CBO Score Confirms "Defunding" Planned Parenthood would mean losing access to care

WASHINGTON, DC – Today, the Congressional Budget Office released their score of the revised version of the ACA repeal bill. The analysis reflects all of the amendments that passed the House of Representatives on May 4, which includes the amendment permitting insurers to charge people more if they have pre-existing conditions.

Statement from Dawn Laguens, Executive Vice President of Planned Parenthood Federation of America:

The CBO score reaffirms what we knew: this bill would devastate health care across America, leave millions uninsured, increase premiums and deductibles, and prevent millions from getting essential health care at Planned Parenthood.

“The American Health Care Act is the worst legislation for women’s health in a generation. This bill cruelly slashes Medicaid -- which one in five women of reproductive age rely on -- while prohibiting millions with Medicaid coverage from getting health care at Planned Parenthood.

“This bill makes it harder to prevent unintended pregnancy, harder to have a healthy pregnancy, and harder to raise a family.

“The fact is, one in five women in America has relied on Planned Parenthood, and their health care shouldn’t be subject to Donald Trump and Paul Ryan’s extreme agenda. The Senate must reject this bill.

The CBO score highlights several key points regarding the far reaching loss of health care coverage prescribed by the AHCA:

• CBO confirms that women will lose access to maternity coverage and other critical health care.  In fact, CBO expects that states that previously did not cover benefits, such as maternity care and mental health services, would again stop ensuring coverage for those services. For instance, CBO notes that before the ACA, only 18 states mandated coverage of maternity care in the nongroup market before 2014.

• CBO says this bill will result in pregnant women being charged thousands of dollars more for insurance. For instance, CBO confirms that instead of maternity care being covered by insurance, many women will have to buy a maternity "rider" if they want care -- at $1,000 per month. Furthermore, CBO states: “out-of-pocket spending on maternity care and mental health and substance abuse services could increase by thousands of dollars in a given year for those in need of such coverage.”

• CBO says that at least half of states will waive protections for people with pre-existing conditions -- allowing people who are or have been sick to be charged significantly more for insurance.

Key takeaways from the CBO score of the ACA repeal bill:

1. AHCA would still result in a dramatic increase in the number of people who are  uninsured. The CBO is now estimating that 14 million people will lose coverage by 2018 and 23 million people will lose coverage by 2026 under the version of the bill that passed the House. By 2026, an estimated 51 million people under the age of 65 would be uninsured (compared to 28 million who would lack insured under current law).

• Importantly, this new score reflects the loss of coverage resulting from the last minute amendments to the bill, whereby states can waive protections that prevent people with pre-existing conditions from being priced out of insurance coverage. In these states,  people with pre-existing conditions would have increased premiums and “ultimately not be able to purchase comprehensive” health coverage.

• This reduced access will impact  those who need coverage the most, such as women living with HIV, breast cancer, diabetes, or other chronic illnesses. This will also impact women who have been pregnant and women or individuals who have experienced domestic violence.

• AHCA would be a huge step back from the gains made under the ACA which has brought the uninsured rate to an all-time low. Specifically, under the ACA, 22 million people have gained coverage. Approximately 9.5 million women have gained coverage. The uninsurance rate for women of reproductive age has fallen 36 percent.

• AHCA harmful policies will overwhelmingly harm African-Americans and Latinx. Under the ACA, the uninsured rate for African-Americans has declined 11.8%, meaning that approximately 3 million African-American adults gained coverage. The uninsured rate for Latinx declined 11.3%, meaning that approximately 4 million Latinx adults gained coverage.

2. AHCA would dramatically increase the cost of insurance for people across the country. . The CBO is now estimating that premiums , are expected to increase by 20 percent in 2018 and another 5 percent in 2019. This increase in costs will happen when AHCA also significantly reduces the amount of financial assistance available to purchase coverage.

• Following the initial analysis, independent reports estimated an average enrollee purchasing a plan could expect to see her/his cost increase $3,174 in 2020 and low-income people would see cost at $4,815 the same year - these costs would be even higher in some parts of the country.

• The CBO score confirms that under current law, most people are insulated from increasing premium costs -- and AHCA cannot make that same guarantee.  Under the ACA, the average American is able to find an insurance plan on the Marketplace for under $75 a month with tax credits. Under the ACA, even as premiums have risen, enrollees were insulated from the rising costs. For instance, enrollees eligible for tax credits on average saw only a $4 per month increase in 2016, and a $1 per month premium increase at the close of 2017.

