Health and the 2016 Election: Implications for Women
Although all elections matter, it is during the presidential election cycle that the contrasts between candidates and political parties become the most crystalized in the eyes of the public. The differences between the policy approaches to various aspects of women’s health taken by the two presidential candidates, Hillary Clinton and Donald J. Trump, and their respective parties are stark.1,2 The Democrats support the continuation and strengthening of the Affordable Care Act (ACA), paid leave for parents and caregivers, and protection of women’s access to the full range of reproductive healthcare. The Republicans, on the other hand, propose a complete overhaul of the ACA and the Medicaid program to return authority to the states. They also support establishing more federal regulations on women’s access to abortion, but do not address paid leave in their party platform.
Health care is a key issue for women voters; however, women are also divided in what they prioritize, largely along party lines (Figure 1). Overall, Democratic women who prioritize health care issues rank efforts to reduce the uninsured at the top, whereas Republican women are more likely to favor repealing the law. Reducing health care costs is an area of common concern.
The Affordable Care Act and Health Coverage
Health coverage and affordability are critical issues for women who, compared with men, have greater health care needs and expenses, lower incomes, and are more likely to use prescription drugs. Since the passage of the ACA, the uninsured rate of women ages 18-64 decreased from 19.3% to 10.8%, and millions of women have gained coverage for preventive services without cost sharing.3 The law has also ensured that all plans include a minimum floor of benefits by requiring plans to cover certain services, such as mammography, prenatal care, pap smears, and contraceptives, and includes considerable protections against gender discrimination. Out of pocket costs, however, are an ongoing problem for many women.
The Obama Administration estimates that nearly 20 million people gained coverage under the ACA, with Medicaid serving as the foundation of the law’s coverage expansions.4 Historically, women were more likely than men to qualify for Medicaid because of their lower incomes and greater likelihood of meeting the pre-ACA categorical eligibility requirements as a pregnant woman, senior, or an individual with a disability. Although the ACA gave states the option to extend Medicaid coverage for all adults up to 138% of the Federal Poverty Level,5 effectively removing the categorical requirements, 19 states have yet to expand their Medicaid programs. This has left roughly 1.5 million poor women uninsured and lacking an eligibility pathway to Medicaid or subsidized coverage through the marketplace.6
The Democratic Party supports the law, and it would encourage expansion nationwide, though it provides no specific information on how it would accomplish this goal. Meanwhile, the Republican Party has repeatedly called for the repeal of the ACA since it was signed into law. Their platform provides little detail with regard to a replacement health care plan; however, a recent proposal released by Republican House Speaker Paul Ryan would eliminate federal coverage requirements on individuals and employers, and phase out further Medicaid expansion.7 The Republicans would convert Medicaid to a block grant, which they argue would increase accountability, budget predictability, and flexibility for states to meet the needs of their unique populations. The ACA prohibits insurers from denying coverage to individuals based on “pre-existing conditions” such as a history of domestic violence, Caesarean section, or breast cancer. The Republican proposal would ban such exclusions against individuals that maintain continuous coverage, but those who do not could be turned down for coverage.
Affordability and Cost Containment
Although women have benefitted from increased coverage under the ACA, out-of-pocket costs are still a challenge for many women, even those with private coverage. In 2012, out-of-pocket spending among females was about $236 higher per capita, and also grew at a faster rate, than their male counterparts.8 This is in part owing to spending on childbirth and maternity care.
The Democratic Party’s cost containment strategy includes a public health plan option and a cap on out-of-pocket costs for prescription drugs. This would be especially important to women, who spend over 46% more on prescription drugs than men.9 The Republican platform relies on the competitive market to drive down costs, allowing individuals to purchase insurance across state lines and advocating for price transparency in the health care industry. Their replacement plan for the ACA also focuses on “patient choice” which they claim will promote wiser consumption of services and reduce spending. Repeal of the ACA would likely lift its bans on gender-based premium pricing, a common practice in the individual insurance market prior to the passage of the ACA that allowed insurers to charge women higher premiums based on their gender.
