Survivors of domestic violence and sexual assault need a range of physical and mental health services, including preventative care, to heal and thrive. Today, affordable and comprehensive care is guaranteed, including for survivors, through the Affordable Care Act (ACA).

What Survivors Need to Know About Health Care Right Now

The Affordable Care Act is still current law. Survivors should be encouraged to sign up for health care. Survivors can get a special enrollment period to enroll in the Marketplace, and Medicaid enrollment is year-round.

How Does the Affordable Care Act (ACA) Help Survivors?

The ACA helps survivors because …

  • Health plans cannot deny coverage to anyone because they have experienced domestic or sexual violence, or for any pre-existing condition (known as guaranteed issue). Before the ACA was signed into law, in 8 states plans could still deny coverage for experiencing domestic or sexual violence.
  • Plans cannot charge more based on health status including domestic violence or other symptoms of trauma (known as community rating).
  • Survivors can access affordable coverage that is not tied to their abuser and addresses the unique situation that survivors face. (e.g. that survivors may experience gaps in health insurance due to circumstances entirely out of their control).
  • Plans must offer a comprehensive benefit package that covers a range of health and behavioral health services (known as the essential health benefits).

The American Health Care Act (AHCA), which passed the House of Representatives last week, allows these protections to be undermined or stripped away.

Impacts of the American Health Care Act (AHCA) on Survivors

The AHCA does maintain the guarantee issue requirements, meaning that plans cannot refuse to issue a policy to anyone based on health status. However, the bill will allow states to waive the rules so that plans can charge some people more based on their health history, including pre-existing conditions, making premiums prohibitively expensive for survivors. It is important to also note that low-income survivors who rely on (or are eligible for) Medicaid will be negatively impacted by this bill as well. Read on to learn how.

Allowing States to Waive Essential Health Benefits

The AHCA allows states to waive the “essential health benefits.” States and plans will control what benefits are required to be offered as well as the scope of those benefits. For example, plans could limit how many counseling visits might be available, or what kinds of services are covered (or not), which could impact what is available to a rape survivor.

This provision also has the impact of eliminating out-of-pocket limits and annual lifetime limits. This means plans could offer bare-bones coverage of services, like mental health benefits. Healthy people who do not anticipate needing much care will purchase these plans because they will be cheapest. Given that most victims are young women and have no plan to be raped or abused, it is highly likely that many would choose these lower-cost plans without realizing how little they’re covered.

Comprehensive plans may be available, but they will be extremely expensive. People with pre-existing conditions who anticipate that they will need care will be forced to pay these high premiums, otherwise they will be forced to pay out-of-pocket for non-covered services or forgo needed care.

The “essential health benefits” waiver makes comprehensive care extremely expensive and puts care out of reach for many survivors.

Allowing States to Waive Community Rating Protections

The AHCA will allow states to waive the community rating protections. If a state waives the rules on community rating, plans will be able to explicitly charge certain people with pre-existing conditions more by “underwriting their risk.”

On a state-by-state basis, health plans will be allowed to charge people with pre-existing health conditions more than a healthy person for the exact same plan. This provision would apply to consumers in the individual market and small group market, currently 18 million people who would be at risk. This could only be applied to consumers who do not have continuous coverage (in other words, those who are uninsured for two months or more).

The AHCA does not explicitly classify which conditions could be underwritten. In other words, the AHCA does not specifically say that exposure to domestic or sexual violence would be deemed a pre-existing condition. However, by rolling back the ACA’s explicit protections against discriminating on domestic violence, this bill puts survivors at high risk of having their health history used in underwriting. The bill will let states make these choices. 

In addition, survivors who have not disclosed their domestic or sexual violence will still be at risk for underwriting because other symptoms of trauma may appear in their health history, such as use of mental health services, a diagnosis of PTSD or emergency room visits.

Replacing the Individual Mandate

The AHCA requires consumers to be continuously covered or face higher premiums. This provision is designed to encourage consumers to get health insurance before they get sick. This replaces the ACA’s requirement that everyone have insurance (known as the individual mandate).

Any consumer with a gap in their health insurance of more than two months will be subject to a 30% premium increase for the first 12 months of coverage. Or, in a state that chose to waive community-rating rules, consumers will be subject to underwriting on their health status.

Survivors are at risk for having gaps in coverage for many reasons, including circumstances entirely out of their control. For example, if an abuser terminates coverage without telling the victim, s/he will face stiff financial penalties because of the abuser’s actions.

Impacts of the AHCA on Medicaid, and What It Means for Survivors

These provisions impact individuals who are purchasing coverage in the individual market, including healthcare.gov. Low-income survivors who rely on (or are eligible for) Medicaid will be negatively impacted by this bill as well. The AHCA changes the financing structure of Medicaid, cuts hundreds of billions of federal Medicaid dollars from the program, and sunsets the Medicaid program. For low-income survivors, there are no other sources of health insurance. Dramatically cutting Medicaid will mean loss of coverage and loss of access to needed services.