The Guttmacher Institute is evaluating how sexual and reproductive health and rights fit into U.S. health care reform efforts. Previous analyses have described people’s wide array of sexual and reproductive health needs and laid out a set of principles for how to address them within the health care system. This analysis applies those principles to one specific health care reform proposal. Evaluations of additional proposals can be found here.

Proposal name and bill number: Consumer Health Options and Insurance Competition Enhancement Act (S. 1033 and H.R. 2085, 116th Congress)

Proposal sponsor/author: Sen. Sheldon Whitehouse (D-RI) and Rep. Janice Schakowsky (D-IL)

Proposal version date: 4/4/2019

Summary

An incremental approach to health reform that establishes a public option for individual and small-group plans to be sold on the Affordable Care Act’s (ACA) health insurance marketplaces. Maintains ACA coverage and eligibility standards, and uses Medicaid and Medicare provider networks.

Ensure Comprehensive Insurance Coverage for Everyone

Provide coverage to all without cost or paperwork barriers: Provides new public options only for U.S. residents already eligible to purchase private insurance through the ACA’s individual or small-group marketplaces. Keeps existing ACA rules blocking undocumented immigrants and Deferred Action for Childhood Arrivals (DACA) recipients from coverage. Offers premium tax credits and cost-sharing reductions that are available for other marketplace plans.

Cover the complete scope of sexual and reproductive health services without barriers: Requires the U.S. Department of Health and Human Services (HHS) to create a benefit package that is "comprehensive and meets the health care needs of patients," including coverage for the ACA’s 10 essential health benefits (which specifically include maternity, contraceptive and some STI and reproductive cancer care). Explicitly overrides state laws that exclude abortion services from coverage, which would allow the public option to cover abortion nationwide, depending on the decision of HHS. Includes language intended to override restrictions on the use of federal funds for abortion coverage and care (like the Hyde Amendment).

Build and Maintain a Robust Provider Network

Ensure that patients may seek care from any qualified provider: Allows access to providers already in the Medicaid and Medicare networks (though providers may opt out), as well as additional providers who choose to accept this coverage. Includes explicit protections for providers, including providers who offer reproductive health services (like Planned Parenthood), to ensure they may not be excluded for reasons other than their ability to provide care.

Fully reimburse providers and invest in their education, facilities and technology: Requires HHS to negotiate reimbursement rates with providers, using Medicare reimbursement rates (which are generally lower than rates under private insurance) if negotiations are unsuccessful.

Keep pace with emerging services and methods, such as telehealth: Not addressed.

Guarantee and Enforce Strong Patient Protections

Eliminate legal, cultural and safety-related barriers to care: Not addressed.

Respect patients’ privacy and autonomy and guard against coercion: Existing ACA protections would apply. Most notably, the ACA prevents the federal government from interfering with the principle of informed consent, patient-provider communication and patients’ timely access to care.

Fight discrimination and promote equitable health care access and experiences: Existing ACA provisions would apply, including its strong antidiscrimination protections for patients. Requires HHS to collect data needed to reduce racial, ethnic, socioeconomic and other disparities.

Overall Assessment

Strengths:

• Creates a new insurance option to encourage competition and potentially lower premiums on all marketplace plans.
• Applies current ACA protections to the new public option, including subsidies, antidiscrimination rules, and coverage requirements for contraception, maternity care and other services.
• Overrides state restrictions on abortion coverage and lifts federal restrictions on that coverage (like the Hyde Amendment).
• Includes specific protections for providers, including those who offer reproductive health services (like Planned Parenthood).

Weaknesses:

• Under a hostile administration, abortion and other specific sexual and reproductive health services could be excluded from coverage in the public option nationwide.
• Maintains the ACA’s existing restrictions that exclude undocumented immigrants and DACA recipients from buying coverage, with or without government subsidies.