PHILADELPHIA -- The Supreme Court health care decision allowing states to not expand Medicaid as the Affordable Care Act intended is a serious blow to a particularly vulnerable demographic that has been largely invisible in the public wrangle over health reform policy: low-income near-elderly women.
55 to 64-year olds Under the provisions of the ACA as passed in 2010, uninsured low-income 55- to 64-year old women were among those who would benefit most from the expansion of Medicaid to cover people with incomes up to 133 percent of the poverty level. But the Supreme Court ruling striking down the federal government's power to enforce Medicaid expansion in 50 states has now left many of these women in insurance limbo.
Led by those of Texas and Florida, a growing number of governors and legislatures have said they won't expand Medicaid or create exchanges. For instance, as he hosted the recent National Governors' Association meeting, Virginia
Low-income women near retirement are a "group that has been understudied and is particularly vulnerable," says University of Texas reseacher Kate Prickett, MP Aff, a doctoral student studying socioeconomic disparities in health care. She was the primary investigator in an extensive 2011 study of near-elderly women and health care law.
Governor Bob McDonnell said it would be "irresponsible" to expand Medicaid coverage in his state.
According to the latest 2011 figures, Texas, Florida and Virginia have a total of more than 1,872,000 near-retirement women, more than 468,000 of whom are uninsured. Nearly 160,000 of those would be newly eligible for Medicaid. Nearly 239,000 others would be eligible for subsidies through the exchanges. A "disproportional number" of these women are reported to be African American and Latino.
A 'huge deal' "This is a huge deal for low-income, pre-elderly women," said Kate Prickett at the University of Texas Department of Sociology & Population Research Center. "These women are being excluded from the health law's benefits. They're not going to receive Medicaid in states like Texas and they won't be able to participate in the health insurance exchanges because the exchange structure assumes that people of their income level will be covered under expanded Medicaid."
Prickett and Jacqueline Angel of the University's LBJ School of Public Affairs are the authors of an extensive 2011 study published in Women's Health Issues that analyzed how pre-retirement women would be affected by the Affordable Care Act.
"This is a group that has been understudied and is particularly vulnerable," said Prickett. "We might not have seen how unstable their situation was until recently. They tend to be women who were reliant on their husband's employer-sponsored health insurance at the same time their own employment tends to be in companies that offer few benefits. Typically, they are younger than their husbands and when he retires and goes on Medicare, or dies and widows them, or divorces them as family dynamics change, they lose coverage until they hit 65 and qualify for Medicare."
In this insurance gap that can be a decade long, low-income women don't qualify for Medicaid or Medicare; they can't afford insurance policies in the individual market;
and they lack the cash to pay for tests, drugs and medical treatments themselves.
Disproportionate needs Dylan Roby, assistant professor at the UCLA Fielding School of Public Health said this female age group is one that "disproportionately really needs preventive care. From a health status perspective they're more likely to have some chronic illness than the rest of the population. They're more likely to use health care services even if they're healthy. They're also more likely to need that health care." Other research confirms these women suffer higher levels premature death than insured women of their same age.
"These women are clearly at heightened risk," said Prickett. "The risk of 20-something women who are uninsured is very different from that of uninsured 60-somethings. They're in menopause, they have a higher likelihood of pre-existing conditions, they're at a heightened risk for all types of cancers, they're becoming more frail and less mobile, and they don't get preventive care. So, they tend to get sicker and more expensive to deal with when they do finally make it into Medicare."
3.7 million uninsured Former Senior Economist for Health Care Policy on the White House Council of Economic Advisers and current University of Pennsylvania Professor of Economics and Health Care Management Mark Duggan estimates there are about 27 million U.S. women in the near-elderly age bracket and about 14% of those -- or 3.7 million -- are currently uninsured. Nationally, one third of these, or more than 1.2 million would be covered if all 50 states expand their Medicaid programs. Fifty percent -- or another 1.8 million -- are eligible for insurance exchange subsidies.
"Even before the Supreme Court ruling, the ACA had already expanded coverage for some groups, like young adults and that made a big dent in the fraction of uninsured among those young adults," said Duggan. "Meanwhile, there has been much less of a dent made among these near-elderly women who are uninsured."
Potential dramatic impact According to the Prickett-Angel analysis, if the ACA's Medicaid expansion program was executed in all fifty states, the overall rate of uninsured near-elderly women would be reduced to about two percent. Illegal immigrants and legal residents in the country for fewer than five years, would comprise part of that 2 percent. It also remains to be seen, Prickett said, whether women who make too much to qualify for the new insurance subsidies will be able to afford the coverage.
Aside from the expansion of Medicaid eligibility, the ACA originally intended to broaden insurance availability for near-elderly women by requiring, guaranteeing approval for and subsidizing coverage, including for people with pre-existing conditions; eliminating gender discrimination in setting premiums in the individual and small-group market; and limiting insurers' ability to charge older people higher rates.
The Prickett-Angel study said future research on the ACA's effects on near-elderly women should focus on state-level discrepancies in implementation of the law, and costs and participation levels in exchanges. It suggested research should also examine the affordability of coverage purchased through the exchanges, even with the help of subsidies.
Offering some hints to potential problems in these areas is a 2011 Women's Health Issues study led by Susan Sered of Boston's Suffolk University. It looked at the effects of the Massachusetts health reform law on adult women of all ages in a effort to better understand what might happen nationally with a full ACA rollout. While the numbers of uninsured women in Massachusetts were lower, interviews with women indicated significant issues in terms of policy affordability, continuity of coverage and complexities in selecting plans.
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Dinah Wisenberg Brin is a journalist and former staff reporter for Dow Jones Newswires, the Associated Press and Congressional Quarterly.firstname.lastname@example.org