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American living abroad demonstrates EXACTLY why ACA regulations are needed.

Jill Filipovic is an American journalist living abroad. She's from New York, but has been living overseas for some time, reporting for the Guardian and a whole mess of other respected publications.

About an hour ago, she tweeted the following:

My insurance company @Cigna confirms it won't cover contraception, abortion, or, for the 1st year, pregnancy. What are women supposed to do?

— Jill Filipovic (@JillFilipovic) May 25, 2016

A bunch of people immediately expressed confusion since, as HHS spokesman Aaron Albright pointed out, under the ACA...

Every health insurance plan sold in the Marketplace will offer 10 essential health benefits.

What’s covered in the Health Insurance Marketplace

These essential health benefits include at least the following items and services:

  • Outpatient care—the kind you get without being admitted to a hospital
  • Trips to the emergency room
  • Treatment in the hospital for inpatient care
  • Care before and after your baby is born
  • Mental health and substance use disorder services: This includes behavioral health treatment, counseling, and psychotherapy
  • Your prescription drugs
  • Services and devices to help you recover if you are injured, or have a disability or chronic condition. This includes physical and occupational therapy, speech-language pathology, psychiatric rehabilitation, and more.
  • Your lab tests
  • Preventive services including counseling, screenings, and vaccines to keep you healthy and care for managing a chronic disease.
  • Pediatric services: This includes dental care and vision care for kids

Specific health care benefits may vary by state. Even within the same state, there can be small differences between health insurance plans. When you fill out your application and compare plans, you’ll see the specific health care benefits each plan offers.

I (and several others) speculated that Ms. Filipovic might be enrolled in either a short-term or pre-ACA policy (grandfathered, since New York never allowed transitional policies to be extended past 2013 anyway), but Filipovic quickly clarified the problem (which makes total sense once you remember that she's living abroad):

@charles_gaba @jkarsh It's not. It's expat insurance.

— Jill Filipovic (@JillFilipovic) May 25, 2016

Yup, there you go. The ACA only holds domestic insurance policies up to the "10 essential benefits" requirements. Grandfathered, transitional, short-term and expatriate policies don't have to cover any of the above.

And the reason given by Cigna for not covering contraception?

The reason @Cigna doesn't have to cover contraception is because it's expat insurance & they say contraception isn't a medically necessity.

— Jill Filipovic (@JillFilipovic) May 25, 2016

Ah. Of course.

The response from a Donald Trump supporter (check their profile) was pretty much what you'd expect:

@JillFilipovic @Cigna How about learning to keep your legs closed. Your lack of self-restraint is not my problem.

— jtomka (@jtomka) May 25, 2016

...but to her credit, Filipovic was having none of it:

This is good advice for ppl whose insurance doesn't cover contraception, abortion, or pregnancy. Celibacy til death. https://t.co/8pgdbUwPnh

— Jill Filipovic (@JillFilipovic) May 25, 2016

Sex is a normal & frankly really fun part of human existence. For much of history women have deemed it necessary to not get pregnant from it

— Jill Filipovic (@JillFilipovic) May 25, 2016

When women weren't able to reliably avoid pregnancy? Lots of women died, and died young. Lots still do. "Medically unnecessary" though.

— Jill Filipovic (@JillFilipovic) May 25, 2016

BTW people who are like "buy your own birth control": You know when insurance doesn't cover BC, women often go to taxpayer-funded clinics?

— Jill Filipovic (@JillFilipovic) May 25, 2016

And so private insurers not covering birth control means that financial burden gets shifted to the public?

— Jill Filipovic (@JillFilipovic) May 25, 2016

There are two takeaways here:

First, Republicans still can't seem to get it thorugh their heads that sex is as normal a part of life as breathing, eating, drinking, urinating and defecatingHealth insurance not covering the most obvious medical expenses related to sex would be like, I don't know, a high school not allowing students to go to the bathroom when they need to. Oh, wait...

Second, the next time you hear someone griping about the ACA being "overly burdensome", remember that if the law is repealed, insurance companies could kick every woman under the bus if they wanted to. That's what "removing burdensome regulations" and allowing "the invisible hand of the free market" to dictate everything (including your health) means, folks: Not profitable enough? Go pound sand.

UPDATE: Thanks to Amy Lotven for this link which explains how expatriate policies managed to escape the ACA regulation requirements in the first place:

Since the passage of the Affordable Care Act (ACA), expat plans have had some trouble fitting in. Sensing this mismatch, the Departments of Labor, Health and Human Services and the Treasury (collectively, the Departments) issued a FAQ in March 2013 and another in January 2014 extending temporary relief from a number of ACA requirements for expat plans. The Expatriate Health Coverage Clarification Act (the Expat Act) expands on the previous FAQs and provides expat plans permanent relief, but not without preconditions.

...FAQ XIII provided relief to expat plans ending on or before December 31, 2015. The Departments defined expat health plans as “insured group health plans for employees who reside outside of their home country for at least six months of the plan year (and any covered dependents).” Such plans were exempt from many of the ACA’s mandates, including annual and lifetime limits, preventative services, dependent coverage, summaries of benefits and coverage, nondiscrimination based on compensation and health status, prohibitions of preexisting condition exclusions and excessive waiting periods, essential health benefits, etc. This FAQ also deemed expat coverage to satisfy the minimum essential coverage requirement of both the individual mandate and the employer shared responsibility mandate.

In FAQ XVIII, the Departments extended the temporary relief to expat plans ending on or before December 31, 2016 and clarified the definition of an expat plan.