State officials take center stage in ACA stabilization efforts

http://www.fiercehealthcare.com/aca/state-officials-take-center-stage-aca-stabilization-efforts?mkt_tok=eyJpIjoiTXpka1pUSXhNMll5WldZeiIsInQiOiJCNWJNNHZ4Y1RxVHpCckY1WSswVGsyMjVpNituQ2RVUVp0UElNMmtqTlhkVUVQWFVINFhNU1RwcE9aU0Rad3Y3aFNhNjZWVXY3Ym02bXVkZFk3U3F6Y1pvbGJ4Rno4ZWM2M21jTUpcL2pVM3BsSnJNU2RWcVE1NEZDV1wvaUZzR1FmIn0%3D&mrkid=959610&utm_medium=nl&utm_source=internal

John Kasich speaking at lectern

As efforts to stabilize the Affordable Care Act exchanges begin to take shape, it’s become increasingly clear that states will play a major role.

On Tuesday, Sen. Lamar Alexander, R-Tenn., and Sen. Patty Murray, R-Wash., announced that the Senate’s upcoming bipartisan healthcare hearings will feature testimony from “those closest to the problem”—state insurance commissioners and governors. The hearings are planned for Sept. 6 and 7.

“These state leaders understand full well the challenges facing healthcare today, and many have been outspoken about how the uncertainty caused by this administration has impacted the individual insurance market and therefore families’ premiums for 2018,” Murray said.

Alexander said the goal is to pass a “small, bipartisan and balanced” ACA exchange stabilization package before the Sept. 27 deadline for insurers to lock in their final plans for 2018. He also wants the package to fund cost-sharing reduction payments and “give states more flexibility in approving insurance policies” by improving section 1332 of the ACA.

Kasich, Hickenlooper join the fray

Two state governors, meanwhile, are preparing to offer up their own healthcare plan even before the Senate hearings begin. Ohio Governor John Kasich, a Republican, and Colorado Gov. John Hickenlooper, a Democrat, told Colorado Public Radio on Monday that they hope to unveil the plan within a week.

Previously, Hickenlooper and Kasich joined other state governors in speaking out against the House version of an ACA repeal-and-replace bill, arguing in a letter to Senate leaders that it “calls into question coverage for the vulnerable and fails to provide the necessary resources to ensure that no one is left out, while shifting significant costs to the states.”

That letter, as well as a Washington Post op-ed authored by Kasich and Hickenlooper, outlined a set of core principles for bipartisan healthcare reform—principles that their upcoming ACA stabilization plan will build upon, according to the CPR article. They include improving affordability, restoring stability to insurance markets, providing state flexibility, encouraging innovation and improving the regulatory environment.

Iowa submits stabilization plan

At least one state, though, isn’t waiting on Congress to rescue its individual health insurance market.

On Monday, Iowa officials submitted their application for federal regulators to approve the “Iowa Stopgap Measure,” a short-term stabilization plan formulated by the state’s insurance commissioner with the help of local health plans.

In the application (PDF), Iowa Gov. Kim Reynolds urged federal officials to quickly approve the measure, noting the state faces “an immediate collapsing market that could leave thousands without health insurance and the rest with 56% or higher premium rate increases.”

The plan, which requires the use of a section 1332 waiver, would redirect the $305 million in federal funding that currently goes toward the ACA’s premium tax credits and instead fund fixed, age- and income-based premium subsidies for consumers.

It would also use federal funds to implement a reinsurance program that will reimburse insurers for high-cost individuals who incur claims greater than $100,000 on an annual basis. As part of the program, insurers would have to agree to care-management protocols.

 

Special Report—How to fix the Affordable Care Act

https://pages.questexweb.com/rs/294-MQF-056/images/FierceHealthcare-HowtofixtheAffordaleCareAct.pdf

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As Congress prepares to get back to business, the industry is holding its collective breath to see if healthcare reform will fall off the agenda. It’s pretty clear that rushing through repeal, replace or repair legislation or letting the Affordable Care Act fail isn’t the answer. In this special report, FierceHealthcare’s editors—experts on the business of healthcare—outline ways to fix the nation’s healthcare system.

