Women’s Health Insurance Coverage

Health insurance coverage is an important factor in making health care affordable and accessible to women. Among the 98 million women ages 19 to 64 residing in the U.S., most had some form of coverage in 2020. However, gaps in private sector and publicly funded programs and lack of affordability left a little over one in ten women uninsured. Over the past decade, the Affordable Care Act (ACA) has expanded access to affordable coverage through a combination of Medicaid expansions, private insurance reforms, and premium tax credits. This factsheet reviews major sources of coverage for women residing in the U.S. in 2020, as the coronavirus pandemic continued in the U.S. and globally, discusses the impact of the ACA on women’s coverage, and the coverage challenges that many women continue to face.

Sources of Health Insurance Coverage

Employer-Sponsored Insurance

Approximately 60 million women ages 19-64 (61%) received their health coverage from employer-sponsored insurance in 2020 (Figure 1).1 Women are less likely than men to be insured through their own job (38% vs. 46% respectively) and more likely to be covered as a dependent (23% vs. 16%).2

Figure 1: Women’s Health Insurance Coverage, 2020

  • Women in families with at least one full-time worker are more likely to have job-based coverage (71%) than women in families with only part time workers (30%) or without any workers (17%).3
  • In 2020, annual insurance premiums for employer sponsored insurance averaged $7,470 for individuals and $21,342 for families. Family premiums have increased 55% over the last decade. On average, workers paid 17% of premiums for individual coverage and 27% for family coverage with the employers picking up the balance.

Non-Group Insurance

The ACA expanded access to the non-group or individually purchased insurance market by offering premium tax credits to help individuals purchase coverage in state-based health insurance Marketplaces. It also included many insurance reforms to alleviate some of the long-standing barriers to coverage in the non-group insurance market. In 2020, about 7% of nonelderly adult women (approximately 7.2 million women) and 7% of nonelderly adult men purchased insurance in the non-group market.4 This includes women who purchased private policies from the ACA Marketplace in their state, as well as women who purchased coverage from private insurers that operate outside of Marketplaces.

  • Most individuals who seek insurance policies in their state’s Marketplace qualify for assistance with the costs of coverage. Individuals with incomes below $53,860 (400% of the Federal Poverty Level) can qualify for assistance in the form of federal tax credits which lower premium costs. Additionally, the American Rescue Act (ARPA) of 2021 provides a temporary extension of Marketplace subsidies to people with higher income levels as well.
  • The ACA set new standards for all individually purchased plans, including plans available through the Marketplace as well as those that existed prior to the ACA. The ACA bars plans from charging women higher premiums than men for the same level of coverage (gender rating) or from disqualifying women from coverage because they had certain pre-existing medical conditions, including pregnancy. All direct purchase plans must also cover certain “essential health benefits” (EHBs) that fall under 10 different categories, including maternity and newborn care, mental health, and preventive care.

Medicaid

The state-federal program for low-income individuals, Medicaid, covered 16% of nonelderly adult women in 2020, compared to 13% of men. Historically, to qualify for Medicaid, women had to have very low incomes and be in one of Medicaid’s eligibility categories: pregnant, mothers of children 18 and younger, a person with a disability, or over 65. Women who didn’t fall into these categories typically were not eligible regardless of how poor they were. The ACA allowed states to broaden Medicaid eligibility to most individuals with incomes less than 138% of the FPL regardless of their family or disability status, effective January 2014. As of November 2021, 38 states and DC have expanded their Medicaid programs under the ACA.

  • Medicaid covers the poorest population of women. Forty percent of low-income women (income below 200% FPL) and 47% of poor women (income below 100% FPL) have Medicaid coverage.5
  • By federal law, all states must provide Medicaid coverage to pregnant women with incomes up to 133% of the federal poverty level (FPL) through 60 days postpartum; states may not impose cost sharing for pregnancy related services. In states that adopted the ACA’s Medicaid expansion, many women are now able to remain on Medicaid once they become mothers because of the higher eligibility threshold in these states, but in the 12 states that have not adopted Medicaid expansion, many women no longer qualify for Medicaid coverage 60 days after the birth of their child because their income is above the eligibility level for parents in those states. In recent years, there has been a growing interest in expanding the length of the postpartum period under Medicaid, and to date, over half of states have taken steps to extend postpartum Medicaid coverage beyond 60 days.
  • Medicaid financed 42% of births in the U.S. in 2019, accounts for 75% of all publicly-funded family planning services and half (52%)6 of all long-term care spending, which is critical for many frail elderly women.
  • Over half of the states (27 states) have established programs that use Medicaid funds to cover the costs of family planning services for low-income women, and most states have limited scope Medicaid programs to pay for breast and cervical cancer treatment for certain low-income uninsured women.

Uninsured Women

Women are less likely than men to be uninsured, as a higher share of adult women are enrolled in Medicaid. On average, women have lower incomes and have been more likely to qualify for Medicaid than men under one of Medicaid’s eligibility categories; pregnant, parent of children under 18, disabled, or over 65. In 2020, 13% of men 19-64 were uninsured compared to approximately 11% of women ages 19 to 64 (10.3 million women). In spite of significant job losses, uninsured rates among women held steady during the first year of the COVID-19 pandemic. However, it is important to recognize that there has been challenges to comprehensive data collection on the number of uninsured people during 2020 due to some delays and data quality problems in federal surveys typically used to measure health coverage in the US. These limitations are described in more detail here.

