Vice President, Affordable Health Insurance THE COMMONWEALTH FUND Realizing Health Reform’s Potential: Women and the Affordable Care Act of 2010 Sara R. Collins, Ph.D. Vice President, Affordable Health Insurance The Commonwealth Fund Media Teleconference July 29, 2010

Exhibit 1. Importance of Health Reform For Women Nearly 17 million women, or 18 percent, ages 19-64 were uninsured in 2008 14.5 million women 19-64 with health insurance have such high out of pocket costs relative to income that they are underinsured Women are equally as likely as men to be uninsured, but have greater contact with health care system over lifetime than men because of reproductive health needs, central role in coordinating care of family members (children, spouses, aging parents) More exposed to the rapidly rising costs of care and to problems resulting from loss of health coverage. Higher reported rates of medical bill problems and cost-related delays in getting needed care Thank you Karen. I am going to start with Exhibit 1 in the chart pack. According to the latest available Census data, nearly 17 million working age women ages 19-64 were uninsured in 2008. Given the continuing high unemployment rate over the last year, this number has likely increased as women and/or spouses have lost jobs or health insurance or both. In addition, among women who have health insurance, according to an analysis of the Commonwealth Fund Biennial health insurance survey, an estimated 14.5 million women have such high out of pocket costs relative to their incomes that they are effectively underinsured. While women are equally likely as men to lack health insurance, they have much greater contact with the health care system over their lifetime than men because of their reproductive health care needs and their central, historical, role in coordinating the health care of family members – children, spouses, and aging parents. This means that they are more exposed to health care costs and to problems resulting from loss of health coverage. Because of their greater exposure to health care costs, both their own and family members, women report higher rates of problems paying medical bills and cost related delays in getting needed care than do men. [ Bills: 45% of women vs. 36% of men; Access 52% of women vs. 39% of men]

Exhibit 2. Almost Two of Five Women Who Have or Tried to Buy Individual Insurance Were Turned Down, Charged a Higher Price, or Had a Health Condition Excluded From Coverage Adults ages 19–64 Women Total Men <$40,000/ year $40,000+/ year Health problem No health problem Adults with individual coverage or who tried to buy it in past three years who: Found it very difficult or impossible to find coverage they needed 47% 51% 42% 56% 41% 58% 43% Found it very difficult or impossible to find affordable coverage 57 62 51 69 52 77 48 Were turned down, charged a higher price, or excluded because of a preexisting condition 36 38 34 42 45 31 Never bought a plan 73 74 72 84 55 79 68 In addition, because insurance carriers consider women, particularly young women, a higher risk than men, women experience more difficulty obtaining coverage in the individual market and in most states are charged much higher premiums for the same benefits than men of the same age are. According to an analysis of the CMWF biennial health insurance survey , an estimated 7.3 million women, or 38%, were turned down, charged a higher price, or had a condition excluded from coverage when tried to buy a plan over a recent 3 yr period. A recent study by the National Women’s Law Center found that young women were charged as much as 84% more for premiums than men in some state individual markets. That study and a prior Commonwealth Fund study also found that few policies purchased on the individual market come with maternity benefits. THE COMMONWEALTH FUND Source: The Commonwealth Fund Biennial Health Insurance Survey (2007). 3

