Health coverage plays a critical role in enabling women to access health care. It can alleviate some of health care’s financial burden and often determines whether or not individuals seek care at all. For example, before the passage of the Affordable Care Act (ACA), nearly half (48 percent) of women ages 19–64 reported delaying medical care due to cost, but this number has dropped by more than 40 percent (to only 28 percent) since the law was enacted.1 This decrease was largely driven by expansions in health coverage: the uninsured rate for women has dropped by half since the ACA was passed (20 percent to 10 percent).2

Despite the strides made by the ACA in removing many systemic barriers to care over the past decade, health insurance coverage affordability is still a problem for some women, a concern which pertains not only to plan premiums, but also to deductibles, copays, and any other out-of-pocket expenses—essentially, any cost incurred because the individual’s plan may be inadequate. With premiums expected to rise by as much as 10 percent in 2024—at a time when health care costs also continue to grow—many women still have difficulty accessing the care they need due to inadequate insurance coverage, or to not having any insurance at all.3 The affordability of health insurance is a persistent issue and will continue to be a challenge without action at the federal or state level.4

The affordability of health coverage is a problem across a number of demographics and insurance types. The analysis in this report will focus on women who have private health insurance—which is the most common source of coverage for women (66.4 percent)—and the affordability barriers that they face.5 Women overall have a lower uninsured rate than men (10 percent and 13 percent, respectively), but significant racial disparities exist, and out-of-pocket spending burdens women more than men, even when they have health insurance.6 Inequities along the fault lines of gender impact an individual’s economic security, and, by extension, their access to high-quality coverage and care and ultimately the health outcomes they experience.

This report aims to provide a more comprehensive understanding of the affordability barriers that persist for women in the U.S. health care system, as well as the policy solutions states could take to address these barriers.

It’s crucial to acknowledge that individuals who do not identify as women also require many of the services discussed in this report, including reproductive care and maternity services, and are also impacted by cost-related barriers to care. Unfortunately, research on these topics does not often differentiate between transgender and nonbinary people assigned female at birth and cisgender women, resulting in less data available for those communities. For further discussion, a previous TCF policy paper details affordability challenges for LGBT individuals, including transgender and non-binary individuals who may face obstacles affording reproductive and maternity care.7

Expensive Coverage Is a Continuing Challenge for Women

Prior to the ACA’s passage in 2010, 20 percent of U.S. women were uninsured, and even those who had coverage faced a host of inequities.8 Insurance companies were legally able to—and often did—deny coverage for preexisting conditions such as pregnancy, breast cancer, or treatment for domestic violence. Nearly one in two girls under 18 and nonelderly women had a preexisting condition.9 Insurance companies could also charge women more than men for the same level of coverage—often charging women as much as 1.5 times more—in a practice called gender rating.10 These and other practices served as discriminatory financial barriers to women accessing health insurance and care.

The ACA’s passage in 2010 and subsequent implementation significantly improved women’s experiences with health insurance. The ACA prohibited insurance companies from denying coverage due to preexisting conditions and banned gender rating, enabling over 10 million women to gain health care coverage.11 Further, the ACA guaranteed coverage for preventative services such as mammograms, cervical cancer screenings, and birth control, and mandated that these services be free from cost-sharing, thereby removing another major barrier to care.12 In addition to these provisions, the ACA expanded Medicaid coverage to include everyone whose income was 138 percent of the federal poverty level (FPL), less than $20,000 for a family of three at the time.13 This expansion provided an important pathway to affordable health care for millions of low-income women.

Women Still Experience Persistent Barriers to Affordable Coverage

While women’s coverage rates and guaranteed benefits have improved in the last two decades, significant disparities remain. Efforts to dismantle the ACA led to a 2012 U.S. Supreme Court ruling that limited the federal government’s enforcement powers, effectively making Medicaid expansion optional for states.14 Despite the benefits of Medicaid expansion (both in cost-sharing and health equity), ten states have chosen not to implement this provision, creating a coverage gap where residents have incomes too high to qualify for Medicaid but too low to qualify for Marketplace subsidies.15 In the states that have yet to expand Medicaid, nearly 900,000 women fall into this gap and are left without access to the coverage they desperately need.16

Race and gender pay gaps also persist, and women—particularly Black and Latina women—are overrepresented in low-wage and part-time work in sectors that have historically devalued women’s labor, such as the care sector. As a result, women have lower incomes and less in savings than men, making it more difficult to afford health care premiums and the uncovered costs of care.17

The same systemic racism that pushes women of color into lower-paying and/or part-time work also results in these women being more likely to lack insurance coverage altogether. Around 20 percent of Hispanic women and American Indian/Alaska Native women were uninsured in 2022, as were around 10 percent of Black women.18 Only 6 percent of white women lacked health coverage in 2022.19 Figure 1 shows these disparities.

Figure 1

The impact of high cost-sharing also serves to make care unaffordable. With average deductibles for private insurance reaching $2,379 for insured workers at small firms and $1,397 at larger firms, health care can be a huge financial strain even for those with insurance.20 Despite the ACA’s protections, women with employer-based coverage continue to face 20 percent higher out-of-pocket costs than men.21 In total, out-of-pocket health care is estimated to be $15 billion more per year for employed women than it is for employed men.22

Despite the ACA’s protections, women with employer-based coverage continue to face 20 percent higher out-of-pocket costs than men.

