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The Republican vision for women’s health care is coming into sharp focus — and it’s a harsh reality for women of childbearing years.

Today we learned that the Trump administration is making plans to roll back Obamacare’s birth control mandate. A draft regulation obtained by Vox would allow all employers to opt out of the Affordable Care Act requirement to cover birth control at no cost to the patient. Religious organizations wouldn’t have to notify the government at all.

“This rule would mean women across the country could be denied insurance coverage for birth control on a whim from their employer or university,” says Dana Singiser, Planned Parenthood’s vice president for policy.

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The American Health Care Act that House Republicans passed in mid-May would significantly increase the price of maternity care for women who buy their own insurance. It would also let insurance plans charge some people higher premiums because of their preexisting conditions, whether that's a C-section or heavy periods.

Together, the policy proposals make reproductive health and maternity care more difficult to access and more expensive.

For women’s health advocates who thought 2017 would be the year the first woman president took office, after running on a platform of increased access to reproductive health services, they’re finding themselves stepping into a much different battle. Where they believed they’d be pushing for new wins, they’re finding themselves gearing up to protect hard-fought gains.

Already, legal advocates are plotting lawsuits to challenge the Trump administration’s draft rule. Political groups are spinning up campaigns to protect benefits at the state level. And Democrats in Congress are mobilizing to draw attention to the attacks.

“We believe there will be the space to make a challenge,” says Louise Melling, deputy legal director at the American Civil Liberties Union. “The right to religious freedom gives you a right to beliefs but doesn’t give you a right to impose those beliefs on others. There are fundamental principles at stake here.”

Two big ways Republican proposals hurt women’s health care

Republicans want to dismantle the Obamacare mandates that specifically benefit women in two key ways:

1) End the mandate to cover maternity care. The American Health Care Act would let states opt out of the requirement that all health plans cover maternity care. Right now, the Affordable Care Act mandates this coverage as part of the essential health benefits package. Only 12 percent of individual market plans covered maternity care prior to this requirement.

The Republican plan would allow states to opt out of this requirement, once again letting insurance plans pick and choose what benefits they want to cover. The Congressional Budget Office estimates that in some states, women would need to spend $1,000 each month to purchase a “rider” policy to cover maternity care.

2) Significantly relax Obamacare’s birth control mandate. The ACA requires nearly all businesses to cover contraceptives at no cost to patients. The law included an exemption for religious organizations. The Hobby Lobby lawsuit led to special provisions for religiously affiliated employers, like Catholic universities and hospitals, and “closely held” private businesses with religious owners who objected to such coverage.

The Trump administration apparently wants to allow any employer to opt out of the birth control mandate if they have a moral or religious objection to providing that coverage. Should this regulation become law, it would mean that any employer from a tiny shop to a large, publicly traded company could avail themselves of this exemption.

Legal organizations, advocacy groups are girding for a fight

Two nonprofit organizations have already committed to challenging this regulation in court, should the Trump administration publish this as its final rule. Both the National Women’s Law Center and the ACLU say they would file suit.

“The Trump administration should be ready for a fight if it takes away this essential coverage,” says Gretchen Borchelt, vice president for reproductive rights at the National Women’s Law Center. “If the rule is made final, we will file a lawsuit against it.”

Advocates are also pushing state-level laws that would protect birth control coverage. New York, for example, announced in January that it would mandate all insurance plans in the state to cover contraceptives at no cost to patients.

Four other states are considering similar measures.

Chart of the Day

Only 8 percent of voters want the American Health Care Act passed as is. The Kaiser Family Foundation finds very little support for the Senate passing the House bill. Half of Americans want to see major or minor changes to the AHCA, while 29 percent say they don't want the bill to pass at all.

Kliff’s Notes

Your daily top health care reads, with research help from Caitlin Davis

Today's top news

"Ryan appoints controversial cancer doctor to HHS committee" : “House Speaker Paul Ryan has named Patrick Soon-Shiong, a controversial billionaire scientist, to a committee that will advise the Trump administration on policy around health information technology, a Ryan spokeswoman said this evening. Soon-Shiong, a Los Angeles surgeon who leads a network of for-profit and not-for-profit ventures conducting cancer research, has been the subject of news stories, including by POLITICO and STAT, that have raised questions about potential conflicts of interest.” —Darius Tahir, Politico

