The presidential candidates' health care proposals: what's at stake for women.

THE HEALTH CARE CRISIS IN THIS COUNTRY is weighing heavily on people's minds and taking a toll on our health and our wallets. These worries affect people across the economic spectrum--not just the poor and uninsured, but also middle-class and working families who are at-risk of losing insurance or going deep into medical debt to pay for care their insurance doesn't cover. Women, in particular, are struggling to bear the burden of unaffordable health care.

The widespread insecurity about health care has led the presidential candidates to shine a spotlight on health reform. It's critical that we examine Senators McCain and Obama's current reform proposals to consider their potential impact on women's access to comprehensive and affordable health care. This article identifies seven key questions for women and women's health advocates to use to assess health reform plans. It also provides a brief overview of some of the central elements of the candidates' plans and their possible impact on women. Due to space limitations, we could not address those features of the candidates' plans which lacked sufficient detail, and encourage readers to visit the candidates' websites for more information.

WOMEN AND THE HEALTH CARE CRISIS

Throughout their lives, women have greater health care needs than men. (1) Yet, 18 percent of all women in the United States (over 17 million) are uninsured. For women of color, the story is even bleaker: almost one in four African American women, and more than one in three Latinas, lack health insurance. (2) Even women with insurance are more likely than men to be "underinsured"--with high out-of-pocket costs relative to their income and/or insufficient coverage that leave women vulnerable to financial risk and unmet health needs. (3)

Too many women are unable to afford the health care they need. On average, women have lower incomes than men, (4) and both insured and uninsured women are more likely than men to report problems accessing health care due to cost. (1) Health plans that don't provide comprehensive benefits, or that shift more costs to women and their families, will only make this situation worse. It is critically important that any reform plan address women's needs and the challenges they face in the current health care system.

ASSESSING HEALTH REFORM PLANS

The National Women's Law Center has developed a list of questions to ask about State or Federal health reform proposals to determine whether the plans address women's distinct health care needs and challenges. (5) The questions are:

* Does the plan expand access to ensure that health coverage is available to all? Proposals should ensure coverage is available regardless of income, age, gender, family status, disability, immigration status, or employment status.

* Does the plan provide care that is affordable? The cost of coverage (including premiums and out-of-pocket costs) should be affordable relative to income, and there should be adequate subsidies for those who are ineligible for any public programs (like Medicaid) but cannot afford the total cost of their health coverage.

* Does the plan ensure comprehensive health coverage? Covered services must include preventive care, treatment for chronic conditions, and the full range of reproductive health services.

* Does the plan adopt insurance market reforms to end unfair insurance practices? Reform proposals must provide a strong role for government to end unfair insurance company practices such as denying coverage to those with pre-existing conditions or charging different premiums based on health status, age, or gender (called "gender-rating" and "age-rating").

* What is the role of employer-sponsored health coverage? Proposals that rely on the current employer system must help employers and workers alike. For example, does the plan help small business owners who want to provide health coverage to their employees? Does the plan capture contributions from employers who don't provide health coverage? Given that more than 20 percent of uninsured women work part-time, does the plan help part-time employees and dependents access comprehensive coverage? (5)

* Does the plan address health disparities faced by women of color and women who live in rural and underserved areas? Women of color face many more challenges in our health care system. In addition, provider shortages in rural and underserved areas can present real barriers to health care for women.

* Does the plan take steps to control costs, while ensuring quality care? The rapid growth in the cost of health care continues to be a challenge and must be addressed as part of any reform plan in order to be financially sustainable. At the same time, plans must ensure quality care.

