Women’s Health and Health Care Reform
5
•Eliminatingobstaclestoenrollment;
•Eliminatingrestrictionstoeligibilityforlow-incomewomen;
and
•Monitoringchangesinreproductiveoutcomestohighlight
needed interventions.
The evidence shows that reproductive health care is essential to
women’s health. If national health reform is to fulfill the goal of
correcting our fragmented health system to improve America’s
health, it must address the specific health needs of women. Repro-
duction and sexuality are basic aspects of life, liberty, and the
pursuit of happiness, guaranteed by the Constitution and by inter-
national agreements to which the United States is signatory. Women
make up half of our population and shoulder key responsibilities for
our future generations and our prosperity. Therefore, a well-woman
standard of care—one that includes access to comprehensive care,
including care and services essential to reproductive health—
will help ensure that women can attain good health, maintain it
through their reproductive years and age well. Achieving such an
advance should be a central and established goal of any national
health policy.
Women’s Health and Health Care Reform
6
Current deliberations over approaches to health insurance provide
a window of opportunity to improve access to care to enable
women to attain good health, maintain good health during their
reproductive years, and age well. This is a critical moment to insert
the public health perspective on population level needs and on
the value of evidence based public policy. The scientific data point
to the compelling need to improve the reproductive health of all
Americans. Rates of maternal and infant mortality, low birth weight,
unintended pregnancy, and sexually transmitted infections are
much too high for a nation that is rich in resources and technical
competence. Moreover, health problems are concentrated among
disadvantaged groups, and these disparate rates have stagnated or
worsened over the past three decades.
1
This document grows out of a conference held at the Mailman
School of Public Health at Columbia University on November 8-9,
2007, for the purpose of probing the relationship between what we
know about women’s reproductive health and proposals to improve
health care coverage in the United States. The 23 experts who
attended agreed that reproductive health is a key determinant of
women’s overall health, and should therefore be part of any nation-
al discussion about health care reform. There is significant public
support for this position.
Polls and voter analysis data consistently demonstrate that Americans
value personal responsibility but expect society and government to
provide the information, services, and options that foster it. They
believe that their ability to plan when to start a family and make
other important life decisions is integral to their personal liberty and
to their responsibilities as parents and members of society.
2
The great
majority of Americans, both men and women, believe that women
must have access to family planning services, including birth control,
if they are to achieve equality and reach their full potential.
3
Americans worry about the inadequacies of their health care cover-
age, its high costs, and the problems they face in getting the health
services they need.
4
At the same time, our economy is slowing and
the value of the dollars we have to spend on health care is falling.
5
Current debate over health care priorities and how best to pay for
them presents a critical opportunity to improve the health of all
Americans by including public health data that substantiate the
importance of focusing on women—before pregnancy, during the
child raising years, and as productive seniors, Without addressing re-
productive health as part of overall health, the United States cannot
move forward to redress the health disparities and gaps in overall
health care provision.
We need to enable women to attain
good health, maintain good health
during their reproductive years, and
age well.
The great majority of Americans, both
men and women, believe that women
must have access to family planning
services, including birth control, if
they are to achieve equality and reach
their full potential.
Introduction
Women’s Health and Health Care Reform
7
The Compelling Nature of the Population
While both men and women have reproductive health needs,
women have specific health concerns associated with pregnancy
and childbirth, with preventing and ending unwanted pregnancy,
with contraception, and with the more severe consequences of
sexually transmitted infections.
6
The typical American woman
wants to have two children.
7
To do so, she will spend roughly five
years being pregnant, postpartum, or trying to become pregnant
and three decades trying to avoid pregnancy.
8
Some 62 million U.S. women are in their childbearing years (ages
15–44).
9
Because women’s health affects pregnancy outcome,
children—and society—benefit directly from health care invest-
ments that permit women to grow-up healthy. At the same time,
society benefits from having healthy women who can participate
fully in workforce, family, and community life.
Without addressing reproductive
health as part of overall health,
the United States cannot move
forward to redress the health
disparities and gaps in overall
health care provision.
Entering the Reproductive Years in Good Health
The factors that put pregnancies at risk require care before preg-
nancy. There has been consensus among the medical and public
health experts for decades that women must be healthy in order
to have healthy pregnancies and babies.
10
Many states have incor-
porated strategies for improving preconception health into their
health promotion plans.
11
Today’s health care for women often focuses only on the period
when she is pregnant. By then many risk factors for complications
are already in place, such as poor nutrition, obesity, smoking, high
blood pressure, diabetes, and a stressful environment.