Coverage expansion and primary care access

http://theincidentaleconomist.com/wordpress/coverage-expansion-and-primary-care-access/

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When you have a health problem, your first stop is probably to your primary care doctor. If you’ve found it harder to see your doctor in recent years, you could be tempted to blame the Affordable Care Act. As the health law sought to solve one problem, access to affordable health insurance, it risked creating another: too few primary care doctors to meet the surge in appointment requests from the newly insured.

Studies published just before the 2014 coverage expansion predicted a demand for millions more annual primary care appointments, requiring thousands of new primary care providers just to keep up. But a more recent study suggests primary care appointment availability may not have suffered as much as expected.

The study, published in April in JAMA Internal Medicine, found that across 10 states, primary care appointment availability for Medicaid enrollees increased since the Affordable Care Act’s coverage expansions went into effect. For privately insured patients, appointment availability held steady. All of the gains in access to care for Medicaid enrollees were concentrated in states that expanded Medicaid coverage. For instance, in Illinois 20 percent more primary care physicians accepted Medicaid after expansion than before it. Gains in Iowa and Pennsylvania were lower, but still substantial: 8 percent and 7 percent.

Though these findings are consistent with other research, including a study of Medicaid expansion in Michigan, they are contrary to intuition. In places where coverage gains were larger — in Medicaid expansion states — primary care appointment availability grew more.

“Given the duration of medical education, it’s not likely that thousands of new primary care practitioners entered the field in a few years to meet surging demand,” said the Penn health economist Daniel Polsky, the lead author on the study. There are other ways doctor’s offices can accommodate more patients, he added.

One way is by booking appointment requests further out, extending waiting times. The study findings bear this out. Waiting times increased for both Medicaid and privately insured patients. For example, the proportion of privately insured patients having to wait at least 30 days for an appointment grew to 10.5 percent from 7.1 percent.

The study assessed appointment availability and wait times, both before the 2014 coverage expansion and in 2016, using so-called secret shoppers. In this approach, people pretending to be patients with different characteristics — in this case with either Medicaid or private coverage — call doctor’s offices seeking appointments.

Improvement in Medicaid enrollees’ ability to obtain appointments may come as a surprise. Of all insurance types, Medicaid is the least likely to be accepted by physicians because it tends to pay the lowest rates. But some provisions of the Affordable Care Act may have enhanced Medicaid enrollees’ ability to obtain primary care.

The law increased Medicaid payments to primary care providers to Medicare levels in 2013 and 2014 with federal funding. Some states extended that enhanced payment level with state funding for subsequent years, but the study found higher rates of doctors’ acceptance of Medicaid even in states that didn’t do so.

The Affordable Care Act also included funding that fueled expansion of federally qualified health centers, which provide health care to patients regardless of ability to pay. Because these centers operate in low-income areas that are more likely to have greater concentrations of Medicaid enrollees, this expansion may have improved their access to care.

Other trends in medical practice might have aided in meeting growing appointment demand. “The practice and organization of medical care has been dynamic in recent years, and that could partly explain our results,” Mr. Polsky said. “For example, if patient panels are better managed by larger organizations, the trend towards consolidation could absorb some of the increased demand.”

Although the exact explanation is uncertain, what is clear is that the primary care system has not been overwhelmed by coverage expansion. Waiting times have gone up, but the ability of Medicaid patients to get appointments has improved, with no degradation in that aspect for privately insured patients.

Time Crunch Among Hurdles for Bipartisan Senate Push to Bolster ACA

https://morningconsult.com/2017/08/18/time-crunch-among-hurdles-bipartisan-senate-push-bolster-aca/

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The leaders of a key Senate committee say they are cautiously optimistic about reaching a deal to shore up the Affordable Care Act’s individual marketplaces, but even with a bipartisan effort, it is far from certain whether they can hash out an agreement in time.

The Senate Health, Education, Labor and Pensions Committee leaders of both parties have set a self-imposed mid-September deadline for a bipartisan agreement. To keep lingering animosity from the Obamacare repeal fight from seeping into negotiations, Chairman Lamar Alexander has made clear that what he’s seeking is far from comprehensive.

