The original health care plan that House Speaker Paul Ryan (R-Wisc.) introduced to repeal and replace parts of the Affordable Care Act already stripped away some aspects of women’s health care coverage. It sought to defund Planned Parenthood, restrict access to abortion by limiting the use of tax credits, and sunset Obamacare’s essential health benefits—including maternity care and preventative services like birth control—for those who gained access to Medicaid under the ACA’s expansion of the program.
But things have gotten even worse for women as Congressional Republicans and the White House have tweaked the bill in an effort to jam it through the House. They delayed a vote on the measure on Thursday as support for it stalled. President Donald Trump has demanded a vote be held Friday.
On Monday, House Republicans introduced the “manager’s amendment” to their legislation—known as the American Health Care Act or AHCA—that was aimed at appeasing some House members who objected to the original version. The amendment features a clause that would give states the leeway to revoke Medicaid coverage to unemployed mothers who don’t find work within 60 days of giving birth. The provision is modeled after a state-run program called Temporary Assistance for Needy Families (TANF) that provides financial aid to qualifying poor families and includes similar work requirements. A spokesperson for the House Energy and Commerce Committee, which worked on the new AHCA bill, told Fortune the clause “give[s] states the option to institute policies encouraging individuals enrolled in the Medicaid program to begin looking for work,” and the approach is “based on the successful, bipartisan welfare reform efforts under President Bill Clinton.”
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Alina Salganicoff, the vice president and director of women’s policy at the Kaiser Family Foundation, assessed the provision differently, saying it would put “women in the difficult position of finding work soon after delivery and needing to find childcare, or staying home and being uninsured.”
Women’s health care took another hit on Thursday when Trump agreed to roll back what Obamacare has deemed “essential health benefits”—medical services like doctor visits, ambulance rides, prescription drugs, and maternity care that are so vital the law said all insurance plans must cover them. Trump’s acquiescence on the issue was an effort to placate the Freedom Caucus, a group of hard-line conservatives that say the GOP plan doesn’t go far enough to reduce the regulation and cost of Obamacare, according to The New York Times.
It’s unclear if the essential health benefits could be repealed in this piece of legislation. Republicans are using the filibuster-proof budget reconciliation process to push their legislation through Congress. That means they only need 51 Senate votes for approval, but it also means they can only touch aspects of Obamacare that directly impact federal spending. It’s uncertain whether eliminating the essential health benefits would fit those parameters. If not, it’s possible the Trump administration could modify or soften the essential benefits regulation on its own.
Obamacare introduced the essential health benefits in an effort to beef up insurance coverage and make plans more transparent. Currently, consumers know their plans cover at least those ten services. But critics say the mandate, in addition to imposing regulation on the insurance market, inflates the cost of health care plans because it forces consumers to pay for services they may not need. The prime example of this is an older man purchasing a plan that covers maternity care, which press secretary Sean Spicer cited last week when talking about the issue. “A 54-year-old doesn’t need certain things. They don’t need maternity care,” he said. “They don’t need certain medical services that are being provided to them by this government product that is being forced on them right now.”
Sen. Pat Roberts (R-Kan.) made a similar argument in a quip to a TPM reporter on Thursday.
Roberts later apologized for the remark in a tweet: “I deeply regret my comments on a very important topic. Mammograms are essential to women’s health & I never intended to indicate otherwise.”
The argument against rolling back the essential health benefits is that allowing consumers to buy insurance that covers only what they need would cause the cost of plans that include other services—like maternity care—to skyrocket, if insurance companies offer them at all.
That was the problem women faced before Obamacare. Coverage of birth control was inconsistent from plan to plan and women were required to pay co-pays. Insurers routinely excluded maternity coverage from individual plans; according to the National Women’s Law Center just 12% of individual market plans provided it. Women could purchase maternity riders for their policies in some states, but in many cases those add-ons cost more than a policy itself.
House Minority Leader Nancy Pelosi (D-Calif.) said Thursday that “[eliminating] essential health benefits means Republicans are making being a woman a preexisting condition.”
“Again, stripping guaranteed maternity care is a pregnancy tax, pure and simple,” she said.
It’s important to note that women’s health care landed on a bargaining table where few—if any—women are seated.
Vice President Mike Pence on Thursday tweeted out a photo of his talks with the Freedom Caucus. It featured only men.
