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 2017. However, gaps in private sector and publicly-funded programs left a little over one in ten women uninsured. The Affordable Care Act (ACA) expanded access to 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 2017, 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 58.3 million women ages 19-64 (60%) received their health coverage from their own or their spouse’s employer in 2017 (Figure 1).¹

Figure 1: Women’s Health Insurance Coverage, 2017

• Women in families with at least one full-time worker are more likely to have job-based coverage (69%) than women in families with only part time workers (31%) or without any workers (18%).²
• In 2018, annual insurance premiums for employer sponsored insurance averaged $6,896 for individuals and $19,616 for families, increasing by 55% over the last decade. On average, workers paid 18% of premiums for individual coverage and 29% 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 2017, about 9% of non-elderly adult women (approximately 8.4 million women) purchased insurance on their own.³ This includes women who purchased private policies from the ACA Marketplace in their state, as well as 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 with incomes below 400% of the FPL (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 placed women at a disadvantage, either by charging them higher premiums than men for the same level of coverage (gender rating) 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, 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.
• The Trump administration has released new guidance on Section 1332 waivers that allow states to ask for permission to change how they apply federal subsidies to state insurance marketplaces, including for alternative health plans that do not comply with the ACA coverage requirements. States could subsidize non-ACA compliant short-term plans, which cost less than ACA compliant policies but can deny coverage to people with pre-existing conditions and can exclude 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 2017. 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, disabled, or be 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 or age, effective January 2014. As of December 2018, 36 states and DC have taken up this option.

• Medicaid disproportionately covers the poorest and sickest population of women. Approximately 63% of non-elderly women with Medicaid had incomes below 200% of the FPL.⁴
• By federal law, all states must provide Medicaid coverage without cost sharing for pregnancy-related services to pregnant women with incomes up to 133% of the federal poverty level (FPL) through 60 days postpartum. 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 for parents 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.
• Medicaid financed 43% of births in the U.S. in 2016, accounts for 75% of all publicly-funded family planning services and half (53%) 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

Approximately 11% of women ages 19 to 64 (approximately 10.6 million women) were uninsured in 2017, a decline from a rate of 19% in 2013 (Figure 2). 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 Women Has Dropped Since the Passage of the ACA

• Low-income women, women of color, and immigrant women are at greater risk of being uninsured (Figure 3). One in five women with incomes under 200% of the FPL ($24,100 for a single individual) are uninsured, compared to just 7% of women with incomes over 200% FPL. Single mothers are more likely to be uninsured (13%) than women in two-parent households (10%).

Figure 3: Health Insurance Coverage by Federal Poverty Level and Race/Ethnicity

• The majority of uninsured women live in a household where someone is working: 73% 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.⁵
• 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 and Massachusetts (Figure 4).

Figure 4: Uninsured Rates Among Nonelderly Women, by State, 2017

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 low-income and currently eligible for Medicaid but are not enrolled and another third (3.5 million) are income eligible for a subsidized Marketplace plan but not enrolled (Figure 5).

Figure 5: Eligibility for Assistance Under the ACA Among Uninsured Women Ages 19-64, 2017

• Over 3.7 million uninsured women are not eligible for assistance. Some 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. Another group of poor women are in the so-called “Medicaid coverage gap.” They live in a state that had not expanded their Medicaid programs by the end of 2017, but who otherwise would qualify for Medicaid if their states opted to expanded eligibility to 138% of the federal poverty level as 36 states have done. States that have not expanded Medicaid typically have higher uninsured rates than those that have.
• Some women who are uninsured are ineligible for Medicaid because of their immigration status. They are also prohibited from purchasing insurance on the Marketplaces in nearly all states.

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 and mental health, 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, on November 15, 2018, the Trump Administration issued final regulations expanding the type of employers that may be exempt from the ACA’s contraceptive coverage requirements to include any private employer with a religious or moral objection to contraception. 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.

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 women report that they haven’t obtained coverage is that it is too expensive. Under employer-sponsored insurance, the major source of coverage for women, 58% of all covered workers have deductibles of at least $1,000. Similar affordability challenges exist in the non-group market, which includes the ACA Marketplaces. Forty-seven percent report dissatisfaction with their plan’s annual deductible, and 43% are dissatisfied with their monthly premium.

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 and mental health. 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 10.6 million women still lack coverage. About half of uninsured women qualify for either Medicaid or subsidies to secure coverage through the health care exchanges but many still lack a pathway to affordable coverage. Recent state and federal efforts to roll back ACA-related policies will likely erode the gains in coverage experienced by millions of women in recent years. In particular, the repeal of the individual insurance mandate, reduced resources for outreach and enrollment for individuals to enroll in Marketplace coverage, and policies that destabilize the individual insurance market will undermine many coverage improvements. In addition, efforts to expand the availability of insurance products like short-term plans that do not offer the full range of essential health benefits such as maternity care and preventive services will serve to weaken coverage and could result in higher out-of-pocket costs for women who need these services. Women will continue to have much at stake in the outcomes of the ongoing health care debates in Washington DC and in state capitols across the nation.