Phased-in ban on annual limits Exhibit 3. Affordable Care Act Implementation Timeline: Provisions Benefitting Women Medicaid expansion State insurance exchanges Insurance market reforms, including no rating on health, gender Essential benefit standard including maternity Premium and cost-sharing credits for exchange plans Individual requirement to have insurance Employer shared responsibility penalties Young adults on parents’ plans Ban on lifetime benefit caps and rescissions Phased-in ban on annual limits Preexisting Condition Insurance Plan Preventive services coverage without cost-sharing Medicare Rx “doughnut hole” rebate of $250 Phased-in ban on annual limits Discounts on brand-name drugs in Medicare Rx “doughnut hole” This slide shows a timeline of the major provisions of the ACA that will benefit women that go into effect over 2010-2014. Most women who are uninsured and underinsured will gain access to comprehensive health insurance beginning in 2014 under the ACA, but early provisions of the reform bill, many of which go into effect this year, or have already gone into effect, will provide important transitional relief for millions of women. HHS has released a large number of interim final regulations on these provisions since March. NEXT SLIDE --Requirements that employers and insurers allow young adults to remain on or join their parent’s health plans starting in Sept will cover an estimated 1 million uninsured adult children over the next three years; --Bans on lifetime limits that insurers place on benefits: About 102 million people have health plans with lifetime limits, and about 20K exceed their plan limits and lose coverage each year, we assume about ½ would be women or 10,000 --Phase in restrictions on annual benefit limits: about 18 million people have plans with annual limits, 3500 people exceed limits each year. --Bans on rescissions of coverage: Rescissions are most common in the individual market where about 15 million people are covered, 5.5 million women. About 10,700 people lose their coverage as a result each year, assume about half are women or 5,000 --Enrollment in state high risk pools or preexisting condition insurance plans began in 21 + 18 states and DC in July (39 states) with about 12 states to begin in August , under the current budget these will cover about 200,000 people, again assuming half are women about 100k women --Carriers required to cover recommended preventive services without cost-sharing including mammograms for women 40 and over, cervical cancer screening, genetic counseling and testing for the breast cancer (BRCA) gene. --Medicare begins closing the prescription drug donut hole this year with 250 rebates sent to people who hit it this year. About 16 percent of Medicare beneficiaries hit the donut hole, women are among those most likely to spend enough on Rx to enter the hole (compliance is reason) The law will have its biggest impact on increasing, and improving the comprehensiveness of, HI in 2014 -a substantial expansion of Medicaid to everyone up to 133 percent of poverty (14,404 or 29,327), new ins. market regulations that prevent underwriting on health and gender, new state insurance exchanges and subsidized health insurnace for those with incomes 133-400 percent of povery (14,404- 43,320/ 29,327-88,200). Insurers selling in the exchanges and the individual market must offer an essential standard benefit package similar to those in employer plans including maternity and new born care, which is rarely covered in individual market plans, There will be four different levels of benefits – bronze, silver, gold, platinum - that will vary only by cost-sharing, the benefits covered will remain the same within each level. This will greatly improve both the comprehensiveness and transparency of coverage compared to the individual market of today, people directly purchasing HI will have complete info about what their plans cover and their out of pocket responsibilities. Out of pocket limits and cost sharing subsidies will also limit cost exposure, reducing problems with medical debt and underinsurance. 2010 2011–2013 2014 THE COMMONWEALTH FUND Source: Commonwealth Fund analysis of the Patient Protection and Affordable Care Act (Public Law 111-148 and 111-152). 4

Exhibit 4. Early Provisions of the ACA That Will Benefit Women, 2010-2013 Employers/insurers must allow adult children to remain on or join their parent’s health plans (Sept. 2010): 1 million uninsured adult children to gain coverage Ban on lifetime coverage limits (Sept 2010): About 102 million people have health plans with lifetime limits, 20,400 exceed limits and lose coverage each year, assuming women comprise ½ population, 10,000 women would gain coverage Phased-in restrictions on annual benefit limits (Sept. 2010): about 18 million people have plans with annual limits, 3500 people exceed limits each year, about 1750 women Bans on rescissions of coverage (Sept 2010): Rescissions most common in the individual market where about 5.5 million women covered. About 10,700 people lose their coverage as a result each year, assume about half are women or 5,000 Preexisting condition insurance plans (July-Aug 2010): Enrollment beginning in 39 states in July (21 states with federal plans), 12 states to begin in August. Under the current budget these will cover about 200,000 people, about 100,000 women Insurers must cover recommended preventive services without cost-sharing (Sept. 2010): Includes mammograms for women age 40+, cervical cancer screening, genetic counseling and testing for the breast cancer (BRCA) gene. $250 rebates to Medicare beneficiaries in the Rx doughnut hole (2010): About 16 percent of Medicare beneficiaries enter doughnut hole annually, women are among those most likely to enter the hole. The early provisions of the ACA that will benefit women either as individuals or as parents include: --Starting in Sept, employers and insurers are required, at least by the commencement of their new plan year, to allow young adults to remain on or join their parent’s health plans, HHS in the interim final regulations on this provision estimates about 1 million uninsured adult children will gain coverage over the next three years as a result; [GF plans group and nongroup] [uninsured rates slightly higher among young men] --Also starting in Sept., insurers and employers are banned from placing lifetime limits on benefits: About 102 million people have health plans with lifetime limits, and about 20K exceed their plan limits and lose coverage each year, we assume about ½ would be women or 10,000 [GF plans group and nongroup] --Starting in Sept, the new law Phases in restrictions on annual benefit limits: about 18 million people have plans with annual limits, 3500 people exceed limits each year. [Group GF, not nongroup GF] [9/2010-9/2011: not < $750K; 9/2011-9/2012: not < $1.25m; 9/2012-1/2014: not < $2m] --Again in Sept, carriers are banned prohibited from rescissinding coverage: Rescissions are most common in the individual market where about 15 million people are covered, 5.5 million women. About 10,700 people lose their coverage as a result each year, assume about half are women or 5,000 [GF plans group and nongroup] --Enrollment in state high risk pools or preexisting condition insurance plans began in 21 + 18 states and DC in July (39 states) with about 12 states to begin in August , under the current budget these will cover about 200,000 people, again assuming half are women about 100k women [budget =$5b to 2014] --Starting in Sept, employers and carriers are required to cover recommended preventive services without cost-sharing including mammograms for women 40 and over, cervical cancer screening, genetic counseling and testing for the breast cancer (BRCA) gene. [only non-GF plans both group and nongroup] --Medicare begins closing the prescription drug donut hole this year by automatically sending $250 rebates to beneficiaries who spend enough on prescription drugs to reach the donut hole this year. This will be completely closed by 2020. A recent study found that bout 16 percent of Medicare beneficiaries reach the donut hole each year, and women are among those most likely to reach it and therefore stand to benefit most from the narrowing of the donut hole over the next 10 years. (compliance is reason)