For women, a key provision of the ACA has been the requirement that all new private insurance plans and Medicaid expansion programs cover certain categories of benefits, including maternity care, mental health, and prescription drugs, that were commonly excluded by individual insurers prior to the ACA. The law’s requirement for no-cost coverage of preventive care also has had a disproportionate effect on women, because several services are exclusively or primarily used by women, such as prescription contraception, sexually transmitted infection counseling and testing, cancer screenings, a broad range of pregnancy-related screenings and tests, and well-woman visits. Under Secretary Clinton, these policies would remain intact. She also proposes making maternal depression screening standard practice under Medicaid. The Republicans’ plan to repeal the ACA would eliminate minimum scope of benefits standards, jeopardizing coverage of no-cost preventive services. The loss of this provision could leave millions of women facing additional expenses for copayments, and potentially without coverage for basic preventive care.
In 2011, approximately 45% of all pregnancies in the United States were unintended, and 4 in 10 of those pregnancies ended in abortion.10 Although these rates are at all-time lows, they still remain a major source of concern. The parties’ policies addressing reproductive health reflect very different strategies to further reduce these rates. The Democrats call for a strong defense of a woman’s access to the full-range of reproductive healthcare, evidence-based sex education, and the elimination of the Hyde Amendment, which bans federal funds from being used to pay for abortions unless the pregnancy is a result of rape or incest, or a threat to life of the woman. In contrast, the Republicans would promote additional restrictions on abortion access, remove family planning programs from schools, and prioritize the rights of providers and employers to refuse the provision of services that they claim violate their religious beliefs.
The Federal Hyde Amendment, which greatly restricts federal funding for abortion, was first passed in 1976 and has been renewed annually ever since as an attachment to federal appropriations bills. In particular, it places considerable funding constraints on millions of women enrolled in Medicaid as well as others covered by federal programs, such as the military and Indian Health Service. For the first time, the 2016 Democratic platform has called for the repeal of the Hyde Amendment, which the party argues disproportionately limits low-income women’s access to abortion services; one-half (49%) of women seeking abortions live below the federal poverty line.11 In contrast, the Republican platform seeks to codify the Hyde Amendment, thus permanently banning the use of federal funds for abortion. Moreover, it would extend this ban to federal subsidies for insurance plans that include abortion coverage, which would go further than the current provisions under the ACA that already require insurance plans to separate federal funding from any abortion coverage they may provide. The Republicans also support proposed federal laws such as the Human Life Amendment, which would extend constitutional protections to fetuses, and the Pain Capable Unborn Child Protection Act, which would ban abortion after 20 weeks, legislation that has been enacted in a number of states. The plan also prioritizes protections for providers and employers to exercise religious objections to abortion and promotes legislation that would enforce civil and criminal penalties on providers that “fail to provide treatment to an infant who survives an abortion.”
The Republicans’ opposition to abortion extends to its research platform as well; they oppose the use of embryonic stem cells and propose criminalizing the purchase, transfer, or sale of fetal tissue for scientific research. The party also objects to the Food and Drug Administration (FDA)’s approval of mifepristone (Mifeprex), a drug used in medical abortion, which accounts for nearly one in four abortion procedures.12 The FDA first approved the drug in 2000, but updated their labeling this year to include changes in the dosing amount and regimen, as well as an increase in the gestational age limit at which the drug is considered safe and effective.
The vast majority of the American public is supportive of contraception and greater use of effective methods has been credited for the declines in teen and unintended pregnancy rates,13,14 yet contraceptive access and coverage have been squarely in the middle of political disputes. The Democratic Party’s platform commits to protecting federal funding for Planned Parenthood centers, asserting they provide an underserved patient population with a broader range of reproductive health services and supplies than other health centers have the capacity to handle.
In contrast, the Republican platform explicitly calls for a prohibition on any public funding for Planned Parenthood and other organizations that provide both abortion and contraceptive services. They instead would channel funding to community health centers, claiming this will allow low-income women to maintain their access to reproductive healthcare. Because Medicaid, the largest source of public financing for family planning care, is required to include all participating providers, states have been unable to cut funding to Planned Parenthood without jeopardizing their Medicaid support for other programs, despite attempts by a number of Republican governors and legislators. The Republican platform would change this federal policy and give states the authority to exclude entities that perform or refer for abortions, which would limit millions of women’s access to contraceptive care. The Republican platform also opposes the FDA’s endorsement of over-the-counter contraception, and calls for the replacement of family planning programs in schools with abstinence-only education.