This burden is further exacerbated by the fact that most households’ savings fall short of the maximum out-of-pocket limit allowed for most private plans: the median multi-person household has $6,704 in liquid assets, while the maximum out-of-pocket limit in private plans amounts to $15,800.23 For women of color, paying for these high out-of-pocket costs is especially burdensome. As of 2022, the median wealth of a Black family was $44,900 and Latinx families $61,600, relative to $285,000 for white families.24 Similarly, the gender pay gap also hits women of color hardest: Black women were only paid 70 cents for every dollar a white man was paid in 2022, and Hispanic women were only paid 65 cents.25

When women do not have access to insurance through their employer, they are left to navigate limited choices within public or private insurance options and are further constrained when they are ineligible for Medicaid, or live in non-expansion states. These limitations underscore the importance of robust, affordable coverage sources such as Marketplace plans, especially in the non-expansion states. The financial strain on women—both insured and uninsured—is further intensified by their higher health needs and utilization rates, stemming from longer life expectancy, higher morbidity rates, and specific health care needs related to pregnancy care, family planning, and menopause.26

High costs of care for women also have dangerous implications for their health in more direct ways. Nearly 30 percent of women reported that they have skipped or postponed care within the past year because of concerns about financial security.27 Forgoing care can often lead to delayed or missed diagnoses, and ultimately to poor health outcomes. Women are also much more likely than men to stop taking needed medications because of cost concerns—yet another way in which they are particularly vulnerable to the high out-of-pocket cost of treatments.28

The High Cost and Poor Coverage of Common Women’s Health Services

Women with private insurance often secure their plans through employer-sponsored insurance (56.9 percent) or through state or federal Marketplaces (8.1 percent).29 But regardless of the avenue through which insurance is obtained, women’s health services may remain a challenge to obtain and to afford. For example, the out-of-pocket cost for a prenatal blood test could range from $20 to as much as $80, depending on a person’s health insurance status.30 An investigation by the Washington Post found significant variance in the price charged at the same hospital, depending on how a patient contacted the hospital.31 For uninsured women, health services may be even more expensive if they are paying for the entire costs.

Additionally, an ongoing lawsuit, Braidwood Management Inc. v. Becerra, threatens to undermine the progress made under the ACA by removing zero-cost-sharing access to many critical health services.32 The ACA’s requirement to cover certain services without cost-sharing has repeatedly been shown to have improved access to care.33

Reproductive Health Care

Reproductive health services are a critical area where coverage limitations persist. In the wake of the Supreme Court ruling in Dobbs v. Jackson Women’s Health Organization, which overturned the federal right to an abortion, states across the country have banned abortion care.34 Another case, Idaho and Moyle, et al. v. United States, has the potential to further undermine abortion access.35 In the case, Idaho politicians have sued, arguing that the requirement to provide necessary emergency care, including abortion care, to patients under the Emergency Medical Treatment and Labor Act (EMTALA) does not supersede the state’s abortion ban.36The U.S. Supreme Court recently sent the case back to lower courts after agreeing to hear the case in January in response to Idaho’s emergency request, continuing the potential for this case to further limit abortion access.37

However, these cases and their fallout are not the only barriers women face to reproductive health care. Unlike other essential health benefits, the ACA explicitly exempts abortion from its coverage requirements and allows states to pass laws that further restrict coverage options.38 Currently, twenty-six states have enacted laws prohibiting the coverage of most types of abortions through plans offered on their state’s Marketplace.39 People with employer-sponsored insurance also face coverage issues: eleven states currently have laws in place that restrict the type of abortion coverage that private health insurance plans can offer.40

In addition, one study found that 69 percent of patients who receive abortions, including those with employer-sponsored coverage, pay out-of-pocket.41 The most common reason reported for not using their insurance was that abortion was not covered by their plan. For many people, the cost of an abortion exceeds their ability to pay. Planned Parenthood reports that medication abortion care averages around $580, first-trimester procedural abortion care can cost up to $800, and a second trimester abortion can cost up to $2,000.42

For context, 37 percent of Americans would not be able to pay for a $400 emergency expense with money currently available in their accounts, and women of color are even less likely to have any financial cushion to rely on in times of crisis.43 Although organizations known as abortion funds exist to assist patients with out-of-pocket costs, they do not meet the need created by restrictions on insurance coverage of abortion care.44

In addition to unaffordable abortion care, contraceptive care can also be unaffordable for many women, including women with health coverage. The ACA eliminated deductibles, copayments, and other out-of-pocket costs related to contraception. However, 13 percent of workers with employer-sponsored coverage are enrolled in a “grandfathered” plan that is exempt from many ACA requirements, including these contraceptive requirements.45

On top of these costs, many insurance plans refuse to fully cover newer contraceptive options under the pretense that they already cover other versions in the same category.46 Patients who prefer or need these uncovered options must go through lengthy and confusing prior authorization processes, and yet may still be denied coverage and left with the bill. In addition, legal challenges to the ACA have further restricted access to contraception by allowing employers to claim religious or moral exemptions to contraception coverage, leaving their employees to pay out-of-pocket or find alternative coverage options to receive the care they need.47

In 2020, 21 percent of women with private insurance were still paying some out-of-pocket costs for contraception, whether because of a grandfathered plan, a preference for a brand-name contraceptive, or getting health insurance through an organization that has objections to contraceptive coverage.48 Addressing this gap in coverage is crucial to advancing health equity for women.

