Key Provisions of Health Reform
Health reform will not happen all at once. The law phases in most actions and successful implementation will take time. Together, these provisions set the context for significant improvement in women's health overall, as well as preconception health for women who want to become pregnant and have their babies born in optimal health.
Some key provisions take effect this year and have the potential to improve the health coverage and access for girls and women including the following.
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young adults will be able to continue on their parents' health plans to age 26;
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pre-exisiting condition limits for children in the individual market will be prohibited;
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insurance companies will be prohibited from revoking coverage when people become ill, and from setting lifetime limits on benefits;
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adults with pre-existing conditions will be eligible for subsidized coverage through a national high-risk pool;
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small businesses will be eligible for new tax credits to offset the cost of premiums; and
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new limits will be place on the share of premiums that insurers can spend on non-medical costs.
Between now and 2014, many different provisions of the PPAC will improve coverage, access, and affordability for women.
Eliminating gender rating. Currently, a majority of states permit insurers (health plans) to consider gender when setting premiums (a practice known as "gender rating"). A recent study found that at age 25 women are charged between 6% and 45% more than men for identical insurance coverage. The PPAC prohibits discrimination in coverage on the basis of gender. To learn more, click here.
Providing greater access to coverage. Women are more likely than men to work for small businesses that don't offer currently health insurance, and thus may particularly benefit from: new tax credits to help small businesses offer coverage, reforms in the small group market that would require "guaranteed issue" and renewability of health insurance, and creation of Health Insurance Exchanges (HIE). HIE will be competitive "marketplaces" where individuals and small business can buy affordable health care coverage in a manner similar to that used by large businesses today.
Young women-who are more likely to be uninsured than women in any other age group-will benefit from a new rule that allows young adults to remain on their parents' health insurance policy as a dependent until age 27.
Creating structures for benefit packages. PPAC eliminates cost sharing for preventive care services such as immunizations and breast cancer screening in Medicaid and Medicare. The law identifies maternity care as an essential benefit that must be covered by all plans offered through an exchange (see more below). It also requires the coverage of comprehensive tobacco cessation services for pregnant women in Medicaid. Unlike maternity care, however, family planning counseling and contraceptive devices are not included in the list of essential benefits for HIE.
So called "qualified health plans" eligible for subsidies must include the following essential health benefits: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services, including oral and vision care.
PPAC creates four benefit categories of plans plus a separate catastrophic plan to be offered through the HIE, and in the individual and small group markets, identified as bronze, silver, gold, and platinum, as well as a catastrophic plan for individuals up to age 30 years.
Making coverage more affordable. The law includes provisions to make coverage more affordable by both capping out-of-pocket spending and providing subsidies to individuals seeking to purchase coverage within an exchange. The subsidies (called "premium credits" and cost sharing subsidies) would be available on a sliding scale for families with incomes between 100 and 400 percent of the federal poverty level (FPL) or $22,050 to $88,200 for a family of four under current FPL. States will be permitted to create a Basic Health Plan for uninsured individuals with incomes between 133% and 200% FPL in lieu of premium subsidies to purchase in HIE. (Effective January 1, 2014)
Improving Medicaid. Under PPAC, states will be required to expand Medicaid eligibility to 133% of poverty and to enroll newly eligible Medicaid beneficiaries into the Medicaid program no later than January 2014 (states have the option to expand enrollment beginning in 2011). States are required to maintain current Medicaid and CHIP eligibility levels for children until 2019 and maintain current Medicaid eligibility levels for adults until the Exchange is fully operational (with some exemptions for adult coverage over 133% FPL). All newly eligible adults will be guaranteed a benchmark benefit package that at least provides the essential health benefits. The federal government will contribute at a higher rate of matching (from 100% to 90%).
The law will increase payment rates for primary care doctors in Medicaid, as an incentive for greater participation.
The PPAC will give states an option to extend family planning coverage in Medicaid without having to go through the onerous process of filing for a federal waiver.
Another new Medicaid option will permit enrollees with at least two chronic conditions, one condition and risk of developing another, or at least one serious and persistent mental health condition to designate a provider as a health home. For example, such an option might assist in providing patient-centered medical/health homes for women with chronic conditions. Provide states using this option would receive 90% federal match for two years. (Effective January 1, 2011)
Requiring individuals to obtain coverage. The law phases-in a penalty for individuals and families that fail to obtain mandated health insurance coverage. Learn more from Women's Policy Inc.
Requiring employers to share in the cost. Employers with more than 50 employees will be required in essence to "pay or play," that is offer coverage for their employees or pay the government for those employees who use a subsidy (premium tax credit)
Focusing on quality improvement. The health reform law calls for development of a national quality improvement strategy that includes priorities to improve the delivery of health care services, patient health outcomes, and population health. (Due to Congress by January 1, 2011) It adds maternity care quality to child health quality priorities.
