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Unaffordable Health Care is Inaccessible Health Care: Why Cost Sharing Reductions Matter for Women’s Access to Health Care

Even before the legislative defeat of attempts to repeal the Affordable Care Act (ACA) in the Senate, President Trump threatened to dismantle the ACA through executive action. His threats to “let the law implode” have most recently been accompanied by threats to cut cost-sharing reduction payments, which are payments to insurers that effectively buy down the enrollees’ cost sharing obligations. If he makes good on these threats, then access to affordable health insurance will be significantly undermined—particularly for women for whom cost-sharing assistance is critical to obtaining health coverage.

The main reason that individuals cited for being uninsured prior to the ACA was the inability to afford insurance costs, which particularly affected women struggling to make ends meet. Cost barriers compound for women who are also more likely to live in poverty, earn less than men, and are more likely to work in low-wage jobs with less ability to absorb extra costs.  And, for women of color who are more likely to live in poverty than whites, such cost barriers are particularly prohibitive.  In fact, pre-ACA, women of color were more likely to be uninsured.  Since the ACA became the law of the land, uninsured rates among women have dropped by more than half from 19% of women uninsured to less than 8% uninsured nationwide last year.  The reality for many women is simply: insurance that is unaffordable is inaccessible.

Analysis released yesterday by the Congressional Budget Office (CBO) found that eliminating the cost-sharing reduction (CSR) payments to insurers would have devastating impacts on the health insurance marketplaces, including: withdrawal of insurers from the individual market; premium increases by about 20 percent in 2018 and higher in subsequent years for certain plans; increases in uninsured rates; and increased federal deficits by $21 billion in 2020 and up to $26 billion in 2026.

That’s because insurers who receive the federal payments could not bear the costs of offering these plans without federal assistance, and would opt instead to leave the market.  This would increase individuals’ lack of access to coverage, with more individuals living in areas that simply do not offer affordable plans on the market.  In fact, the CBO projects that the nation’s population of those living in areas with no insurers on the marketplace would rise to 5 percent in 2018 (about 1 million more people—up from 0.5 percent under current law).

Premiums would increase because, according to CBO, most state insurance commissioners would allow insurers to compensate for the loss of federal assistance by raising premium prices.

And, while some individuals may be able to meet increased premium costs with premium tax credits, that is not the case for everyone, and upfront costs in particular can pose significant barriers for women.

Data both pre-and post-ACA show that increased out-of-pocket costs jeopardize women’s access to health care since women are more likely than men to forego health care because of cost.  And women of color would be hit particularly hard by increased upfront costs because research shows that, in the years before the ACA, women of color were more likely to go without health care because of cost at higher rates than men or white women, leaving them vulnerable to a lifetime of illness. According to the Center on Budget and Policy Priorities (CBPP), on average, the cost sharing reductions reduce people’s out-of-pocket costs by roughly $1,100 per person.

The bottom line is that Trump’s threats pose very real harm to the assurance of continued access to affordable health coverage that the ACA made possible for millions of women nationwide.  Without federal assistance, women will once again face cost barriers and be forced to make tough choices like: go without health insurance, forego other necessities to pay for it, or strain their families’ finances to pay for their own health care services.  Trump’s attempts to circumvent the legislative process to undermine the ACA would have particularly devastating effects on women’s access to needed care and return us to a time when affordable coverage was out of reach for far too many women.  We literally cannot afford to go back.