1. The Architecture of Health Reform: Building Access to Reproductive Health Susan Berke Fogel JD LA County Coalition for Women and Health Care Reform September 1, 2011 “Securing Health Rights for Those in Need”

2. NHeLP National public interest law firm working to advance access to quality health care and protect the legal rights of low- income and underserved people Offices in Washington D.C., Los Angeles, and North Carolina Comprehensive analysis of health care reform law; ongoing updates Visit our website at: www.healthlaw.orgwww.healthlaw.org

3. Two Roads at Once State and Federal Cutbacks Anti-Reform Litigation De-funding the ACA State Exchanges ACA Implementation Family Planning Expansions

4. Goals and Ideals * “everyone” excludes undocumented immigrants; coverage excludes abortion “Everyone”* will have coverage* Health coverage will be affordable Insurance companies will be accountable Costs will be controlled

5. The current system 5

6. 6

7. What Will we Build?

8. Uninsured in California 7 million uninsured (2009) – 4.7 million non-elderly will be eligible for exchange – 3.1 million remain uninsured Undocumented Exempt from individual mandate Won’t/can’t participate Source: Unsure the Uninsured Project

9. Insurance Status of Non-elderly Women in California Uninsured by Income* Women ages 18-64 Kaiser Family Foundation Insurance Data 2008-2009 *Income Data 2007 Total: ~2.6 M

10. Insurance and income – LA County Insurance status 21.3% of women (18-64) in LAC are uninsured 20.4 % are enrolled in Medicaid 57.1 % have private insurance Economic status 39.7% of uninsured women <100% FPL 30% of uninsured women 100-199% FPL

11. Health disparities and reproductive health Women of color of child bearing age are disproportionately poor – 10.7% non-Hispanic white – 11.1% Asian Pacific Islander – 25.5% African American – 22.4% Latina – 24.2% Native American/Alaska Natives People of color are the majority of individuals enrolled in Medicaid

12. Health Disparities and Pregnancy 12 Unintended pregnancyAbortion % of all abortions Prenatal care in 1 st trimester African American69% of pregnancies30%73% Latina54% of pregnancies25%74% White40% of pregnancies36%85%

13. How Will We Get Insurance? Medicaid < 133% FPL1 person < $14,4834 people < $29,725Foster kids to age 25 Exchange With sliding scale subsidies 133-400% FPL 1 person $14,484-43,560 4 people $29,726-$89,400 Lawfully present immigrants Exchange or ? No subsidy > 400% FPL1 person > $43,5614 people > $89,401 Undocumented immigrants Large employers; exempt from mandate

14. Medicaid Eligibility: Overview Current Medicaid Citizenship or “qualified immigrant” >5 yrs (no waiting in CA) State resident Fit into a category: Parent of dependent child, child, aged, blind, disabled, pregnant Eligibility varies by state; CA 100% FPL Pregnant women 200% FPL Limited assets ACA Citizenship or “qualified immigrant” > 5yrs State resident Adds new mandatory category of “newly eligible” 133% FPL + 5% No asset test MAGI accounting rules

15. What does this mean for women?  20% of women are uninsured  28% of women of color are uninsured  37% Latinas  23% African Americans  18% API  54% of uninsured women eligible for Medicaid  “Newly eligible” include childless lesbians, young adults, older women under age 65, women with disabilities, women with HIV Source: Kaiser Family Foundation

16. Who is left out? Undocumented immigrants – Do not qualify for Medicaid Can access emergency care, pregnancy, family planning – Cannot buy insurance in the exchange with their own money People above 133% FPL who can’t afford premiums People exempt from mandate People who can’t navigate the system – Homeless, mental disabilities, can’t prove citizenship, LEP, disaster victims, DV survivors

17. What’s Covered? MEDICAID Can be 2-tier; eligible under old rules or newly eligible Guaranteed “basic benchmark plan” equivalent to basic tier in exchange EXCHANGE Mandated Benefits (Bronze+): Ambulatory Emergency Hospital Prescription Maternity Mental health (substance/behavioral) Laboratory Rehabilitation & habilitation Preventive care Chronic disease management Oral and Vision for children EMPLOYER- BASED Stays the same?

