Women’s Health Insurance Coverage

Health insurance coverage is a critical factor in making health care affordable and accessible to women. Among the 97.4 million women ages 19 to 64 residing in the U.S., most had some form of coverage in 2018. However, gaps in private sector and publicly-funded programs and lack of affordability left a little over one in ten women uninsured. The Affordable Care Act (ACA) 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 2018, 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 58.6 million women ages 19-64 (60%) received their health coverage from employer-sponsored insurance in 2018 (Figure 1).1

Figure 1: Women’s Health Insurance Coverage, 2018

  • 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 (33%) or without any workers (18%).2
  • In 2019, annual insurance premiums for employer sponsored insurance averaged $7,188 for individuals and $20,576 for families. Family premiums have increased 54% over the last decade. On average, workers paid 18% of premiums for individual coverage and 30% 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 2018, about 8% of non-elderly adult women (approximately 8.1 million women) purchased insurance in the non-group market.3 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. Those individuals with incomes below $49,960 (400% of the Federal Poverty Level) can qualify for assistance in the form of federal tax credits which lower premium costs.
  • 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. Historically, insurance carriers sold plans on the individual insurance market that often placed women at a disadvantage, either by charging them higher premiums than men for the same level of coverage (gender rating) at many ages or disqualifying women from coverage because they had certain pre-existing medical conditions, including pregnancy. The ACA plans are barred from instituting these policies.
  • Many of the pre-ACA individually purchased policies did not include coverage for services that are important to women’s health, such as maternity care, prescription medications, or treatment for mental health conditions such as depression. As a result of the ACA, 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.
  • Conversely, the Trump administration has effectively eliminated the ACA’s requirement for individuals to have insurance coverage and has promoted health plans that do not comply with the ACA coverage requirements. In particular, the Administration has encouraged greater availability of non-ACA compliant short-term plans, which cost less than ACA compliant policies but can deny coverage to people with pre-existing conditions and often exclude or limit benefits, such as prescription drugs, mental health, and maternity care.

Medicaid

The state-federal program for low-income individuals, Medicaid, covered 17% of non-elderly adult women in 2018. 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 eliminate these categorical requirements and 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 January 2020, 36 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 49% of poor women (income below 100% FPL) have Medicaid coverage. 4
  • 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 14 states that have not adopted Medicaid expansion, many women lose Medicaid coverage 60 days after the birth of their child because their income is above the eligibility level for parents in those states.
  • Medicaid financed 42% of births in the U.S. in 2018, accounts for 75% of all publicly-funded family planning services and half (52%)5 of all long-term care spending, which is critical for many frail elderly women.
  • Half of the states (25 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—in 2018, 14% of men 19-64 were uninsured compared to approximately 11% of women ages 19 to 64 (10.8 million women), a decline from 18% in 2008 (Figure 2). Starting in 2010, the ACA required non-grandfathered private group and non-group health that offered dependent coverage to give workers the option of keeping adult children up to the age of 26 enrolled as dependents, while Medicaid expansion offered coverage to many uninsured low-income women who did not previously qualify for Medicaid. As a result, women under the age of 26 and women with incomes below 200% FPL saw significant declines in uninsured rates between 2008 and 2018. Since 2016, the fall in the share of women who are uninsured has stalled. 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.

Figure 2: Uninsured Rate Among All Women, Low income Women and Younger Women, 2008-2018

  • Low-income women, women of color, and non-citizen women are at greater risk of being uninsured (Figure 3). One in five women with incomes under 200% of the FPL ($26,128 for an individual in 2018) are uninsured, compared to just 7% of women with incomes at or above 200% FPL. A higher share of single mothers are uninsured (13%) than women in two-parent households (9%).6

Figure 3: Health Insurance Coverage Among Non-Elderly Women by Selected Characteristics, 2018

  • The majority of uninsured women live in a household where someone is working: 67% are in families with at least one adult working full-time and 81% are in families with at least one part-time or full-time worker.7
  • There is considerable state-level variation in uninsured rates across the nation, ranging from 23% of women in Texas to 3% of women in Washington DC and Massachusetts (Figure 4). Of the 16 states with uninsured rates above the national average (11%), 11 have not adopted the ACA Medicaid expansion.

Figure 4: Uninsured Rates Among Nonelderly Women, by State, 2018

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 million) uninsured women are currently eligible for Medicaid but are not enrolled and more than a third (4 million) are eligible for a subsidized Marketplace plan but not enrolled (Figure 5). In 10 states and DC, over 40% of uninsured women are eligible for Medicaid coverage, and in 18 states at least 40% qualify for a subsidized Marketplace plan (Table 2).

