Health

Obamacare Scores Big for Women but Stops Short of the Goal

Four women were talking during a coffee break:

Sally: It was a very hard decision, but since my mother died from breast cancer and both my sister and my aunt had lumpectomies, I decided to have a mastectomy before it hit me, too.

Ruth: That is tough.

Sally: Yes, and on top of everything else, my insurance wouldn’t pay for it, but I went ahead anyway.

Anne: But so many doctors are recommending the procedure for women at risk — how can your insurance not cover it?

Sally: Beats me. I thought Obamacare covered everything.

And that isn’t all. Not too long afterwards, I saw the skin was very red and sore, so I went back to the surgeon. He said it was an infection. He drew out some pus — disgusting! — prescribed antibiotics, and sent me a hefty bill. You won’t believe this: the insurance refused to pay!

Liz: Why on earth not?

Sally: They said that since the mastectomy wasn’t covered, they wouldn’t pay for any condition or problem I might have that resulted from the mastectomy.

 

Thanks to the Affordable Care Act (ACA), women are paying less for better health coverage than they had before. But there are still gaps that affect women’s health.

Before the ACA, also known as Obamacare, women were at a distinct disadvantage. Most health insurance plans required women to pay higher premiums than men did. In addition, people were not covered for pre-existing conditions that often made them ineligible for health insurance. For women these included pregnancy, a previous Caesarean section, and even conditions stemming from sexual assault. Many plans excluded maternity coverage. As a result, women paid approximately $1 billion more per year than men did for health care and some women could not afford any health insurance at all.

Obamacare changed all that. Women are now demonstrably better off. Insurers may no longer charge women higher premiums or deny coverage because of current or previous health conditions. Under the ACA, all plans must cover maternity services, birth control, mammograms and mental health.

And yet, some plans have exclusions (conditions that are not covered) that affect women disproportionately. The Commonwealth Fund and the National Women’s Law Center studied qualified health plans from 109 insurers across 16 states for 2014 and 2015 and found six categories of service that are excluded. The most common by far is treatment of conditions that result from non-covered services. The others are maintenance therapy, genetic testing, fetal reduction surgery, treatment of self-inflicted conditions, and preventive services not covered by law.

Many women do not realize that a service they need in one of those categories isn’t covered until they have a claim denied. Often they don’t know beforehand that their insurance plan excludes a particular service because of the way the plans are written. Some are written in language that it is incomprehensible to someone who is not a health professional. Terminology may vary among insurers, so the same condition may have different names, making it difficult to compare plans. Or the exclusions may be hidden deep in the fine print of the policy, in separate sections. These documents may be more than 100 pages, another reason few people read them.

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