Maternal Health Care

While the ACA mandates coverage for childbirth-related services, including prenatal care and delivery, the prices for these services are inordinately high and continue to rise. For example, a 2019 study by the Health Care Cost Institute found that the total costs for a vaginal delivery and cesarean section were $11,170 and $15,030, respectively. The same study found that these prices are far higher than those in other wealthy, industrialized nations: the average price for both delivery types was around half the price charged in the United States. Since 2000, medical inflation has consistently outpaced nationwide inflation and wage growth.49 As costs for maternity care continue to rise, even insured women and other birthing people must shoulder the burden.

The high prices for maternal care trickle through into out-of-pocket spending. For families with employer-sponsored insurance, the average out-of-pocket cost for a vaginal delivery is $2,655, while a cesarean section costs $3,214.50 These price tags are more than many families can afford: about one-third of families and half of single-person households do not have the liquid assets to cover these out-of-pocket costs.51

High out-of-pocket costs are a major barrier and may deter women from seeking necessary care. This is particularly concerning given the country’s poor maternal health outcomes, particularly for Black and Indigenous women. Racial disparities in maternal health are caused by complex and interconnected factors, including discrimination in maternal health care settings, systemic oppression and its impacts on economic well-being, access to health care writ large, and the broader social determinants that allow pregnant people to thrive.52 Cost can be an added deterrent to necessary maternal health services—especially for the communities already facing the worst outcomes.

The existence of maternity care deserts—areas in which maternity care is limited or absent—contributes to and increases the impact of these high costs. The development of these deserts is partially driven by increasing consolidation, wherein private equity firms purchase hospitals and often close less profitable service lines, even if those service lines provide essential care such as maternity care.53 Even when women have access to private insurance, the number of available providers is shrinking, particularly in rural communities, where options have always been more limited.54

Health insurance only works if you have a place to use it.

Health insurance only works if you have a place to use it. For women who have lost their local trusted place of care, the complexities, costs, and travel involved in finding new providers may be layered on top of pre-existing financial barriers related to accessing care. These barriers to physical access to care are only growing worse in the wake of the U.S. Supreme Court’s decision in Dobbs, because women’s health care providers are avoiding setting down roots in states where abortion is criminalized.55

Mental Health Care

In 2022, 50 percent of women reported needing mental health services in the previous two years, compared to 35 percent of men.56 Overall, women experience several mental health conditions, such as depression, at twice the rate as men.57 In addition, some mental health disorders, such as perinatal depression and premenstrual dysphoric disorder, are unique to women and people who can become pregnant.58

The ACA added mental health services to its list of essential health benefits, and other laws have required private insurance to have parity in coverage of mental as well as physical health services.59 However, private insurance companies make it difficult for both patients and providers to prove that services are necessary. For example, private insurance acceptance rates were 30 percent lower for psychiatrists than for physicians of other specialties.60 Of the privately insured women who had a mental health appointment in the previous two years, 20 percent said their provider did not accept their insurance, and one-third of privately insured women reported not making an appointment due to cost concerns.61

State-Level Policies That Can Minimize Affordability Challenges

States seeking to tackle the problems of inaccessible and unaffordable coverage for women should pursue policies that would 1) expand coverage, 2) make coverage more affordable, and 3) lower the root cost of care, which drives high premiums and out-of-pocket costs. This section outlines several ways states can accomplish these goals.

Expand Coverage

In order for health care to be affordable, states must first ensure that all residents have access to some form of health insurance. Insurance status is one of the biggest predictors of struggling to afford health care. There are a couple ways states can expand coverage.

Expand Medicaid. A critical step to expanding access to affordable health care is for states to expand Medicaid eligibility to cover all residents with incomes up to 138 percent of the FPL (around 20,800 for a single adult or $35,600 for a family of three, in 2024), as originally proposed in the ACA. Medicaid expansion helps all individuals access affordable health care of all kinds, yet it has an outsized impact on women because it ensures coverage of reproductive and maternal health services.62

Medicaid expansion helps all individuals access affordable health care of all kinds, yet it has an outsized impact on women because it ensures coverage of reproductive and maternal health services.

Expanding Medicaid also makes financial sense for states, as the federal government pays 90 percent of expansion costs.63 Recent federal laws provide additional payments to states that expand Medicaid, and these payments may result in states paying no new costs for some period after expanding Medicaid.64

Extend postpartum coverage. Another way for states to enhance women’s health coverage is to extend postpartum coverage to a full year.65 The American Rescue Plan has provided states with the option to extend postpartum coverage from the previous duration of sixty days to twelve months.66 Having only sixty days of coverage after birth poses both mental and physical health risks.

Extending coverage to twelve months is crucial not only for protecting new parents from medical debt but also ensuring that they are able to seek care for any postpartum health issues they may face, as risks of maternal morbidities persist throughout the postpartum period.67 This includes risks to mental and emotional health, such as postpartum depression, which often does not appear until six months or more after childbirth.

