Medicaid Works for Women — But Proposed Cuts Would Have Harsh, Disproportionate Impact

These cuts would have devastating consequences for the nearly 40 million women who rely on Medicaid.Republican leaders in Congress and the White House have proposed to deeply cut Medicaid by effectively eliminating the Affordable Care Act’s (ACA) Medicaid expansion, and breaking the federal government’s decades-long guarantee to pay a set share of states’ Medicaid costs.  These cuts would have devastating consequences for millions of Americans, including the nearly 40 million women who rely on Medicaid.  Women would bear a disproportionate share of the burden because they make up a majority (53 percent) of Medicaid beneficiaries, are the primary utilizers of family planning and maternity care benefits, and are much more likely to use Medicaid’s long-term services and supports as they age.  The Appendix tables at the end of this report provide state-specific data on Medicaid’s significant role in women’s health.

Medicaid Changes Have Expanded Women’s Access to Care

Originally, most adult women weren’t eligible for Medicaid: eligibility was limited almost exclusively to children, cash assistance recipients, seniors, and people with disabilities.  Eligibility expansions in the 1980s and 1990s enabled many more low-income children, parents, and pregnant women in working families to qualify.  Even with these changes, before the ACA, many low-income women were left out because they weren’t in a population category eligible for the program.^[1]

The ACA’s Medicaid expansion changed that.  In the 32 states that have expanded, women with incomes at or below 138 percent of the poverty line ($16,643 for a single person or $28,180 for a family of three in 2017) can enroll. 

The Medicaid expansion gave women not raising children access to coverage and offered continuous coverage to new mothers who had qualified for Medicaid while pregnant but whose incomes were not low enough to qualify as a parent.^[2]  States that have yet to expand Medicaid have largely maintained Medicaid’s narrow eligibility criteria, preventing many low-income women from enrolling in Medicaid until they become pregnant and ending their eligibility 60 days after the birth of their child.^[3] 

Medicaid Provides Essential Health Services to Women of All Ages

Medicaid allows women to obtain the health care they need throughout their lives.  Women have unique health care needs — they are the primary users of maternity care, family planning, and long-term care services — and nearly half of all women have an ongoing condition requiring regular monitoring, care, or medication.^[4]  Moreover, women use many other health benefits differently from men, such as mental health and substance use disorder treatment. 

Women of reproductive age rely especially on Medicaid’s family planning and maternity care services.  Medicaid covered 12.9 million women ages 15-44 in 2015 — 20 percent of all women in this age group and 48 percent of women in this age group with incomes below the poverty line.^[5]   Medicaid is also an essential support for women of color ages 15-44: 31 percent of African American women and 27 percent of Hispanic women in this age group are enrolled in Medicaid.^[6] 

Family Planning

Nearly all women use some form of family planning during their reproductive years, and Medicaid finances 75 percent of all publicly funded family planning services.^[7]  Family planning services are essential for women’s health: almost half of all pregnancies are unintended, and unintended pregnancies are associated with negative health and economic consequences for families as well as increased spending for states and the federal government.^[8] 

States must offer family planning services for women enrolled in Medicaid.  The federal government funds 90 percent of the cost of these services — significantly higher than the 64 percent average federal match for most other Medicaid services.  States have considerable flexibility deciding which family planning services to cover, but they generally cover contraceptive services and supplies, Pap smears, sexually transmitted disease testing, and counseling. These services are effective: in 2013, women with Medicaid coverage were more likely than women with private insurance to report they had spoken with a provider about sexual history, HIV, and intimate partner violence.^[9]  (See Figure 1.)

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Medicaid’s family planning services have no cost-sharing charges, and women have “freedom of choice” of family planning providers.  This means they can receive family planning services and supplies from any willing and qualified Medicaid provider.^[10]

Over 20 years ago, states began using Medicaid waivers (technically known as section 1115 demonstration authority) to expand access to family planning services to women who would otherwise not qualify for Medicaid.  These waivers provide family planning-related coverage to women with incomes above the state’s Medicaid limit, including those who lost Medicaid eligibility after having a baby.  Before the ACA, 28 states used these waivers to provide family planning services to women.^[11]  More than half of states have used this authority to establish permanent family planning programs for people who would not otherwise qualify for Medicaid.  Recognizing the success of these programs, the ACA allows states to permanently adopt their family planning programs as a state option without a waiver.^[12] 

Maternity Care

Medicaid provides health care for nearly half of all pregnant women, supporting them through their pregnancies and ensuring that their babies have a healthy start.^[13]  Medicaid has historically required states to cover pregnant women at much higher eligibility levels than other adults.  All states must cover pregnant women up to 133 percent of poverty, and 34 states cover pregnant women with family incomes above 200 percent of poverty as of January 2017.  Eligibility at these higher income thresholds extends through pregnancy and the 60 days after childbirth.^[14]  

The Medicaid expansion, by enabling states to bring other adults up to 138 percent of poverty without a federal waiver, has allowed many women to maintain continuous access to primary care and family planning services before and after pregnancy, and to avoid unintended pregnancy.  When women have health coverage before becoming pregnant as well as between pregnancies, they are healthier during pregnancy and their babies are more likely to be healthy at birth, research shows.  Between the birth of one child and the conception of another, health coverage gives women access to care that can improve the outcomes of subsequent pregnancies.  This can include treatment for diabetes and hypertension; clinical interventions focused on combating family violence, depression, and stress; and other forms of parental support.^[15]

