1. 1 MASSACHUSETTS HEALTH REFORM: IMPACT ON WOMEN’S HEALTH Tracey Hyams, JD, MPH, Director Laura Cohen, Policy Analyst Women’s Health Policy and Advocacy Program Connors Center for Women’s Health and Gender Biology Brigham and Women’s Hospital Women’s Health Policy and Advocacy Program

2. 2 DATA SOURCES Women’s Health Policy and Advocacy Program The Blue Cross Blue Shield of Massachusetts Foundation: http://bluecrossfoundation.org/ http://bluecrossfoundation.org/ Ibis Reproductive Health: http://www.ibisreproductivehealth.org/ Brigham and Women’s Center for Community Health and Health Equity: www.brighamandwomens.org/communityprograms/

3. 3 MASSACHUSETTS BEFORE HEALTH REFORM Prohibited Insurance Practices: –Gender and disease-based premium rating –Denial of coverage based on sex, age, occupation, health status or actual or expected health condition –Designation of domestic violence or pregnancy as a pre-existing condition Pre-existing Condition Limitations- technically allowed by law but no major insurer imposed Pro-choice legislature and government 26 Mandated Benefits including maternity, mammography and contraceptive services Women’s Health Policy and Advocacy Program

4. 4 HOW DOES REFORM IN MA COMPARE TO NATIONAL REFORM? ProvisionMAUS Individual mandate√√ Employer Mandate  √√ Medicaid expansion√√ Insurance Exchanges√√ Sliding scale subsidies for certain individuals and families√√ A required set of health benefits for all private plans√√ No gender or health-status premium rating allowed√√ Caps on out-of-pocket spending√√ Direct access to an OB/GYN without referral√ √ Women’s Health Policy and Advocacy Program

5. 5 LANGUAGE OF MASSACHUSETTS HEALTH REFORM Health Insurance Connector Minimum Creditable Coverage (MCC) Commonwealth Care (subsidized) Commonwealth Choice (unsubsidized) Women’s Health Policy and Advocacy Program

6. 6 EVALUATING MASSACHUSETTS HEALTH REFORM Coverage Access Affordability Transitions Remaining Opportunities Women’s Health Policy and Advocacy Program

7. 7 Coverage Women’s Health Policy and Advocacy Program

8. 8 IMPROVEMENT IN COVERAGE SINCE REFORM MA Health reform extended coverage to 364,000 residents, the majority (68%) of whom receive subsidized insurance The Massachusetts Health Reform Survey found that all populations of women experienced significant coverage gains since reform Total enrollment in subsidized coverage remains higher among women than men Women’s Health Policy and Advocacy Program

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13. 13 IMMIGRANT WOMEN Prior to June 2009, Massachusetts insured Legal Permanent Residents (LPRs) under subsidized Commonwealth Care but cut coverage due to budget constraints The state created a separate insurance plan to cover the nearly 30,000 LPRs that lost coverage but the plan has capped enrolment Women’s Health Policy and Advocacy Program

14. 14 WHO ARE THE UNINSURED? Women that remain uninsured are disproportionately young, single and Hispanic More than half of uninsured women are employed (often in smaller firms) More than 75% of the nearly 60,000 uninsured women in MA have incomes under 300% FPL, meaning they may qualify for subsidized coverage Women’s Health Policy and Advocacy Program

15. 15 Access to Care Women’s Health Policy and Advocacy Program

16. 16 THE NUMBERS As of Fall 2009, 97.1% of Massachusetts women were insured, up from 91.4% in 2006 92.8% of Massachusetts women had a usual source of health care in 2009 90% had a general doctor visit and 82% had a preventative care visit Women’s Health Policy and Advocacy Program

17. 17 ACCESS AMONG WOMEN IN MA Essential Women’s Health Benefits –Reproductive Health –Primary Care (Ob/Gyn) –Mental Health, Dental Care, Preventive Screenings Vulnerable Populations –Younger Women –Racial and Ethnic Minorities –Immigrants Women’s Health Policy and Advocacy Program

18. 18 REPRODUCTIVE HEALTH Women’s Health Policy and Advocacy Program In general, health reform has expanded access to contraceptives Barriers to Accessing contraceptives - New ways of obtaining contraceptives - Some Young Adult Plans and Student Health Plans do not have prescription drug coverage - Difficulty understand what contraceptive services plans will cover - Frequent changes in insurance status impact cost and continuity of contraceptive use Cost does not appear to be a barrier to contraceptive use after health reform MA funds medically necessary abortions for Medicaid recipients

19. 19 ACCESS TO PRIMARY CARE PROVIDERS Percent of Massachusetts Primary Care Providers Accepting New Patients Service20082009 Family Medicine 65%60% Internal Medicine 52%44% Obstetrics and Gynecology 92%81% Women’s Health Policy and Advocacy Program

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21. 21 Affordability Women’s Health Policy and Advocacy Program

22. 22 Women’s Health Policy and Advocacy Program WHO IS MOST AT RISK? Moderate-income women Women on low-premium, subsidized insurance plans Young women enrolled in Young Adult Plans (YAPs) Women transitioning from no cost-sharing to cost-sharing plans