Broadening the safety net
. Community health centers are a vital source of care for low-income women of childbearing age. The health reform law will improve access to care by: increasing funding by $11 billion for community health centers and the National Health Service Corps over five years (effective fiscal year 2011). It also establishes new programs to support school-based health centers and nurse managed health clinics (effective fiscal year 2010). The law increases support for nurse midwives and free-standing birth centers, particularly through Medicaid. It also will establish a Community-based Collaborative Care Network Program to help providers coordinate and integrate health care services for low-income uninsured and underinsured populations. (Funds appropriated for five years beginning in FY 2011)
The law provides for grants to states to promote Community Health Teams that support the Patient-Centered Medical Home. Such community-based interdisciplinary teams will provide support services to primary care practices, including OB-GYN practices. Teams roles would include: collaboration with primary care providers; coordinate disease prevention and management; case management; early identification and referral for children at risk for developmental or behavioral problems; and support for transitional health care needs from adolescence to adulthood. To learn more from the Association of Maternal and Child Health Programs about how health reform will help women and children through state and community action, click here.
Increasing the primary care workforce. The PPAC will increase the workforce supply and support training of health professionals through a variety of mechanisms, including: scholarships and loans; support primary care training and capacity building; provide state grants to providers in medically underserved areas; train and recruit providers to serve in rural areas; establish a public health workforce loan repayment program; provide medical residents with training in preventive medicine and public health; promote training of a diverse workforce; training programs for nurses and nurse practitioners, and promote cultural competence training of health care professionals. (Effective dates vary)
Creating administrative structures to promote women's health. The law codifies the establishment of Offices on Women's Health in major federal agencies, including Department of Health and Human Services (DHHS), Centers for Disease Control and Prevention, the Food and Drug Administration, Health Resources and Services Administration, and an office of Women's Health and Gender-Based Research at the Agency for Healthcare Research and Quality. It also permanently establishes the DHHS Coordinating Committee on Women's Health to coordinate the activities of these offices, as well as a National Women's Health Information Center.
Focusing on community wellness and prevention. PPAC creates a grant program to support the delivery of evidence-based and community-based prevention and wellness services. (Funds appropriated for five years beginning in FY 2010) It also provides grants for up to five years to small employers that establish wellness programs. (Funds appropriated for five years beginning in fiscal year 2011) The law will establish the National Prevention, Health Promotion and Public Health Council to coordinate federal prevention, wellness, and public health activities, with a national strategy due one year following enactment. Learn more from the Trust for America's Health.
The law establishes a Prevention and Public Health Fund to expand and sustain funding for prevention and public health programs. (Initial appropriation in fiscal year 2010; $15 billion over 10 years, beginning with $500 million/ FY2010, ramping up to $2 billion in FY2015 and each year after) It also creates task forces on Preventive Services and Community Preventive Services to develop, update, and disseminate evidenced-based recommendations on the use of clinical and community prevention services. (Effective upon enactment)
Supporting epidemiology and surveillance. The health reform law includes provisions designed to increase funding for epidemiology and surveillance of infection diseases and other conditions of public health importance. Learn more about city and county health here.
Aiming to reduce health disparities. The PPAC defines health disparities. Perhaps more important are provisions that add incentive payments for activities to reduce health disparities, including through use of language services, community outreach, and cultural competency training. It also require the collection and reporting of data on race and ethnicity, gender, geographic location, socioeconomic status (including education, employment or income), primary language, and, disability status, data at the smallest geographic level such as State, local, or institutional levels if such data can be aggregated; data by racial and ethnic subgroups. To learn more visit the Trust for America's Health.
Creating a new national home visiting program. PPAC establishes a $1.5 billion federal grant program for state-based home visiting programs to serve higher-risk families during pregnancy and the infant-toddler years. The legislation does not include optional coverage of nurse home visitation services through Medicaid-a provision included in earlier drafts of the bill. The voluntary programs will connect new and expectant families with trained professionals to provide parenting information, linkages to community resources, and support during pregnancy and throughout their child's first three years. Such home visiting programs can reduce risks associated with adverse pregnancy outcomes and promote healthy child development. Learn more from the Pew Center.
At the same time, there is much left to do to improve women's health. Writing in The Nation (March 18, 2010), Katha Pollitt said: "The way I see it, the Democratic Party and the Obama administration owe supporters of women's rights a huge payback for cooperating on its signature issue." Her suggestions include: full funding for the Title X family planning program and a multifaceted national plan confront maternal mortality. These ideas fit with a national agenda to improve the health of women before, between, and beyond pregnancy. 
