How Much Does PPACA Really Benefit Women?

A recent article by the Commonwealth Fund entitled Realizing Health Reform’s Potential: Women and the Affordable Care Act of 2010¸forecast that “over the next decade, the Affordable Care Act (ACA) is likely to stabilize and reverse women’s growing exposure to health care costs.”  However, a review of the claimed benefits shows that many are equally important to men and women.

Such claims of gender-specific benefits without statistical support are also available from the White house.  That being said, there are some provisions that will greatly benefit women — and to supporters’ detriment — have not received the focus that they should.

Intended Benefits

Several portions of PPACA are intended to benefit women.  The prohibitions against gender-based insurance denials or premium pricing are aimed at combating blatant gender-discrimination in the insurance market.  7.3 million women (38%) in the individual insurance market reported that they were turned down, charged a higher price, or had a preexisting condition excluded from coverage (see graphic below).  As the White House reports, “Right now, a healthy 22-year-old woman can be charged premiums 150 percent higher than a 22-year-old man.”  Such gender-based rating is allowed in 42 states, with some plans charging women as much as 84% more than men for the same age group.  As Secretary Sebelius phrased it, “[b]eing a woman is no longer a pre-existing condition!”

S. Collins, S. Rustgi, and M. Doty, Realizing Health Reform’s Potential: Women and the Affordable Care Act of 2010, The Commonwealth Fund, July 2010.

The essential benefits standards require insurers to cover maternity care, eliminating previously reported pregnancy-discrimination.  Only 13 percent of plans sold in the individual market provide maternity benefits and “in 22 states, no plan covered costs related to pregnancy.”  Other plans impede access to maternity benefits by placing severe limits on costs covered or implementing long waiting periods before coverage begins.

Other services that must be covered by all non-grandfathered health plans beginning September 2010 include:

• Breast cancer screening every one to two years for women age 40 and older
• Cervical cancer screening
• Genetic counseling for the breast cancer (BRCA) gene
• Osteoporosis screening for all women 65 and older, and 60 and older for those at high risk
• Aspirin to prevent cardiovascular disease in women ages 55 to 79

PPACA has several other provisions focused on breast cancer–including, “a special provision directed at raising awareness of, and increasing screening for, breast cancer in young women,” and a directive to pursue breast cancer prevention research in younger women.

Section 4207 of PPACA amends Section 7 of the Fair Labor Standards Act (”FLSA”) by requiring employers to provide “reasonable break time for an employee to express breast milk for her nursing child for 1 year after the child’s birth each time such employee has need to express the milk… [in] a place, other than a bathroom, that is shielded from view and free from intrusion from coworkers and the public…”  The Department of Labor Fact Sheet #73 further explains that a space temporarily converted or made available will be sufficient.

Unintended Benefits

The ban on pre-existing conditions exclusions will remedy a number of  unfair and discriminatory insurance industry practices. It will benefit women in the eight states and District of Columbia where insurers may legally reject a woman’s application on the basis of her prior experience as a victim of domestic violence.  It will also benefit women who would have been previously denied, on the basis of a previous cesarean section, either future C-sections or health insurance as a whole.

Also, the phase-out of the “doughnut hole” coverage gap in the Medicare prescription drug benefit )Part D) will incidentally help more women than men.  Of the 16% of Medicare beneficiaries that reach the doughnut hole each year, women (along with Alzheimer’s and diabetes patients) are the most likely to reach the gap in coverage.

Benefits for Men

So how do men benefit from PPACA?  For starters more men will benefit from the extended health insurance coverage mandated by PPACA.  Although women comprise 60% of adult Medicaid beneficiaries (in 2006), 54.6% of all uninsured are men (in 2007-2008).  The Medicaid safety net has caught more women than men.  However, that is a completely different social discussion to be had another day.

*Note: uncited statistics can be found in the Commonwealth Fund article, S. Collins, S. Rustgi, and M. Doty, Realizing Health Reform’s Potential: Women and the Affordable Care Act of 2010, The Commonwealth Fund, July 2010.

