By Susan Blumenthal, M.D. and Alexandrea Adams

The recent commemoration of National Womens Health Week provided an important time to mark the progress that has been made in advancing womens health over the past two decades and to highlight what more needs to be done to achieve womens health equity in America. Historically, women have experienced discrimination in health care despite making 80 percent of health care decisions for their families, using more medical services than men, and suffering greater disability from chronic disease. Before the mid 1990s, women were often excluded as subjects from medical research studies and underrepresented in the majority of clinical trials. Men were considered to be the generic humans in scientific studies, and the results from all male studies were then generalized to guide the diagnosis, treatment, and prevention of disease in women. Additionally, interventions to promote healthier lifestyles and prevent diseases like HIV/AIDS did not target womens unique needs. Inequalities in health care limited womens access to lifesaving diagnostic, treatment, and prevention services. Furthermore, many women paid more for their health insurance than men because of the possibility of pregnancy and their longer life expectancy (on average). This omission of women as research subjects and as the focus of prevention campaigns, as well as limitations on access to health care services had put their health at risk with rising rates of heart disease, diabetes, lung cancer, autoimmune illnesses, mental and substance use disorders, and the epidemic of AIDS.

I am proud to have played a leadership role in the 1990s as the countrys first Deputy Assistant Secretary for Womens Health in the U.S. Department of Health and Human Services to write a new national prescription to improve womens health in the Federal government, working with a broad range of partners in the public and private sectors in America and globally. The guiding principle of this prescription was that our countrys research, prevention, and service delivery programs must target all of the nations womenacross all ages, socioeconomic, racial and ethnic backgroundsaddressing the health needs of the whole woman, in body, mind and spirit. Some of the actions that were taken during my tenure in the position include weaving a focus on womens health into the missions of all U.S. health agencies, establishing National Centers of Excellence on Womens Health at academic centers across the country to foster multidisciplinary research, increasing public education, enhancing health care professional training on sex differences in disease, and fostering the career development of women in medicine. I also established the National Womens Health Information Center, which is a resource hub for comprehensive materials on a broad range of womens health issues and the Missiles to Mammograms initiative that transferred imaging technology from the CIA, NASA and DOD to improve the early detection of breast cancer and others.

In 1993, as a result of powerful advocacy efforts, the National Institute of Health Revitalization Act was passed. This Act requires women and minorities to be included in clinical trials supported at the NIH as a requirement for obtaining funding. Just last year, a new NIH regulation was enacted to ensure that both male and female animals and cells were included in basic science studies and that findings were analyzed for sex differences. These transformational policies guide how research is to be conducted in the United States to help achieve womens health equity.

The Patient Protection and Affordable Care Act of 2010 (ACA) legislation has also had transformational effects, adding an important element for advancing womens health that had been missing for all too longaccess to affordable, comprehensive health care. Prior to implementation of the ACA, there were 50 million uninsured Americans of whom 19 million were women. Women often paid more for insurance premiums than did men and were more likely to lose their insurance if divorced or widowed. In 2007, the number one cause of bankruptcies in the U.S. was lack of funds to pay medical bills. The American Journal of Public Health published a report in 2009 that estimated that 45,000 Americans died annually due to lack of health insurance. The United States was spending more than twice that of any other nation on health care but ranked 42nd on life expectancy and 37th out of 191 countries on the health status of our citizens. We were simply not getting what we paid for.

How the Affordable Care Act of 2010 (ACA) Improves Womens Health

Signed into law on March 23, 2010, The Patient Protection and Affordable Care Act included multiple provisions to achieve an efficient, effective, and equitable health care system for both women and men. Since its implementation in 2012, the ACA has reduced the number of uninsured women by 9.5 million in the United States. Additionally, the legislation allows youth to remain on their parents insurance plan until age 26 which resulted in 7.7 million young women currently having health insurance. Another victory of the ACA is its inclusion of a Patients Bill of Rights which eliminates the gender rating of premiums. Insurance companies are now prohibited from charging women higher rates than men for similar coverage. Insurance companies also cannot deny coverage to those people who have pre-existing conditions which often prevented women who were pregnant, had cancer, a mental illness, or any other condition from obtaining insurance or paying much higher premiums. Furthermore, the ACA prevents insurance companies from instituting lifetime benefit caps, dropping patients who file reimbursement claims, and ensures that at least 80 percent of premium payments are spent on health care instead of administrative costs.

The ACA established Health Exchanges in states around the country for people who do not have employer insurance or qualify for Medicaid to purchase individual plans. Women whose incomes are between 100 and 400 percent of the Federal Poverty Level (FPL) are now eligible for tax-credits towards the purchase of insurance plans within the Marketplaces established by the law.