The bill will have to be “small, bipartisan and balanced,” the Tennessee Republican said in a statement Wednesday.

Above all, Democrats want to make sure insurers continue to receive payments that help them cover out-of-pocket costs for some low-income patients. President Donald Trump has threatened to cut off the payments, and the administration has kept insurers on tenterhooks by making them only on a month-to-month basis.

Without the subsidies, known as cost-sharing reductions, some insurers warn they’ll be forced pull out of the ACA markets or hike premiums. The companies need certainty about payments at the latest by Sept. 27, the final deadline for them to decide whether to sell Obamacare plans in 2018.

If the committee can reach agreement next month, it would still be a challenge to get a bill through the full Senate and House before the key deadline for insurers. And Trump would still have to sign a bill into law that extends payments he is loath to continue.

The potential for chaos was highlighted this week when the nonpartisan Congressional Budget Office released a report estimating average premiums would rise 20 percent next year and the federal deficit would grow by $194 billion by 2026 if the administration stops paying.

While some conservative hard-liners want to cut off the CSRs, Alexander and other top Republicans have shown they’re willing to work with Democrats to have Congress extend the payments.

Sen. Patty Murray of Washington, the panel’s ranking Democrat, on Thursday called for quick action.

“People across the country are facing much higher premiums next year because of uncertainty driven by the Trump Administration, so I hope Republicans will join Democrats to act quickly to protect patients and families from paying more for care they need — and then continue working in a bipartisan way to make health care more affordable, accessible, and higher quality for all,” Murray said in a statement.

Democrats also want some sort of reinsurance program, an idea that has bipartisan support and would help insurers pay for their most expensive enrollees.

But in return for extending CSRs and including reinsurance, Republicans want to give states more authority over their health care systems, and Democrats could balk at some of their proposals.

Alexander has specifically pointed to changing the ACA’s 1332 waiver program, which allows states to opt out of key ACA regulations as long as it doesn’t lead to reduced coverage, skimpier benefits, more expensive insurance or a higher federal deficit.

In remarks to reporters earlier this month, Alexander noted a proposal that would eliminate all of those requirements besides increasing the federal deficit, in order to give states “more of an opportunity to approve insurance plans.” The plan, which was included in Senate Republicans’ health overhaul bill, would also bar the administration from rejecting a waiver as long as it doesn’t increase the federal deficit.

Democrats would likely oppose that proposal, wary of allowing states to undercut key Obamacare requirements without those other conditions in place.

Sen. Tim Kaine (D-Va.) said he’s interested in a proposal from Sens. Bill Cassidy (R-La.) and Susan Collins (R-Maine) to let states replace Obamacare’s most contentious provision — the mandate requiring people to purchase health insurance or pay a penalty — with a system that automatically enrolls individuals in low-cost coverage if they don’t do so on their own.

Backers of this approach argue it would offer comparable coverage to the individual mandate while being less intrusive, allowing people to opt out.

“I think that’s intriguing,” Kaine said earlier this month in a brief interview. “We ought to have that discussion, but you can’t blow the mandate without something to bring people into the program and do what insurance needs to do, which is to spread risk.”

But auto-enrollment has raised concerns among some liberal health care analysts, including over how to implement and administer such a system. The outstanding questions cast doubt on whether it could garner enough backing to be included in the stabilization bill.

Trump needs to stop sabotaging Obamacare — before it’s too late

https://www.washingtonpost.com/opinions/trump-needs-to-stop-sabotaging-obamacare–before-its-too-late/2017/08/17/1c1404ba-8133-11e7-902a-2a9f2d808496_story.html?utm_term=.40564141606c

THE CONGRESSIONAL Budget Office released on Tuesday yet another damning report on health care, this time highlighting the damage President Trump will do if he continues his Obamacare sabotage campaign. Over the next few weeks, during which the government and insurers must sort out what will happen to Obamacare insurance markets next year, everyone in the administration and every member of Congress must recognize that they have no more time to entertain repeal-and-replace fantasies. The fate of the health-insurance markets on which millions of people rely hangs on their willingness to accept reality.