Exhibit 5. Provisions of the ACA That Will Benefit Women, 2014+ Expansion in Medicaid eligibility to cover adults with incomes under 133% poverty ($14,000 individual; $29,000 for family of four) New state insurance exchanges with premium and cost-sharing subsidies up to 400% poverty ($43,000 individual, $88,000 family of four): Premiums capped at 3%-9.5% of income between 133-400% poverty; spending capped at 6%-27% total spending 133-250% poverty Essential health benefit standards that include maternity and newborn care and limits on cost-sharing for plans sold in insurance exchanges and the in the individual and small group markets: Four different levels of benefits – bronze, silver, gold, platinum – that will vary only by cost sharing, benefits are the same at each level Prohibitions on insurance carriers from denying coverage or charging higher premiums on the basis of health or gender The law will have its biggest impact on increasing, and improving the comprehensiveness of, HI in 2014. Provisions that go into effect that will benefit women include: -an expansion of Medicaid to everyone up to 133 percent of poverty (14,404 or 29,327) – this represents a substantial change in Medicaid’s coverage of adults where currently most states do not cover adults without children, - new state insurance exchanges with premium and cost-sharing subsidies up to 400% of poverty (43K, 88K): Premiums are capped at 3-9.5% of income between 133 and 400 percent of poverty; spending is capped at 6%-27% of spending between 133 and 250% poverty. -Insurers selling in the exchanges and the individual and small group markets must offer a federally determined essential standard benefit package similar to those in employer plans including maternity and new born care, which is rarely covered in individual market plans, There will be four different levels of benefits bronze, silver, gold, platinum - that will vary only by cost-sharing, the benefits covered will remain the same within each level. This will greatly improve both the comprehensiveness and transparency of coverage compared to the individual market of today, people directly purchasing HI will have complete info about what their plans cover and their out of pocket responsibilities. Out of pocket limits and cost sharing subsidies will also limit cost exposure, reducing problems with medical debt and underinsurance. -Insurance carriers will be prohibited from denying coverage or charging higher premiums on basis of health or gender. [children pre-x does not apply to nongroup GF plans, assume this will be case for this reg]

Premium Cap As A Share of Income Exhibit 6. Distribution of 16.8 Million Uninsured Women by Federal Poverty Level and Provisions of the Affordable Care Act Uninsured Women ages 19-64 Federal Poverty Level Percent Number Uninsured Premium Cap As A Share of Income Cost Sharing Cap <133% FPL 49% 8,237,639 Medicaid 133%–149% FPL 6% 1,025,277 3.0%–4.0% 150%–199% FPL 13% 2,158,344 4.0%–6.3% 200%–249% FPL 9% 1,571,793 6.3%–8.05% 27% 250%–299% FPL 1,007,372 8.05%–9.5% 30% 300%–399% FPL 7% 1,205,784 9.5% Subtotal (133%-400%FPL) 41% 6,968,570 3.0%–9.5% 6%–30% >400% FPL 10% 1,641,979 -- Total 100% 16,848,188 In terms of the provisions that go into effect in 2014, we used current counts of uninsured women from the Current Population Survey to examine the potential effects of the provisions. So these are not estimates of take-up in 2014, but a distribution of current uninsured working age women by the provisions in the law. It is also important to note the some unknown share of these uninsured women are undocumented immigrants and thus will not be eligible for the coverage expansions. Of all the provisions in the law, the expansion of Medicaid to 133 percent of poverty, will potentially have the largest effect on reducing the number of uninsured women. About half of working age women about 8.2 m- are in households with income under 133 percent of poverty (14,404 or 29,327). The next biggest impact of the law on reducing the number of uninsured women is the availability of subsidized coverage through the exchanges. Women with incomes between 133%-400% poverty can buy coverage through the exchanges and have their premiums capped between 3%-9.5% of their incomes. More than 40 percent of uninsured women, or 6.9m, had household incomes in this range in 2008. About 10% or 1.6m uninsured women have incomes at 400 percent of poverty or above (43K for single, 88k for family) and could also buy coverage thru the exchange or the individual insurance market. While they would not be eligible for premium subsidies, they would benefit from new ins. market regs against underwriting on the basis of health and gender, the essential benefit package, choice of different cost-sharing levels, and also a catastrophic policy avail to those who cannot find a plan with a premium that is less than 8% of their income, that would have the essential benefit package, but higher cost sharing, and presumably lower premiums, than other plans thru the exchanges. All told, the provisions have the potential to cover up to 17 million uninsured women (this is 18 percent of all adult women), 90 percent of whom would be eligible for subsidized health insurance. This is about 37 percent of the 45.7 million people under age 65 uninsured in 2008. [Those with incomes (one person) between 14,404 and 27,075 (133-250%) 4 m (would have their premiums capped at 3%to8% of income, those with incomes between 27,075 and 43,320 (250-400) would have their premiums capped at 8-9.5% of income). Source: Analysis of the March 2009 Current Population Survey by N. Tilipman and B. Sampat of Columbia University for The Commonwealth Fund; Commonwealth Fund analysis of Affordable Care Act (Public Law 111-148 and 111-152). 7