THE CANDIDATES' PROPOSALS: SENATOR MCCAIN (R-AZ)

According to Senator McCain's website, his health reform proposal would, among other things, allow families to buy health insurance in any state. His plan would offer tax credits to be used towards the purchase of employer-provided health insurance coverage or to purchase insurance directly from insurers through the individual insurance market. He would "encourage and expand Health Savings Accounts (HSAs)" and "work with states to establish a Guaranteed Access Plan"--high-risk pools for people with pre-existing conditions. (6)

Senator McCain's Proposal includes: (6)

1. Providing refundable tax credits of $2,500 for individuals and $5,000 for families for the purchase of health insurance in the individual market or under an employer-sponsored plan.

2. Working with States to develop, and providing Federal support for, a "Guaranteed Access Plan" (GAP), a "high-risk pool" to cover people with preexisting conditions who have previously been denied coverage. A non-profit entity would contract with insurers to cover these high-risk patients. There would be "reasonable limits on premiums," with "assistance" for those below a certain income level.

3. "[E]ncourag[ing] and expand[ing] the benefits of Health Savings Accounts (HSAs)," a type of savings account that is combined with a high-deductible health plan and used to purchase health services. Funds left over from an individual's tax credit could be put into the HSA.

4. Allowing people to buy health insurance in the individual insurance market across State lines. Currently, people can only buy health insurance in their home State, subject to that State's laws and regulations. So, a New Jersey resident cannot buy coverage directly from an insurance company operating only in New York.

EFFECTS ON COVERAGE OF THE MCCAIN PLAN

1. Buying health insurance directly from insurers can be expensive, so tax credits could make individual insurance more affordable. For tax credits to be most useful for low-income people, however, they should be refundable (for those with limited or no tax liability), advanceable (available to be used whenever premiums are due), and assignable (directly and automatically paid to the insurance company). Sen. McCain proposes a tax credit that is refundable and assignable, but the plan is silent on advanceability.

But, even a tax credit that includes all of these features would not cover the average cost of premiums or any additional out-of-pocket costs in the individual market, where average annual premiums are $3,664 for individual and $5,568 for family coverage. (7) Thus, women would still have to pay any difference between the tax credit and their premiums, as well as their out-of-pocket costs. Women are also often charged higher premiums than men due to gender-rating, and maternity coverage is typically only available for extra cost (called a "rider"); older individuals are also charged more than younger individuals. (8) Furthermore, since insurers can refuse to sell insurance to people with even minor health conditions, there is no guarantee that women can secure coverage, even if they received tax assistance to pay for it.

In addition, senior advisors to Senator McCain have indicated that the tax credit would replace the current income tax exclusion for employer-provided health benefits; thus the value of employer contributions to health coverage would be added to employee salaries to calculate income tax liability. (9) For some women, the value of the tax credit could offset the increase in income tax, but others may see their tax liability increase.

2. Though high-risk pools have existed for over 30 years, they cover less than .5 percent of the total number of uninsured people, due to expensive premiums and restrictions on coverage. (10) In addition, these plans often cannot afford the cost of claims, forcing states to fund the difference. (9)

Without extensive protections to ensure that high-risk pools are adequately funded and provide affordable and comprehensive coverage, it is unclear to what extent such a proposal would help assist those who are uninsured. Furthermore, it is critical that the plan include standards to ensure that high-risk pools do not give insurers further license to cherry-pick applicants--essentially keeping only the healthiest--and rejecting all others into the high-risk pool.

3. Funds in an HSA are portable and can be used for medical costs only. (11) Because women are more likely than men to cycle in and out of the labor force, they benefit from portable forms of coverage. HSAs are set up with high-deductible health plans, however, which have higher out-of-pocket costs; thus, women with less disposable income and/or greater health care needs may be less able to afford them. In addition, people with less income to contribute to an HSA may not have enough funds in their accounts to cover their health care needs. While proponents argue that HSA's discourage overuse of "unnecessary" services, higher cost-sharing--as is required by the high deductible health plan that accompanies the HSA--has been shown to lead to the under-use of needed services, particularly for those with low incomes and/or chronic illnesses. (12)

4. State insurance regulations provide critical consumer protections and require that important health services are covered, which helps ensure that women receive coverage that meets their health care needs. Allowing individuals to purchase insurance over State lines could result in people buying insurance that is less regulated, however. The insurance may be cheaper, but people may end up with insufficient coverage of important health services and/or at financial risk.

