An ACA overturn could threaten years of insurance gains, women’s health access

By Erica Hensley | November 10, 2020

As a federal lawsuit looms that threatens to strike the Affordable Care Act and the benefits it ensures, women in Mississippi stand to lose a world of healthcare benefits.

On Tuesday, the U.S. Supreme Court will hear arguments for California v. Texas, which challenges the constitutionality of the ACA.  If it is struck down, nearly all Mississippians will be touched in one way or another, and women in particular could lose access to insurance that affords them preventive care, such as prenatal care, birth control and cancer screenings, and protections that prevent them from being charged more for routine care — a common practice before the ACA.

As open enrollment kicks off for next year’s coverage, enrollment counselors are putting the law’s unknown fate in the back of their mind and moving forward with enrolling as many in-need as they can reach, citing COVID-19 as reason to make sure as many people as possible are covered. The ACA rolls have grown over recent years after a nation-wide dip in enrollment in 2017. On average, 91,000 Mississippians use the ACA’s Healthcare Marketplace yearly to buy their health insurance. 

Women outpace men using the marketplace, accounting for 60% of Mississippi’s total enrollees in 2018, and 54% nationally. ACA insurance sign-ups have particularly helped Black Mississippians gain health insurance, whose uninsured rate dropped by 35% since 2008, compared to a 27% drop for the state. 

If the law is invalidated, the number of Mississippians without insurance could surge to 450,000, erasing the gains of the last decade. The 600,000 with pre-existing conditions — now including COVID-19, which has disproportionately impacted women and Black Mississippians — could be charged more or denied coverage altogether. 

New research finds an estimated 3 million people lost employer-sponsored coverage due to COVID-19 job losses, but state and federal sponsored programs, like Medicaid and ACA, largely offset large insurance losses. 

The law’s patient protections are popular across the political spectrum and favorability has increased over time as the provisions have become normalized in policy. By 2017 the majority of Mississippians favored the law’s main provisions, according to research from the Center for Mississippi Health Policy. 

Though Mississippians still report knowing very little about the law, they have come around to the parts they do know. In 2013 and 2015 the majority of Mississippians did not favor the law, but in 2017 more had a positive opinion of the ACA than a negative one, says Zach Smith, who specializes in health law at the Center for Mississippi Health Policy. 

“We cannot say what exactly changed Mississippians opinions of the ACA but it is possible that as people began to understand some of the core provisions their favorability of the law increased generally,” Smith said.

He noted other public health and preventive care provisions of the law that are lesser known, but that work behind the scenes to create healthier communities, such as smoking cessation programs, premium rebates and nutrition labeling.

Women in particular have benefited from the law’s patient protections and tend to favor the law. The ACA ensured certain essential health benefits, like birth control, cancer screenings and prenatal care are covered. It also codified that women can use OB-GYNs as their primary care provider, as many women do for preventive and reproductive health care, and that insurers cannot charge women more for care. This was a common practice before ACA protections known as “gender rating.”

The law also mandates that workplaces with 50 or more employees support breaks and private rooms for breastfeeding women, which is still a tall order for some Mississippi communities but the backing of the federal law helps rally public health support. Women are entitled to insurance-covered breastfeeding support, such as lactation counseling and breast pumps — two historical barriers to breastfeeding, especially in poor communities. 

Women in general are more likely to have a pre-existing condition that could disqualify them from coverage without ACA protections. They tend to make less money, use more health care and are more likely to be unpaid family caregivers — all of which pose a greater burden if health care is more expensive or all-together absent. Women are also more likely to forgo insurance due to cost concerns

To help fill affordability gaps, the law expanded state governments’ role in fostering health insurance access by offering states leeway to expand Medicaid eligibility to residents living in poverty. Before, not earning enough money to buy health insurance didn’t qualify for Medicaid eligibility. Now, in 39 states, those earning up to 138% of the federal poverty line, or about $17,000 for an individual, qualify. 

Several other states, like Georgia most recently, used federal waivers to take advantage of parts of Medicaid expansion but not others. Georgia also extended its Medicaid eligibility for postpartum women from two to six months of coverage after birth — a move supported by maternal health experts. 

Expanding Medicaid to enroll women before they become pregnant has shown to improve maternal and infant outcomes, but for states that won’t expand the program to all people living in poverty, advocates say extending the coverage to women beyond the 60 days after birth helps improve outcomes. Research shows states that extended postpartum Medicaid eligibility subsequently decreased the number of mothers dying during and after childbirth. 

Mississippi is one of 10 states to neither expand eligibility nor take advantage of a partial waiver to cover more low-income folks through Medicaid. The state has also not extended eligibility to part-partum women, despiste high maternal and infant mortality rates. Nearly 40% of Mississippi women who die due to birth complications do so after six weeks of birth — when Medicaid cuts off. 

During the COVID-19 crisis, Mississippi Medicaid has temporarily extended eligibility to postpartum women. As a condition of federal COVID-19 relief dollars, states cannot kick women off of Medicaid who gained coverage while they were pregnant. As of now, the benefit goes through late January, but it could be extended if the federal government expands the official timeline of the federal public health emergency.

Linda Dixon, health policy attorney for Mississippi Center for Justice, says you can’t talk about the ACA without talking about what was left behind. About 150,000 Mississippians fall in the coverage gap — meaning they don’t qualify for Medicaid because it wasn’t expanded to cover non-disabled folks living in poverty, but they make too little to qualify for marketplace tax credits to help pay for insurance. 

The marketplace is only eligible for incomes above 100% of the poverty line because it was created with Medicaid expansion in mind. At the time of its inception, the idea was for Medicaid to catch folks under the federal poverty line and the marketplace to assist folks above it. Because in the dozen states that chose not to expand Medicaid, folks living in poverty qualified for neither and fell in that gap, uninsured and unprotected. Those states still have the highest uninsured rates and hospital closures

With a looming decision to overturn the ACA, the gap risks widening. Policy experts estimate more than 21 million people nationally and at least 100,000 people in Mississippi would lose insurance if the law falls — widening the gap here and reversing insurance gains over the last decade.

“There are so many things to factor in that Americans and Mississippians have had access to for 10 years, and what does that look like moving forward, how is that going to affect Mississippians?” Dixon asked rhetorically, echoing health policy experts across the state who say undoing gains from the ACA risks tossing more unknowns to the state as COVID-19 rattles the health care system. “Mississippi families deserve better than this.”

Open enrollment on the federal marketplace runs through Dec. 15, 2020 for 2021 coverage. Visit for more information, or get help from certified community counselors and navigators.

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Erica Hensley, a native of Atlanta, has been working as an investigative reporter focusing on public health for Mississippi Today since May 2018. She is a Knight Foundation fellow for our newsroom’s collaboration with local TV station WLBT and curates The Inform[H]er, our monthly women and girls’ newsletter. She is the 2019 recipient of the Doris O'Donnell Innovations in Investigative Journalism Fellowship. Erica received a bachelor’s in print journalism and political science from the University of Southern California Annenberg School for Communication and Journalism and a master’s in health and medical journalism from the University of Georgia Grady College for Journalism and Mass Communication.