Clinical Review
UPDATE: CONTRACEPTION
Unpredictable bleeding with progestin-only contraceptives can lead to dissatisfaction and discontinuation. The authors scrutinize the reported...
States that didn’t expand their Medicaid program didn’t show any noticeable change, with the uninsured rate declining only two points, from 38% to 36%.4
Coverage resulted in access to care for the majority of the newly covered. Sixty percent of people with new coverage visited a provider or hospital or paid for a prescription. Sixty-two percent of these individuals said they wouldn’t have been able to access this care before getting this coverage. Eighty-one percent of people with new coverage said they were better off now than before.4
ACA works better in some states than others
The Kaiser Family Foundation looked at four successful states—Colorado, Connecticut, Kentucky, and Washington state—to see what lessons can be learned. Important commonalities include the fact that the states run their own marketplace, adopted the Medi-caid expansion, and conducted extensive outreach and public education, including engaging providers in patient outreach and enrollment.5
Other tools of success were developing good marketing and branding, providing consumer-friendly assistance, and attention to systems and operations.5
How the Hobby Lobby decision affects individual states
Because the Supreme Court’s decision concerned interpretation of a federal law—the Religious Freedom Restoration Act (RFRA)—it does not supersede state laws that mandate coverage of contraceptives.
Twenty-eight states have laws or rulings requiring insurers to cover contraceptives, most of them dating from the 1990s and providing some exemption for religious insurers or plans. Only Illinois allows an exemption for secular bodies.
Although these state laws remain in effect, state officials may opt to stop enforcing them with regard to certain companies. For example, after the Hobby Lobby decision, Wisconsin officials announced that they no longer will enforce contraceptive coverage when a company has a religious objection.
For companies that self-fund or self-insure worker health coverage, the state coverage laws don’t apply—only federal law does. These companies do not have to adhere to state insurance mandates.
Some states have their own version of the RFRA. See the chart at right for details on a state-by-state basis.
The Supreme Court ruling also has no effect on state laws that guarantee access to emergency contraception in hospital emergency departments and that require pharmacists to dispense contraceptives.
| State | Contraceptive equity law? | Employer/insurer exemption to equity law? | Religious freedom law? |
| Alabama | ✔ | ||
| Alaska | |||
| Arizona | ✔ | ✔ | ✔ |
| Arkansas | ✔ | ✔ | |
| California | ✔ | ✔ | |
| Colorado | ✔ | ||
| Connecticut | ✔ | ✔ | ✔ |
| Delaware | ✔ | ✔ | |
| Florida | ✔ | ||
| Georgia | ✔ | ||
| Hawaii | ✔ | ✔ | |
| Idaho | ✔ | ||
| Illinois | ✔ | ✔ | ✔ |
| Indiana | |||
| Iowa | ✔ | ||
| Kansas | |||
| Kentucky | ✔ | ||
| Louisiana | ✔ | ||
| Maine | ✔ | ✔ | |
| Maryland | ✔ | ✔ | |
| Massachusetts | ✔ | ✔ | |
| Michigan | ✔ | ✔ | |
| Minnesota | |||
| Mississippi | ✔ | ||
| Missouri | ✔ | ✔ | ✔ |
| Montana | ✔ | ||
| Nebraska | |||
| Nevada | ✔ | ✔ | |
| New Hampshire | ✔ | ||
| New Jersey | ✔ | ✔ | |
| New Mexico | ✔ | ✔ | ✔ |
| New York | ✔ | ✔ | |
| North Carolina | ✔ | ✔ | |
| North Dakota | |||
| Ohio | |||
| Oklahoma | ✔ | ||
| Oregon | ✔ | ✔ | |
| Pennsylvania | ✔ | ||
| Rhode Island | ✔ | ✔ | ✔ |
| South Carolina | ✔ | ||
| South Dakota | |||
| Tennessee | ✔ | ||
| Texas | ✔ | ||
| Utah | |||
| Vermont | ✔ | ||
| Virginia | ✔ | ||
| Washington | ✔ | ||
| West Virginia | ✔ | ✔ | |
| Wisconsin | ✔ | ||
| Wyoming | |||
| TOTAL | 28 | 20 | 18 |
Narrow networks limit access to care
Huge concerns abound regarding implementation and real-life experiences related to the ACA. A number of them—high deductibles, low payment rates, limited access to physicians, long drive and wait times—can be related to “narrow networks.” Insurers exclude certain providers and offer all providers lower payment rates (which leads some physicians to drop out of the plan); they also create tiers (charging consumers lower copays and deductibles for using inner-tier preferred providers and high out-of-pocket costs for using other providers, even though they may be in the network).
Narrow networks work for insurers as an effective tool for lowering provider payment rates to keep premiums low and gain market share. The narrower the network, the lower are physician payments and premiums.
The ACA promises expanded access to high-quality, affordable health care for millions of Americans—a promise being compromised in many areas of the country through narrow networks. In these instances, insurers offering new plans in a health-care marketplace limit patient access to the numbers, types, and locations of physicians and hospitals covered under certain plans. Insurers typically offer patients low premiums, offer selected providers a high volume of patients at low payment levels, and exclude other providers whom the insurer deems to be high-cost.
Narrow networks aren’t new
As with so many elements of the ACA, narrow networks aren’t a new phenomenon. Many of us remember the public relations price that HMOs paid in the 1980s and 1990s for exceedingly limiting patients’ access to care while charging low premiums. The consumer outcry led the National Association of Insurance Commissioners to urge states to require managed-care plans to maintain adequate networks, the approach adopted by the federal government in the ACA.6
