Women's Coverage Losses in 2023 If the American Rescue Plan Act's Premium Tax Credits Expire Jessica Banthin, Andrew Green, and Michael Simpson July 2022 About 850,000 additional adult women of reproductive age (19 to 44) will be uninsured in 2023 if the enhanced premium tax credits (PTCs) passed under the American Rescue Plan Act (ARPA) are allowed to expire at the end of 2022 as they are slated to under current law (table 1). 1 Uninsured women are at higher risk than insured women of having an unintended pregnancy due to more limited access to free or low-cost reproductive health services, including the most effective forms of contraception. 2 Further, many of these additional women who will be uninsured live in states that tightly restrict or plan to tightly restrict access to abortion. In the wake of the Supreme Court's elimination of the constitutional right to an abortion, uninsured women who are facing an unintended pregnancy and living in certain states are now at a higher risk of being denied access to the full range of reproductive health services, including abortion, than at any time in recent decades. TABLE 1 Uninsurance among Nonelderly Adult Women, 2023 Enhanced PTCs Enhanced PTCs Expire Are Extended Change Number of Number of uninsured Uninsurance uninsured Uninsurance Nonelderly adult women (1,000s) rate (%) (1,000s) rate (%) 1,000s % All 11,407 11.3 10,144 10.0 -1,262 -11.1 Ages 19–44 7,523 13.0 6,672 11.6 -850 -11.3 Ages 45–64 3,884 9.0 3,472 8.0 -412 -10.6 In Medicaid expansion states 6,211 8.9 5,836 8.4 -375 -6.0 Ages 19–44 4,036 10.2 3,777 9.5 -259 -6.4 Ages 45–64 2,175 7.3 2,059 6.9 -116 -5.3 In nonexpansion states 5,196 16.4 4,308 13.6 -887 -17.1 Ages 19–44 3,487 19.3 2,896 16.1 -591 -17.0 Ages 45–64 1,709 12.6 1,413 10.4 -296 -17.3 Source: Urban Institute Health Insurance Policy Simulation Model, 2022. Notes: Enhanced PTCs = enhanced premium tax credits under the American Rescue Plan Act. The 12 states that have not expanded Medicaid are Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming. The Affordable Care Act (ACA) vastly improved access to health benefits for women in the nongroup market by prohibiting gender rating of premiums and coverage exclusions due to preexisting conditions. Under the ACA, qualified health plans must offer 10 essential health benefits, including maternity care and mental health benefits. Moreover, preventive care services must be covered without cost sharing. For women, this means well-woman visits and reproductive health services, including contraception and cancer and other screenings, are free. 3 Access to Urban Institute 500 L'Enfant Plaza Washington, DC 20024 202.833.7200 www.urban.org these important preventive services may partially explain why more than half of adult Marketplace enrollees are women. 4 Of the 850,000 additional adult women of reproductive age who will be uninsured in 2023 if the ARPA PTCs expire, about 259,000 live in states that have expanded Medicaid eligibility up to 138 percent of the federal poverty level as permitted under the ACA (table 2). More than double that number-591,000 women-live in the 12 states that have not expanded Medicaid. Coverage losses will be larger in nonexpansion states because, compared with expansion states, nonexpansion states have a larger share of women with low incomes enrolled in the Marketplace instead of