Create a public option. Another way states could effectively expand access to affordable coverage for women is by establishing a public option. A public option is a public health insurance plan through which residents can purchase coverage, primarily targeted at nonelderly adults whose incomes make them ineligible for Medicaid.68 Three states—Washington, Colorado, and Nevada—have enacted public option laws, and Washington and Colorado’s public options have already gone into effect.

Notably, all three states operate their public options as public–private partnerships, creating tightly regulated private plans, rather than the state taking on the actuarial risk.69 These plans all have goals of improving access to affordable coverage, and Colorado and Nevada both include improving health equity as a goal as well. A public option has the added benefit of introducing more competition into a marketplace that is becoming increasingly financialized and consolidated.

In particular, a state public option could be a useful tool to connect lower-income women who are not eligible for Medicaid with comprehensive health coverage. Around one in five women with incomes below 200 percent FPL are uninsured, compared to only 7 percent of women above this threshold.70 When combined with the cost-containment goals and mechanisms like those seen in every state’s public option so far, public options could represent a new, more affordable form of coverage, especially for women whose incomes make them ineligible for Medicaid.

Improve the Affordability of Coverage

States can also enact policies that improve the overall affordability of coverage for women. To be comprehensive, these policies should address every part of the health system where patients may face affordability barriers: premiums should be affordable, needed health services should be covered, and cost-sharing should not deter patients from seeking care.

Ensure comprehensive contraceptive coverage. State-level laws should, at a minimum, align with federal standards that mandate coverage for the full range of contraceptive methods, counseling, and services without cost-sharing. Additionally, states can build on federal requirements by mandating coverage for contraceptive methods available over the counter and approving extended supplies of contraceptives (for example, a one-year supply, rather than a typical one- or three-month supply) without out-of-pocket costs.71

Require abortion coverage. States should support abortion access within their Marketplaces and other private plans. Currently, only ten states require abortion coverage in Medicaid, private, and Marketplace plans.72 By requiring private plans and Marketplace insurers to cover abortion services without cost-sharing, states can ensure that women with private insurance can access abortion just as they can every other reproductive health service. Even beyond those directly affected, private coverage of abortion care without cost-sharing would also benefit the population without private insurance by freeing up additional resources from abortion funds to be distributed to others who do not have coverage for their care.

Mandate no-cost mental health preventive service coverage. States can improve the affordability of high-quality health care by mandating that private insurance plans cover recommended mental health and behavioral health services to treat conditions early without any patient cost-sharing. Some states have already taken steps in this direction; for instance, New Mexico enacted the No Behavioral Health Cost Sharing Act in 2021, which requires private insurers to waive copays, coinsurance, and deductibles for all behavioral health services. Similarly, states such as Colorado, Connecticut, Delaware, Massachusetts, and Maine have passed legislation mandating coverage of annual mental health wellness exams without patient cost-sharing.73

Improve insurance rate review. Another strategy to address the high cost of private insurance in enhanced insurance rate review. The ACA requires insurers planning to significantly increase their plan premiums to submit their rates for review by either the state or federal government.74 This process is “designed to improve insurer accountability and transparency. It ensures that experts evaluate whether the proposed rate increases are based on reasonable cost assumptions and solid evidence and gives consumers the chance to comment on proposed increases.”75

Enhanced insurance rate review processes serve as effective tools for containing costs and ensuring that insurance premiums remain reasonable and equitable for all policyholders. More powerful rate review processes—specifically, prior approval authority that requires that regulators approve rates in advance—have been associated with lower premiums in the individual market.76

Rhode Island, for example, is unique in that their health insurance commissioner is charged with promoting greater accessibility, quality, and affordability in the health insurance market, ultimately leading to insurance regulators overseeing the negotiated rates between insurers and hospitals.77 The Rhode Island state insurance department also has the authority to examine proposed premium increases charged by health insurance companies. This review process ensures that insurance companies have a legitimate reason to raise their prices. This enhanced insurance review has led to an average quarterly spending reduction of $55 per enrollee since 2010.78

Lower the Root Cost of Care

In addition to simply improving affordability of care for women, states should also work to lower the root cost of care. Doing so will support efforts to make care more affordable, lowering premiums and out-of-pocket costs by reducing the amount that insurers must spend on covered services.

Leverage a public option to lower costs. States can use the power of a public option to lower health care costs. Every state that has enacted a public option included lowering costs as a goal, often by requiring lower premiums to ensure that lower costs benefit patients. Building on these expected lower premiums, Washington and Colorado both applied for section 1332 waivers to further lower the cost of health insurance. These waivers, named for the section of the ACA which established them, allow states to test innovative ways to provide health coverage, and they allow for states to receive any savings achieved as “pass-through” funding.79

States that implement public options could then use these savings in a variety of ways: subsidizing premiums, lowering out-of-pocket costs (such as for maternal, reproductive, or behavioral health services), or requiring coverage of additional services. These subsidies could even be combined with existing state-funded subsidy programs, which nine states currently offer.80

In addition to these benefits, a public health insurance plan is also a statement that health care is a public good that should be accessible to everyone. It challenges the narrative that privatized health care is the best way forward and shows that government programs can and do work for people.

