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The House ACA Repeal Bill Limits Access to Health Insurance Coverage for Survivors of Sexual Assault and Domestic Violence

The House-passed bill to repeal the Affordable Care Act (ACA), the American Health Care Act (AHCA), threatens access to affordable health insurance coverage for survivors of domestic violence and sexual assault. The bill effectively prices survivors out of the individual health insurance market and leaves them without adequate health coverage necessary to meet particular health needs.  The ACA repeal bill would either deter survivors from seeking or receiving the treatment that they need to recover and live healthy lives or force them to pay more for health insurance coverage, which could harm their wellbeing and economic security.

Here is how the ACA repeal bill jeopardizes access to health care for survivors of domestic violence and sexual assault:

  1. The House bill allows states to apply for waivers from the ACA’s community rating requirements that otherwise prohibit insurers from considering health status in determining how much to charge for coverage. Pre-ACA, health status underwriting was regularly practiced and, as a result, women were routinely denied health insurance or quoted high premium rates for a range of reasons that disproportionately affect women. These reasons include having received treatment for domestic violence or sexual assault, such as prophylactic medication to prevent HIV infection or mental health services.  A rape survivor described the insurance rates she was quoted pre-ACA as being equivalent to her monthly rent payment. As a result of these high rates, she went three years without health insurance coverage. The ACA prohibits this practice, so that all individuals – including those with pre-existing conditions or those who need treatment due to sexual assault or domestic violence – can’t be charged more because of those needs.

But the ACA repeal bill would undo that critical protection. The term “health status’’ is not defined in the ACA repeal bill, and could include almost anything, ranging from medical history, to claims experience, to receipt of health care, to genetic information, to evidence of insurability.

Supporters of the ACA repeal bill claim that survivors of domestic violence are protected because the bill retains a portion of the ACA that prohibits insurers from considering “conditions arising out of acts of domestic violence” in determining evidence of insurability. But this protection is not enough to ensure survivors of domestic violence are treated fairly in the insurance market. For example, if a survivor of domestic violence needs treatment for injuries, but doesn’t report that the injury is due to domestic violence (because many survivors don’t, for good reason), then she could still face health status underwriting because of her medical treatment. What survivors need is what the ACA currently provides: specific protection related to domestic violence and the general health status underwriting prohibition.  And of course the provision on domestic violence does not reach survivors of sexual assault, so they are without any protections at all in the ACA Repeal bill.

If the drafters of the ACA repeal bill had women’s needs in mind, and wanted to guarantee access to affordable health coverage for survivors of sexual assault or domestic violence, they certainly could have done so through several means, including preserving the ACA’s prohibition on health insurance underwriting. However, they did not, and as a result, survivors of sexual assault or domestic violence are vulnerable to discriminatory practices that were prevalent pre-ACA, which effectively priced many out of the private insurance market and deterred many from seeking the treatment that they need.

  1. The House bill also permits states to waive required coverage of the ACA’s 10 essential health benefits (EHB): (1) Emergency services; (2) Hospitalizations; (3) Outpatient care; (4) Maternity and newborn care; (5) Mental health and substance use disorder treatment; (6) Prescription drugs; (7) Rehabilitation services; (8) Laboratory services; (9) Preventive services and chronic disease management; and (10) Pediatric care. This means that survivors no longer have guaranteed coverage of the services that they will likely need and will have to pay more to receive coverage for those services, like mental health services or prescription drug coverage. This also means, for example, that a survivor might not be screened for domestic violence in an emergency room, delaying early identification and intervention. By making EHB optional, the ACA repeal bill would return us to a time when a woman’s access to critical coverage will depend on where she lives.  If she is in a state that doesn’t require coverage of the care she needs, she will be forced to go without it or pay far more for that coverage, again putting her at risk of being priced out of the market. Gone with the EHB in the ACA repeal bill are also the attached prohibitions on insurers imposing annual or lifetime limits, which means a survivor with serious medical needs could reach her annual or lifetime coverage cap and be forced to pay out-of-pocket for the care that she needs.
  1. Finally, the ACA repeal bill ends the ACA’s cost-sharing assistance that helps to make insurance more affordable and makes harmful changes to the tax credits that help individuals with premium costs. While both women and men will be impacted by these changes, women have historically had a harder time affording health insurance due to lower wages and discriminatory practices in the private market. In addition, financial security is a primary reason that many women stay in abusive relationships and being able to access affordable insurance through the ACA enables many women to leave an abusive situation without fear of losing health coverage.  But, by eliminating the cost-sharing subsidies and modifying the premium tax credits in ways that hurt those who need it the most, the ACA repeal bill will further put affordable coverage out of reach for many survivors of sexual assault or domestic violence.

Supporters of the ACA repeal bill claim that state laws offer protections to survivors of domestic violence or sexual assault that ensure them access to coverage if federal law does not.  It is true that the vast majority of states have laws that offer some protections in this area.  But each law varies – whether it reaches sexual assault and/or domestic violence (most specifically protect only domestic violence survivors); whether it prohibits denials of coverage and/or charging more for coverage; whether there are other barriers in place in order to take advantage of the law’s protections.  This patchwork of state laws does not in any way provide the assurances against insurance company discrimination for survivors of domestic violence and sexual assault that the ACA guarantees. And of course in states without such laws, survivors are left wholly unprotected.

This is the bottom line—without all of the protections put into place by the ACA, survivors of domestic violence and sexual assault are at the mercy of insurance companies and states. The ACA repeal bill disregards the past history that states and insurance companies often left survivors of domestic violence and sexual assault Nowhere to Turn for coverage in the individual health insurance market.