12
Therefore
prenatal care alone cannot achieve the goals of better health for
babies and their mothers
13
as care limited to pregnancy comes too
late and ends too soon.
Complications occurring during pregnancy such as gestational
diabetes often foretell health problems in subsequent pregnancies
and later in women’s lives. High blood pressure (pre-eclampsia)
can be a clue to subsequent coronary heart disease, and a low
birthweight birth can signal later maternal health problems.
14
The factors that put pregnancies at
risk require care before pregnancy.
Women’s Health and Health Care Reform
8
Having a Healthy Pregnancy
What We Know about Maternal
Health Risks
The U.S. has a higher maternal mor-
tality rate than most other developed
countries—15.1 maternal deaths per
100,000 live births.
15
We are far from achieving the goal
established in the Surgeon General’s
Report Healthy People 2010 of 3.3
maternal deaths per 100,000 live
births, and have been moving in the
wrong direction.
16
After remaining stagnant for the past
30 years, maternal mortality has
recently increased.
17
Large disparities in maternal mor-
tality persist by race, income, and
geography. The overall rate for black
women is 3.3 times the rate for white
women.
18
In some states, the black
rate is six times higher than the white
rate.
19
Some groups of women have signi-
cantly higher life expectancies than
others due to disparities in health
care, income, education, and other
factors. Asian American women, in
particular, live 12.8 more years than
high-risk urban black women.
20
American women have children at varied stages of their reproduc-
tive years and need to be healthy throughout in order to do so
successfully. When the average American woman is interested in
childbearing, she has specific health care needs and faces pregnancy-
associated risks. While steps to improve maternal and infant health
have been taken, many American women continue to fare poorly
in this domain.
While our pregnancy associated death rates have been worsening,
infant mortality, by contrast, has declined because of advances in
neonatal care.
21
Yet, disparities by race and geography persist here as
well.
22
Infant death rates can be more than twice as high for black
mothers as for white mothers, with rates highest in the South.
23
Meanwhile, rates of preterm birth and low birthweight have risen
and are now the highest they have been in more than three decades.
Babies born too early or too small are at higher risk for death, and
for both short- and long-term health problems.
24
Existing health insurance coverage is not preventing this situation.
The health insurance program for low-income women—Medicaid
—expands its eligibility criteria to cover pregnant women with
incomes up to 200 percent of the poverty level. But access to care
for this high-risk group of women ends with the postpartum visit.
Women who have private insurance or work for small firms exempt
from the Pregnancy Discrimination Act often have health plans that
exclude pregnancy-related care and treatment for complications of
pregnancy.
25
Men’s health is also an important part of healthy reproduction.
Men can affect fertility and pregnancy outcomes by spreading
sexually transmitted diseases, smoking, and engaging in other
risky behaviors as well as having health conditions that directly
affect their fertility.
26
In addition, men influence important life
decisions on contraception, abortion, pregnancy and childbirth,
and infertility.
27
A new national health plan should link prenatal,
family planning and medical care as part of a seamless continuum
of care for women.
Women’s Health and Health Care Reform
9
Staying Healthy in the Reproductive Years
There is a 30-year period during which the average American wom-
an of reproductive age does not want to be pregnant. The great
majority of Americans use contraception.
28
The U.S. Centers for
Disease Control (CDC) considers the widespread use of modern
contraception to be one of the greatest public health achievements
of the 20
th
century.
29
Smaller families and longer intervals between
births have significantly contributed to improvements in the health
of infants and women, as well as to improvements in women’s
socioeconomic status.
30
Nonetheless, nearly half of all pregnan-
cies among American women are unintended.
31
And unintended
pregnancy is associated with a host of medical problems and with
receiving less medical care.
32
Contraceptive use patterns vary with
education, income and health insurance status. For example, women
without health insurance are 30% less likely to use contraceptive
methods requiring prescriptions.
Unintended Pregnancy and Abortion
Uneven access to family planning information and services also
characterizes use of abortion. While more than 40 percent of all
American women will have had an abortion by age 45,
41
here, too,
disparities persist. Those who are young, unmarried, poor, and
members of racial minorities have lower levels of contraceptive
protection and, therefore, higher levels of unintended pregnancy.
Not only is abortion more concentrated among disadvantaged
women, but they are more likely to obtain the procedure later in
their pregnancy, placing them at increased health risk.
42
While 33 states require parental involvement for minors to obtain
abortions,
43
no state requires parental involvement for minors to
obtain prenatal care.
44
The goal established by Healthy People 2010
is to reduce the unintended pregnancy rate to 30 percent.