What “Free Markets” Really Look Like

Garden of Death, Hugo Simberg (1896)

In health reform, as so many continue to extol the virtues of an unfettered private market– a “free market” if you will–it may be of some help to consider just what a free market is. What that calculus entails. Considered by many as the theoretical underpinning of the modern market (though, as Professor Frank Pasquale has noted, the economics of Health Care are decidedly “unconventional”) the work of Adam Smith is worth considering. Smith championed self-interest as the best means to societal benefit. “Self-interested competition in the free market, he argued, would tend to benefit society as a whole by keeping prices low, while still building in an incentive for a wide variety of goods and services.”  In Robert L. Heilbroner’s, “The Worldly Philosophers: The Lives, Times, and Ideas of the Great Economic Thinkers, we may find the following:

To Adam Smith, laborers, like any other commodity, could be produced according to the demand. If wages were high, the number of workpeople could multiply; if wages fell, the numbers of the working class would decrease. Smith put it bluntly: “…the demand for men, like that for any other commodity, necessarily regulates the production of men.”

Nor is this quite so naïve a conception as it appears at first blush. In Smith’s day infant mortality among the lower classes was shockingly high. “It is not uncommon,” says Smith, “… in the Highlands of Scotland for a mother who has borne twenty children not to have two alive.” In many places in England, half the children died before they were four, and almost everywhere half the children lived only to the age of nine or ten. Malnutrition, evil living conditions, cold, and disease took a horrendous toll among the poorer element. Hence, although higher wages might have affected the birth rate only slightly, they could be expected to have a considerable influence on the number of children who would grow to working age.

Hence, if the first effect of accumulation would be to raise the wages of the working class, this in turn would bring about an increase in the number of workers. And now the market mechanism takes over. Just as higher prices on the market will bring about a larger production of gloves and the larger number of gloves in turn press down the higher prices of gloves, so higher wages will bring about a larger number of workers, and the increase in their numbers will set up a reverse pressure on the level of their wages. Population, like glove production, is a self-curing disease-as far as wages is concerned.

And that is the free market calculus with regard to working people. Higher wages equals more food, better shelter and medical care and more babies living which in turn will produce more workers which in turn will force that greater number of living workers to compete for jobs which will then lower wages. Those lower wages will then produce less food, worse shelter, and less medical care which will produce less babies living– which in turn will produce less workers. A cycle of sweat, blood and tears unencumbered by the “distortions” of regulation.  That is the “human element” of a sheer free market calculus for workers. No regulation, no aid to dependent children or social security, no FDA–just the invisible hand of the market– that most efficient of instruments– “correcting itself” through infant mortality.

So as pundits, tea bag protesters and blog commenters across the nation call out in favor of “private markets,” “free markets” and the like, let us realize that few have the stomache for an actual pure free market. As is as it should be. So when we talk about governmental intervention in the market– let us be clear: we speak only of extent and degree– not principle.

This passage from Dickens, remembering life as a 12 year old boy working ten hours per day, 6 days per week in  early 1800’s industrial England gives some view of life under a veritable Laissez-Faire free market, as do many of his books:

As told to John Forster (from The Life of Charles Dickens):

Dickens at the Blacking Warehouse

The blacking-warehouse was the last house on the left-hand side of the way, at old Hungerford Stairs. It was a crazy, tumble-down old house, abutting of course on the river, and literally overrun with rats. Its wainscoted rooms, and its rotten floors and staircase, and the old grey rats swarming down in the cellars, and the sound of their squeaking and scuffling coming up the stairs at all times, and the dirt and decay of the place, rise up visibly before me, as if I were there again. The counting-house was on the first floor, looking over the coal-barges and the river. There was a recess in it, in which I was to sit and work. My work was to cover the pots of paste-blacking; first with a piece of oil-paper, and then with a piece of blue paper; to tie them round with a string; and then to clip the paper close and neat, all round, until it looked as smart as a pot of ointment from an apothecary’s shop. When a certain number of grosses of pots had attained this pitch of perfection, I was to paste on each a printed label, and then go on again with more pots. Two or three other boys were kept at similar duty down-stairs on similar wages. One of them came up, in a ragged apron and a paper cap, on the first Monday morning, to show me the trick of using the string and tying the knot. His name was Bob Fagin; and I took the liberty of using his name, long afterwards, in Oliver Twist.