Medicaid. Uninsurance rates for adult women of reproductive age will also be much higher in nonexpansion states (19.3 percent) than in expansion states (10.2 percent), again mostly because of lower Medicaid eligibility cutoffs in nonexpansion states. Proposed policies to close this coverage gap by broadening eligibility for Marketplace coverage to people with very low incomes in nonexpansion states would reduce these disparities between the two groups of states. To highlight the impact of the Supreme Court decision, we show coverage changes among women if the ARPA PTCs expire and abortion access in each state using ratings from the Guttmacher Institute (table 2). 5 Many nonexpansion states are rated as having "most" or "very" restrictive abortion access. Though state laws are changing rapidly, we estimate that 2.5 million uninsured adult women of reproductive age live in states with the most restrictive or very restrictive access to abortion (regardless of Medicaid expansion status). If the enhanced ARPA PTCs were extended, 384,000 fewer adult women of reproductive age in these states would be uninsured, and most would instead have free access to contraception and other reproductive health services through Marketplace plans to help avoid an unintended pregnancy. They would also have access to comprehensive health insurance benefits that would cover the necessary services to support a healthy pregnancy and delivery and ongoing maternal health and well-being. TABLE 2 Uninsurance among Women Ages 19 to 44, by State, 2023 Enhanced PTCs Enhanced PTCs Expire Are Extended Change Abortion Number of Number of access uninsured Uninsurance uninsured Uninsurance status (1,000s) rate (%) (1,000s) rate (%) 1,000s % All women ages 19–44 7,523 13.0 6,672 11.6 -850 -11.3 Women ages 19–44 in Medicaid expansion states 4,036 10.2 3,777 9.5 -259 -6.4 Alaska 5 20 13.2 19 12.6 -1 -4.3 Arizona 3 187 14.6 179 14.0 -8 -4.2 Arkansas 1 57 11.0 50 9.6 -7 -12.3 California 5 902 12.4 847 11.6 -55 -6.1 Colorado 5 120 11.6 114 11.0 -6 -5.0 Connecticut 4 42 7.2 42 7.1 -1 -1.7 Delaware 4 14 8.2 13 7.8 -1 -4.9 District of Columbia 4 14 7.9 14 7.8 0 -0.9 Hawaii 4 19 7.7 19 7.5 -1 -3.3 Idaho 3 43 13.9 40 12.9 -3 -7.0 Illinois 5 248 11.1 244 10.9 -4 -1.4 Indiana 3 116 10.2 110 9.7 -5 -4.4 Iowa 3 33 6.5 32 6.2 -1 -3.8 Kentucky 3 61 8.2 48 6.5 -13 -20.9 Louisiana 1 104 12.7 86 10.4 -18 -17.5 Maine 5 11 5.5 10 5.0 -1 -9.6 2 Enhanced PTCs Enhanced PTCs Expire Are Extended Change Abortion Number of Number of access uninsured Uninsurance uninsured Uninsurance status (1,000s) rate (%) (1,000s) rate (%) 1,000s % Maryland 5 96 8.7 93 8.4 -3 -3.3 Massachusetts 4 63 5.2 63 5.1 0 -0.7 Michigan 4 116 7.7 103 6.8 -13 -11.5 Minnesota 4 61 6.5 58 6.1 -3 -5.5 Missouri 1 128 12.2 113 10.7 -16 -12.1 Montana 4 20 11.7 18 10.6 -2 -9.3 Nebraska 3 28 8.8 26 8.1 -2 -8.4 Nevada 4 105 17.4 99 16.3 -6 -6.2 New Hampshire 4 15 7.4 13 6.3 -2 -14.9 New Jersey 5 175 11.7 158 10.5 -18 -10.1 New Mexico 5 51 13.9 50 13.5 -1 -2.7 New York 5 270 7.3 268 7.2 -2 -0.7 North Dakota 3 16 12.9 15 12.1 -1 -6.2 Ohio 2 150 8.2 132 7.2 -19 -12.4 Oklahoma 1 92 13.3 77 11.1 -15 -16.1 Oregon 7 82 11.4 80 11.1 -2 -2.5 Pennsylvania 3 143 6.9 132 6.3 -11 -7.4 Rhode Island 4 12 6.8 12 6.8 0 -0.4 Utah 3 63 10.1 59 9.5 -4 -6.2 Vermont 5 8 9.1 8 8.8 0 -2.8 Virginia 4 160 10.1 152 9.6 -8 -4.8 Washington 5 157 11.7 152 