Uninsured women often have inadequate access to care, get a lower standard of care when they are in the health system, and have poorer health outcomes. Compared to women with insurance, uninsured women have lower use of important preventive services such as mammograms, Pap tests, and timely blood pressure checks. They are also less likely to report having a regular doctor.

  • Low-income women, women of color, and non-citizen women are at greater risk of being uninsured (Figure 2). One in five (21%) women with incomes under 200% of the FPL ($26,930 for an individual in 2020) are uninsured (Table 2), compared to just 7% of women with incomes at or above 200% FPL. Over one in five Hispanic (22%) and American Indian and Alaska Native (23%) women are uninsured. A higher share of single mothers are uninsured (13%) than women in two-parent households (8%).7

  • The majority of uninsured women live in a household where someone is working: 71% are in families with at least one adult working full-time and 85% are in families with at least one part-time or full-time worker.8
  • There is considerable state-level variation in uninsured rates across the nation, ranging from 22% of women in Texas to 3% of women in Washington DC, Massachusetts, and Vermont (Figure 3). Of the 16 states with uninsured rates above the national average (11%), eight have not adopted the ACA Medicaid expansion.

Eligibility for Coverage

Many women who are uninsured are potentially eligible for coverage but are not enrolled. Some, however, still lack any pathway to affordable coverage.

  • Over half of uninsured women are eligible for either Medicaid or tax subsidies under the ACA. One in five (2.1 million) uninsured women are currently eligible for Medicaid but are not enrolled and 42% (4.3 million) are eligible for a subsidized Marketplace plan but not enrolled (Figure 4).

Figure 4: Eligibility for Assistance Under the ACA Among Uninsured Women Ages 19-64, 2020

  • 3.8 million uninsured women are not eligible for financial assistance for coverage. One million poor women are in the so-called “Medicaid coverage gap.” They live in a state that has not expanded its Medicaid program and do not qualify for Medicaid but have incomes below the lower level for Marketplace subsidies.
  • Some women who are uninsured are ineligible for coverage because of their immigration status, while other women have incomes that are too high to qualify for federal premium subsidies or have an offer of employer-based insurance but have not enrolled in workplace coverage. The American Rescue Act (ARPA) of 2021 temporarily extends subsidy eligibility to people buying marketplace plans with incomes over 400% FPL as well as increases subsidy levels for ACA marketplace shoppers that are already eligible for financial assistance. KFF analysis found that large shares of uninsured adults who are eligible for subsidies or no-cost plans are young adults, Hispanic people, adults with a high school education or less, and those living in rural areas.

Scope of Coverage and Affordability

The ACA set national standards for the scope of benefits offered in private plans. In addition to the broad categories of essential health benefits (EHBs) offered by marketplace plans, all privately purchased plans must cover maternity care which had been historically excluded from most individually purchased plans. In addition, most private plans must cover preventive services without co-payments or other cost sharing. This includes screenings for breast and cervical cancers, well woman visits (including prenatal visits), prescribed contraceptives, breastfeeding supplies and supports such as breast pumps, and several STI services. Conversely, abortion services are explicitly prohibited from being included as EHBs, and 26 states have laws banning coverage of most abortions from the plans available through the state Marketplaces.

Affordability of coverage and care continues to be a significant concern for many women, both for those who are uninsured as well as those with coverage. The leading reason why uninsured nonelderly adults report that they haven’t obtained coverage is that it is too expensive. Under employer-sponsored insurance, the major source of coverage for women, 57% of all covered workers with a general annual deductible have deductibles of at least $1,000 for single coverage. Thirty-seven percent of women with employer sponsored coverage report that it is difficult to meet their deductibles.9

Looking Forward

Health coverage matters for women. Those with health coverage are more likely to obtain needed preventive, primary, and specialty care services, and have better access to new advances in women’s health. Today, because of the ACA, most women can get coverage without worrying that they will be charged more for insurance than men, be assured that their insurance provides them with no-cost coverage for a wide range of recommended preventive services, and coverage for critical services for women such as maternity care. However, 10 million women remain uninsured, with rates highest in states that have not expanded Medicaid eligibility. Medicaid expansion in the 12 states that have not yet expanded and more proactive outreach about Medicaid eligibility could make substantial inroads in extending coverage to many women who are currently uninsured.

Endnotes
  1. KFF estimates based on the Census Bureau's March Current Population Survey (CPS: Annual Social and Economic Supplements), 2021.

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  2. Ibid.

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  3. Ibid.

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  4. Ibid.

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  5. Ibid.

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  6. National LTSS expenditures totaled $379 billion, including spending on residential care facilities, nursing homes, home health services, HCBS waivers, ambulance providers, and some post-acute care. Medicare post-acute care spending ($83.3 billion) is excluded. LTSS payers include Medicaid (52%), other public and private insurance (20%), out-of-pocket spending (16%), and private insurance (11%). All HCBS waivers are attributed to Medicaid. KFF estimates based on 2018 National Health Expenditure Accounts data from CMS, Office of the Actuary.

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  7. KFF estimates based on the Census Bureau's March Current Population Survey (CPS: Annual Social and Economic Supplements), 2021.

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  8. Ibid.

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  9. KFF June 2019 Health Tracking Poll.

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