FACTS: Health Care for Survivors of Domestic & Sexual Violence

Survivors of domestic violence and sexual assault need a range of health and mental health services, including preventive care, to heal and thrive. Today, affordable and comprehensive care is guaranteed, including for survivors through the Affordable Care Act (ACA). Importantly, the Affordable Care Act is still current law and survivors should be encouraged to get care and know they can sign up for health care at any time as can Medicaid enrollees.

The Affordable Care Act helps survivors because:

  • Health plans cannot deny coverage to anyone because they have experienced DV/SA, or for any pre-existing condition (this is known as guaranteed issue). Before the ACA was signed into law, in 8 states plans could still deny coverage for experiencing DV/SA.
  • As important, plans cannot charge more based on health status including DV or other symptoms of trauma (this is known as community rating).
  • Survivors can access affordable coverage that is not tied to their abuser and addresses the unique situations that survivors face (e.g., that survivors may experience gaps in health insurance due to circumstances entirely out of their control).
  • Plans must offer a comprehensive benefit package that covers a range of health and behavioral health services (this is known as the essential health benefits)


The Better Care Reconciliation Act (BCRA) allows these protections to be undermined or stripped away.

Impacts of the BCRA

The BCRA does maintain the guarantee issue—meaning that plans technically cannot deny coverage to anyone.  But they can charge people whatever they want and using someone’s pre-existing condition as the justification for changing their rates, including to the point of making them completely cost-prohibitive.


  • The BCRA allows states to apply for a waiver to waive the “essential health benefits.” In those states plans who can control what benefits are offered and the scope of those benefits, so for instance they can limit how many counseling visits might be available or what kinds of services are given to a rape survivor.
    • This means plans could offer bare-bones coverage of services, like mental health benefits and care for chronic conditions. Healthy people who do not anticipate needing much care will purchase these plans because they will be cheapest. Young people with less money are likely to be drawn to these bare-bones plans without realizing how little they are covered – but that is exactly the population that is most likely to be assaulted and who might need more comprehensive care.
    • Comprehensive plans may be available, but they will be extremely expensive. People with preexisting conditions who anticipate that they will need care will be forced to pay these high premiums, otherwise they will be forced to pay out of pocket for non-covered services or forgo needed care.
    • This provision makes comprehensive care extremely expensive and puts care out of reach for many survivors.
  • The BCRA will allow states to waive the community rating protections. If a state waives the rules on community rating, plans will be able to explicitly charge certain people with pre-existing conditions more by “underwriting their risk.”
    • On a state-by-state basis, health plans will be allowed to charge people with pre-existing health conditions more than a healthy person for the exact same plan.
    • This provision would apply to consumers in the individual market and small group market—that’s currently 18 million people who would be at risk.
    • This could only be applied to consumers who do not have continuous coverage (in other words, who are uninsured for two months or more).
    • The BCRA does not explicitly classify which conditions could be underwritten. In other words, the BCRA does not specifically say that exposure to DV/SA would be deemed a pre-existing condition. However, by rolling back the ACA’s explicit protections, this bill puts survivors at high risk of having their health history used in underwriting.  The bill will let states make these choices.
    • Survivors who have not disclosed their DV/SA will still be at risk for underwriting because other symptoms of trauma may appear in their health history, such as use of mental health services, a diagnosis of PTSD or emergency room visits.
  • The BCRA requires consumers to be continuously covered or face higher premiums. This provision is designed to encourage consumers to get health insurance before they get sick.

This replaces the ACA’s requirement that everyone have insurance (known as the individual mandate).

  • Any consumer with a gap in their health insurance of more than two months will be subject to a 30% premium increase for the first 12 months of coverage. Or, in a state that chose to waive community-rating rules, consumers will be subject to underwriting on their health status.
  • Survivors are a risk for having gaps in coverage for many reasons, including circumstances entirely out of their control. For example, if an abuser terminates coverage without telling her, the survivor will face stiff financial penalties because of his actions.

TAKE ACTION: Write and call your Senators today to tell them to preserve essential protections for domestic and sexual violence survivors by rejecting this harmful legislation. Speak out now before it’s too late!