Figure 5: Uninsured Rates Among Nonelderly Women, by State, 2018

  • Over 4.7 million uninsured women are not eligible for financial assistance for coverage. 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. Over a 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. States that have not expanded Medicaid typically have higher uninsured rates than those that have. In Alabama and Mississippi, about one in three uninsured women are in the Medicaid coverage gap (Table 2).

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 those 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. However, the Trump administration’s expansion of short-term plans that do not have to comply with any of these benefits standards could erode the scope of coverage some women receive. Additionally, in 2018, the Trump Administration issued final regulations expanding the type of employers eligible for an exemption from the ACA’s contraceptive coverage requirement to include private employers with a religious or moral objection to contraception. While these regulations are currently blocked by federal courts’ rulings, if these regulations go into effect women who work for exempt employers and female dependents will no longer be entitled to contraceptive coverage. Abortion services are explicitly prohibited from being included as EHBs. Twenty-six states have laws banning coverage of most abortions from the plans available through the state Marketplaces, and plans offered in states that don’t ban coverage must segregate payments for abortion coverage, charging no less than $1.00 for that coverage.

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 non-elderly 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, 55% 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.8

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, 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 . While there has been much progress in expanding coverage and reducing the number of uninsured women since the passage of the ACA, affordability continues to be a challenge for many women and 10.8 million women still lack coverage. Over half of uninsured women qualify for either Medicaid or subsidies to secure coverage through the Marketplace but many still lack a pathway to affordable coverage.

The significant drop in the share of uninsured women has stalled in recent years. Recent state and federal efforts to roll back ACA-related policies could further weaken coverage and may result in higher out-of-pocket costs for women who need these services. A lawsuit working its way through the courts could result in the entire ACA being invalidated. Meanwhile, a variety of proposals to expand coverage options and lower costs are currently being debated in Congress, on the campaign trail, and by the states. They range from proposals that build on the ACA—expanding Medicaid in states that have not yet done so, enhancing and extending marketplace subsidies to more people, and offering a public plan option alongside private insurance in the marketplaces—to proposals to adopt a single Medicare-for-all program that would replace existing forms of coverage. The outcome of this ongoing debate has substantial implications for women and families who face the health and financial consequences of not having health insurance or who must shoulder significant out-of-pocket cost for their coverage.

