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When the National Women’s Law Center (NWLC) in Washington, DC, released its premier issue of Making the Grade on Women’s Health: A National and State-by-State Report Card in August, a lot of policy-makers and state health leaders took notice.
But now even health plans are taking a look at the data, says one of the authors of the report, Michelle Berlin, MD, MPH, assistant professor of obstetrics, gynecology, and epidemiology and co-director of FOCUS on Health and Leadership for Women at the University of Pennsylvania in Philadelphia. "Right now the Blue Cross/Blue Shield organizations in Georgia have expressed a lot of interest," she says. "They are avidly looking at ways to incorporate this information into their plans and act on it."
The data included in the report give plans, hospitals, and even individual physicians plenty of areas on which to work. Of the 25 indicators for which benchmarks were available, only one — mammography for women over 50 — was met by every state and the District of Columbia, and all missed 10 of the benchmarks.
Those included women without health insurance, first trimester prenatal care, no leisure time physical activity, overweight, eating five fruits and vegetables a day, high blood pressure, diabetes, life expectancy, poverty, and the wage gap. Nine states received failing grades, with the other 41 states and Washington, DC, getting unsatisfactory ratings. None received a satisfactory mark.
Along with clinical benchmarks, the report card placed a strong focus on women’s wellness. Berlin and her co-authors from the NWLC and the San Francisco consulting firm Lewin Group included health behaviors, social supports, economic independence, and safety and health conditions as critical indicators in assessing the status of women’s health in each state and nationwide. The study also examined statutes, regulations, public policies, and government investment in resources that promote women’s health.
"There are no commonly accepted sets of indicators for women’s health," Berlin says. "I think this [issue] has been plaguing us for a while and prevented us from characterizing what is going on with women’s health."
Berlin says her interest, as well as the law center’s interest in forwarding policies that advance women’s physical and social well-being led to the collaboration. "I wanted to put together something that academicians and public health officials would use."
The group decided not to do any primary data collection but rather concentrate on information that was already available. (For a list of the indicators on which data was collected, see table.)
Women Without Health Insurance
Women Living in Poverty
|• New Mexico||21.4%|
|• Washington, DC||21.6%|
Women Who Smoke
Women 50 and older Who Had
|• Washington, DC||89.4%|
Women Who Are Overweight
Source: National Women’s Law Center, Washington, DC.
"There are a huge number of topics we could have looked at," says Berlin, "but there is a limit to what we can do. The most common illness is the cold, but looking at that won’t help anyone. Surveys of what people go to the doctor for find that the most common thing they suffer from is other.’ We decided to look at what women suffer from, what they are sick with, what they die from. And we wanted to look at wellness issues, prevention, and a healthy environment."
In all, status and policy indicators were taken in four categories: access to health care services; wellness and prevention; key health conditions, diseases, and causes of death; and living in a healthy community. The results aren’t very promising.
• Access to health care is compromised by inadequate health insurance. Nationally, about 14% of women are uninsured, and that number is growing, says the report. No state met the goal of having all people insured, and only eight came within 10% of it. Prescription drug coverage also is lacking, and only 19 states have significant support beyond what Medicaid covers.
Coverage of specific conditions is often excluded from general insurance. Only four states require mental health insurance parity, and just eight states require coverage for post-mastectomy hospital stays and reconstructive surgery after mastectomy.
Just two states require public and private insurance plans to provide contraceptive coverage, and only six states require coverage for hospital stays after childbirth deemed necessary by the women’s physician.
Key health care services aren’t being met, in part because nearly a 10th of the national population lives in a medically underserved area. In Louisiana, nearly a quarter of the population is underserved. No state met the benchmark of 90% of pregnant women getting prenatal care in the first trimester, although Maine was close with 89.9%.
• Wellness and prevention programs still are lacking. No state has met national goals for increasing physical activity, reducing overweight, or improving diet. Only Utah met the national goal for reducing the percentage of adults who smoke, and 18 states met the national goal for reducing binge drinking.
• States did better in screening for key diseases. All the states meet mammogram goals for women 50 and older, but some populations — those who are uninsured, some racial and ethnic groups, and older women — don’t receive such screenings at the national rate. Washington, DC, and 24 states met the goal for Pap smears, and the district and 19 states met the national goal for colorectal cancer screenings. But only two states require private insurers to cover the latter.
Thirty states met the goal for the number of women dying from heart disease, but only four met the goal for deaths from strokes, the third leading cause of death among women. Lung cancer, the second most common cause of death among women, is adequately targeted by 24 states and the District of Columbia, and 36 states met the goal for deaths from breast cancer.
Controlling high blood pressure can help prevent heart disease and stroke, but no state met the goal for reducing high blood pressure. Diabetes prevention also failed nationwide. Maternal health levels nationwide also show a need for improvement.
The World Health Organization ranks 20 countries ahead of the United States in maternal mortality levels, and the number of mothers who die is four times higher among African-Americans than for white women. Only three states met the national goal for maternal mortality.
• Living in a healthy environment could help increase women’s life expectancy, which at just under 80 years lags behind 19 other countries. Among the dangers women face are exposure to hazardous agents in the air, water, and soil; violence including gun violence; and discriminatory practices that prevent women from securing education, financial independence, or insurance.
Perhaps the biggest surprise in the study was the wide disparity among the states. For instance, in maternal death, New Hampshire had only 1.9 per 100,000 live births, while the District of Columbia had 22.8.
In life expectancy, Hawaii ranked No. 1 with 81.3 years, compared to Washington, DC, where women can expect to live 74.2 years. Minnesota, which may be a template for others, had just 65.4 deaths per 100,000 women from coronary heart disease, compared to Mississippi, where there were 141.2 such deaths per 100,000 women. (For more on the disparities, see "Report Card Health Status Indicators," in this issue.)
Data were limited, lacking, or nonexistent for several key areas, such as state level data on arthritis or osteoporosis, mental health status, or data on physical and sexual assault, and Berlin says that drilling down even more — to the county or city level — would have been impossible. "But this does offer a snapshot, and you can see where you stand." The lack of data was mentioned in the report, along with a call for more research on women’s health, better enrollment of women in clinical trials, and more research on the racial, ethnic, and socioeconomic disparities in health conditions that affect women.
The project will become annual, so when the next issue comes out, there may be some better data, Berlin says, as well as a way to see how states are improving in various areas. "I think the best use of this report is for organizations and states to plan what to do next," she says. "Take this into account when you look at what you will emphasize in the next few years. Make it a five-year plan. Ask your state legislators what they will do to help you fix some of these things. Incorporate this into what you do."
[For more information, contact:
• Michelle Berlin, MD, MPH, assistant professor of obstetrics, gynecology, and epidemiology, co-director of FOCUS on Health & Leadership for Women, University of Pennsylvania, 915 Blockley, 423 Guardian Drive, Philadelphia, PA 19104-6021. Telephone: (215) 898-1539.
To read the report in its entirety, visit this Web site: University of Pennsylvania FOCUS center at cceb.med.upenn.edu/focus. Information on ordering hard copies is also available.]