18. Delivery Systems Qualified Health Plan Comply with Reforms Essential Health Benefits Preventive Care Network Adequacy Essential Community Providers Medicaid Benchmark Plans

19. Preventive Screening Services U.S. Preventive Taskforce A and B Level Recommendations Lifestyle/Healthy Behaviors CancerSTI/STDsChronic ConditionsPregnancy Alcohol ScreeningColorectalHIVHypertensionTobacco Depression ScreeningBreast ScreeningGonorrheaDiabetesRh Incompatibility Screening Healthy Diet Counseling Breast Chemoprevention ChlamydiaObesity ScreeningHepatitis B Screening TobaccoBreast/Ovarian High Risk/BRCA SyphilisOsteoporosisIron Deficiency Anemia Screening ImmunizationsCervical CancerLipid DisordersBacteriurea Screening

20. Publicly-funded family planning Medicaid Eligible for full scope Scope of services varies state by state Prevention and treatment No cost sharing Confidentiality Freedom of choice Medicaid Family Planning expansions Eligible but income too high Scope of services varies by state Prevention and limited treatment (family planning related services) No cost sharing Confidentiality Title X Uninsured & low income All FDA-approved methods Prevention and limited treatment Confidentiality Non-directional counseling

21. Pregnancy care Insurers must cover maternity care Funding for research and treatment of post- partum depression Pregnancy supports – especially educational support for pregnant and parenting teens and young adults Medicaid coverage of birthing centers

22. Abortion restrictions in Exchanges: Nelson Amendment Plans can cover abortion: Every “enrollee” has to make 2 payments – one for regular coverage, one for abortion coverage Plans must segregate funds; pay abortion claims out of segregated funds No “subsidy” funds can be used for abortion except for rape, incest, life endangerment (Hyde) States can ban insurance coverage for abortion outright 22

23. The Exchange Web Portal & Navigation Which insurers can participate? Interplay with Medicaid Who qualifies for what coverage? Which providers are included? Do people get what they need?

24. Systems Issues Qualified Health Plans must include Essential Community Providers (ECP) “such as” – Community clinics (FQHC and others) – Title X and other family planning clinics Implementation issues – Contracting – Recognizing ECPs as medical homes Network adequacy: access to all covered services; religiously-controlled health systems

25. Impact of Religiously-controlled Health Systems Ethical and Religious Directives for Catholic Health Care Services – US Conference of Catholic Bishops – Absolute bans on abortion, sterilization, family planning – Limits on treatment miscarriage mgmt, ectopic pregnancy care, EC, end of life care – No health or life exception – May refuse some services to LGBT communities – Refusal to provide referrals = barrier in managed care Some California Catholic hospitals allow some limited services under limited circumstances 25

26. Refusal Clauses Exempt Providers from Meeting the Standard of Care Refusal clauses shield individual providers and institutions from liability for their failure to deliver care that would otherwise be required – accepted medical standards of care – legal requirements for care Refusal clauses allow institutions to prevent providers from meeting the standard of care Regardless of health outcome

27. The California Exchange Board 5 member board: – Kimberly Belshe, Diana Dooley, Paul Fearer, Susan Kennedy, Robert Ross Executive Director: Peter Lee Responsibilities: – Determine structure of Exchange – Determine criteria for participation in Exchange – selective contracting – Stakeholder input – Accountability

28. Access and affordability “No Wrong Door” Web Portal – Eligibility and enrollment – Language access Toll-free hotline Navigators – Assist with outreach and enrollment – New proposed rules – open comment period Affordability – Subsidies – Cost-sharing

29. Low Income Health Program ACA allow states to begin Medicaid expansion CA waiver: county option (LAC is up and running) – <133% FPL; resident; citizen or lawful immigrant 5 yrs+ – Medical home – No categorical eligibility – No cost – Preventive, mental health, specialty care

30. Other options on the horizon Basic Health Plan (SB 703) State option 134 – 200% FPL Enrollees don’t get subsidies or tax credits, but premiums cannot be higher than in exchange State gets 95% of federal share of subsidies and tax credits Managed care Essential health benefits Lower cost-sharing

31. A few of the many remaining questions Transitions between Medi-Cal and Exchange – Fluctuations in income – Pregnant women above 133% FPL Family planning expansions post 2014? Breast and Cervical Cancer Treatment Title X, Ryan White, etc – what will happen to targeted funding? Refusal Clauses? Citizenship documentation How much “flexibility to the states” is good for consumers?

32. Stakeholder Input Comment on federal regulations www.healthcare.gov – Exchanges – Medicaid eligibility and enrollment – Women’s health preventive services – Essential Health Benefits Participate in California Exchange Board meetings www.healthexchange.ca.gov – In person meetings in Sacramento – Web-cast

33. NHeLP www.healthlaw.org www.healthconsumer.org Fogel@healthlaw.org 310-204-6010 ext 113