Table 1: Health Insurance Coverage of Women Ages 19–64 in 2018, by State
  Number of Women (Thousands) Percent Distribution by Coverage Type
Employer Sponsored Direct Purchase Medicaid Other Uninsured
United States 97,429 60% 8% 17% 3% 11%
Alabama 1,460 59% 8% 14% 6% 14%
Alaska 213 56% 5% 18% 8% 14%
Arizona 2,052 55% 7% 20% 4% 13%
Arkansas 874 53% 8% 24% 5% 10%
California 11,959 56% 9% 24% 2% 9%
Colorado 1,711 62% 9% 16% 4% 9%
Connecticut 1,076 65% 8% 19% 2% 6%
Delaware 289 63% 6% 21% 4% 6%
DC 240 61% 9% 25% 1% 3%
Florida 6,242 53% 14% 12% 4% 17%
Georgia 3,218 59% 8% 11% 5% 18%
Hawaii 399 68% 7% 15% 7% 4%
Idaho 490 59% 12% 9% 4% 16%
Illinois 3,829 64% 8% 17% 2% 9%
Indiana 1,957 65% 6% 15% 3% 10%
Iowa 892 67% 7% 18% 2% 6%
Kansas 828 67% 8% 10% 4% 11%
Kentucky 1,320 57% 6% 26% 5% 7%
Louisiana 1,396 53% 7% 27% 4% 9%
Maine 399 61% 10% 16% 4% 10%
Maryland 1,860 66% 7% 16% 4% 7%
Massachusetts 2,114 65% 7% 23% 2% 3%
Michigan 2,971 62% 7% 22% 3% 6%
Minnesota 1,636 69% 7% 17% 2% 4%
Mississippi 883 55% 7% 16% 5% 17%
Missouri 1,803 64% 8% 11% 4% 12%
Montana 301 57% 11% 18% 4% 9%
Nebraska 546 67% 9% 9% 4% 11%
Nevada 904 58% 7% 17% 4% 14%
New Hampshire 403 70% 7% 13% 4% 6%
New Jersey 2,700 68% 7% 14% 2% 9%
New Mexico 603 47% 7% 31% 4% 12%
New York 6,011 60% 7% 24% 2% 6%
North Carolina 3,130 59% 9% 12% 6% 14%
North Dakota 215 67% 10% 10% 5% 8%
Ohio 3,435 63% 6% 20% 3% 7%
Oklahoma 1,133 57% 8% 11% 5% 19%
Oregon 1,250 59% 9% 20% 3% 9%
Pennsylvania 3,768 65% 8% 18% 3% 6%
Rhode Island 320 64% 7% 22% 3% 5%
South Carolina 1,519 57% 9% 15% 5% 14%
South Dakota 245 66% 11% 9% 4% 10%
Tennessee 2,042 57% 8% 17% 5% 13%
Texas 8,526 57% 8% 9% 3% 23%
Utah 891 67% 11% 8% 3% 11%
Vermont 185 64% 8% 21% 3% 4%
Virginia 2,556 65% 8% 9% 7% 10%
Washington 2,256 63% 7% 18% 4% 8%
West Virginia 517 56% 5% 27% 5% 8%
Wisconsin 1,701 68% 8% 14% 2% 7%
Wyoming 163 64% 11% 8% 4% 13%
NOTES: “Other” category includes those covered under the military or Veterans Administration as well as nonelderly Medicare enrollees. Percentages may not sum to 100% due to rounding.
SOURCE: KFF estimates based on 2018 Census Bureau’s American Community Survey.
Table 2: Eligibility for Medicaid Coverage or Tax Credits Among Uninsured Women 19–64 and Share in the Coverage Gap,
by State, 2018 Estimates
  Total Uninsured Tax Credit Eligible Medicaid-Eligible Medicaid Coverage Gap Not Eligible for Assistance due to Income, Immigration Status or Offer of ESI
United States 10,760,000 37% 19% 11% 33%
Alabama  202,000 43% 6% 30% 21%
Alaska  29,000 34% 45% 21%
Arizona  274,000 28% 35% 37%
Arkansas  88,000 26% 44% 29%
California  1,023,000 25% 32% 43%
Colorado  147,000 33% 25% 41%
Connecticut  66,000 25% 25% 49%
Delaware  18,000 27% 28% 45%
DC  8,000 N/A 47% 38%
Florida  1,085,000 47% 3% 17% 33%
Georgia  569,000 43% 5% 23% 29%
Hawaii  15,000 30% 26% 45%
Idaho  77,000 32% 41% 27%
Illinois  343,000 27% 34% 39%
Indiana  198,000 32% 41% 27%
Iowa  51,000 37% 35% 27%
Kansas  95,000 45% 5% 20% 30%
Kentucky  89,000 38% 34% 28%
Louisiana  131,000 30% 41% 29%
Maine  40,000 31% 43% 26%
Maryland  131,000 28% 26% 47%
Massachusetts  64,000 26% 27% 46%
Michigan  186,000 34% 38% 28%
Minnesota  72,000 27%^ 35% 37%
Mississippi  146,000 43% 7% 34% 15%
Missouri  219,000 49% 4% 24% 23%
Montana  28,000 35% 43% 22%
Nebraska  61,000 24% 47% 29%
Nevada  127,000 24% 30% 46%
New Hampshire  25,000 42% 25% 33%
New Jersey  244,000 30% 26% 44%
New Mexico  70,000 32% 39% 29%
New York  363,000 28%^ 34% 38%
North Carolina  442,000 43% 4% 22% 31%
North Dakota  17,000 42% 32% 26%
Ohio  256,000 35% 39% 27%
Oklahoma  210,000 44% 7% 21% 29%
Oregon  112,000 33% 33% 34%
Pennsylvania  237,000 33% 36% 31%
Rhode Island  15,000 35% 17% 48%
South Carolina  209,000 49% 6% 22% 24%
South Dakota  25,000 54% 8% 24% 14%
Tennessee  261,000 46% 8% 21% 25%
Texas  1,956,000 43% 4% 21% 33%
Utah  96,000 26% 33% 41%
Vermont  8,000 53% N/A 28%
Virginia  268,000 27% 43% 30%
Washington  180,000 27% 25% 49%
West Virginia  42,000 40% 41% 20%
Wisconsin  119,000 41% 26% 34%
Wyoming  21,000 42% N/A 20% 30%
NOTES: ^ Tax credit-eligible population in Minnesota and New York include uninsured adults who are eligible for coverage through the Basic Health Plan. † Wisconsin covers adults up to 100% FPL in Medicaid under a waiver but did not adopt the ACA expansion. Some estimates are “N/A” because point estimates do not meet minimum standards for statistical reliability. “—“ indicates state does not have a Medicaid coverage gap. Idaho, Maine, Nebraska, and Utah have approved Medicaid expansion and implementation in these states is expected in the future.
SOURCE: KFF estimates based on 2018 Census Bureau’s American Community Survey.
Endnotes
  1. KFF estimates based on the Census Bureau's American Community Survey, 2008-2018.

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  2. Ibid.

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  3. Ibid.

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  4. Ibid.

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  5. National LTSS expenditures totaled $364.9 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 ($81.5 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 2017 National Health Expenditure Accounts data from CMS, Office of the Actuary.

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  6. KFF estimates based on the Census Bureau's American Community Survey, 2008-2018.

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  7. Ibid.

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  8. KFF June 2019 Health Tracking Poll.

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