These Are The Women Who Will Be Affected Most By Trump's Order On Health Care

by Seth Millstein

On Friday, President Trump signed a presidential memorandum authorizing changes to how the Affordable Care Act is administered. Although Obamacare itself is still the law of the land, both its interpretation and its effectiveness could change drastically as a result of the move, and health care experts tell Bustle that Trump's order on Obamacare could seriously affect women's health benefits — namely, by offering fewer of them.

First, though, it's important to know that the order is very vague, could be implemented any number of ways, and won't take effect for months. The order directs three federal agencies — Labor, Health, and the Treasury — to pursue several general goals with regard to health care policy, but it doesn't actually tell them how they might accomplish those goals. These agencies will have to research and craft proposals for achieving these goals, and once they do, they'll be posted for public comment before being implemented.

"There’s nothing that happens right away except that these agencies begin to work," Nancy Nielson, an associate dean of health care policy at the University of Buffalo, tells Bustle. "They will then post proposed rules, and there will be public comment. So this is going to take at least six months, probably, to work its way out. Nothing happens immediately.”

There are also plenty of folks whose insurance won't be affected one way or the other by Trump's order. Namely, Medicaid recipients: Although Obamacare drastically expanded Medicaid, Trump's order doesn't touch those benefits at all, so low-income women who, say, use their Medicaid to get health care from Planned Parenthood won't see any change in their services or benefits as a result of Trump's order. Similarly, anybody with individual insurance who receives federal health subsidies most likely won't see any changes to their policies.

Trump's order has the potential to affect two groups of American women: those who work for small businesses and get their insurance through their employer, and those who buy insurance on the individual market (that is, or a state exchange) but do not qualify for federal subsidies. Anybody in one of those two categories could experience either an increase in premiums or a decrease in benefits as a result of Trump's order.

Women Working For Small Businesses

Trump's order seeks to increase the number of Associated Health Plans, or AHPs, which is when a group of small businesses band together and create what's essentially a mini-insurance market for their employees. If this happens, women who work for such businesses could receive lower-quality maternity and newborn care; those services would still be offered, but they might be less comprehensive and usable than they are now. Additionally, anybody insured under an AHP could see a complete loss of mental health and substance abuse coverage.

The policy reasons behind this are complex, but at the crux of the issue is Obamacare's 10 Essential Health Benefits, a list of services that most insurance plans (including AHPs) have to cover. Maternity and newborn care fall under those benefits, and so in theory, nothing about AHPs threatens them. But in reality, it's not so simple.

“The key to understanding that is that although there are 10 categories that have to be covered, the federal government deferred to the states to decide what the nature of that coverage might be," Nielson explains. "So, there might have to be ‘maternity coverage,’ but it might be limited.”

Different states have "interpreted" the Essential Health Benefits in wildly different ways, and their laws reflect that. For instance, California insurance plans must cover 38 specific benefits, including hospice care, HIV testing, chemotherapy, and cervical cancer screening. In Alabama, however, insurers only have to cover six types of services, and even those don't apply to all types of insurance plans. (If you'd like to see what your own state's requirements are, click here, find your state, and click "state-required benefits").

Why is this relevant? Because AHPs are allowed to operate across state lines, which means they can find the state with the fewest minimum coverage requirements and then base their own plans on that state's laws. The result is that folks covered by AHPs end up with coverage that, in practice, is much less comprehensive — even if they live in a place like California, which in theory guarantees relatively comprehensive coverage to all of its residents.

“Any protections you have as a resident of your state would not apply to you any longer," Alina Salganicoff, director of Women's Health Policy at the Kaiser Family Foundation, tells Bustle.

Meanwhile, Matthew Fielder of the Brookings Institute noted that AHPs most likely would not be allowed to skirt the ACA's contraceptive requirement (although Trump is already attempting to do that in other ways), because that's governed by a different component of the ACA.

Women Purchasing Individual Plans

The second major component of Trump's order attempts to expand the number of short-term, limited-duration insurance plans, or STLDIs. These are non-employer plans that offer cheap, stripped down insurance but only for a temporary period of time. What's crucial to know about STLDIs is that they are almost completely unregulated; they aren't bound by the 10 Essential Health Benefits in any shape, way, or form, nor must they adhere to other federal laws, like the Pregnancy Discrimination Act, that address coverage requirements.

“The short-term plans are subject to almost nothing in the way of regulations," Fielder tells Bustle. "They are not subject to the Essential Health Benefits, they can discriminate based on pre-existing conditions in whatever way they wish, they’re not subject to the preventive services requirement, they’re not subject to the lifetime limit ban. They’re not subject to anything.”

STLDIs appeal primarily to young, healthy people, because they're cheaper and offer less coverage. But as more and more healthy people switch over to STLDIs, that makes insurance more expensive for anybody who isn't in an STLDI.

As a result of this, premiums would skyrocket for a certain subset of women who want preventative, maternity, newborn, and contraceptive care covered under their plans. Specifically, any woman who purchases health insurance through, but does not qualify for federal health subsidies, could see either a reduction in benefits or an increase in premiums.

“People who have significant health care needs, or want more comprehensive coverage are going to have to pay more for it in the existing individual market," Fielder says. "For the 45 percent of people in the individual market who don’t get a subsidy, they will pay more as premiums in those markets rise.”

The flipside of this is that any woman who couldn't afford this increase in premiums might be forced into an STLDI — which again, are practically unregulated and offer far fewer services than standard insurance plans.

“There’s no requirement for what they have to cover, and they could basically exclude you [from coverage] due to health status," Salganicoff says. "So, if you’re pregnant, they could say that it’s a ‘declinable condition.’ Or if you become pregnant, they could choose not to renew you later. I mean, they don’t have to cover maternity care.”

Ultimately, Trump's order will probably result in higher premiums for some women and fewer benefits for others, depending largely on individual circumstances. But still given its vagueness, it's hard to say anything definitive just yet.

“There are a lot of unknowns right now, and it’s going to go through a whole rule-making progress," Salganicoff says. "There are folks working for the federal government who are going to have to take this executive order and make something that is legal and fits with existing law and current regulations.”