THE CANDIDATES' PROPOSALS: SENATOR OBAMA (D-IL)

According to Senator Obama's website, his health reform proposal would, among other things, establish a new public insurance program for those without group health insurance; create a National Health Insurance Exchange, where individuals could buy either private health insurance or the public plan; require employers to provide coverage or contribute to the cost of coverage for the uninsured; and expand eligibility for Medicaid and the State Children's Health Insurance Program (SCHIP). (13)

Senator Obama's Proposal includes: (13)

1. Creating a new "national health plan," available to small businesses, the self-employed, people without access to employer coverage, and/or those who are ineligible for government programs like Medicaid. Eligibility for coverage would be "guaranteed." The benefit package under the public plan would be similar to the Federal Employees' Health Benefits Plan (FEHBP). The proposal would cover "essential medical services, including preventive, maternity and mental health care."

2. Expanding eligibility for public programs such as Medicaid and SCHIP.

3. Creating a National Health Insurance Exchange, available to individuals looking to purchase health insurance, where approved private insurers could compete against the new public plan for enrollees. Insurance companies in the Exchange would be prohibited from denying coverage, or rating premiums, based on a preexisting condition, and above-average premium increases would have to be justified. Private insurers participating in the Exchange would also be required to offer coverage "at least as generous" as that available through the public plan. Additionally, some Federal subsidies would be available for premiums relative to income, which can be used to purchase a private health care plan or to buy into the public plan. Participants will be charged "fair" premiums and "minimal" co-pays for deductibles for preventive services under the public plan.

4. Requiring employers to "meaningful[ly]" cover or contribute to their employees' health care or pay a percentage of payroll towards the costs of the new public plan: Employers would be reimbursed for a portion of their catastrophic health costs if these are used to help reduce the cost of employees' premiums.

EFFECTS ON COVERAGE OF THE OBAMA PLAN

1. Women are more likely to cycle in and out of the workforce, and a new public plan offering coverage regardless of employment status could provide new options for the 17 million women who are currently uninsured. Small business employees (who make up nearly half of the total uninsured population (14)) would also have a new health care option. This is particularly relevant for women, as small businesses that do not offer health benefits, largely due to cost, are more likely to have a larger proportion of female workers. (15)

The new public plan would provide a benefit package "similar" to the FEHBP, and private insurance offered through the National Health Insurance Exchange would have to be at least as generous. While FEHBP is generally comprehensive, it has some gaps. For example, it only covers abortion in cases of rape, incest, or life endangerment. The practical application of "similar to FEHBP" remains to be seen, but we believe that any health plan must cover a full range of reproductive health services, including abortion and maternity care. FEHBP does include maternity coverage, which, in the individual market, is often only available as an "insurance rider"--a supplemental insurance policy at an additional cost that is often prohibitively expensive.

2. Medicaid is a critically important program for low-income women, who make up 69 percent of the plan's adult enrollees. (16) At the same time, more than 30 percent of low-income women aged 18-64 remain uninsured, (17) and expansions to the Medicaid program could help cover this population. Women also rely on SCHIP as both beneficiaries and the caregivers primarily responsible for their children's health. (18)

3. Accessing health coverage in the individual insurance market can be expensive and difficult, as insurers can refuse to sell insurance to people with pre-existing health conditions--or even to women who have ever had a Caesarean section. (19) Proposals that guarantee eligibility and prohibit insurance plans from denying coverage or charging more to individuals with pre-existing health conditions could provide new sources of health coverage to women. The plan does not, however, address whether insurers would be prohibited from setting premiums based on gender or age. Women can face higher premiums than their male peers in the individual insurance market, as it is currently legal in 40 States and D.C. to consider gender when setting insurance premiums. Providing income-based subsidies for premiums could help low-income women afford insurance. The proposal, however, is silent on assistance for other out-of-pocket costs, like co-pays, for insurance purchased through the Exchange; high out-of-pocket costs relative to income can leave women underinsured and at financial risk.