Importantly, the ACA significantly expanded eligibility for the Medicaid program, which insures low-income individuals at or below 138 percent of the FPL. 31 states and Washington, D.C. have accepted the Medicaid expansion provision of the legislation. Medicaid provides health insurance to more than 74 million Americans, among them 60% of nursing home residents and millions of disabled people. Currently, two-thirds of Medicaid beneficiaries are women. In 2010 Medicaid paid for 48 percent of all births, three quarters of all public family planning services, and provided supplemental coverage for nearly 1 out of 5 senior women on Medicare. The Medicaid expansion also included a provision for continuous coverage 60 days following the birth of a womans baby. Before the ACAs Medicaid expansion, new mothers were ineligible in most states. The legislation has also helped women who do not have children obtain coverage.

The ACA mandates that all non-grandfathered insurance plans in the individual market and government health care plans must include ten Essential Health Benefits including ambulatory services, emergency services, hospitilization, maternity and newborn care, mental health and substance abuse services, prescription drugs, rehabilitive services, laboratory services, preventive and wellness services, and pediatric care. These comprehensive benefits are essential elements for improving womens health.

The ACA emphasizes prevention as well as the treatment of disease. The United States spends $3.2 trillion on health care18 percent of its gross domestic product (GDP)but functions more as a sick care system rather than a health care system. In 2009, only 3-5 percent of the U.S. health budget was spent on prevention while 75 percent of medical costs were linked to the treatment of preventable lifestyle-related diseases. The ACA includes a provision that all insurance plans provide a range of preventive health services with no deductible or cost-sharing, including well-woman visits, pap smears, mammography, HIV testing, and cervical cancer screenings. Additionally, the ACA covers screenings and counseling for women who are victims of violence. The ACA also established the Prevention and Public Health Fund which allocated $18.75 billion for prevention services in communities and states including immunizations, heart health screenings, pandemic preparedness initiatives and other interventions. Incentives are included in the ACA for workplace wellness programs as well.

The ACA improves health care for women across the lifespan. It includes important reproductive health services for women. Contraceptives are covered as part of the basic package of no cost preventive services that insurers are required to provide with some exceptions given for religiously-affiliated organizations. The ACA also includes funding for a new education program that aims to inform teens about safe sexual practices and ensures that screenings for sexually-transmitted infections, including HIV, are readily available, especially for high-risk youth. The legislation helps pregnant women receive the care that they need. Although the United States is among the most advanced countries in the world, it ranks 136th in maternal mortality rate , having the highest maternal mortality rate in the industrialized world. To protect the health of mothers and babies, the ACA covers screenings for pregnant women for gestational diabetes, Hepatitis B, Rh incompatibility, HIV, and iron deficiency. Interventions to prevent birth complications due to alcohol consumption and tobacco use during pregnancy are also covered, as are folic acid supplements to prevent infant birth defects. Moreover, the ACA includes provisions to improve maternal and child health after birth by requiring coverage of breastfeeding support services, and workplace protections for nursing women. Postpartum depression (PPD) detection and treatment services as well as PPD research are included in the ACA. All of these interventions have important protective effects for both the physical and mental health of mothers and their children.

Furthermore, the ACA focuses on the special needs of women as they age. Women constitute 57 percent of the U.S. population over the age of 65, and 65 percent of the population over age 85. While women have a longer life expectancy than men (on average) and are at greater risk for chronic illness, women are less likely than men to have the financial resources to maintain their good health later in life. The ACA expands Medicare benefitswomen constitute 59% of the programs enrolleescovering preventive screenings for osteoporosis and other diseases, and providing a discount on prescription drugs for those who find themselves in the donut hole.

The ACA has also been a job creator in communities. With 20 million more people insured because of the legislation, the bill resulted in an increased demand for health care and the workers to provide it. The health care industry now employs 15.5 million people5 million new jobs since the ACA legislation passed.

The American Health Care Act Will Reverse Progress in Womens Health

With only Republican support, the U.S. House of Representatives passed the American Health Care Act (AHCA) on May 4th, 2017 to repeal and replace the ACA. This legislation is now being debated in the U.S. Senate .

The AHCA eliminates many mandates, requirements, and funds provided under the Affordable Care Act of 2010 (ACA), providing states with greater autonomy about how they administer insurance coverage. Key AHCA provisions include eliminating individual and employer insurance mandates, ending Medicaid expansion, slashing tax subsidies that help low income Americans purchase health insurance, banning federal funding of Planned Parenthood , eliminating funding for the Public Health and Prevention Fund and allowing states to waive or modify the Essential Health Benefits package as well as eliminate the prohibition on charging people more for insurance if they have a pre-existing condition.