In August this year, the infamous "Harry and Louise" ads of 1993 returned. This time, Harry and Louise weren't complaining that the government would take away their options on health care. Instead, they called for health care reform and worried about skyrocketing costs. Health care reform remains a top domestic concern, and the candidates for president have proposed very different ideas of how to correct rising medical costs. The two different plans would affect women in very different ways.

Push Toward the Individual Market vs. Expansion of Federal Benefits

Republican presidential nominee Sen. John McCain's plan promotes the individual health care market. Currently, Americans pay for employer-sponsored health care premiums with pre-tax income. McCain's plan would require workers to pay for insurance out of post-tax income; his plan would offset this by extending a tax credit of $2,500 for individuals and $5,000 for families. This tax credit can either be applied to a person's employer-sponsored plan or to one on the individual market. Additionally, McCain calls for opening up options by allowing people to purchase health care plans from providers in other states.

But this push to the individual market isn't optimal for women. According to a report recently released by the National Women's Law Center, women have a hard time finding equitable coverage on the individual market, often paying more and getting less. Right now about two-thirds of women get coverage though an employer, 16 percent of women get coverage through public programs like Medicaid, and just 7 percent of women currently get coverage through the individual market.

Of women who bought insurance on the individual market, the NWLC report found that they pay more in monthly premiums at almost every age than men--6 to 45 percent more for women aged 25 and 4 to 48 percent more at age 40. How can this be legal in the individual market and not in employer-sponsored coverage? Courts have ruled that Title VII of Civil Rights Act applies to employer insurance coverage. Only ten states prohibit such discrepancies in individual market premiums, and two states limit it.

McCain's plan to allow the purchase of insurance across state lines could allow some women to purchase coverage in a state where the insurance industry is regulated against discrimination by gender on the individual market. However, this is unlikely to happen in practice, since insurance plans in states with non-discrimination policies are likely to be far more expensive, and many health policy experts believe that if insurance companies can insure individuals regardless of their state of residence, the companies would relocate to the least regulated states, much like the lax financial regulations in South Dakota and Delaware are magnets for credit card companies.

Frighteningly, too, for women the list of pre-existing conditions that can lead to a legal denial of health care coverage is long.  Insurers in nine states and the District of Columbia are legally allowed to deny coverage to survivors of domestic violence. Insurers can classify it as a pre-existing condition and deny coverage; other such conditions include diabetes, a family history of breast cancer, or even pregnancy. Recent research even shows that some women can be denied coverage for having had a c-section. This is largely exclusive to the individual market because the Health Insurance Portability and Accountability Act (HIPAA), which was enacted by Congress in 1996, prevents employers from denying coverage for pre-existing conditions for more than 12 months. No such limit exists on the individual market.

On the individual market, women also often struggle to obtain coverage for maternity care, which often includes prenatal care, the costs associated with childbirth, and even infant care. Many individual plans simply do not offer maternity coverage; if they do, maternity care is often covered as an optional extension to a plan called a rider. A rider often requires a woman to pay a higher premium for an average of 12 months before she gets covered for maternity care. The plans often only offer a benefit of a few thousand dollars--often much less than total maternity care costs.

The NWLC report concludes that riders often end up being a bad deal for women. Judy Waxman, Vice President and Director of Health and Reproductive Rights at the NWLC, notes, "Nobody knows that the [individual market] plans out there don't cover maternity [care] and the benefits are terrible."

Employers, meanwhile, are required to cover maternity care because courts determined it falls under the Pregnancy Discrimination Act of 1978.

McCain has appended a Guaranteed Access Plan to his larger plan on health care reform, which is a state-by-state strategy for mandating that those with pre-existing conditions are not denied coverage. The plan offers little in the way of what conditions qualify as pre-existing and which states should be targeted first. Some have called this component of his reform plan "empty rhetoric."

In contrast, Democratic presidential nominee Sen. Barack Obama's plan to reform the health care system sets up a very different set of incentives. Obama's plan maintains current employer-based health coverage but would also open up the purchase of federal employees' plans to the general public. Additionally, Obama's proposed plan would prevent insurance companies from denying coverage for pre-existing conditions. Though the plan raises a lot of questions about who would be covered--for instance, would the plan be available only to U.S. citizens or those with legal documents?--and how to make such wide access to coverage affordable, the plan ultimately seeks to make plans accessible and affordable to anyone wanting to purchase health insurance.

Will Reproductive Health Care Be Covered?

Women need coverage for maternity care, access to insurance without pre-existing condition exclusions, and fair premiums, but they also need comprehensive reproductive health care coverage. Moving forward with health care reform makes many health policy officials that are concerned with women's health nervous that services like abortion, perhaps even birth control, might be eliminated from publicly subsidized plans. Share Your Story!

"One of the critical elements of the benefits package has got to address the reproductive health care needs of women.  That to me is not negotiable," said Kathleen Stoll, director of health policy at Families USA.

The expansion of the Federal Employees Health Benefits package, which Obama's plan calls for, is unlikely to include abortion coverage because the package currently has a ban on abortion services (PDF). Congress briefly reversed this ban on coverage for abortion for federal employees in 1993, only to have the ban reinstated by Congress two years later.

"The problem with the choice issue is that it can derail some things. And we want to get health care reform and we want to make it happen," Stoll said. "But it's hard for me to imagine how you can take one finite reproductive service off the table out of the many that women need and call that comprehensive reproductive service."

How low-income people are covered tends also to disproportionately affect women, because women tend to be poorer than men in every racial and ethnic group. "Medicaid is sort of the major option for low-income people," said Usha Ranji, a senior policy analyst at the Kaiser Family Foundation.

Currently public programs such as Medicaid don't cover the individual service of abortion in most states, except in very rare circumstances when the procedure might save the life of the mother. But except for its ban on abortion, Medicaid tends to have much better coverage than the individual market for reproductive services like annual exams, prescription drug benefits for birth control, and testing for sexually transmitted infections than the individual market does.

The proposed changes to Medicaid differ slightly between the two candidates. Obama proposes expanding eligibility for Medicaid and the State Health Insurance Program (SCHIP), which is a program designed for low-income children. He also proposes states to have flexibility for implementing the plan, but would require a federal list of clinical preventative services, like cancer screenings, be covered under Medicaid. Again, McCain's plan advocates the individual market by allowing funds originally dedicated to Medicaid and SCHIP to be used for individual insurance plans and opposes expansion of eligibility for these public plans.

Although health care reform for women, who tend to be getting poorer care on the individual market and are more likely to be living in poverty than men, will be an uphill battle, there is some room for optimism. There are a number of women's organizations fighting to ensure comprehensive reproductive health care coverage in any upcoming health care reform. Raising Women's Voices has been gathering stories and using grassroots tactics to mobilize women immigrants, women of color, and the most impoverished. They hope that by collecting the stories of these women's experiences with the health care system, they can begin to call for appropriate policy action. "Once [women] hear that they're not alone with these problems then they're willing to speak out about it," said Lois Uttley, the organization's director. "[Health care is] getting costly and the coverage is getting worse."

Women's health care is an critical component of any future health care reform. Women need to make their reproductive needs a priority in the upcoming health care debate. But the type of plans that we shift toward will be just as important as making sure reproductive services are covered.