On June 28, the Supreme Court in a 5-4 decision upheld almost all of the Patient Protection and Affordable Care Act (ACA), including the much-debated "individual mandate." The decision means that starting in 2014, tens of millions of Americans who otherwise would remain uninsured will instead have comprehensive health coverage through Medicaid or the private market.

Significantly, all of those newly insured Americans will have strong coverage of reproductive health care—with the notable exception of abortion coverage, which is highly restricted under the ACA and already barred in many states under Medicaid and private insurance . The decision also means that new requirements for most private health plans to cover contraceptive counseling and methods without additional cost-sharing are still slated to go into effect on August 1, 2012 (affecting plans written or renewed after that date).

However, the Supreme Court did strike a potentially serious blow to a key piece of the ACA: its major expansion of the joint federal-state Medicaid program. Eligibility for Medicaid generally has been limited to only certain categories of the lowest-income Americans, such as children and their parents, pregnant women and disabled adults; income eligibility ceilings vary widely from state to state. Under the ACA, starting in 2014, states were to be required to expand eligibility under Medicaid to all Americans with a family income up to 133% of the federal poverty level. Yet, the court ruled that the federal government cannot enforce that requirement, effectively making the expansion a state option.

The Supreme Court’s decision leaves a potentially sizable hole in the patchwork of programs created by the ACA to help ensure that all Americans have access to affordable coverage. If a state opts out of the Medicaid expansion, most of the people who would have been eligible for Medicaid will not be, but they also will be ineligible for the federal subsidies that the ACA will provide to higher-income Americans to help them purchase private insurance coverage. In effect, many poor Americans in states that opt not to expand Medicaid will find themselves in a health care "no man’s land," a scenario that will only exacerbate current health disparities, including in sexual and reproductive health. Poor and low-income Americans already experience much higher rates of STIs, unintended pregnancy and abortion than their better-off counterparts.

It is not at all clear, however, how many states will actually decide to opt out of the Medicaid expansion. The federal government will be paying 100% of the cost for the first three years, and almost all of it in subsequent years. Moreover, states will feel pressure from many groups with a vested interest in seeing the Medicaid expansion go forward, including hospitals (which are worried about uncompensated care), insurance companies (which would profit from helping to run the expansion) and advocates for the poor. Conservative political pressure and perceived fiscal constraints may push in the opposite direction.

The uncertainty over the Medicaid expansion could make another provision in the ACA even more valuable than expected—a provision that has made it easier for states to expand Medicaid specifically for family planning services to individuals otherwise ineligible for the program. Twenty-six states already have implemented this type of Medicaid family planning expansion—eight of them using this new authority under the ACA and the remainder through a more complicated process known as a "waiver."

In sum, and despite the uncertainty over the ACA’s broad Medicaid expansion, the Supreme Court decision marks a significant victory for reproductive health, as it means that a series of important provisions that have implications for reproductive health will continue. These include:

• a requirement that insurance plans allow individuals to remain on their parents’ policy through age 26;
• requirements for private plans to cover—without additional out-of-pocket costs—a range of preventive reproductive health services beyond contraception, including Pap tests, STI screening and counseling, prenatal care and the human papillomavirus vaccine;
• a requirement for private plans to allow patients to access obstetric and gynecologic care without preauthorization or referral;
• prohibitions on charging women higher premiums than men and on excluding coverage for preexisting medical conditions;
• funding for the Personal Responsibility Education Program, which provides education to adolescents on both abstinence and contraception, along with such subjects as healthy relationships, parent-child communication and decision making;
• new funding for community health centers and school-based health centers, most of which provide family planning services and other basic reproductive health care to their clients; and
• funding to support maternal, infant and early childhood home visiting programs, which are designed to improve prenatal, maternal and newborn health, including pregnancy outcomes, and to otherwise improve childhood outcomes.

Yet, additional legal, political and technical challenges loom large. The contraceptive coverage guarantee is being challenged in a series of separate lawsuits that will continue despite the Supreme Court ruling. And the ACA itself will continue to be the subject of political attacks and repeal attempts through the November 2012 election and beyond. Meanwhile, federal and state officials, along with the health care industry, are scrambling to set up new agencies and systems, and otherwise prepare for the immense changes to the health care marketplace slated for 2014.

For more information, please see:

Holding on to health care reform and gains for reproductive health

Political tug-of-war over Medicaid could have major implications for reproductive health care

The case for insurance coverage of contraceptive services and supplies without cost-sharing

Estimating the impact of expanding Medicaid eligibility for family planning services