• The increased costs of care would disproportionately impact women, particularly women of color, given the inequities in earnings for women. Subsequently, AHCA will exacerbate existing health disparities. People of color already report less confidence in being able to afford care.

3. CBO notes that needed access to health care services, such as maternity care, would depend on where you live. CBO estimates that one-sixth of the population would reside in an area where the non-group market would start to become unstable beginning in 2020, resulting from states being permitting to waive community rating and essential health benefit requirements.

• CBO also estimated how premiums would be impacted in states that have been granted waivers for community rating and EHBs. They predict that about half of the population resides in states that would request a waiver. In the states with a waiver, plans would, as expected, begin to cover a smaller percentage of expected health care costs.

• CBO also finds that people with pre-existing conditions would have higher costs and be less likely to afford care. We know that pre-existing conditions can include a range of health conditions, such as breast cancer and HIV, but also insurers can deem as a “pre-existing” condition pregnancy, C-section, or domestic violence.

• CBO notes that before the ACA only 18 states mandated coverage of maternity care in the nongroup market before 2014. It is expected that states that previously mandated fewer benefits would be more likely to apply to modify the EHBs to again restrict coverage.

• CBO explicitly states that pregnant women would likely face substantially higher out-of-pocket health care costs or see the scope of benefits narrowed. For example, maternity benefits could be sold as a rider by insurers in states that do not include maternity care, which could cost more than $1,000 per month.

4. As the previous CBO score estimated, the “defund” Planned Parenthood provision targets Planned Parenthood exclusively -- resulting in reduced access to care for patients who live in areas where Planned Parenthood is the only health care option or where Planned Parenthood serves low-income populations. (CBO has not changed that assessment in this updated score.)

• Fifty-four percent of Planned Parenthood health centers are in health professional shortage areas, rural or medically underserved areas. The report stated that, “The people most likely to experience reduced access to care would probably reside in areas without other health care clinics or medical practitioners who serve low-income populations. CBO projects that about 15 percent of those people would lose access to care.”  

• CBO is totally clear that the provision singles out Planned Parenthood. It states: "CBO expects that, according to those criteria, only Planned Parenthood Federation of America and its affiliates and clinics would be affected.” This undermines proponents’ claim that the provision does not violate the Byrd Rule because it affects a “class of providers,” and not just Planned Parenthood. Thus, this CBO analysis confirms that the purpose for including the “defund” Planned Parenthood provision in the ACA repeal bill is not budgetary. Instead, it is to advance the political goal of preventing Planned Parenthood health centers from participating in the federal Medicaid program. It would appear that this provision violates the Byrd Rule, since the Byrd Rule stipulates that if a provision’s budgetary impact is “merely incidental” to the non-budgetary components of the provision, it should not qualify for reconciliation in the United States Senate.

• CBO estimates that “defunding” Planned Parenthood for one year would result in $156 million less in direct spending from the federal government over 10 years. This is a result of not providing Medicaid reimbursements to Planned Parenthood coupled with increased spending for Medicaid services for patients who would have reduced access to care. This is significantly less than the $235 million in savings CBO estimated for the same provision in 2015. Of note, CBO has also previously estimated that permanently defunding Planned Parenthood would actually cost the federal government $130 million over ten years.

BACKGROUND: Eleven Ways the AHCA is the Worst Legislation for Women in a Generation

1. Prevents women from receiving birth control, cancer screening and other important care at Planned Parenthood. The AHCA includes a provision that prohibits anyone who relies on Medicaid from coming to Planned Parenthood for basic health care services, such as birth control, cancer screenings, STD testing and treatment, and well-woman exams. This so-called “defunding” of Planned Parenthood would be devastating, and put the health of Planned Parenthood’s 2.5 million patients at risk. Many of Planned Parenthood’s patients, particularly those in rural areas and medically underserved areas, will have nowhere else to turn to for care if Planned Parenthood health centers are forced to close their doors. Despite false claims, community health centers simply cannot absorb Planned Parenthood’s patients. States, such as Texas and Wisconsin, have suffered serious public health consequences when communities lost access to Planned Parenthood.

2. Discriminates against women. Despite the fact that the proposal claims to maintain the current prohibition on gender rating, it still allows states to waive current protections and lets insurers once again discriminate against women. Eliminating the community rating provision disproportionately affects women –insurers can claim having given birth, having had a C-section, or having been a survivor of domestic violence is a so-called pre-existing condition. For example, a woman who had breast cancer could be charged a premium surcharge of more than $28,000 per year for coverage.