Enhance merger review laws. Another way to lower the root cost of care is to enhance merger review laws. Hospital consolidations decrease competition in a given area and increase hospitals’ negotiating power, leading to fewer choices and higher costs for patients with no associated improvement in quality.81 This is particularly concerning, given that hospital consolidation has increased dramatically in recent years.82 From 1998 to 2021, the American Hospital Association reported 1,887 hospital mergers—reducing the total number of hospitals from around 8,000 to just over 6,000.83 Although hospital operating costs decrease between 15 and 30 percent following a hospital merger, the price of hospital services can increase upwards of 6 to 18 percent.84 Consumers are often led to believe consolidation is key to driving down costs and improving quality of care, but research has proven both claims to be false.

Over the past decade, a growing number of religiously affiliated institutions have acquired smaller hospital systems. These consolidations often limit care options, particularly those related to reproductive health and pregnancy-related care. For example, when the acquiring health care system is affiliated with Catholicism, the acquired provider becomes beholden to the the Ethical and Religious Directives for Catholic Health Care Services, which explicitly prohibits the provision of contraception, abortion, and infertility services.85 Often, religiously affiliated hospitals are the only care available for patients in a geographic region, meaning women and other people who can become pregnant are denied access to these services, as well as sterilization and miscarriage management. Patients have been denied care even when facing life-threatening pregnancy complications.86 This trend is particularly troubling in the post-Dobbs landscape, where other reproductive health care options are quickly disappearing.

To combat these mergers and acquisitions, states can enhance their merger review laws. The National Academy for State Health Policy (NASHP) has launched the Model Act for State Oversight of Proposed Health Care Mergers, a tool that states can use to bolster their current merger review processes.87 The model authorizes the attorney general to review and block, or approve proposed mergers administratively, rather than go through the courts. This approach lowers the barriers to entry for a state to intervene in a proposed merger, allows states to more easily block problematic transactions, and empowers states to more easily impose requirements onto proposed mergers.

Women’s Health Care Affordability Is a Burden States Can Relieve

Despite the advances brought about by the ACA, women continue to face substantial barriers to accessing affordable private health coverage. Because women are less likely to be eligible for employer-sponsored coverage, have higher health needs than men, and have less overall savings to afford care, keeping private insurance affordable is important to maintaining women’s access to quality care.

States have a number of opportunities to improve the affordability of health insurance by expanding Medicaid and state laws pertaining contraceptive and maternal health access and coverage, ensuring that coverage of abortion services is required under private plans, reinforcing their insurance rate review process, and creating a public coverage option that is more affordable than the ones currently offered in the marketplace. Lastly, strong merger review and public option laws can help reduce the root cost of care, which has the downstream effect of making health care more affordable.