Exhibit 7. Distribution of 37 Exhibit 7. Distribution of 37.6 Million Uninsured Adults Ages 19-64 by Federal Poverty Level and Gender Uninsured Adults ages 19-64 Total Population Women Men Federal Poverty Level Percent Millions <133% FPL 45% 17.0 49% 8.2 43% 8.8 133%–149% FPL 6% 2.3 1.0 1.3 150%–199% FPL 13% 4.9 2.2 2.8 200%–249% FPL 10% 3.7 9% 1.6 2.1 250%–299% FPL 7% 2.5 1.4 300%–399% FPL 8% 3.0 1.2 1.8 Subtotal (133%-400%FPL) 44% 16.4 41% 7.0 9.4 >400% FPL 11% 4.1 12% Total 100% 37.6 16.8 20.8 To give you a sense of how women will benefit from the 2014 expansions relative to men, there are actually more uninsured adult men at every income level than there are uninsured women. But of women who are uninsured, a larger share than men earn less than 133 percent of poverty. About 23.4 percent of women are uninsured under 133 percent of poverty compared to 19 percent of men. [overall women are uninsured at 18% vs. 23% for men] So the Medicaid expansion goes a bit farther in reducing the rate of unisurance among women than it does for men. But men still are uninsured in greater numbers at this income range than women. There are somewhat more uninsured men who exceed the threshold for premium subsidies than there are women. Source: Analysis of the March 2009 Current Population Survey by N. Tilipman and B. Sampat of Columbia University for The Commonwealth Fund. 8

Exhibit 8. Eighteen Percent of Women Ages 19-64 Are Uninsured Nationally, Many States Have Higher Rates State Percent Uninsured Number Uninsured United States 18.1% 16,853,700 North Carolina 18.3% 520,600 Montana 18.9% 53,900 Idaho 19.5% 85,500 Nevada 20.0% 154,500 Kentucky 20.2% 266,400 Oklahoma 20.3% 216,500 West Virginia 21.0% 116,200 California 21.3% 2,365,500 Georgia 655,400 Arizona 21.6% 419,700 Alaska 22.0% 46,200 Mississippi 22.1% 196,800 Arkansas 22.3% 194,500 Louisiana 23.8% 313,300 Florida 24.0% 1,316,000 New Mexico 28.6% 173,700 Texas 29.2% 2,107,900 Women in states where they are uninsured at higher rates will particularly benefit from the expansions in coverage. 17 states have uninsured rates among women that exceed the national average. Nearly 30 percent of adult women are uninsured in Texas – or 2.1 million women. (12 percent of all uninsured women in the country). Adult women without children are not eligible for Medicaid in TX, as in the majority of states. And parents are eligible in Tx only if they earn 27 percent of poverty, which is $6000 annual income for a family of four. So Texas women stand to make enormous gains in health insruance coverage , both access to and the comprehensiveness of their plans. To give you a sense of where things are headed, the uninsured rate among women in Massachusetts, a state which has implemented a law vastly similar to the ACA, is 5.6 %. More recent data from the National Health Interview survey suggest that that rate in Mass fell even lower in 2009, while rates have grown as a result of the poor economy in other states. So this new law marks a dramatic departure from the past in women’s ability to gain affordable and comprehensive health insurance coverage, and is certain to stabilize and reverse the growing exposure to health care costs that women have experienced over the last decade, ensuring that they can get the health care that they need without the risk of incurring catastrophic medical bills. I am going to stop here and look forward to your questions. Source: Health Insurance Coverage of Women 19–64, states (2007–2008), Kaiser Family Foundation, statehealthfacts.org. Estimates based on the Census Bureau's March 2008 and 2009 Current Population Survey.