3. Reduces women’s access to no-copay birth control. While the bill does not specifically repeal the no-copay birth control benefit, the fact that millions of women will lose coverage means they will no longer have access to no-copay birth control. Under the ACA, more than 55 million women gained access to no-copay birth control in the private insurance market, and approximately 1 in 4 women of reproductive age benefit from Medicaid coverage, which also covers birth control at no cost. Paying out-of-pocket for birth control pills can cost a woman up to $600 per year, which is simply unaffordable for many young women and people with low incomes. A recent poll found that 33 percent of women could not afford to pay more than $10 for birth control.

4. Creates a nationwide ban on abortion coverage. Abortion is a safe, legal, and common medical procedure that approximately one in three women will have in her lifetime. Fifty-nine percent of the women in America who have an abortion are already mothers. Yet the AHCA will coerce insurance plans to drop coverage of abortion because it will prohibit individuals from using their federal financial help to purchase a plan on or off the ACA Marketplace that covers abortion. At least 870,000 women will lose access to ACA Marketplace insurance plans that cover their full reproductive health care needs, including abortion, and millions more could lose access to abortion coverage in other plans given this provision extends outside of the Marketplace. Insurance plans, when not barred by state law, typically cover abortion. Women, no matter how much money they make or how they get health insurance -- should be able to able to access the full-range of reproductive health care, including abortion and make their own decisions about pregnancy based on their own unique circumstances.

5. Kicks millions of women and men off their insurance. The CBO reports that 23 million people will lose coverage over the next 10 years, 14 million of whom will lose Medicaid coverage due to the bill's measures to kick people off of Medicaid.

6. Ends Medicaid expansion and guts the Medicaid program. The AHCA will effectively end the Medicaid expansion, which has provided coverage to at least 11 million people, starting January 1, 2020, and will result in women, disproportionately women of color, losing critical access to care. The AHCA also provides states the option to receive federal payments in the form of a block grant or per capita cap, both of which will slash the amount of federal support states receive today and will force states to either come up with extra money or make difficult decisions about which services, benefits, or eligibility groups to cut. Reduced federal funds for state Medicaid programs will disproportionately harm women -- women of color, in particular. For example, to save money, states may choose to limit coverage of prenatal visits and family planning services, or states may cut people from their programs. Approximately 25 percent of women of reproductive age rely on Medicaid to access no-cost, critical reproductive health care such as birth control, lifesaving cancer screenings, and maternity care. Nearly half of all births in America are covered by the Medicaid program.

7. Imposes Additional Costs on Women. The AHCA will require people to pay more for less coverage. First, the bill reduces financial assistance by repealing the existing cost-sharing subsidies that assist with copays and deductibles, and replacing the ACA-created tax credits, which fluctuate by need, with less generous tax credits for low- and middle-income individuals. This will disproportionately impact women, particularly women of color, given the inequities in earnings for women, and exacerbate health care disparities, given insured people of color already report less confidence in being able to afford care.

8. Threatens maternity coverage, newborn care and more. The bill allows states to gut the Essential Health Benefits provision, which requires the majority of health plans to cover services like maternity and newborn care.  Approximately 13 million women who gained access to maternity coverage under the ACA stand to lose their coverage. Prior to the ACA only 12% of individual market health plans covered maternity care.  

9. Pregnancy is once again a “pre-existing” condition and moms can be charged more for insurance because they had a baby.  For those women who won’t completely lose their coverage for maternity care, they can be charged more for insurance just because they were pregnant -- an additional surcharge of more than $17,000 per year for coverage for a woman who was previously pregnant.  Prior to the ACA, some insurance plans did not cover C-sections at all; when they did, they charged women 25 percent more in premiums.

10. Threatens Pediatric Services. Another Essential Health Benefit that could be eliminated by states in the AHCA is pediatric services. This hits mothers especially hard: in two-parent households where at least one parent is a woman, women tend to bear a disproportionate share of childcare and caregiving responsibility for children. In addition, women head 80 percent of  single-parent households.

11. Forces new mothers with Medicaid coverage to find work shortly after giving birth. The bill gives states the option to impose work requirements as a condition of obtaining Medicaid coverage. It also gives states the ability to revoke Medicaid from new mothers if they don’t find work within 60 days of giving birth. Work requirements are generally unnecessary and harmful, as nearly 60 percent of Medicaid enrollees who can work do, and if they don’t work it’s as a result of a major impediment. Work requirements disproportionately impact women, as women are more likely to provide informal and undervalued caregiving to family members, including spouses and parents, and account for 62 percent of Medicaid enrollees who are not working. Work requirements for new mothers are especially harmful.