States’ coverage of pre- and post-natal services varies significantly.  Most states cover prenatal vitamins, ultrasounds, and prenatal testing such as amniocentesis, as well as substance use disorder treatment services for pregnant and postpartum women.  Some states also offer education services to support childbirth, infant care, and parenting and to help women initiate and maintain breastfeeding, including breast pumps and lactation counseling.^[16]  

Infants born to women on Medicaid are automatically enrolled in the program until their first birthday.^[17]  This immediate and uninterrupted coverage is essential: research shows that people who had Medicaid during early childhood have better long-term health and achievement in adulthood than those who were uninsured.^[18]

Medicaid can also play an important role in identifying children whose mothers experience depression and connecting mothers and children to the help they need.  Guidance that the Centers for Medicare & Medicaid Services (CMS) released in 2016 cites evidence showing that between 5 and 25 percent of all pregnant, postpartum, and parenting women have some type of depression; for mothers with low incomes, rates of depressive symptoms are between 40 and 60 percent.  More than half of infants living in poverty are being raised by mothers with some form of depression.^[19] 

The guidance clarifies that states can include screening mothers for maternal depression as part of well-child visits even if the mother isn’t enrolled in Medicaid, because of evidence that maternal depression can place children at risk of adverse health consequences.^[20]  

Long-Term Care

Medicaid helps women as they age, even when they become eligible for Medicare.  Women live longer than men and are significantly more likely to need long-term care services through Medicaid.  Sixty-nine percent of the 9 million dually eligible beneficiaries — people covered by both Medicare and Medicaid — are women.  “Duals” are typically over 65 years of age or younger low-income individuals with disabilities who have significant health care needs.  Medicaid plays an especially critical role for older women of color, covering nearly 40 percent of Latina and African American women over 65 who are also enrolled in Medicare.^[21]  (See Figure 2.)

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Medicaid pays for half of the nation’s long-term services and supports,^[22] and women make up seven in ten nursing home residents and over two-thirds of people receiving home and community based care.^[23]  Medicaid offers these services and supports in institutional settings like nursing homes as well as care in people’s homes, usually referred to as home- and community-based services (HCBS).  HCBS include case management, home health aides, personal attendant services to help with daily living activities such as bathing and dressing, and adult day health. 

Enormous progress has been made over the decades to increase access to care in home- and community-based settings, which are less expensive and where many seniors and people with disabilities prefer to live.  In 2013, for the first time in the program’s history, Medicaid spent more on home- and community-based care than on institutional care.^[24] 

Medicaid Cuts Would Disproportionately Harm Women

The House Republican bill to repeal the ACA, the American Health Care Act (which passed the House on May 4), would radically restructure and deeply cut Medicaid, reducing enrollment by 14 million people by 2026.  While the cuts would jeopardize care for all Medicaid beneficiaries, they would disproportionately affect women due to the higher proportion of women who rely on Medicaid and the specific services at risk of cuts. 

The bill would cut $839 billion in federal spending from Medicaid over ten years by effectively eliminating the Medicaid expansion and permanently capping annual funding for states, regardless of the cost of services for their Medicaid beneficiaries.^[25] 

The legislation also specifically targets access to women’s health care services by barring states from reimbursing Planned Parenthood for its preventive health and family planning services for women and men enrolled in Medicaid.  This would cause thousands of low-income women to lose access to care and raise state and federal Medicaid costs related to unplanned pregnancies.  Fifteen percent of women on Medicaid who rely on Planned Parenthood for family planning services would lose access to those services, the Congressional Budget Office estimates.^[26] 

The bill also permits states to impose work requirements on Medicaid beneficiaries, which would penalize those least able to get and hold a job while keeping others from improving their health and participating in the workforce.  Almost two-thirds of the 11 million beneficiaries who risk losing coverage from a work requirement are women.^[27]  Many of these are women with a disability or chronic health condition or who are caring for a family member.  Many others have low-wage jobs that don’t offer health coverage.

The Republican bill isn’t the only threat to women’s health coverage.  Health and Human Services Secretary Tom Price, and CMS Administrator Seema Verma recently notified governors that the Trump Administration will give states greater flexibility to limit access to Medicaid enrollment and access to care.^[28]  CMS could allow states to waive many legal requirements and consumer protections that could disproportionately affect women and their access to coverage, including family planning services.  These waivers would be a sharp departure from the family planning waivers discussed above, which enabled states to expand access to coverage.

Several states are considering seeking waivers to impose premiums and cost-sharing as a condition of Medicaid eligibility for people in poverty, which would limit access to care for many women.^[29]  States are also considering drug-testing Medicaid beneficiaries, setting time limits on Medicaid benefits, and requiring people to work or search for work in order to maintain their benefits.  These proposals fail to advance Medicaid’s core objective of delivering health care to vulnerable populations who can’t otherwise afford it, as federal law requires of Medicaid waivers, and they would significantly restrict access to care for millions of women who rely on Medicaid as an essential support.