State policymakers have two major pathways for tailoring the Affordable Care Act (ACA) to better fit the needs of their residents, local politics and their ideological preferences. Currently, they can implement the law’s Medicaid expansion via a "waiver" of federal Medicaid law and, starting in 2017, states will also be able to revisit the main pillars of the law’s private insurance expansion via ACA innovation waivers. Both options are designed to increase flexibility for states in implementing the ACA, while still protecting enrollees’ coverage and access to care. A new analysis in the Guttmacher Policy Review argues that reproductive health advocates should monitor these waivers closely, as they could have far-reaching implications for sexual and reproductive health and rights.

States have long been able to apply for Medicaid waivers, which enable them to experiment with new approaches to enhance coverage and care for low-income residents insured through the program. Notably, Medicaid waivers have been used by numerous states to expand access to publicly supported family planning services. In recent years, Medicaid waivers have been used by several conservative states to expand Medicaid eligibility under the ACA, but in a manner that better fits their conservative principles. The ACA innovation waivers that will become available in 2017 will be similar in many respects to Medicaid waivers, allowing states to modify all of the major aspects of the ACA’s private insurance marketplaces, as well as the so-called individual and employer mandates.

"The opportunity to reshape health reform through Medicaid waivers and ACA innovation waivers is intriguing for policymakers across the political spectrum," says Adam Sonfield, author of the analysis. "Advocates should be ready to identify and support proposed changes that could strengthen and expand provision of services to vulnerable populations. But they should also guard against potential waivers that could negatively affect sexual and reproductive health coverage and care."

Sonfield notes that Congress has set important limitations to states’ waiver options to protect enrollees’ coverage and access to care. For instance, changes proposed in the ACA innovation waivers may not result in less comprehensive coverage, less affordable coverage or fewer state residents with coverage, and they may not increase federal costs. And the Obama administration has made it clear that it will enforce these "guardrails" to protect low-income and other vulnerable populations. However, the next administration that will take office in January 2017 has the opportunity to interpret these rules, and those for Medicaid waivers, in ways that might undermine or advance access to comprehensive coverage and care, including sexual and reproductive health care.

In addition to discussing changes with broad impacts on who has coverage and on what terms, Sonfield outlines several potential ways in which Medicaid and ACA innovation waivers could be used in efforts to undermine access to sexual and reproductive health services. For instance, he suggests continued vigilance against conservatives’ efforts to ban specific reproductive health providers and services from coverage under Medicaid and private insurance. Similarly, he encourages reproductive health advocates to be prepared for attempts to change health plans’ provider network and payment rules in ways that could negatively affect safety-net family planning centers. Conversely, progressive policymakers might experiment with waivers to expand access to coverage and care for vulnerable groups, including for immigrants who face myriad policy barriers to obtaining coverage.

"The November elections may bring political change that could have severe consequences for the ACA in general and sexual and reproductive health care in particular," Sonfield says. "If conservatives sweep to power at the federal level, the entire ACA may be in danger. Yet, under many other election scenarios, Medicaid and ACA innovation waivers may be seen by conservative and progressive state policymakers alike as a useful tool for advancing their health reform priorities. Regardless of election outcomes, it is vital that sexual and reproductive health advocates remain aware and engaged in the waiver application process."

Full article: "How Might State Innovations in Health Reform Affect Sexual and Reproductive Health Care?" by Adam Sonfield