Notes

  1. Munira Z. Gunja et al., “How the Affordable Care Act Has Helped Women Gain Insurance and Improved Their Ability to Get Health Care,” The Commonwealth Fund, August 10, 2017, https://www.commonwealthfund.org/publications/issue-briefs/2017/aug/how-affordable-care-act-has-helped-women-gain-insurance-and; Lunna Lopes et al., “Americans’ Challenges with Health Care Costs,” KFF, March 1, 2024, https://www.kff.org/health-costs/issue-brief/americans-challenges-with-health-care-costs/.
  2. Ibid.
  3. Jared Ortaliza, Matthew McGough, Meghan Salaga, Krutika Amin, and Cynthia Cox. “How Much and Why 2024 Premiums Are Expected to Grow in Affordable Care Act Marketplaces,” Peterson-KFF Health System Tracker, August 4, 2023, https://www.healthsystemtracker.org/brief/how-much-and-why-2024-premiums-are-expected-to-grow-in-affordable-care-act-marketplaces/.
  4. “Why Are Americans Paying More for Healthcare?” Peter G. Peterson Foundation
  5.  Robin A. Cohen and Emily P. Terlizzi, “Demographic Variation in Health Insurance Coverage: United States, 2022,” Centers for Disease Control and Prevention, November 9, 2023, https://www.cdc.gov/nchs/data/nhsr/nhsr193.pdf.
  6. “Women’s Health Insurance Coverage,” KFF, December 13, 2023, https://www.kff.org/womens-health-policy/fact-sheet/womens-health-insurance-coverage/.
  7. Thomas Waldrop, “Equitable Insurance Coverage and Access Can Advance LGBT Health,” The Century Foundation, October 2, 2023, https://tcf.org/content/commentary/equitable-insurance-coverage-and-access-can-advance-lgbt-health/.
  8. “New Women’s Health Care Report: 20 Percent of U.S. Women Were Uninsured in 2010, up from 15 Percent in 2000; U.S. Women Much More Likely to Struggle with Medical Bills and Go without Needed Care than Women in Countries with Universal Coverage,” The Commonwealth Fund, July 13, 2012, https://www.commonwealthfund.org/press-release/2012/new-womens-health-care-report-20-percent-us-women-were-uninsured-2010-15-percent.
  9. Nicole Rapfogel, Emily Gee, and Maura Calsyn, “10 Ways the ACA Has Improved Health Care in the Past Decade,” Center for American Progress, March 23, 2020, https://www.americanprogress.org/article/10-ways-aca-improved-health-care-past-decade/.
  10. Ibid.
  11. Sara Sugar, Joel Ruhter, Sarah Gordon, Amelia Whitman, Christie Peters, Nancy DeLew, and Benjamin D. Sommers, “Health Coverage for Women under the Affordable Care Act,” Office of the Assistant Secretary for Planning and Evaluation, March 21, 2022, https://aspe.hhs.gov/reports/health-coverage-women-under-aca.
  12. Lois Kaye Lee, Michael Carl Monuteaux, and Alison Amidei Galbraith, “Women and Healthcare Affordability after the ACA,” Journal of General Internal Medicine, March 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7080875/.
  13. “Medicaid Expansion & What It Means for You,” Medicaid & CHIP, accessed April 3, 2024, https://www.healthcare.gov/medicaid-chip/medicaid-expansion-and-you/.
  14. National Federation of Independent Business v. Sebelius, 567 U.S. 519 (2012).
  15. Thomas Waldrop, “Mississippi Is Looking to Expand Medicaid. Other Holdout States Should Too.” The Century Foundation, April 2, 2024, https://tcf.org/content/commentary/mississippi-is-looking-to-expand-medicaid-other-holdout-states-should-too/.
  16. Madeline Guth and Karen Diep, “What Does the Recent Literature Say about Medicaid Expansion?: Impacts on Sexual and Reproductive Health,” KFF, June 29, 2023, https://www.kff.org/medicaid/issue-brief/what-does-the-recent-literature-say-about-medicaid-expansion-impacts-on-sexual-and-reproductive-health/.
  17. Juli Adhikari, Jessica Milli, and Maggie Jo Buchanan, “The Economic, Educational, and Health-Related Costs of Being a Woman,” Center for American Progress, March 30, 2022, https://www.americanprogress.org/article/the-economic-educational-and-health-related-costs-of-being-a-woman/; “Part-Time Workers Are Facing Heightened Uncertainty during COVID-and Most Are Women,” National Women’s Law Center, February 2, 2022, https://nwlc.org/resource/part-time-workers-factsheet/.
  18. “Women’s Health Insurance Coverage,” KFF.
  19. Ibid.
  20. Gregory Young, Matthew Rae, Gary Claxton, Emma Wager, and Krutika Amin, “How Many People Have Enough Money to Afford Private Insurance Cost Sharing?” Peterson-KFF Health System Tracker, March 10, 2022, https://www.healthsystemtracker.org/brief/many-households-do-not-have-enough-money-to-pay-cost-sharing-in-typical-private-health-plans/.
  21. “Hiding in Plain Sight: The Health Care Gender Toll.” Deloitte, September 28, 2023, https://www2.deloitte.com/us/en/pages/life-sciences-and-health-care/articles/womens-health-equity-disparities.html.
  22. Ibid.
  23. Young et al, “How Many People Have Enough Money to Afford Private Insurance Cost Sharing?”
  24. Aditya Aladangady, Andrew C. Chang, Jacob Krimmel, and Eva Ma, “Greater Wealth, Greater Uncertainty: Changes in Racial Inequality in the Survey of Consumer Finances,” Board of Governors of the Federal Reserve System, October 18, 2023, https://www.federalreserve.gov/econres/notes/feds-notes/greater-wealth-greater-uncertainty-changes-in-racial-inequality-in-the-survey-of-consumer-finances-20231018.html#fig1.
  25. Rakesh Kochhar, “The Enduring Grip of the Gender Pay Gap,” Pew Research Center, March 1, 2023, https://www.pewresearch.org/social-trends/2023/03/01/the-enduring-grip-of-the-gender-pay-gap/#gender-pay-gap-differs-widely-by-race-and-ethnicity.
  26. Avni Gupta and José A. Pagán, “Reported Health Care Affordability for US Men and Women with Employer-Sponsored Health Coverage,” JAMA, December 27, 2022, https://jamanetwork.com/journals/jama/fullarticle/2799923.