45
Sexually Transmitted Disease and Confidentiality
Another major public health concern stemming directly from
sexual activity is the possibility of acquiring a sexually transmitted
infection (STI). More than 1 in 2 Americans will contract an STI at
some point over the course of their lives.
46
Teens and young adults
have the highest rates of STIs.
47
Minors are more likely to seek treatment for STI if they don’t need
to notify their parents, though many do voluntarily; confidentiality
laws will also affect whether they accurately disclose their health
history and where they go for services.
48
Facts about Unintended Pregnancy
Nearly half of all women in the
United States have experienced an
unintended pregnancy.
33
Unintended pregnancy rates are
about twice as high for blacks, poor
women, and women with only a high
school diploma.
34
40 percent of those experiencing un-
intended pregnancy have abortions.
35
Facts about Teenage Pregnancy
While the adolescent pregnancy rate
decreased substantially from 1994 to
2001, it has recently risen.
36
The United States continues to have
the highest teen pregnancy rate of
developed countries.
37
One-third of teens have not received
any formal information about contra-
ception.
38
More than 20 percent of adolescents
receive abstinence education without
receiving information about birth
control.
39
One fth of adolescents lack any
health insurance.
40
Women’s Health and Health Care Reform
10
A new national health plan should assure that Americans receive
accurate health information, and are assured of confidentiality
so that they seek needed care.
Cervical and other Cancers
Race and low socioeconomic status are linked to higher rates of
both new cancers and cancer deaths. Women with low income
and African-American women are less likely to receive preventive
health screenings for breast cancer, cervical cancer, and other gyne-
cological cancers.
53
Cervical cancer death rates for African-American women are
double that of all other groups (4.5/100,000 for blacks compared
to 2.2/100,000 for whites).
54
While human papilloma virus (HPV)
vaccine is now available to help prevent cervical cancer, certain
groups, especially older women and those living in rural areas, have
not readily accepted the vaccination for their daughters and need
more information.
55
More priority needs to be given to this area of
women’s health.
56
Some 40 percent of women who lack health insurance do not
receive regular Pap tests,
57
although early detection has been proven
to reduce cervical cancer death rates by 20-60 percent.
58
The
Healthy People 2010 goal is for 90 percent of American women to
receive Pap tests regularly.
59
Reproductive health care providers often detect gynecologic and
related cancers in women, such as ovarian, endometrial, uterine
and breast cancers. More black women die from breast cancer
than white women, the second most lethal form of cancer among
women in the United States (lung cancer is first) and the most
common among women (24/100,000 for white women compared
to 32/100,000 for black women in 2004).
60
One in eight women
will develop invasive breast cancer in her lifetime; there are nearly
183,000 new cases per year, and 1 in 35 will die from this cancer,
although this rate is decreasing, especially among younger women,
due to better screening and treatments.
61
However, mammography
rates declined from 2003-2005, especially for women most in need
—those over age 50.
62
This decline is notable for Latina women
(down from 65 percent in 2003 to 59 percent in 2005), and African
American women (down from 70 percent in 2003 to 65 percent in
2005).
63
In fact, often the older a women is and the less her income,
the less likely the provider is to order a mammogram for her.
64
As with cervical cancer, the higher breast cancer mortality rate for
minority women can be partly blamed on lack of health insurance,
Facts about Sexually Transmitted
Diseases
At every age, women are more likely
than men to contact herpes, Chla-
mydia, and gonorrhea.
49
Herpes infection can be painful,
presents a risk to newborns, and
increases women’s risk of Cesarean
section.
50
Chlamydia and gonorrhea put
women at risk of pelvic inamma-
tory disease, ectopic pregnancy, and
infertility.
51
Certain strains of human papilloma
virus (HPV) are associated with cervi-
cal cancer.
52
Women’s Health and Health Care Reform
11
perceived high cost, lack of access to a regular source of care, delays
in obtaining screening, poor follow-up, and inadequate treatment.
65
Even a co-payment as low as $12 can impede use of screening.
66
The Healthy People 2010 goal is for 70 percent of American women
to have received a mammogram within the past two years.
67
A new national health plan should link reproductive health care
with screening and follow up for health needs in later life, so that
women’s care is integrated across the lifecourse.
Noncontraceptive Benets of Contraception
68
The benefits of contraception extend beyond birth spacing and
family size. For example, oral contraceptive pills reduce the risks of
both endometrial and ovarian cancers, reduce certain types of be-
nign breast disease, can be useful in the treatment of endometriosis
and may help decrease bone loss in older women. Barrier methods,
such as condoms and diaphragms help to protect against sexually
transmitted infections.
