sending the entire individual insurance market into a death spiral? Will 20 million people currently receiving insurance through the ACA continue with their coverage? Pertinent to the point of being unavoidable, there is also the question of whether access to reproductive healthcare for women will remain intact—a substantial concern given that one of the planks of the ACA’s initial architecture was women’s healthcare. The capacity in which any proposed replacement to the ACA would continue to provide access to women’s healthcare has left even moderate Republicans—those opposed to the party’s open hostility towards abortion and contraception—struggling to explain alternate suggestions for legislation.

From its inception, the ACA was designed to address the shortfall in women’s healthcare coverage. The ACA made it illegal to charge women more than men for the same health insurance policy and mandated that individual health insurance policies cover maternity care as a basic benefit—a circumstance that fewer than 15 percent of policies addressed before the law’s enactment.¹ Under a recommendation made by an Institute of Medicine panel for basic preventive care, ACA provisions also required that women receive no-cost coverage of all Food and Drug Administration–approved contraceptives through their insurers.

Many moderate Republicans support the ACA goal of expanding women’s access to care, especially access to contraceptives. “I was delighted when birth control was put into ACA,” said Republican Joan Culver, who is on the board of Planned Parenthood of St. Louis as well as Planned Parenthood Federation of America’s Republican Advisory Board. “There’s a reason they put it on the same level as vaccines. It’s one of the major advances of 20th-century medicine. It improves women’s lives and the human condition and should be available.”

Making birth control available isn’t just a matter of good medicine and, as Culver is Catholic, good morality, it’s also fundamental to her understanding of Republican values. The Republican Oath, among other things, states that “good government is based on the individual and that each person’s ability, dignity, freedom and responsibility must be honored and recognized.” Culver cites this very passage before noting that “The Republicans say you are responsible for yourself and it is up to you to care for yourself in the best way possible. Birth control makes that possible.”

Though they think the ACA requires reform, particularly with regard to increased competition, other Republicans agree with Culver. “I would like to see that women have access to healthcare in general and access to contraception and abortion if needed,” says Suzi Bassi, a Republican and former Illinois state representative. “I have heard too many cases where women have been denied access to care,” Bassi asserts, adding that “insurance across state lines would increase competition and make it more affordable.” However, she points out that the Republican Party has done little work regarding policy specifics, particularly with regard to retaining popular features of the ACA, like allowing young adults to stay on their parents’ plans until age 26 or banning pre-existing condition exclusions. “Republicans have been talking about it for long time,” Bassi admits, “but because they have been so obstinate about ObamaCare for so long they haven’t done the work to fix it.”

Nonpartisan health policy analysts caution that GOP health reform proposals don’t add up fiscally—the potential results of their implementation result in either soaring healthcare costs or upsetting the healthcare marketplace to such a fundamental extent that most insurers will simply withdraw from the individual market. “What Republicans are promising can’t work,” explains John Porter, former Illinois Republican Congressman and chair emeritus of the state House Appropriations Committee Subcommittee on Labor, Health and Human Services. “You can’t keep the 26-year-old and pre-existing condition provisions without the revenue stream. They will run into big problems with funding.”

Removing financial barriers to contraception resulted in higher rates of use for the most effective methods and “substantial reductions in teen pregnancy, birth and abortion.”

Porter finds it unlikely that the no-cost contraception mandate could survive GOP reform efforts—the explicit or implicit design of which would undermine access to contraception. Bassi agrees: Removing the contraceptive mandate would be a blow to the effort to improve women’s health and reduce abortion. From a Republican standpoint, Bassi would be comfortable with a “low-cost” contraception option rather than a no-cost option, adding that robust contraceptive access is good public policy. Culver references a study of 10,000 women in St. Louis conducted by the local Planned Parenthood and Washington University. The findings of the study indicated that removing financial barriers to contraception resulted in higher rates of use for the most effective methods and “substantial reductions in teen pregnancy, birth and abortion.”²

Temporarily setting aside the contraceptive mandate, low-cost access to less expensive forms of contraception (i.e., generic birth control pills) may be maintained by insurers. While this approach represented a growing trend with insurers even before the passage of the ACA, it is worthwhile to note that studies indicate that even modest price increases to inexpensive forms contribute to reduced contraceptive use.³

Despite the even-keeled pragmatism of moderates, healthcare experts have found reason for alarm. Chief among the concerns of healthcare professionals is the potential under Republican proposals to replace the ACA and reduce access to the more expensive “highly effective” forms of long-acting, reversible contraceptives (LARCs), which include IUDs and implants. “One of the big impediments to long-acting forms of contraception like IUDs is cost,” explains Scott Radloff of Johns Hopkins University’s Bloomberg School of Public Health’s Population, Family and Reproductive Health Program. “I had hoped that the ACA would level the playing field in terms of access, and we may see those gains reversed.”

And it appears that the ACA has, in fact, leveled the playing field for LARC access. According to the Guttmacher Institute, from 2009 to 2012, the percentage of women choosing LARCs as their preferred means of contraception increased from 8.5 percent to nearly 12 percent.⁴ The previously cited St. Louis study found that “access to LARC methods can result in fewer unintended pregnancies and abortions, and considerable cost savings to the healthcare system.”⁵

Though some moderate Republicans have voiced support for efforts to increase LARC access as part of the GOP commitment to fiscal responsibility, this hardly constitutes a majority within the party. Culver characterizes Republican plans seeking to block an increase in access—proposals maneuvering to save money by gutting provisions such as the contraceptive mandate—as “shortsighted.” “I don’t think they understand the issue thoroughly,” she elaborates, going on to counter fiscal critiques of individual IUD costs, which sometimes extend upwards of $1,000, by pointing out that “if you amortize that over 10 years, it’s the same cost as the pill.”

Taken as a whole, the current reality of every Republican replacement option on the table is that they fail to provide protections for women’s access to reproductive healthcare. The option that seems to have the most support among the GOP rank-and-file is returning to the system that existed before passage of the ACA—a system in which individuals receive tax breaks to buy high-deductible, “catastrophic plans” under which coverage doesn’t kick in until $10,000 or $15,000 in medical costs is exceeded. Even some Republican women’s health advocates—like St. Louis Planned Parenthood board member and lawyer, Joe von Kaenel—advocate for this option on the basis that it hews closer to Republican ideals. “I don’t agree with mandating what insurers should cover; it’s economically inefficient,” say von Kaenel. “Individuals should be able to get as much or as little insurance as they want, including high-deductible insurance with some kind of safety net for individuals who can’t afford insurance.”

In practice, even plans such as these run the risk of leaving women without coverage for maternity care as well as birth control. Other options, including keeping some form of the system currently in place but decreasing subsidies that allow low and middle-income consumers to buy plans, and stripping out minimum coverage standards like the contraception mandate, would put health insurance financially out of reach for many, thus decreasing women’s access to care. With even such well-meaning and earnest compromises facing formidable obstacles to coverage within the party, it is difficult to see how any plan would make women’s reproductive care a priority—an observation made by Bassi just before she points out that her failed bid for reelection had more than a bit to do with fewer and fewer Republicans who care to support a prochoice candidate. Culver says the problem is that the Religious Right has usurped the party, making it harder for moderate voices to be heard. “Politically, advocates for women’s health have been less vocal than we should have been,” she said. “But as a Catholic, I think the inability to talk liberal Catholic theology around issues regarding sex has really hampered the issue. It’s a matter of education. The ACA simply should include birth control. Part of the problem is a Republican Party driven by men.”