At a town hall meeting in Willingboro, N.J., on Wednesday, U.S. Rep. Tom MacArthur was confronted by angry constituents who demanded to know how the Republican health care bill that he helped write would affect rape victims.
A young man named Joseph said he understood that the bill would allow insurance companies to deem rape a pre-existing condition and deny coverage to people who have been raped.
He demanded MacArthur defend his support of the bill, which, he said, would "force women to choose between justice and silence to protect their affordable health care."
MacArthur tried to assure the crowd that rape victims would be protected under the bill. He said the notion that rape could be treated as a pre-existing condition had been debunked.
"You cannot be denied or charged more because of having been raped," MacArthur told the booing crowd.
Later at the town hall meeting, another young woman asked the congressman a similar question.
"Is rape considered a pre-existing condition under your amendment? Yes or no?" demanded a 17-year-old named Daisy, drawing cheers from the crowd. "Yes or no, yes or no? One word, please!"
But, as with most things in health care, the reality is too complex to reduce to yes-and-no questions, or simple statements.
Before the Affordable Care Act
Before the Affordable Care Act was passed in 2010, insurance companies didn't specifically include rape as a pre-existing condition that would allow them to deny victims coverage or charge them more. But a handful of conditions and interventions that can follow a sexual assault could have led people who were raped to be excluded from buying policies.
"What could happen, and we don't know for sure, is that the ways people access the health care system after an assault could be flagged by some insurance companies as high risk," says Dr. Diane Horvath-Cosper, an OB-GYN who is the reproductive health advocacy fellow at Physicians for Reproductive Health.
Horvath-Cosper says some rape victims are given medications after the assault to prevent them from contracting HIV or other sexually transmitted infections. And some people who are sexually assaulted seek mental health counseling for post-traumatic stress disorder or other conditions.
Before the Affordable Care Act, also known as Obamacare, people could be denied coverage or charged more for insurance if they took medications to treat HIV/AIDS or had existing mental health conditions. For example, seeking treatment for depression was listed as a "permanent decline" in a pre-Obamacare underwriting guide for the insurance company Humana. Underwriting guides from before the ACA for four insurance companies all show AIDS as a "declinable" condition.
An investigation published by the Huffington Post Investigative Fund in 2010 showed that many victims of rape were denied coverage because they contracted a sexually transmitted disease or took medications to prevent one, or they were denied coverage of mental health care to treat the psychological effects of the assault.
That all changed with the Affordable Care Act.
Under the ACA, insurance companies must provide comprehensive coverage, as defined by a list of "essential health benefits," including mental health care, prescription drug coverage and maternity care. And insurers are required to charge everyone of the same age and living in the same community the same price.
What's in the House GOP bill
The bill passed by House Republicans last week, called the American Health Care Act, retains the "essential health benefit" language in federal law, as Health and Human Services Secretary Tom Price said in an interview with NPR's Rachel Martin scheduled to air Friday on Morning Edition.
"There's a specific statement within the proposed legislation itself, that went through the House and is now in the Senate, that says that no insurance company can decrease the access to coverage for anybody based upon a pre-existing condition," Price said.
However, the bill includes a huge loophole. States are allowed to apply for waivers to exempt them from many of those federal rules. States could redefine the essential benefits to allow insurers to offer less comprehensive policies and could allow insurance companies to charge people more money for pre-existing conditions.
"By dismantling all those consumer protections, essentially you leave people in the market and insurance companies could return back to those discriminatory practices of the past," says Janel George, director of federal reproductive rights and health at the National Women's Law Center.
The loophole in the Republican bill could lead women to routinely pay more for health insurance, as they did before the Affordable Care Act. Some of the conditions women may seek care for, such as pregnancy and mental health disorders, were among those that cost more or were not covered before the ACA.