Contraception and Health Care Coverage
One-quarter of American women obtain contraceptive care from
a publicly funded provider.
69
Coverage for family planning care is
highly variable in the insured market.
Studies document the cost savings of providing health coverage
for family planning services in terms of unintended pregnancies
avoided. California’s 1115 Medicaid family planning demonstration
project saved $2.76 for every $1 spend after two years and $5.33
within five years and spent considerably less on the project than the
public sector health and social service costs if those pregnancies had
occurred.
76
A low-income family planning initiative in Iowa cost
$59/person for groups, and benefited teenagers especially.
77
Adolescents, Contraception, Abortion, and Confidentiality
Some studies report that restrictions on minors through parental
consent notification laws for contraception seem to lead to increases
in teen pregnancy rates.
78
On the other hand, there is no empirical
evidence to support the claim that that access to contraception
increases the teen birth rate
79
and, conversely, there are data dem-
onstrating that access to contraception contributed importantly
to the decline in teen pregnancies. As of July 2007, 35 states had
enacted parental consent or notification laws for teenagers request-
ing abortions.
80
Coverage for family planning
care is highly variable in the
insured market.
Facts about Contraception
Only half the states regulate con-
traceptive coverage as part of pre-
scription drug regulation under state
insurance law, and many of these
plans contain exclusions of preex-
isting conditions and long waiting
periods.
70
Congress voted in 1998 that federal
employees can receive prescription
coverage for contraceptives and has
annually renewed this provision.
71
Only half the states have used waiv-
ers to expand Medicaid coverage for
contraception.
72
Employee health benets offered by
self-insuring private rms are exempt
from state insurance regulation,
with coverage design at employer
discretion, and thus may exclude
contraceptive coverage.
73
However,
all employers that have 15 or more
employees, including those that self-
insure, are covered by Title VII of the
Civil Rights Act of 1964.
74
Title VII
has been interpreted to require cover-
age of prescription contraceptives
to the same extent and on the same
terms that employers cover other
types of drugs, devices, and preven-
tive care.
The 6 percent of women who have
private insurance face very uneven
coverage of contraception.
75
Women’s Health and Health Care Reform
12
Almost all health care workers support the notion of confidential-
ity, particularly for adolescents, who may, otherwise, avoid care.
81
Provisions of the Title X family planning program and Medicaid
uphold the right to confidentiality of adolescents as well as adults.
82
The Health Insurance Portability and Accountability Act (HIPPA) of
1996 can help adolescents maintain their confidentiality and safe-
guard information already protected under individual state law.
83
As one might expect, federal and state laws prohibiting the use of
public funds for abortions spill over into private-sector financing as
well. Four states prohibit private insurance policies sold in the state
from covering abortions unless the mother’s life is in danger, while
11 states either restrict or prohibit abortion coverage under policies
sold to public employees.
84
A new national health care plan should provide the full range of
family planning services , medications and devices, and assure
confidentiality so that women seek needed care in a timely way.
Comprehensive Reproductive Health Coverage for Women
Employer-based coverage is still the most common way for
Americans under age 65 to be insured.
85
The proportion of women
with employer sponsored coverage stood at 63% in 2006, at the
same time, only 38 percent of American women have job-based
coverage in their own name.
86
Nearly one-quarter of all women
depend on coverage through their husbands’ employment, leaving
them vulnerable to the loss of coverage if divorced or widowed,
or if their husbands lose their jobs.
87
Recent years have seen an
overall decline in health insurance coverage for women.
88
In 2006,
10% of American women received coverage through Medicaid,
while 18% of women were completely uninsured.
89
Medicaid provides the widest range of covered services but is a
state-based program, with no national guarantee of specific services.
It has very restrictive eligibility requirements, and thus only covers
about 26 percent of low-income women, most of them earning less
than 185 percent of poverty. In 2004, 48 percent of children under
21 years of age were Medicaid recipients but accounted for only
17 percent of expenditures. Low-income adults with dependent
children accounted for 26 percent of the recipients, but only 17
percent of expenditures. Over half—57 percent—of these women
were considered poor and one-quarter near poor (with incomes
between 100 and 200 percent of poverty).
90
Twice as many whites
as blacks received Medicaid in 2004.
91
Recent years have seen declines
in coverage for women.
Studies document the cost savings
of providing health coverage for
family planning services in terms of
unintended pregnancies avoided.
Characteristics of Uninsured Women
Half of uninsured women have no
regular doctor.