  27. Lopes et al., “Americans’ Challenges with Health Care Costs.”
  28. Lee, Monuteaux, and Galbraith, “Women and Healthcare Affordability after the ACA.”
  29. Robin A. Cohen and Emily P. Terlizzi, “Demographic Variation in Health Insurance Coverage: United States, 2022.”
  30. Stephanie Guinan, “Costs of Common Prenatal Tests,” ValuePenguin, March 4, 2024, https://www.valuepenguin.com/costs-common-prenatal-tests.
  31. Lindsey Bever, “Having a Baby? The Cost of Birth Varies by State, Website and Phone Call.” Washington Post, October 4, 2023, https://www.washingtonpost.com/wellness/2023/10/04/hospital-prices-childbirth/.
  32. Thomas Waldrop, “Access to Preventive Care Is Essential to Achieving Health Equity,” The Century Foundation, March 21, 2023, https://tcf.org/content/commentary/access-to-preventive-care-is-essential-to-achieving-health-equity/.
  33. Ibid.
  34. Dobbs v. Jackson Women’s Health Organization, 597 U.S. ___ (2022); “State Bans on Abortion throughout Pregnancy,” Guttmacher Institute, May 1, 2024, https://www.guttmacher.org/state-policy/explore/state-policies-abortion-bans.
  35. “Idaho and Moyle, et al. v. United States,” American Civil Liberties Union, April 24, 2024, https://www.aclu.org/cases/idaho-and-moyle-et-al-v-united-states.
  36. Ibid.
  37. Ann E. Marimow and Dan Diamond, “Supreme Court Officially Allows Emergency Abortions in Idaho, for Now,” Washington Post, June 27, 2024, https://www.washingtonpost.com/politics/2024/06/27/supreme-court-abortion-emergency-room-hospital-impact/.
  38. Alina Salganicoff, Adara Beamesderfer, Nisha Kurani, and Laurie Sobel, “Coverage for Abortion Services and the ACA,” KFF, September 19, 2014, https://www.kff.org/womens-health-policy/issue-brief/coverage-for-abortion-services-and-the-aca/.
  39. “Women’s Health Insurance Coverage,” KFF.
  40. Ushma D. Upadhyay et al., “Trends in Self-Pay Charges and Insurance Acceptance for Abortion in the United States, 2017–20,” Health Affairs 41, no. 4 (April 1, 2022): 507–15, https://doi.org/10.1377/hlthaff.2021.01528.
  41. Ibid.
  42. “How Much Does an Abortion Cost?” Planned Parenthood, April 29, 2022, https://www.plannedparenthood.org/blog/how-much-does-an-abortion-cost.
  43. “Report on the Economic Well-Being of U.S. Households,” Board of Governors of the Federal Reserve System, May 22, 2022, https://www.federalreserve.gov/consumerscommunities/sheddataviz/unexpectedexpenses.html.
  44. Ann Bernstein and Benny Del Castillo, “Spotlight on an Abortion Fund: How Funds Help Fill the Gap for Pregnant People in Need,” The Century Foundation, October 12, 2022, https://tcf.org/content/report/spotlight-on-an-abortion-fund-how-funds-help-fill-the-gap-for-pregnant-people-in-need/.
  45. Adam Sonfield, “A Fragmented System: Ensuring Comprehensive Contraceptive Coverage in All U.S. Health Insurance Plans,” Guttmacher Institute, February 2, 2021, https://www.guttmacher.org/gpr/2021/02/fragmented-system-ensuring-comprehensive-contraceptive-coverage-all-us-health-insurance.
  46. Abigail Abrams, “Why Your Insurance Doesn’t Want to Cover Your Birth Control,” TIME, April 25, 2022, https://time.com/6168840/birth-control-insurance-coverage/.
  47. Nina Totenberg, “Supreme Court Undercuts Access To Birth Control Under Obamacare,” NPR, May 8, 2020, https://www.npr.org/2020/07/08/884104509/supreme-court-undercuts-access-to-birth-control-under-obamacare.
  48.  Brittni Frederiksen, Usha Ranji, Alina Salganicoff, and Michelle Long, “Women’s Sexual and Reproductive Health Services: Key Findings from the 2020 KFF Women’s Health Survey,” KFF, April 21, 2021, https://www.kff.org/womens-health-policy/issue-brief/womens-sexual-and-reproductive-health-services-key-findings-from-the-2020-kff-womens-health-survey/.
  49. Shameek Rakshit et al., “How Does Medical Inflation Compare to Inflation in the Rest of the Economy?,” Peterson-KFF Health System Tracker, May 17, 2024, https://www.healthsystemtracker.org/brief/how-does-medical-inflation-compare-to-inflation-in-the-rest-of-the-economy/.
  50. Matthew Rae, Cynthia Cox, and Hanna Dingel, “Health Costs Associated with Pregnancy, Childbirth, and Postpartum Care,” Peterson-KFF Health System Tracker, July 13, 2022, https://www.healthsystemtracker.org/brief/health-costs-associated-with-pregnancy-childbirth-and-postpartum-care/.
  51. Ibid.
  52. Jamila Taylor, “Structural Racism as a Root Cause of America’s Black Maternal Health Crisis,” The Century Foundation, May 6, 2021, https://tcf.org/content/commentary/structural-racism-root-cause-americas-black-maternal-health-crisis/.
  53. Oakman, Waldrop, and Brierley, “How States Can Advance Equity When Addressing Health Care Consolidation.”
  54. Christina Brigance et al., “Maternity Care Deserts Report,” March of Dimes, October 2022, https://www.marchofdimes.org/maternity-care-deserts-report.
  55. Dobbs v. Jackson Women’s Health Organization, 597 U.S. ___ (2022); Stolberg, Sheryl Gay. “As Abortion Laws Drive Obstetricians from Red States, Maternity Care Suffers.” The New York Times, September 6, 2023. https://www.nytimes.com/2023/09/06/us/politics/abortion-obstetricians-maternity-care.html.
  56. Karen Diep, Brittni Frederiksen, Michelle Long, Usha Ranji, and Alina Salganicoff, “Access and Coverage for Mental Health Care: Findings from the 2022 KFF Women’s Health Survey,” KFF, December 20, 2022, https://www.kff.org/mental-health/issue-brief/access-and-coverage-for-mental-health-care-findings-from-the-2022-kff-womens-health-survey/.