While requiring "minimal" co-pays for deductibles for preventive services under the public plan may help reduce women's prohibitively high out-of-pocket costs, some studies have shown that even minimal co-pays can deter individuals from seeking important preventive services, such as mammograms. (20) Additionally, to reduce the financial burden on women, it is critical to impose limits on, or provide appropriate financial assistance for, all cost-sharing requirements on all health care services--beyond just co-pays for preventive services.

4. Almost two-thirds of women ages 18-64 currently receive health insurance coverage through an employer. (21) Senator Obama's proposal builds on that system, as individuals would be offered the choice of keeping their employer coverage or enrolling in an alternative plan through the new Exchange. Providing employers with Federal subsidies to assist with their employees' catastrophic health costs could provide savings to both employers and employers. Requiring employers to either offer coverage or pay an assessment could level the playing field between employers who offer coverage and those who don't.

CONCLUSION

While the candidates agree on several proposals such as the need to make prescription drug coverage more affordable by increasing the use of generics and allowing reimportation--the plans are very different. While space limitations did not allow a review of every aspect of the candidates' proposals, we hope that this brief overview will inspire you to learn more about the plans and their effect on women's health.

REFERENCES

(1) Patchias EM and J Waxman, Women and Health Coverage: The Affordability, Washington, DC: The Commonwealth Fund and the National Women's Law Center (NWLC), April 2007, p. 4. On-line at: http://www.nwlc.org/pdf/NWLCCommonwealthHealthInsuranceIssueBrief1007.pdf.

(2) NWLC, National Report--Making the Grade on Women's Health: A National and State-by-State Report Card 2007, Washington, DC: NWLC, October 2007. On-line at: http.//hrc.nwlc.org.

(3) Specifically, "underinsured" is defined either as having medical expenses (excluding premiums) representing 10% or more of income; medical expenses (excluding premiums) for low-income people (defined as being below 200% of the Federal poverty level) that represent 5% or more of income; or a deductible that represents 5% or more of income. Schoen C, Dory MM, Collins Set al., "Insured But Not Protected: How Many Adults Are Underinsured?', New York, NY: Health Affairs, June 14 2005, pp. w5-289-w5-302. Health Affairs Web Exclusive, available on-line at: http://www.commonwealthfund.org/ publications/publications_show.htm?doc_id=280812.

(4) DeNavas-Walt C, Proctor BD and Smith J, Current Population Reports: Income, and Health Insurance Coverage in the United States: 2006, Washington, DC: U.S. Census Bureau, 2007, pp. 60-233. On-line at: http://www.census.gov/prod/2007pubs/p60-233.pdf.

(5) These questions are based upon those initially developed in: Patchias EM and J Waxman, Women and Health Coverage: A Framework for Moving, Washington, DC: NWLC, April 2007, p. 3. On-line at: http://www.nwlc.org/pdf/NWLCHealthInsuranceIssueBrief2007.pdf.

(6) John McCain 2008, Straight Talk on Healthy System Reform, http://www.johnmccain.com/Informing/Issues/19ba2f1c-co3f- 4ac2-8cd5-5cf2edb527cf.htm (last visited July 14, 2008).

(7) Bernard D and J Banthin, Medical Expenditure Panel Survey: Premiums in the Individual Health Insurance Market for Policyholders under Age 65: 2002 and 2005 (Statistical Brief #202), Rockville, MD: Agency for Health Care Research and Policy, April, 2008, p. 1. On-line at: http://www.meps.ahrq.gov/mepsweb/data_ files/publications/st202/stat202.pdf.

