March 23 marks 10 years since President Obama signed the Affordable Care Act (ACA) into law. Over this decade, the law has dramatically reduced the number of uninsured people in the United States, eliminated many unfair private insurance practices, expanded the scope of what health insurance covers, instituted new patient protections, supported the U.S. health care system’s ability to better deal with crises like the COVID-19 outbreak, and generally led to improved health and economic well-being for millions of people.

More specifically, it has expanded access to sexual and reproductive health services in numerous ways. Yet, continued challenges from the Trump administration and other conservative policymakers threaten its future.

ACA Victories

The ACA has supported millions of people’s sexual and reproductive health by expanding health coverage and the scope of services covered by insurers. Specifically, the law has:

• Made health insurance more affordable and accessible. State Medicaid expansions and federal subsidies for plans sold on the ACA marketplace have made coverage cheaper and easier to get. The proportion of women of reproductive age (15–44) who were uninsured declined from 20% (12.5 million women) in 2013 to 12% (7.7 million) in 2018 in the wake of the ACA’s coverage expansions. This 40% decline was driven by substantial gains in both Medicaid coverage and private insurance.
• Guaranteed coverage for maternity care. The ACA requires private insurance plans sold to individuals and small employers to cover a list of "essential health benefits," including maternity care. Prior to the ACA’s enactment, eight in 10 individual market plans excluded maternity care entirely, and a federal requirement to cover maternity care did not apply to many small employers.
• Expanded coverage for contraceptives. The ACA requires most private health plans to include coverage for a full range of contraceptive methods, services and counseling, without copayments or other patient out-of-pocket costs. This contraceptive coverage guarantee has eliminated cost barriers that could be prohibitively high and helped women use the birth control method of their choice and use it effectively.
• Guaranteed coverage for other preventive sexual and reproductive health services. Beyond contraception, the ACA requires most private health plans to cover dozens of preventive services without out-of-pocket costs, including HIV and other STI screening and counseling, cervical cancer screening, HPV vaccination, and breast-feeding support and pumps. Notably, the ACA’s policies have been linked to improvements in how long women breast-feed their children.
• Made coverage more accessible for survivors of intimate partner violence. The ACA set up expedited insurance plan enrollment processes for people experiencing intimate partner violence (IPV) and their dependents. The law also made it easier for IPV survivors to qualify for marketplace subsidies to make coverage more affordable, and required coverage of IPV screening and basic counseling.
• Banned preexisting condition policies. Prior to the passage of the ACA, insurers could deny or raise the price of coverage for people with a wide range of preexisting conditions, including HIV, breast and cervical cancer, pregnancy, a previous cesarean section, a history of infertility and gender dysphoria. According to one estimate, 27% of nonelderly adults, or 54 million people, have a health condition that could lead to being declined insurance coverage, if insurers were still allowed to do so.

Threats to the ACA

Conservative lawmakers are pursuing several policies that jeopardize both the ACA writ large and its specific protections for sexual and reproductive health. If executed, these policies would undermine the important achievements in health care accessibility and affordability made possible by the ACA.

In 2018, the Trump administration announced a policy that, if allowed to go into effect, would weaken the contraceptive coverage guarantee by exempting employers, schools, individuals and insurers with religious or moral objections to contraception. As the Guttmacher Institute and others have argued, the rules would compromise women’s ability to obtain contraceptive methods, services and counseling and heighten their risk of unintended pregnancy and the negative health, social and economic consequences that can result. This spring, the U.S. Supreme Court will rule on the legality of this policy.

Meanwhile, conservative policymakers are pushing for several changes to Medicaid that threaten to undo coverage expansions made possible by the ACA. The Trump administration is approving "waivers" of federal law that take away Medicaid coverage from people who do not engage in paid work, educational pursuits or other related activities for a certain number of hours per month. State and federal policymakers are also seeking to undermine Medicaid by proposing unprecedented caps on federal funding for the program in the form of a fixed sum (a block grant), rather than based on reimbursement. Work requirements and block grants would deny people sexual and reproductive health care by forcing them out of Medicaid.

Finally, a potentially even bigger ACA-related case will be heard by the Supreme Court in fall 2020, with a likely decision in 2021. A group of 20 states, led by Texas, is seeking to overturn the entire ACA by arguing that when Congress eliminated the ACA’s tax penalty for not having insurance in 2017, it effectively invalidated the rest of the law. The Trump administration is largely siding with Texas, while 17 other states, led by California, are defending the ACA in court. A decision that strikes down most or all of the ACA would lead to massive upheavals in the U.S. health care system, including elimination of all of the ACA’s gains for sexual and reproductive health.

These ongoing threats have also interfered with and distracted from efforts to build on the progress of the ACA and further improve the U.S. health care system. Millions of people are still uninsured, important services like abortion and infertility care are often excluded from coverage, access to providers is limited in many areas and for many services, and people’s health and rights still often take a back seat to bureaucracy and the financial bottom line. Much more needs to be done to ensure the health care system nationwide fully meets people’s sexual and reproductive needs and rights, as well as their broader health care needs.