“House Speaker Paul Ryan has named Patrick Soon-Shiong, a controversial billionaire scientist, to a committee that will advise the Trump administration on policy around health information technology, a Ryan spokeswoman said this evening. Soon-Shiong, a Los Angeles surgeon who leads a network of for-profit and not-for-profit ventures conducting cancer research, has been the subject of news stories, including by POLITICO and STAT, that have raised questions about potential conflicts of interest.” —Darius Tahir, Politico "Medicaid chief Seema Verma blames Obamacare's collapse on its founders" : “When the Obamacare insurance exchanges collapse and leave some Americans stranded without health coverage, top Trump administration official Seema Verma says, blame the folks who created them in the first place. 'Right now, if we look at it, this is all because of the Affordable Care Act,' says Verma, the administrator of the Centers for Medicare and Medicaid Services. 'I mean, the individual market was working much better than it is now, so this is all the impact of the Affordable Care Act.'” —Susan Page, USA Today

“When the Obamacare insurance exchanges collapse and leave some Americans stranded without health coverage, top Trump administration official Seema Verma says, blame the folks who created them in the first place. 'Right now, if we look at it, this is all because of the Affordable Care Act,' says Verma, the administrator of the Centers for Medicare and Medicaid Services. 'I mean, the individual market was working much better than it is now, so this is all the impact of the Affordable Care Act.'” —Susan Page, USA Today "Higher taxes on cars and dining to pay for California health care? Nurses have a proposal": “The high cost of paying for universal health care for all Californians has for more than two decades killed proposals by politicians to adopt such a system. But the pricetag could no longer stand in the way of two Democratic state senators trying to remake California’s health care market into a taxpayer funded model that gets rid of the need for insurance companies and covers everyone regardless of immigration status or ability to pay.” —Angela Hart, Sacramento Bee

Longer reads and analysis

"Two decades ago, Washington state Republicans repealed and replaced a healthcare overhaul. It didn't end well" : “Republicans in the state of Washington didn’t wait long in the spring of 1995 to fulfill their pledge to roll back a sweeping law expanding health coverage in the state. Coming off historic electoral gains, the GOP legislators scrapped much of the law while pledging to make health insurance affordable and to free state residents from onerous government mandates. It didn’t work out that way: The repeal left the state’s insurance market in shambles, sent premiums skyrocketing and drove health insurers from the state.” —Noam N. Levey, Los Angeles Times

“Republicans in the state of Washington didn’t wait long in the spring of 1995 to fulfill their pledge to roll back a sweeping law expanding health coverage in the state. Coming off historic electoral gains, the GOP legislators scrapped much of the law while pledging to make health insurance affordable and to free state residents from onerous government mandates. It didn’t work out that way: The repeal left the state’s insurance market in shambles, sent premiums skyrocketing and drove health insurers from the state.” —Noam N. Levey, Los Angeles Times "How the Molina Brothers Got Bounced From the Family Health-Care Firm" : “Many insurers lost money on ACA plans due to higher-than-expected costs and the complicated, evolving rules under the law. Molina’s smaller size and thinner margins compared with rivals left it exposed when it ran into problems, analysts said.” —Anna Wilde Mathews, Wall Street Journal

“Many insurers lost money on ACA plans due to higher-than-expected costs and the complicated, evolving rules under the law. Molina’s smaller size and thinner margins compared with rivals left it exposed when it ran into problems, analysts said.” —Anna Wilde Mathews, Wall Street Journal "The G.O.P. Health Care Bill Is Fixable" : “Contrary to recent headlines, the biggest problem with the A.H.C.A. — one that the C.B.O. highlighted — is not how the bill deals with the sick. While that part of the bill needs to be fixed, it represents a smaller problem. Indeed, the biggest problem with the Republican bill — by far — is that it fails people who can’t afford health insurance, regardless of their pre-existing health status.” —Avik Roy, New York Times

“Contrary to recent headlines, the biggest problem with the A.H.C.A. — one that the C.B.O. highlighted — is not how the bill deals with the sick. While that part of the bill needs to be fixed, it represents a smaller problem. Indeed, the biggest problem with the Republican bill — by far — is that it fails people who can’t afford health insurance, regardless of their pre-existing health status.” —Avik Roy, New York Times "Most healthcare providers don't know cost of a common ER visit, study says": “Researchers have found that an average of only 38 percent of emergency medicine healthcare professionals — including physicians, physician assistants and nurse practitioners — accurately estimated the costs for three common conditions seen in the emergency department. Improving that percentage has the potential to lower costs for patients and the overall healthcare system, according to a study published in The Journal of the American Osteopathic Association.” —Jeff Lagasse, Healthcare Finance

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