On June 28, the U.S. Supreme Court rendered a historic decision that will assure vastly improved access to health care for Americans. By upholding the constitutionality of the Affordable Care Act (ACA), the court has freed state and federal governments to expand health insurance coverage to more than 30 million people. This extraordinary reform will be achieved by mandating that everyone either carry insurance or pay a fine, prohibiting insurers from discriminating against those with pre-existing conditions, establishing markets for the purchase of insurance, and expanding subsidies and Medicaid eligibility for those who cannot afford to purchase insurance.

The significance of the ACA for women is enormous. In a recently published report, “Through the Lens of Equality: Eliminating Sex Bias to Improve the Health of Pennsylvania’s Women,” the Women’s Law Project (WLP) examines the profound impact of persistent societal bias and discrimination on women’s health. Women and girls are disproportionately subjected to sexual and intimate partner violence and discrimination in their homes, schools, workplaces and the health care system. They bear the brunt of caregiving responsibilities and poverty. They are also denied essential reproductive health care and are subjected to discrimination in insurance coverage. As a consequence, their physical and mental health suffers and their need for health care, which has been unfairly denied to them, is great.

“Through the Lens of Equality” relies on implementation of the ACA to rectify many of the health issues that plague women. The ACA prevents insurers from using pregnancy, domestic violence, and sexual violence as a basis for denying women coverage as pre-existing conditions; prohibits the practice of charging women higher insurance premiums than men for the same insurance (known as gender rating); guarantees maternity coverage; ensures that new insurance plans cover preventive services without cost-sharing, including contraception, Pap tests, STI screening and counseling, prenatal care and the human papillomavirus vaccine; and provides access to obstetric and gynecologic care without preauthorization or referral and funding to support maternal, infant and early childhood home visiting programs.

The ACA, however, does not solve all of the health problems experienced by women and girls. The Supreme Court’s invalidation of the enforcement mechanism for the ACA’s requirement that states expand Medicaid eligibility to 133 percent of poverty places implementation of this expansion at risk and raises serious questions about access to health care for poor women and decision-making by states.

If states fail to comply with the Medicaid expansion, many poor women will be left without health coverage. Lack of health coverage leads to lack of access to even basic health care, leading to long-term health consequences.

Women are disproportionately burdened by poverty and suffer from conditions associated with it, including malnutrition, diabetes, coronary heart disease, asthma, HIV, cervical cancer, obesity, high blood pressure and a host of mental health conditions.

The Medicaid expansion is in large part federally funded. The federal government picks up 100 percent of the tab in 2014. States do not begin to contribute until 2016 and are capped at 10 percent in 2020. Pennsylvania stands to gain an estimated $17 billion in federal spending if it participates in the program. The Medicaid expansion, if undertaken by Pennsylvania, will provide coverage to almost 800,000 Pennsylvanians. Governor Tom Corbett has stated that he “will work to ensure Pennsylvanians have access to affordable and quality health care” and an administration spokesperson has said that the commonwealth will “take the time to review the decision and see what our options are.”

While Medicaid and the ACA will provide access to important health care for poor women, both exacerbate the current crisis in access to abortion care. Medicaid does not cover abortion care except in cases of rape, incest or life endangerment of the pregnant woman.

The ACA not only fails to solve the crisis in access to abortion care but compounds it. It incorporates the same limitations Medicaid imposes and permits states to ban the sale of insurance coverage that more broadly covers abortion care in the exchanges that will serve as the primary marketplace for insurance for individuals and small businesses.

The Pennsylvania General Assembly, like many legislatures across the country, is considering legislation that will ensure that insurance plans sold through the ACA’s state exchanges do not include abortion coverage except in cases of life endangerment, rape, or incest. Even if the ban is not adopted, any abortion coverage provided through these exchanges must comply with complicated rules requiring segregation of private premium payments, which would likely discourage insurers from offering abortion coverage.

This politicizing of women’s health care will harm women who need comprehensive reproductive health care, as described in “Through the Lens of Equality.” In Pennsylvania, as in other states, women are experiencing a backlash against their equality and freedom. This backlash has found expression in an outpouring of legislative proposals and enactments that restrict, burden, or ban safe abortion care. State by state, women’s equality is being hammered.

In the first six months of 2011 alone, the Pennsylvania General Assembly spent fully one-third of its voting session days advancing anti-abortion bills. Despite a year of intense advocacy by a statewide coalition of pro-choice organizations convened by the Women’s Law Project, we were unable to stop one of the most dangerous bills from passing. In December 2011, Corbett signed into law Act 122, legislation that confines the performance of even very early, very simple abortion procedures to facilities that meet the costly and inappropriately sophisticated standards applied to ambulatory surgical facilities.

Abortion care in Pennsylvania is already difficult for many women to obtain. Only 10 of 67 counties have at least one freestanding clinic providing abortion care. These providers offer high-quality care at low cost, an important consideration given the fact that Medicaid and many private insurance plans generally do not cover abortion procedures.

The provider shortage problem was worsening even before Pennsylvania enacted Act 122. Since 2000, Pennsylvania has lost 23 percent of its abortion care providers, a rate of loss higher than the national average. The pressures forcing abortion providers to close include a hostile regulatory climate and targeted protests that single out individual doctors and clinic staff for highly personal, intensely threatening harassment, stalking and home picketing. Should that dwindling number of freestanding women’s health care providers shrink further, many of the roughly 37,000 women who turn to them for care will effectively face the loss of their right to choose.

Deep-seated cultural bias about women’s role in society not only limits women’s opportunities; gender bias also harms women’s health. The ACA is an important step in the right direction, but if we want to protect women’s health fully, we must eliminate all barriers to gender equality and provide essential services, educational initiatives, and effective monitoring systems.

WLP’s report, “Through the Lens of Equality: Eliminating Sex Bias to Improve the Health of Pennsylvania’s Women,” is available on its website at www.womenslawproject.org. •

Carol E. Tracy is the executive director of Women’s Law Project. Terry L. Fromson is WLP’s managing attorney, and Amal Bass is a WLP staff attorney.