95
40 percent do not ll a prescription
because it costs too much.
96
Two-thirds do not get needed health
care because of cost.
97
Young women are more likely to lack
insurance in their 20s than during
any other period in their reproductive
lives.
98
They are more likely to delay receiv-
ing care, including preventative care,
and going to the emergency room.
99
They are less likely to receive follow-
up care.
100
Women’s Health and Health Care Reform
13
Many experience periods without health insurance—called churn-
ing—resulting in lack of care and medicines. Young adults, Latinas,
people with low levels of education, people transitioning in and
out of poverty, and people with private nongroup insurance are the
most likely to experience churning and the least likely to be able to
pay out of pocket for their medical care.
92
Nearly one in five—20
percent—of nonelderly women are without any health insurance.
93
This proportion varies by state as employer-sponsored and Medicaid
plans vary.
94
Many women experience periods
without health insurance—called
churning—resulting in lack of care
and medicines.
Reproductive health is a key
determinant of overall women’s
health, and should therefore be
part of any national discussion
about health care reform.
Reforming Women’s Reproductive Health
A health reform agenda that has women’s reproductive health as a
national goal must address certain core issues that span the health
system:
Health insurance coverage that makes care available and
affordable
Direct investments in infrastructure and a qualified workforce
Public health investments in community health promotion
and surveillance
Health Insurance Coverage
Quality and continuity are of paramount importance in reproductive
health care. Effective coverage should be universal, rapid and contin-
uous, affordable, maintain high standards of care and medical neces-
sity, and aim at achieving good health and eliminating disparities.
1) Coverage is universal.
Coverage is available to everyone regardless of work status,
place of residence, health status, or any other factor unrelated to
need. Barriers such as waiting periods and preexisting-condition
exclusions are eliminated.
2) Coverage is rapid and continuous.
Coverage is furnished from birth through end of life without
interruption or delay. This means that there are multiple entry
points for getting coverage or renewing coverage and an absolute
assurance that coverage will continue uninterrupted regardless of
life events that can alter coverage, such as changes in family sta-
tus or residence, entering independent adulthood, or movement
in and out of the labor force.
Women’s Health and Health Care Reform
14
3) Coverage is affordable.
Making sure that health care is affordable means more than
just keeping premium rates low. It means that:
•Costofobtainingandkeepingcoverageisreasonableand
is pegged to a real-world estimate of what individuals and
families can afford when considering premiums, deductibles,
and cost sharing.
•Premiumsarereasonableinrelationtofamilyincome,can
be rapidly modified if incomes fluctuate, and remain low
enough so that families and individuals are also able to afford
the deductibles and coinsurance that many health insurance
plans charge for covered services.
•Servicesessentialtoreproductivehealth,includingroutine
gynecological exams, clinical preventive services and supplies,
and pregnancy-related and postpartum care, are furnished
without deductibles, and no, or only minimal, cost-sharing
is involved.
•Healthinsuranceplanssetannualandlifetimeout-of-pocket
payment maximums so that when serious health problems do
occur, families are not left uncovered.
•Totalassociatedcostofcoverageiskeptsufcientlyreasonable
so that individuals and families can continue to afford to pay
for the out-of-pocket health care costs that invariably remain
uncovered, even under relatively generous insurance plans.
4) Coverage is tied to goals and standards.
Benchmarks such as in Healthy People 2010, or taskforce recom-
mendations from the Institute of Medicine, American College of
Obstetricians and Gynecologists, or U.S. Preventive Services Task
Force (see Suggestions for Further Reading) recognize the impor-
tance of proper evidence based care in ensuring that women will
be able to enter their reproductive years healthy, maintain their
reproductive health, and age well.
5) Coverage is focused on achieving quality outcomes and
eliminating disparities.
In the case of covered benefits, payments must be sufficient
to assure the reasonable availability of high-quality care, and
structured to encourage health care providers to pursue practices
that achieve evidence-based outcomes in health care.
Essential Elements for Women’s
Reproductive Health Benet Plans
Clinical preventive services, contra-
ceptive services, and supplies
Medical, surgical, and clinical care
Prescribed drugs and biologicals,
including all vaccines recommended
by the Advisory Committee on Im-
munization Practices
Diagnostic, outpatient, and inpatient
care
Health care items and services and
patient supports that are used to treat
and manage pregnancy, preexist-
ing conditions that could compli-
cate pregnancy or the health of the
mother, or complications arising from
or during pregnancy that could affect
the health of the mother and child
A reproductive health standard of
medical necessity
101
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