Senate Republicans revealed new legislation—a much-anticipated follow-up to the American Health Care Act passed by the House of Representatives last month—intended to repeal and replace the Affordable Care Act. The Senate’s version of the bill, called the Better Care Reconciliation Act of 2017, keeps much of the framework of the ACHA, with a few changes.
But many health care experts and medical groups are voicing concern with the Senate's version of the bill—especially with its potential impact on low-income Americans, people with pre-existing conditions and specifically women.
“This legislation deliberately strips the landmark women’s health gains made by the Affordable Care Act and would severely limit access to care,” said Dr. Haywood Brown, president of the American Congress of Obstetricians and Gynecologists (ACOG), in a statement. “If enacted, this legislation will turn back the clock on women’s health.”
Many top health groups said they tried to offer their input on the bill but were turned down. Haywood, too, said ACOG tried many times, but their “women’s health expertise was rejected,” as the legislation was crafted behind closed doors. Now, Haywood urges the Senate to “reject this bill and begin anew.”
Other health experts that TIME spoke with agree. Here are four ways they say the bill, as it stands now, would affect women and families across the country.
Many women could lose basic benefits
Under the Affordable Care Act, insurance plans sold on the individual market must cover “essential health benefits,” often at no cost to the patient. These include many women-focused services like maternity coverage, contraception, mammograms, cervical cancer screenings, well-woman visits, breast pumps and domestic violence screening and counseling. Large employer plans aren’t required to include these benefits, but if they do (and almost all do), they must provide the same level of coverage without annual or lifetime limits.
But the House bill would allow individual states to decide which essential health benefits would be covered for their residents and at what level. While the language in the Senate bill isn’t quite the same, it appears to offer a similar loophole, says Leighton Ku, professor of health policy and management at George Washington University’s Milken Institute School of Public Health. “It’s certainly possible you could have health insurance being sold in a state that does not provide maternity coverage or really limits prescription drug coverage,” says Ku—a scenario that could apply to employer-sponsored plans as well as private insurers. “It’s too early to predict exactly how that will play out and what the government will allow for, but it’s a possibility that would not really be permitted under the existing system.”
Medicaid would suffer deep cuts
Like the House Bill, the Senate’s new legislation calls for cuts in federal funding to Medicaid expansion, which many states have used in recent years to reduce their numbers of uninsured residents. It also places caps on the amount of money each state can receive for Medicaid and uses a funding formula that would leave the program even more underfunded than under the House bill. (Currently, Medicaid is funded based on how many people are enrolled and what their health-care costs are.)
Medicaid covers more women than men, and it also covers half of all births in the United States. “These cuts are going to either mean coverage for fewer people or fewer services,” says Dr. Michelle Moniz, assistant professor of obstetrics and gynecology at the University of Michigan. “And if those essential health benefits like maternity care and contraception aren’t protected, women and children could be in real danger of losing care.”
Ku points out that the Senate bill, like the House bill, also lets states add requirements that a person must be working in order to be eligible for Medicaid. “This could affect, for example, a young mother,” he says. “Medicaid would not cover the costs of her child-care needs, which could create a problem.”
Preventive care could be curtailed
Under the new Senate bill, Medicaid reimbursement to Planned Parenthood would be eliminated for at least one year. Republicans want to defund Planned Parenthood because the organization provides abortions—even though it’s already illegal for federal money to be used toward these procedures (except in cases of rape, incest or when the mother’s life is in danger).
With the elimination of Medicaid reimbursement, however, women on Medicaid would not be able to use any of Planned Parenthood’s services, which include well-woman visits, cervical cancer screenings, access to low-cost contraception and testing for sexually transmitted infections. Funding cuts could also lead more Planned Parenthood locations to close.
“The bill includes some money to boost community health centers as an alternative, but many of those centers don’t have the trained professionals who can provide long-acting contraceptives and ongoing health-care services that many women need,” says Dr. Hal Lawrence, executive vice president of ACOG. “They’re not equipped to fill that gap.”
Fewer women may have insurance
The Senate bill also eliminates the individual mandate that required all individuals to have health insurance or pay a tax, as well as the requirement for companies with 50 or more employees to provide health coverage for their workers. While the Senate bill does follow the Affordable Care Act’s policy of providing financial assistance based on income (unlike the House bill), those subsidies will be smaller, and eligible to fewer people, than under the current plan.
“Because of this, I think we’ll see more people who are uninsured, some by choice and some because they no longer have access to affordable health insurance,” says Moniz. While this is a gender-neutral issue, women face unique circumstances, especially around childbirth, that make health insurance especially important for them, she says.
The United States already has the highest maternal mortally rate in the developed world, she says, and reducing coverage for women is very likely to make the problem worse. “It is clear that access to a doctor before and during pregnancy—screening for complications like hypertension and diabetes, having appropriate care during labor and delivery—saves lives and improves health for women and children,” she says. “It’s the foundation of the future of that family’s health.”