PSN 2013 Health Care Session Roundup: Getting Ready for the ACA, Fighting Back Against the War on Women

With 2013 legislative sessions largely adjourned in statehouses across the nation, this is the second in a series of issue-specific session roundups from Progressive States Network highlighting trends in different policy areas across the fifty states.

For the past four years, the focus of progressive state lawmakers has largely been on shaping, passing, implementing, and securing the very survival of the Affordable Care Act. But following last year’s historic U.S. Supreme Court decision upholding the law, that focus shifted in legislative sessions this year to preparing to implement the law fully and effectively before critical elements of the legislation take effect in 2014 — a focus made more urgent by the Court’s decision to leave the question of Medicaid expansion up to the states. At the same time, and despite the political consequences, conservatives continued to ramp up their War on Women in statehouses across the nation, attacking abortion rights and making it more difficult for women to receive much needed care.


Moving Forward: Bipartisan Support Grows for Expanding Medicaid under the ACA

Progress was made on fully implementing the Affordable Care Act in 2013 through pushing for Medicaid expansion and creating Health Insurance Marketplaces (the new term for Exchanges).

Medicaid: Conservatives Increasingly Push for Expansion

Last year, the U.S. Supreme Court ruled that states can decide whether to expand Medicaid coverage to those earning up to 138% of the federal poverty line without financial conditions. If they decide to expand their programs, the federal government would cover 100 percent of the newly eligible until 2017 and 90-plus percent thereafter. As of June, 24 states and the District of Columbia have decided to expand coverage, 18 have refused to participate, and 7 have not yet decided. Three states are also implementing or considering an alternative premium assistance model: Arkansas, Iowa, and Tennessee.

Conservative governors, including those in Arizona, Florida, Michigan, New Mexico, North Dakota, Ohio, and Nevada, proved to be some of the loudest advocates for Medicaid expansion. They have acknowledged both the moral imperative of covering those who need it and the financial benefits that Medicaid expansion offers, despite political backlash from other conservatives. In Arizona, that battle manifested itself in a late-session showdown between Gov. Jan Brewer (R) and legislative leadership in her own party which saw Medicaid expansion ultimately pass. In Florida, the endorsement of Medicaid expansion by Gov. Rick Scott (R) — a longtime opponent of the Affordable Care Act — made big news earlier in the year, but his effort was stymied by legislators in his own party who refused to pass expansion this session. In some conservative-controlled states, the debate was less dramatic: in North Dakota, expansion passed relatively quietly and was signed into law by Gov. Jack Dalrymple (R). 


Map: Status of State Medicaid Expansion

Health Insurance Marketplaces: Ready or Not, Here They Come

With enrollment beginning in just a few months — October 1, 2013 — and coverage beginning on January 1, 2014, states were required to declare the type of health insurance marketplace they planned to enact this year: whether their plan would be state-run, a federal-state partnership, or federally facilitated. As of June, 16 states plus the District of Columbia have declared they will be running a state-based marketplace, 7 are planning to partner with the federal government to run a partnership marketplace, and 27 states have defaulted to a federally facilitated marketplace:

Map: Status of State Exchanges

Source: Center on Budget and Policy Priorities, “Status of State Health Insurance Exchange Implementation,” last updated June 14, 2014.


Moving Backward: The War on Women Continues

As the War on Women continued to escalate, progressives knew that 2013 would be a rough year. Opponents of women's health often choose odd years to focus their attacks on women's health — non-election years in nearly all states — because they know that their anti-woman agenda is deeply unpopular with voters.

During the first three months of 2013, legislators introduced 694 provisions that attacked women’s access to health services and providers (according to the Guttmacher Institute). These included:

Abortion Bans

During the first three months of 2013, legislators in 10 states introduced proposals that would ban, or nearly ban, all abortions. In 8 of those states, the bills included the same "personhood" provision that has been defeated every time it appears on the ballot, even in Mississippi where it was defeated by a 17 point margin in 2011. Arkansas passed a 12-week abortion ban in March by overriding Gov. Mike Beebe's veto with a simple majority — a ban which was then blocked by a federal judge in May for violating the U.S. Constitution. Just weeks after Arkansas’ legislation passed, North Dakota passed and enacted three separate anti-abortion laws, including one that counts the start date of pregnancies at 2-3 weeks prior to conception and would ban abortion as early as six weeks into a pregnancy. These state efforts paralleled similar efforts by conservatives in the U.S. House of Representatives, where a 22-week abortion ban was approved in June — one of the most draconian restrictions on abortion to be considered by Congress in years.

Limiting Access to Non-surgical Abortion

Women's access to non-surgical abortion was attacked in two ways: prohibiting access through telemedicine and requiring outdated and needlessly burdensome protocols instead of the safe and effective medical standards currently adhered to by most medical professionals. Because 87 percent of counties in the U.S. do not have a single abortion provider, the attack on access through telemedicine creates a barrier to care for most women, especially women in rural areas who often live several hours away from the nearest provider. Legislation prohibiting the use of telemedicine in non-surgical abortion was introduced in three states this year, with Alabama adopting it. Additionally, two states (Indiana and Alabama) currently require women to follow an outdated protocol for non-surgical abortion, and Iowa and Texas have pending legislation.

Other Attacks on Women's Health

South Dakota enacted legislation that in some cases doubles the waiting period for an abortion by prohibiting weekends or holidays from being included in the waiting period. Two states (Kansas and Montana) enacted laws that allow health care providers to refuse to share pertinent medical information from a pregnant woman if it could inform her decision to terminate a pregnancy. And the legislature in Kansas adopted a law that requires abortion providers to tell women seeking an abortion that it increases their risk for breast cancer (even though that is not true) and also preemptively enacted legislation that bans abortion in the event that Roe v. Wade is ever overturned.


Other 2013 Highlights

Despite the continuing wave of attacks on women’s health, there were a few bright spots in the states in 2013: good and innovative policies that we hope become trends in future years. 

States continued to reject the failed, and dangerous, policy of abstinence-only sex education. In 2013, three states (Colorado, Illinois, and Hawaii) adopted laws requiring comprehensive sex education, which is proven to increase contraceptive use, reduce the spread of sexually transmitted infections, and dramatically reduce teen pregnancy rates.

A legislative victory for home health care workers in Vermont also reversed the trend of rolling back secure, public sector jobs. Even though states across the nation have seen governors and legislatures continue to attempt to limit collective bargaining rights for public sector workers, some states are rising up to protect their public employees. By passing legislation protecting collective bargaining for public sector home health care workers, Vermont joined a list of courageous states — including California, Oregon, Washington, Illinois, Massachusetts, and Missouri — that have chosen to protect their workers. Publicly funded home health workers often work with underserved populations, and protecting these home health workers not only improves economic conditions for workers, but also establishes important continuity of care needed for optimum health of the elderly, disabled and ill people they serve.

These types of policies, as well as others that protect and expand reproductive rights and advance women’s health, are the types of measures progressive state legislators should be focused on advancing in 2014 and beyond. 


Additional Resources:

Kaiser Family Foundation – State Health Facts – About the Health Insurance Marketplace
Guttmacher Institute – State Center
New York Times – States Chipping Away at Roe v. Wade