11.4 -5 -3.0 West Virginia 3 31 11.0 28 10.3 -2 -6.8 Women ages 19–44 in nonexpansion states 3,487 19.3 2,896 16.1 -591 -17.0 Alabama 1 145 17.2 133 15.7 -13 -8.8 Florida 3 672 18.8 547 15.3 -125 -18.6 Georgia 3 401 19.8 315 15.6 -85 -21.3 Kansas 3 84 16.9 78 15.7 -6 -7.1 Mississippi 1 94 18.1 81 15.7 -12 -13.1 North Carolina 4 308 16.3 250 13.2 -58 -18.9 South Carolina 2 140 15.8 112 12.7 -28 -20.0 South Dakota 1 22 15.3 20 13.7 -2 -10.0 Tennessee 2 173 14.7 150 12.8 -22 -13.0 Texas 1 1,361 25.0 1,129 20.8 -232 -17.1 Wisconsin 3 69 7.4 64 6.8 -6 -8.3 Wyoming 4 18 17.2 17 16.3 -1 -5.1 Sources: Urban Institute Health Insurance Policy Simulation Model, 2022; and "Interactive Map: US Abortion Policies and Access after Roe," Guttmacher Institute, accessed July 11, 2022, https://states.guttmacher.org/policies/. Notes: Enhanced PTCs = enhanced premium tax credits under the American Rescue Plan Act. State abortion access status is classified from most restrictive to most protective: 1 = most restrictive, 2 = very restrictive, 3 = restrictive, 4 = some restrictions/protections, 5 = protective, 6 = very protective, and 7 = most protective. NOTES 1 This fact sheet provides additional information based on our earlier brief: Matthew Buettgens, Jessica Banthin, and Andrew Green, "What If the American Rescue Plan Act Premium Tax Credits Expire?" (Washington, DC: Urban Institute, 2022). 2 Kate Grindlay and Daniel Grossman, "Prescription Birth Control Access among U.S. Women at Risk of Unintended Pregnancy" Journal of Women's Health 25, no. 3 (2016): 249–54, https://doi.org/10.1089/jwh.2015.5312; Megan L. Kavanaugh and Emma Pliskin, "Use of Contraception among Reproductive-Aged Women in the United States, 2014 and 2016" F&S Reports 1, no. 2 (2020): 83–93, https://doi.org/10.1016/j.xfre.2020.06.006; and Emily M. Johnston and Stacey McMorrow, "The Relationship 3 between Insurance Coverage and Use of Prescription Contraception by Race and Ethnicity: Lessons from the Affordable Care Act" Women's Health Issues 30, no. 2 (2019): 73–82, https://doi.org/10.1016/j.whi.2019.11.005. 3 "Preventive Care Benefits for Women," Healthcare.gov, accessed July 11, 2022, https://www.healthcare.gov/preventive-care- women/. 4 Data on plan selections at the end of open enrollment periods in all years since 2014 show that 54 percent or more of enrollees of all ages were women; see "State Category | 2022 Marketplace Open Enrollment," Kaiser Family Foundation, accessed July 11, 2022, https://www.kff.org/state-category/affordable-care-act/2022-marketplace-open-enrollment-period/. 5 "Interactive Map: US Abortion Policies and Access after Roe," Guttmacher Institute, accessed July 11, 2022, https://states.guttmacher.org/policies/. ABOUT THE AUTHORS Jessica Banthin is a senior fellow, Andrew Green is a research analyst, and Michael Simpson is a principal research associate in the Health Policy Center at the Urban Institute. ACKNOWLEDGMENTS This research is funded by the Robert Wood Johnson Foundation. The views expressed do not necessarily reflect the views of the Foundation. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders. Further information on the Urban Institute's funding principles is available at urban.org/fundingprinciples. Copyright © July 2022. Urban Institute. Permission is granted for reproduction of this file, with attribution to the Urban Institute. 4