The Trump administration has shown some flexibility. The Department of Health and Human Services last week offered insurers an extra few weeks to file rates for next year. Earlier, Alaska got $323 million in federal money to backstop its individual insurance market in a reinsurance arrangement that could drive down premiums and serve as a model for stabilizing insurance markets across the nation. Though Mr. Trump has repeatedly vowed to let Obamacare collapse, these moves show willingness to bolster, not undermine, the insurance markets that Obamacare created.

Yet the administration has stoked more uncertainty than it has allayed, leaving the health system in peril. The White House has been deciding month-to-month whether to keep important subsidy payments flowing to insurance companies — payments that were simply assumed during the Obama administration. Without these payments, insurers would have to jack up premiums or leave Obamacare markets next year. The CBO estimated Tuesday that average premiums would jump by 20 percent next year if the Trump administration pulled them. Moreover, because of how the payments interact with other elements of the health-care system, the government would end up losing money — $194 billion over a decade.

Though it would be irrational to subvert the health-care system and the budget, Mr. Trump has repeatedly threatened to do so. His officials also have taken steps in that direction, pulling advertisements meant to encourage people to enroll in health insurance, cutting programs that helped people sign up, railing about Obamacare’s “victims” and generally insisting, against the facts, that the law is a disaster. The administration’s moves to weaken the individual mandate, which requires all Americans to carry health coverage and underpins the Obamacare system, have led insurers to contemplate increasing premiums or leaving the system.

The president wanted and failed to overhaul Obamacare. That does not excuse him from faithfully executing the law. Unless Mr. Trump wants to be blamed for health-care chaos, the administration’s mixed messages must stop. Mr. Trump should commit to keeping the subsidies going permanently, to enforcing the individual mandate and to working with Congress on a bipartisan bill that would bolster insurance markets.

The broad strokes are clear: Democrats would ensure that subsidy payments are made permanent and Republicans would get more flexibility for states in administering Obamacare. More money should also go into reinsurance programs like Alaska’s. Though such a bill might come too late to hold down 2018 premiums, serious legislative activity could persuade insurers to stay in the market, riding out next year with the promise of a more stable situation in 2019.

All of this would be easier if the administration would commit to a strategy of stewardship, not sabotage.

For Covered California, Uncertainty Is The New Certainty

For Covered California, Uncertainty Is The New Certainty

Covered California’s board made several multimillion-dollar decisions Thursday, all addressing one unsettling theme: uncertainty.

Over and over, board members blamed “uncertainty” at the federal level for interfering with their ability to finalize premiums for 2018 and prepare consumers for open enrollment, which begins Nov. 1.

In response to that uncertainty, the board agreed to delay a critical decision on 2018 rate hikes, boost Covered California’s marketing budget by more than $5 million and allow its participating insurers to make higher profits in the future — under certain circumstances.

“The lack of clarity and direction at the federal level continues to be a challenge,” said Covered California Executive Director Peter Lee. “While we are doing our best to manage a difficult situation, we hope Congress and the administration will provide clear guidance on how [they intend] to stabilize the individual insurance market.”

One of the most pressing questions facing Covered California and other Obamacare exchanges across the country is whether President Donald Trump will continue to fund critical subsidies that help reduce many consumers’ out-of-pocket expenses.

The White House announced this week it would fund those so-called cost-sharing reduction payments this month but did not say whether it would continue to do so after that.

Covered California is seeking a long-term commitment to fund the subsidies, which are available only to consumers whose incomes are low enough to qualify and who purchase silver-level plans, the second-least expensive among the exchange’s four tiers of coverage. The subsidies reduce what they pay for medical expenses such as copayments and deductibles.

Earlier this month, the exchange announced proposed average statewide rate hikes of 12.5 percent for 2018. It also floated an additional average surcharge of 12.4 percent on silver plans if the federal government does not commit to making the payments.

Covered California was supposed to decide by the end of this month whether to apply the surcharge next year. But on Thursday, its board announced it will push the deadline to Sept. 30.

“Our hope is that by changing the deadline to allow Congress to act, we will not have to deal with the … surcharge,” Lee said.

The surcharge would vary by region and plan, ranging from 8 percent to 27 percent — on top of the regular annual premium increases, Lee said.

