Obamacare Scores Big for Women but Stops Short of the Goal

Six Plan Exclusions that Adversely Affect Women’s Health

1. Conditions resulting from non-covered services

After fighting a bout of breast cancer, a woman might decide to have her fallopian tubes and ovaries removed. This surgery is not covered by her insurance, but it is her best option to lower her risk of breast cancer recurrence. What she doesn’t know is that she could have a complication, like post-operative bowel obstruction, that would require re-hospitalization and another surgical procedure. And because the first surgery was not covered by insurance, the complications would not be covered either.

2. Maintenance therapy

There are two types of maintenance therapy.

  • Treatments that stabilize but do not improve such conditions as lupus, depression, and chronic pain, all more common in women.
  • Treatments that prevent or slow the progression of such diseases as breast or lung cancer, the most common cancers in women.

3. Genetic testing

To determine the need for preventive services, genetic testing is often advisable. It can often detect increased risk for breast or gynecological cancers. Many genetic mutations are involved, however, and the law requires insurance to cover the testing of only two genes. The ability to pass on hereditary conditions, such as Tay-Sachs or sickle cell diseases, can also be detected by genetic testing and will influence a woman’s decision to become pregnant.

4. Fetal reduction surgery

Carrying multiple fetuses implies multiple risks. These include abnormally high blood pressure and excessive bleeding after childbirth. The risks increase with the number of fetuses. Only one of the insurers studied allowed an exception for medical necessity.

5. Treatment for self-inflicted injuries or illnesses

Women are more likely than men to attempt suicide and also to survive a suicide attempt, so these exclusions impact them more than they do men. As a result, women and their families are burdened with large medical bills. In addition, many plans don’t define “self-inflicted.” Is malnutrition that proceeds from bulimia self-inflicted? Mental health is covered, but are eating disorders? The vagueness of the law allows insurers to interpret it as they choose.

6. Preventive services not currently required by law

Preventive mastectomies for women judged to be at risk for breast cancer are widely considered to be appropriate. So is antiretroviral prophylaxis for individuals exposed to HIV or other sexually transmitted diseases — especially significant in the case of sexual assault, suffered principally by women. Although the ACA requires coverage of many preventive services, these are chosen by their relevance to the general population. Women are at risk for conditions that are exclusively or largely female.

Recommended Changes in Policy

Women have benefited greatly from the changes in health insurance regulations mandated by the ACA, but gaps in women’s health coverage still persist, because the coverage exclusions have a greater effect on women. In their report “Women’s Health Coverage Since the ACA: Improvements for Most, But Insurer Exclusions Put Many at Risk,” the authors Dania Palanker and Karen Davenport recommend that the ACA prohibit exclusions that undermine protections of women. They also recommend that insurers increase transparency in their plans, so that women may be aware of exclusions when choosing coverage.


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