  57. “Women’s Increased Risk of Depression,” Mayo Clinic, January 29, 2019, https://www.mayoclinic.org/diseases-conditions/depression/in-depth/depression/art-20047725.
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  60. Nicole Rapfogel, “The Behavioral Health Care Affordability Problem,” Center for American Progress, May 26, 2022, https://www.americanprogress.org/article/the-behavioral-health-care-affordability-problem/.
  61. Ibid.
  62. Jamila Taylor and Anna Bernstein, “The Medicaid Coverage Gap and Maternal and Reproductive Health Equity,” The Century Foundation, May 26, 2023, https://tcf.org/content/commentary/medicaid-coverage-gap-maternal-reproductive-health-equity/.
  63. “Medicaid Expansion to the New Adult Group,” Medicaid and CHIP Payment and Access Commission, March 30, 2023, https://www.macpac.gov/subtopic/medicaid-expansion/.
  64. Emily Gee and Thomas Waldrop, “Policies to Improve Health Insurance Coverage as America Recovers from Covid-19,” Center for American Progress, April 11, 2022, https://www.americanprogress.org/article/policies-improve-health-insurance-coverage-america-recovers-covid-19/.
  65. Jamila Taylor, “Promoting Better Maternal Health Outcomes by Closing the Medicaid Postpartum Coverage Gap,” The Century Foundation, October 16, 2020, https://tcf.org/content/report/promoting-better-maternal-health-outcomes-closing-medicaid-postpartum-coverage-gap/.
  66. Judith Soloman, “Closing the Coverage Gap Would Improve Black Maternal Health,” Center on Budget and Policy Priorities, July 26, 2021, https://www.cbpp.org/research/health/closing-the-coverage-gap-would-improve-black-maternal-health.
  67. Lindsay K. Admon, Vanessa K. Dalton, and Giselle E. Kolenic, “Comparison of Early and Late Postpartum Severe Maternal Morbidity in the US,” JAMA Network Open, December 8, 2021, https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2786942.
  68. Jamila Taylor and Thomas Waldrop, “States Must Prioritize Health Equity as They Expand Coverage through Public Options,” The Century Foundation, September 8, 2022, https://tcf.org/content/report/states-must-prioritize-health-equity-as-they-expand-coverage-through-public-options/.
  69. Dylan Scott, “The Public Option Is Now a Reality in 3 States,” Vox, June 17, 2021, https://www.vox.com/policy-and-politics/22535267/public-option-health-insurance-nevada-colorado-washington.
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  71. “Insurance Coverage of Contraceptives,” Guttmacher Institute, September 1, 2023, https://www.guttmacher.org/state-policy/explore/insurance-coverage-contraceptives.
  72. “Interactive: How State Policies Shape Access to Abortion Coverage,” KFF, December 11, 2023, https://www.kff.org/womens-health-policy/issue-brief/interactive-how-state-policies-shape-access-to-abortion-coverage/.
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  75. Ibid.
  76. Pinar Karaca-Mandic, Brent D. Fulton, Ann Hollingshead, and Richard M. Scheffler, “States with Stronger Health Insurance Rate Review Authority Experienced Lower Premiums in the Individual Market in 2010–13,” Health Affairs, August 2015, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2014.1463?journalCode=hlthaff.
  77. Ann Hwang and Michael H. Bailit, “Using Rate Review to Make Health Insurance More Affordable,” Commonwealth Fund, January 2023, https://www.commonwealthfund.org/sites/default/files/2023-01/Hwang_implementation_guide_rate_review.pdf.
  78. Johanna Butler, “Insurance Rate Review as a Hospital Cost Containment Tool: Rhode Island’s Experience,” NASHP, January 2, 2021, https://nashp.org/insurance-rate-review-as-a-hospital-cost-containment-tool-rhode-islands-experience/.
  79. Katie Keith, “Section 1332 Pass-Through Funding for 2021, New Health Plan Guidance,” Health Affairs, March 9, 2021, https://www.healthaffairs.org/content/forefront/section-1332-pass-through-funding-2021-new-health-plan-guidance.
  80. Louise Norris, “Which States Offer Their Own Health Insurance Subsidies?” healthinsurance.org, February 13, 2024,  https://www.healthinsurance.org/faqs/which-states-offer-their-own-health-insurance-subsidies/.
  81. Imani Telesford et al., “How Does the Quality of the U.S. Health System Compare to Other Countries?” Peterson-KFF Health System Tracker, October 24, 2023, https://www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries/.
  82. Andrea Flynn, Rakeen Mabud, and Emma Chessen, “The Plight of Health Care in Rural America: How Hospital Mergers and Closures Harm Women,” Roosevelt Institute, July 10, 2019, https://rooseveltinstitute.org/publications/plight-of-health-care-in-rural-america-hospital-mergers-closures-harm-women/.
  83. Hoag Levins, “Hospital Consolidation Continues to Boost Costs, Narrow Access, and Impact Care Quality,” Penn LDI, January 19, 2023, https://ldi.upenn.edu/our-work/research-updates/hospital-consolidation-continues-to-boost-costs-narrow-access-and-impact-care-quality/.
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  85. Morgan Casey, “Catholic Health System Mergers Limit Abortion, Birth Control in Blue States,” America After Roe, August 12, 2023, https://americaafterroe.news21.com/stories/catholic-hospital-erds-threaten-reproductive-abortion-safe-havens/.
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  87. “A Model Act for State Oversight of Proposed Health Care Mergers,” NASHP, December 11, 2021, https://nashp.org/a-model-act-for-state-oversight-of-proposed-health-care-mergers/.

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