In just the past two years, the court heard three landmark cases affecting women’s health: Zubik and Hobby Lobby, which addressed the ACA’s contraceptive coverage mandate and the religious rights of employers, and most recently, Whole Woman’s Health, which addressed abortion clinic regulations. With the death of Justice Antonin Scalia, and three of the remaining seven justices well over the age of 75 years, the next president will likely appoint more than one justice to the Supreme Court during their term. The Democratic and Republican platforms both speak to their support of the appointment of justices that share their respective views on abortion. The Democrats have specified that they would seek nominees who support a woman’s right to a safe and legal abortion. The Republicans seek to overturn Roe v Wade through the appointment of justices who oppose abortion.
Older Women’s Health
The Medicare program is a critical source of coverage and economic security for seniors, particularly older women who on average have longer lifespans, poorer health status, and are more likely than men to live alone and require long-term care supports.15 The candidates and their parties have very different proposals regarding Medicare. The Democrats propose allowing individuals 55 to 64 to buy into the program, whereas the Republicans would raise the eligibility age as well as fundamentally change the program’s structure from primarily fee-for-service to a “defined contribution” model in which the federal government would provide a payment on behalf of each beneficiary toward the purchase of a private plan or traditional Medicare. The Republicans’ proposed repeal of the ACA could also eliminate Medicare’s no-cost coverage for preventive services, such as mammograms and bone density testing recommended for older women. Both platforms state that they favor policies that will help aging individuals remain in their homes, which is especially important for older women, because they are twice as likely as older men to live alone.16 The Democrats also identify the need to improve pay and training for caregivers, most of whom are women, and propose passing a law that provides workers at least 12 weeks of paid time off to care for aging or sick relatives as well as for a new child.
In recent years the issue of sexual violence and assault has gained recognition as a preventable health problem that disproportionately affects women. Approximately one in five women report having been raped at some point in their lives, and one in four women have experienced severe physical violence by an intimate partner.17 Federal authority, such as that provided by the Violence Against Women Act (VAWA), currently funds various violence prevention efforts, support services for survivors, and enforcement mechanisms. The Democratic platform provides support for survivors of sexual assault and increases sexual violence prevention programs in schools. They also support the continuation of VAWA’s law enforcement provisions. The Republican platform asserts that sexual assault should be handled by civil authorities and prosecuted by the courts and criticizes federal agencies’ involvement in the investigation and punishment of campus sexual assault.
The Democratic and Republican Parties have outlined distinct, and often diametrically opposing, policy proposals addressing private and public health insurance coverage, reproductive health, and paid leave, among other issues, that will affect women in every stage of life. These policies reflect the parties’ very different approaches to the role of government, regulation, and abortion policy. Although the media has been focused most intensely on the presidential elections, when it comes to health and access to care, the choices made in state houses and capitols across the country will also greatly impact women’s health care. Whatever the result, the 2016 election cycle is certain to have significant ramifications for health care, and in particular for women’s health.
This article was published as an article in press in Women’s Health Issues on October 12, 2016 and will be included in Women’s Health Issues Volume 26, pages 584-6, Copyright Jacobs Institute of Women’s Health, 2016, Published by Elsevier.
Democratic Platform Committee. (2016). 2016 Democratic Party Platform.
Republican National Platform Committee. (2016). Republican Platform 2016.
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Federal Poverty Level (FPL) was $11,880 for an individual in 2016.
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Guttmacher Institute. (2016). Induced Abortion in the United States.
Finer, L.B., & Zolna, M.R. (2016). Declines in Unintended Pregnancy in the United States, 2008–2011. New England Journal of Medicine, 374 (9), 843-852.
Lindberg, L., Santelli, J., Desai, S. (in press). Understanding the Decline in Adolescent Fertility in the United States, 2007-2012. Journal of Adolescent Health.
Kaiser Family Foundation. (2013). Medicare’s Role for Older Women.
Kaiser Family Foundation. (2013). Medicare’s Role for Older Women.
Centers for Disease Control and Prevention (CDC). (2014). National Data on Intimate Partner Violence, Sexual Violence, and Stalking.