(8) Collins SR, Schoen C, Doty MM, et al. Paying More for Less: Older Adults in the Individual Insurance Market New York, NY: The Commonwealth Fund, June 2005, p.1. On-line at: http:/.www.commonwealthfund.org/ publications_show.htm?doc_id=282104.

(9) Sack K and M Cooper, "McCain Health Plan Could Mean Higher Tax," The New York Times, May 1, 2008, p. 1. On-line at: 2008/05/01/us/politics/01mccain.html?partner=rssnyt.

(10) Sack K, "McCain Plan to Aid States Could Be Costly," The New York Times, July 9, 2008, p. 2. Available online at: http://www.nytimes.com/2008/07/09/us/politics/09health. CONTINUED ON PAGE 10 html?hp=&pagewanted=print.

(11) Withdrawals from an are not taxed if they are used to pay for qualified medical expenses; withdrawals for non-qualified expenses are subject to regular tax as+ well as a 10% penalty, which is waived if the HSA owner dies, becomes disabled, or becomes eligible for Medicare. See notes 1 and 5.

(12) A 2005 study found that those in high-deductible health plans were more likely to have high out-of-pocket payments and to avoid or delay care. Fronstin P, and S Collins, Earl Experience with High-Deductible and Consumer-Driven Health Plans: Findings from the EBRI/Commonwealth Fund Consumerism in Health Care Survey, New York, NY: The Commonwealth Fund, and Washington, DC: Employee Benefit Research Institute, Dec. 2005, p. 1. On-line at: commonwealthfund.org/publications/publications_show. htm?doc_od=326359.

(13) Barack Obama 2008, Plan for a Healthy America, http://www.barackobama.com/issues/healthcare (last visited July 10, 2008.)

(14) Abelson R, "Small Business is Latest Focus in Health Fight," The New York Times, July 10, 2008, p. 1. On-line at: 2008/07/10/business/smallbusiness/10bizhealth.html.

(15) Fronstin P and R Helman, Small Employers and Health Benefits: Findings From the 2002 Small Employer Health Benefits Survey, Washington, DC: Employee Benefit Research Institute, Jan. 2003, p. 1. On-line at: http://www. ebri.org/pdf/briefspdf/0103ib.pdf.

(16) Henry J Kaiser Family Foundation (KFF), Medicaid's Role for Women, Washington, DC: KFF, Oct. 2007, p. 1. On-line at: http://www.kff.org/womenshealth/upload/7213_03.pdf.

(17) Henry J Kaiser Family Foundation, Health Insurance Coverage of Low-Income Women Ages 18-64, 2005-2006, Washington, DC: KFF, Dec. 2007, p. 2. On-line at: http://www.kff.org/womenshealth/upload/1613_07.pdf.

(18) Henry J Kaiser Family Foundation, Women Work and Family Health: A Balancing Act, Washington, D.C.: KFF, April 2003, 1. Online at: http:www.kff.org/womenshealth/loader.cfm? url=/commonspot/security/getfile.cfm&PageID=14293.

(19) Grady D, "After Caesareans, Some See Higher Insurance Cost," The New York Times, June 1, 2008, 1. On-line at: 2008/06/01/health/01insure.html?r=1&oref-slogin.

(20) Amal Trivedi A, W Rakowski and JZ Ayanian, "Effect of Cost Sharing on Screening Mammography in Medicare Health Plans," NEJM 2008; 358(4):375-83. Findings were magnified among women in low-income areas. See also: JP Newhouse, Free for All? Lessons from the Rand Health Experiment Insurance Experiment Group, Cambridge, MA: Harvard University Press, 1993.

(21) Henry J Kaiser Family Foundation, Women's Health Insurance Coverage, Washington, DC: KFF, Dec. 2007, 1. On-line at: womenshealth/upload/6000_06.pdf.

Lisa Codispoti and Julia Kaye, National Women's Law Center

Lisa Codispoti is Senior Counsel, and Julia Kaye is a Health Policy Associate, at the National Women's Law Center