Covered California consumers who receive tax credits to reduce their monthly premiums would not bear the full brunt of the increase, however, because those credits would also rise.

Delaying the decision until the end of September doesn’t leave much time for Covered California — its health plans — to finalize rates and prepare consumers to renew their health plans or shop for new ones, said Diana Dooley, board chair and secretary of the state Health and Human Services Agency.

But the board doesn’t want to raise silver plan rates prematurely, in case Congress acts next month to fund the cost-sharing subsidies on a more durable basis, she said.

If Congress doesn’t act until the very end of September, “that will put extraordinary pressure on our system,” she said.

Charles Bacchi, president and CEO of the California Association of Health Plans, said 1.2 million renewal packets will have to be dispatched to enrollees on a very tight timeline.

“It is going to be a heavy lift, but the plans will work to do the best we can under difficult circumstances,” he said.

The board also agreed to modify its contracts with participating insurers to allow them to make higher profits in 2019, 2020 and 2021 if they lose money next year as a result of continued uncertainty or changes in existing federal policy.

For example, one way insurers could lose money is if the federal government stops enforcing the Obamacare requirement to have health insurance, known as the individual mandate, Covered California said.

The change also requires plans that reap increased profits next year — again, because of uncertainty or changes in federal policy — to lower their premiums over the next one to three years.

Lee explained that Covered California’s insurers usually make a profit of about 1 to 3 percent annually. But, for example, if one should lose money next year, its profit margin could grow to 6 to 8 percent in the subsequent three years, he said.

Any profit increase would be decided on a case-by-case basis and depend on the amount of the loss, he said.

The contract amendment would not change any laws or violate any rules, such as the Medical Loss Ratio provision of the Affordable Care Act, Lee said. That provision requires most insurance companies that cover individuals and small businesses to spend at least 80 percent of their premium dollars on medical care and the remaining 20 percent on administration, marketing and profit.

Consumer advocates testified Thursday that they were initially skeptical of the change, but they now hope it will save consumers money in the long run.

“We like the idea that it is balanced and if [there is profit], it could go to reducing premiums,” said Doreena Wong, project director at Asian Americans Advancing Justice, a Los Angeles-based civil rights group.

In another move tied to the uncertainty over federal policy, the board agreed to increase its marketing budget by $5.3 million, bringing the total to $111.5 million for 2017-18. The additional money will pay for more radio and television spots, and more direct mail to consumers.

Some of the advertising will target Covered California enrollees who are losing their Anthem Blue Cross plan next year.

Anthem will exit the individual market in 16 of the state’s 19 pricing regions, which will force 153,000 enrollees to find new plans. Anthem cited uncertainty and market instability for its pullout.

“This open enrollment is going to be our most challenging since year one,” Lee said.

Often Missing From The Current Health Care Debate: Women’s Voices

http://www.npr.org/sections/health-shots/2017/08/16/543723927/often-missing-from-the-current-health-care-debate-womens-voices?utm_campaign=KFF%3A%20The%20Latest&utm_source=hs_email&utm_medium=email&utm_content=55441015&_hsenc=p2ANqtz-9nhXUhC_zqpJNwIaw0vOuF3PfAn3PBrmE3HVyeYM_l7-5vAx-FPWjwuS3F0Ac1H67HXbfu9Hfyvmuf37WeEGpqXqf-Sw&_hsmi=55441015

Women have a lot at stake in the fight over the future of health care.

Not only do many depend on insurance coverage for maternity care and contraception, they are struck more often by autoimmune conditions, osteoporosis, breast cancer and depression. They are more likely to be poor and depend on Medicaid, and to live longer and depend on Medicare. And it commonly falls to them to plan health care and coverage for the whole family.

Yet in recent months, as leaders in Washington discussed the future of American health care, women were not always invited. To hammer out the Senate’s initial version of a bill to replace Obamacare, Majority Leader Mitch McConnell appointed 12 colleagues, all male, to closed-door sessions – a fact that was not lost on female Senators. Some members of Congress say they don’t see issues like childbirth as a male concern. Why, two GOP representatives wondered aloud during the House debate this spring, should men pay for maternity or prenatal coverage?

