I. Background of Health Care Access in the United States
A. Health Care Access Landscape prior to the ACA
When the ACA was enacted, the picture of health care access in the United States was grim. In 2008, 202.6 million Americans (67.2%) were covered by private health insurance. Of those insured, 177.5 million had employer-based insurance, 87.6 million had government health insurance, 43.0 million were covered by Medicare, and 42.8 million were covered by Medicaid.
Meanwhile, 14.9% of Americans (44.8 million people) were uninsured in 2008 and as many as 25 million more Americans, 60% more than in 2003, were considered underinsured. This rapid rise in the underinsured was largely the result of changes in insurance design that increased out-of-pocket costs.
Inadequate access has not been merely a plight of the poor; from 2003 to 2007, the underinsurance rate for those earning above 200% of the poverty line tripled. In practice, a huge swath of Americans, including many of those who are “adequately” insured, have had less access than they required: 68% of the uninsured, 53% of the underinsured, and 31% of the insured forewent needed *97 care, including doctor's visits, filling prescriptions, or following recommendations for tests or treatment. In addition, Americans have had substantial difficulty paying their out-of-pocket medical bills.
Under this patchwork system of health care coverage, women have fared especially poorly. In 2008, approximately 17.2 million American women lacked health insurance. Among low-income Americans (those under 100% of the federal poverty level), there were more uninsured women than men, a disparity that is problematic in light of women's unique health requirements, including reproductive services. These health requirements have a considerable impact on the cost of women's health care. Over the course of a lifetime, the average woman spends approximately 68% more than the average man on out-of-pocket medical expenses, a potential lifetime difference of $10,000. Private insurers recognize these cost differences and factor them into their coverage decisions.
Further, women tend to lack coverage through their own employment. According to the Kaiser Family Foundation, 35% of women have insurance coverage through their employer, 29% are covered as dependents through their spouses' employer, and 7% depend on Medicaid as their primary source of health care. In contrast, even though they are lower utilizers of health care, men are much more likely to have insurance coverage through their own employment: 49% of men have their own coverage, while only 13% are covered as dependents. Even after corrections for skill level, education, pay status, and job type, men are still much more likely than women to have job-based *98 insurance. Without access to quality health care, it is more difficult for women to adequately care for themselves and their families. These problems are exacerbated because women are more susceptible to premium increases, reductions in employers' family coverage contributions, divorce, and the death of their spouse, and are less likely to have retirement coverage or pensions through an employer to fund coverage gaps.