More than 19 million adult women were uninsured in 2011. This is because they typically do not qualify for Medicaid (pre-ACA), do not have access to employer-sponsored plans, and either cannot afford or do not qualify for individual policies because of pre-existing medical conditions. Uninsured women are more likely than women with private or public coverage to have inadequate access to care and have poorer health outcomes.

38% of Latina women are uninsured compared to 14% of white and 23% of black women in 2011. Native American women as well as women who are younger and poorer are also particularly at risk for being uninsured.

On average, 20% of women are uninsured nationally, but there is a wide range between states.  Texas has the highest share of uninsured women in the U.S. (30%). However, California has the highest number of uninsured women (3.2 million), approximately 20% of the state’s adult women. In New York, 14% of women are uninsured. Massachusetts has the lowest share of uninsured women (5%).

Under current Medicaid rules, adult women must meet both income eligibility rules set by states AND fall into one of the following categories: being pregnant, being a mother of a child under 18, being a senior citizen, or having a disability. Therefore, some poor women do not qualify for Medicaid because they do not fall into one of these categories.  States that adopt the Medicaid expansion under the ACA will be able to offer Medicaid to citizens and legal residents that have been in the U.S. for more than five years with incomes below 138% of the Federal Poverty Level.

More than half (56%) of Medicare beneficiaries are women and among the oldest beneficiaries (ages 85 and older), 70% are women. Women, on average, live longer than men and are more likely to be widowed, live alone, and live in poverty. The ACA requires Medicare to now cover recommended preventive services without cost-sharing, which was not previously the case. Prior to the ACA, cost-sharing was common for many preventive services.

As part of the Essential Health Benefits, maternity care will be a required component of health insurance beginning 2014. Previously, most insurance plans available through the individual market excluded maternity coverage and, if available, sold a rider so that women had to pay a surcharge for that benefit.  In 2014, the ACA will also prohibit insurance companies from denying coverage due to a pre-existing condition. Gender rating, charging higher premiums for the same coverage based on gender, is a practice that was used by more than 90% of plans in the individual market in 2012, but will be banned by the ACA starting in 2014. (National Women’s Law Center, Turning to Fairness)

Under the ACA, new private health plans must provide coverage without cost-sharing for evidence-based preventive services. Plans are exempt from this requirement if they hold “grandfathered” status, meaning they have not changed substantially since the passage of the ACA in March 2010. The preventive services that are covered without cost sharing are those that have a rating of “A” or “B” from the United States Preventive Services Task Force and immunizations recommended by the Advisory Committee on Immunization Practices. In addition to these services, the Health Resources and Services Administration (HRSA) has determined additional services important for women to be covered without cost sharing. The services include those mentioned above as well as testing and counseling for gestational diabetes, HPV, STDs and HIV, support for breast feeding, and contraceptive counseling and methods as prescribed.

Most new private plans must cover without cost-sharing FDA approved contraceptives (including sterilization procedures), for women as prescribed by a physician, as well as patient education and counseling on contraception. Only contraceptives for women are required to be covered without cost-sharing; male contraceptives do not qualify.  Plans may impose some restrictions on contraceptive coverage.  For example, plans may cover generic oral contraceptives without cost-sharing and impose cost-sharing for equivalent branded drugs.  However, plans may not limit coverage to only oral hormonal methods and must also have a “waiver” process to accommodate a woman’s request for a drug or device that is limited but is necessary for her. Grandfathered plans and some employers with religious objections to contraception are not required to pay for their workers’ contraceptive coverage.

The ACA has multiple provisions regarding breastfeeding supports, as it is one of the HRSA women’s preventive services required for coverage without cost sharing by new private plans. These services can include consultation with a certified lactation consultant and breast pump purchase or rental. However, this coverage is subject to “reasonable medical management” limitations, so the woman does not necessarily have coverage for the pump of her choice.  Plans can decide what types of equipment they cover, and some plans have already decided that they will only cover manual pumps as opposed to electric pumps (Kaiser Health News). Grandfathered plans are exempt from these provisions. The ACA also requires that employers with 50 or more employees support breastfeeding mothers by providing them with a private space and adequate break time to pump.

A number of states have enacted laws that prohibit private insurance plans from offering coverage for abortions or require that policy holders purchase a separate rider for abortion coverage.  In addition, 20 states have banned abortion coverage from being available through plans offered by the Health Insurance Exchanges, new private insurance marketplaces that will be run by the state or the federal government beginning in 2014. If a state does allow abortion to be covered by health plans within the exchange, the plan must follow strict accounting guidelines and there must be at least one plan that does not cover abortion beyond what is permitted by federal law. The Hyde Amendment currently bans federal funds to be used for abortion, except in the cases where pregnancy is the result of rape or incest, or endangers the life of the mother and applies to women in Medicaid, federal employees, women in the military, and women in the Indian Health Service.