As the debate over health care continues, one of the challenges in addressing women’s health concerns is that they have different priorities, depending on their stage in life. A 20-year-old may care more about how to get free contraception, while a 30-year-old may be more concerned about maternity coverage. Women in their 50s might be worried about access to mammograms, and those in their 60s may fear not being able to afford insurance before Medicare kicks in at 65.

To get a richer sense of women’s varied viewpoints on health care, we asked several women around the country of different ages, backgrounds, and political views to share their thoughts and personal experiences.

Patricia Loftman, 68, New York City

Loftman spent 30 years as a certified nurse-midwife at Harlem Hospital Center and remembers treating women coming in after having botched abortions.

Some didn’t survive.

“It was a really bad time,” Loftman says. “Women should not have to die just because they don’t want to have a child.”

When the Supreme Court ruled that women had a constitutional right to an abortion in 1973, Loftman remembers feeling relieved. Now she’s angry and scared about the prospect of stricter controls. “Those of us who lived through it just cannot imagine going back,” she says.

A mother and grandmother, Loftman also recalls clearly when the birth control pill became legal in the 1960s. She was in nursing school in upstate New York and glad to have another, more convenient option for contraception. Already, women were gaining more independence, and the Pill “just added to that sense of increased freedom and choice.”

To her, conservatives’ attack on Planned Parenthood, which has already closed many clinics in several states, is frustrating because the organization also provides primary and reproductive health care to many poor women who wouldn’t be able to get it otherwise.

Now retired, Loftman sits on the board of the American College of Nurse-Midwivesand advocates for better care for minority women. “There continues to be a dramatic racial and ethnic disparity in the outcome of pregnancy and health for African-American women and women of color,” she says.

Terrisa Bukovinac, 36, San Francisco

Bukovinac calls herself a passionate pro-lifer. As president of Pro-Life Future of San Francisco, she participates in marches and protests to demonstrate her opposition to abortion.

“Our preliminary goal is defunding Planned Parenthood,” she says. “That is crucial to our mission.”

As much as the organization touts itself as being a place where people get primary care and contraception, “abortion is their primary business model,” Bukovinac says.

She said the vast majority of abortions are not justifiable and that she supports a woman’s right to an abortion only in cases that threaten her life. “We are opposed to what we consider elective abortions,” she says.

Bukovinac says she also tries to help women in crisis get financial assistance so they don’t end their pregnancies just because they can’t afford to have a baby. She supports women’s access to health insurance and health care, both of which are costly for many. “Certainly, the more people who are covered, the better it is” for both the mother and baby.

Bukovinac herself is uninsured because she says the premiums cost more than she would typically pay for care. Self-employed, Bukovinac has a disorder that causes vertigo and ringing in the ear and spends about $300 per month on medication for that and for anxiety.

She doesn’t know if the Affordable Care Act is to blame, but she said that before the law “I was able to afford health insurance and now I’m not.”

Irma Castaneda, 49, Huntington Beach, Calif.

Castaneda is a breast cancer survivor. She’s been in remission for several years but still sees her oncologist annually and undergoes mammograms, ultrasounds, and blood tests.

The married mom of three, a teacher’s aide to special education students, is worried that Republicans may make insurance more expensive for people like her with pre-existing conditions. “They could make our premiums go sky high,” she says.

Her family previously purchased a plan on Covered California, the state’s Obamacare exchange. But there was a high deductible, so she had to come up with a lot out-of-pocket money before insurance kicked in. “I was paying medical bills up the yin yang,” she says. “I felt like I was paying so much for this crappy plan.”

Then, about a year ago, Castaneda’s husband got injured at work and the family’s income dropped by half. Now they rely on Medicaid. At least now they have fewer out-of-pocket expenses for health care.

Whatever the coverage, Castaneda says, she needs high-quality health care. “God forbid I get sick again,” she says. And she worries about her daughter, who is transgender and receives specialized physical and mental health care.

“Right now she is pretty lucky because there is coverage for her,” Castaneda says. “With the Trump stuff, what’s going to happen then?”

Celene Wong, 39, Boston

The choice was agonizing for Wong. A few months into her pregnancy, she and her husband learned that her fetus had chromosomal abnormalities. The baby would have had severe special needs, she said.