23. 23 Malika is a student who became pregnant while covered through her college’s student health plan (SHP). Although her SHP covers pregnancy, coverage is capped at $25,000 per injury or illness. Malika had a complicated delivery, which required ambulance transportation to a hospital better able to handle her high-risk care. Unfortunately, her plan has an individual service cap on ambulance transportation, leaving her responsible for $1,500 in out-of-pocket costs. The hospital charged $24,000 for Malika’s care and $32,000 for her baby’s care. Her health plan decided to count Malika and her baby’s care as a single episode of illness, leaving her with $31,000 in additional out-of-pock costs. Her massive medical bills qualify her for the Health Safety Net; however, she is still responsible for paying a significant portion of the costs herself - $16,000. MEET MALIKA “If the insurance barely helped me then what am I paying them for?” Women’s Health Policy and Advocacy Program

24. 24 MEET ANN Ann is 56 years old, divorced with two adult children. She makes $62,000 a year and a realtor for a small firm not required to offer health insurance. This year, Ann had an annual mammogram which detected an abnormal mass in her right breast. She was diagnosed with breast cancer and had a mastectomy. Ann’s income qualifies her for a Commonwealth Choice plan. This chart highlights her out-of-pocket costs (premiums, deductibles and co pays) for one year under different Commonwealth Choice Plans. Plan (with Rx)Total Annual Cost Bronze$7,128 Silver$4,004 Gold$5,234 Women’s Health Policy and Advocacy Program

25. 25 AGE RATING Lowest-cost Commonwealth Choice Plans for a 31 year-old vs. 59-year old woman in Boston, MA Plan31 year-old59 year-old Bronze$224$444 Silver$272$544 Gold$392$799 Women’s Health Policy and Advocacy Program

26. 26 MEET JENNIFER Jennifer is 31 years-old and self-employed. She makes $32,600 a year and does not qualify for subsidized Commonwealth Care. The next slide shows lowest cost Bronze, Silver and Gold plans available to her by geographic breakdown: Boston and Springfield, MA. It is important to note that Jennifer make $100 dollars more than the income cut off for Commonwealth Care program ($32,500) yet she pays between $83 and $108 more per month on premiums. She will pay between $996-$1,296 more per-year just on premiums because she makes $100 dollars more than the income cap for Commonwealth Care. Women’s Health Policy and Advocacy Program

27. 27 MEET DIANA Diana is a 28-year old single adult working at a small firm that does not provide health insurance. She makes 32,400 dollars a year, which makes her eligible for Commonwealth Care. She pays $116 a month on premiums, far less than her sister Jennifer, despite the fact that Jennifer only makes $200 dollars more than Diana. Women’s Health Policy and Advocacy Program

28. 28 Coverage and Eligibility Transitions Women’s Health Policy and Advocacy Program

29. 29 Women are more likely to experience life changes like enrollment in college, pregnancy or marriage and variable income, which impact income eligibility Income eligibility for Medicaid and subsidized coverage are only dollars apart In 2009, an average of 9,80 people transitioned into MassHealth from Commonwealth Care and the Health Safety Net (HSN) 9,400 transitioned from MassHealth and HSN to Commonwealth Care Women’s Health Policy and Advocacy Program

30. 30 MEET CHRISTINA Christina is a 27 year old single woman earning 150% of the Federal Poverty Level ($16,245 a year) working as a waitress and is eligible for Commonwealth Care. Christina become pregnant and is now categorically eligible for Medicaid because her income is below 200% FPL. Christina must apply for Medicaid because eligibility for public insurance negates Commonwealth Care eligibility. While she waits for MassHealth eligibility, she in insured by MassHealth Prenatal, a short-term program designed to cover pregnant women while they wait for MassHealth approval. After birth, she must re- apply to Commonwealth Care because her income makes her MassHealth ineligible (mothers with Medicaid eligible children can remain beneficiaries if they make 133% or less of the FPL). In one year, Christina has applied to three insurance plans and transitioned between plans four times. Women’s Health Policy and Advocacy Program

31. 31 OPPORTUNITIES FOR MA AND NATIONAL HEALTH REFORM Collect and Stratify Data by Sex Reduce Costs / Monitor Affordability Administrative Simplicity / Patient Navigation Primary Care Shortage Vulnerable Populations - Young Women - Immigrant Women - Racial and Ethnic Minorities - Caregivers Women’s Health Policy and Advocacy Program

32. 32 To read the Women’s Health Policy and Advocacy Program’s Issue Brief, please click this link: http://www.brighamandwomens.org/ConnorsCent er/images/ConnorsCenter.pdf http://www.brighamandwomens.org/ConnorsCent er/images/ConnorsCenter.pdf Contact Information Tracey Hyams, JD, MPH Director, Women’s Health Policy and Advocacy Program Connors Center for Women’s Health and Gender Biology Brigham and Women’s Hospital Boston, MA 617-525-7516 thyams@partners.org thyams@partners.org www.brighamandwomens.org/womenspolicy Women’s Health Policy and Advocacy Program