“We always said we couldn’t handle that,” Wong recalls. “We had to make a tough decision, and it is not a decision that most people ever have to face.”

The couple terminated the pregnancy in January 2016, when she was about 18 weeks pregnant. “At the end of the day, everybody is going to go away except for your husband and you and this little baby,” she says. “We did our research. We knew what we would’ve been getting into.”

Wong, who works to improve the experience for patients at a local hospital, says she is fortunate to have been able to make the choice that was right for her family.

“If the [abortion] law changes, what is going to happen with that next generation?” she wonders.

Lorin Ditzler, 33, Des Moines, Iowa

Ditzler is frustrated that her insurance coverage may be a deciding factor in her family planning. She quit her job last year to take care of her 2-year-old son and was able to get on her husband’s plan, which doesn’t cover maternity care.

“To me it seems very obvious that our system isn’t set up in a way to support giving birth and raising very small children,” she says.

While maternity benefits are required under the Affordable Care Act, her husband’s plan is grandfathered under the old rules, which is not uncommon among employers that offer coverage. Skirting maternity coverage might become more common if Republicans in Congress pass legislation allowing states to drop maternity coverage an “essential benefit.”

Ditzler looked into switching to an Obamacare plan that they could buy through the exchange, but the rates were much higher than what she pays now.

If she goes back to work, she could get on a better insurance plan that covers maternity care. But that makes little sense to her. “I would go back to a full-time job so I could have a second child, but if I do that, it will be less appealing and less feasible to have a second child because I’d be working full time.”

Ashley Bennett, 34, Spartanburg, S.C.

Bennett describes herself as devoutly Christian. She is grateful that she was able to plan her family the way she wanted, with the help of birth control. She had her daughter at 22 and her son two years later.

“I felt free to make that choice, which I think is an awesome thing,” she says. She’s advised her 12-year-old daughter to wait for sex until marriage but has also been open with her about birth control within the context of marriage.

But she draws the line at abortion. “I just feel like we’re playing God. If that conception happens, then I feel like it was meant to be.”

Bennett had apprehensions about Trump but voted for him because he was the anti-abortion candidate. “That was the deciding factor for me, [more than] him yelling about how he’s going to build a wall.”

For her, opposition to abortion must be coupled with support for babies once they are born. She supports adoption and is planning to become a foster parent.

She also is concerned about the mental and physical well-being of young women. Bennett teaches seventh-grade math and coaches the school’s cheerleading and dance teams.

She watches the girls take dozens of photos of themselves to get the perfect shot, then add filters to add makeup or slim them down.

“There’s going to be an aftermath that we haven’t even thought about,” she says. “I worry we’re going to have more and more kids suffering from depression, eating disorders and even suicide because of the effects of the social media.”

Maya Guillén, 24, El Paso, Texas

When Guillén was growing up, her family spent years without health insurance. They crossed the border into Juárez, Mexico, for dental care, doctor appointments, and optometry visits.

Guillén is now on her parents’ insurance plan under a provision of the Affordable Care Act that allows children to stay on until they turn 26. She’s been disheartened by Republicans’ proposed changes to contraception and abortion coverage, she says.

In high school, Guillén received abstinence-only sex education. She watched her friends get pregnant before they graduated.

When it came time to consider sex, she thought she’d be able to count on Planned Parenthood, but the clinic in El Paso closed, as have 20 other women’s health clinics in Texas. She worries that if Republicans defund Planned Parenthood, more young girls, especially those in predominantly Hispanic communities like hers, will not be able to get contraceptives.

Jaimie Kelton, 39, New York City

When Jaimie Kelton’s wife gave birth to their baby 3½ years ago, she thought the country was finally becoming more open-minded toward gays and lesbians.

“Now I am coming to realize that we are the bubble and they are the majority and that’s really scary,” says Kelton, now pregnant with her second child.

Kelton says it seems as though Republicans have launched a war against women in general, with reproductive rights and maternity care at risk.

“It is crazy to think that most of the people making these laws are men,” she said. “Why do they feel the need to take away health care rights from women?”