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The 2004 Making the Grade on Women’s Health: A National and State-by-State Report issued by the National Women’s Law Center and the Oregon Health & Science University says states are making some progress in improving health care for women, but often are taking two steps forward and one step back, so they don’t make sufficient progress.
This is the third report issued by the two organizations. It ranks states on 27 health status benchmarks developed largely from goals laid out in the U.S. Department of Health and Human Services’ Healthy People initiative. The report ranks the nation as a whole "unsatisfactory" for meeting only two benchmarks — the percentage of women receiving regular mammograms and the number of dental visits.
The best any individual state did was "satisfactory minus," and there were eight states in that category. Minnesota was first overall, followed by Massachusetts, Vermont, Connecticut, New Hampshire, Hawaii, Colorado, Utah, Maine, and Washington. The 10 lowest-ranking states were Mississippi, Louisiana, Arkansas, West Virginia, Oklahoma, Texas, Alabama, the District of Columbia, Kentucky, and Tennessee.
In addition to grading and ranking each state, the report evaluates whether states have adopted 67 key women’s health policies. Only Medicaid coverage for breast and cervical cancer was met by all states, up from 40 states in the 2001 report. New York, California, and Rhode Island met a majority of the policy goals (more than 35), while Idaho, South Dakota, and Mississippi met the fewest policy goals. Preventing tobacco sales to minors was the most consistently improved policy, with 18 states now meeting it, compared to only five in the 2001 report.
"State policy-makers’ piecemeal approach to our health care crisis has resulted in a complex and ineffective system that fails to meet the health care needs of women," says National Women’s Law Center vice president for health Judy Waxman. "Lawmakers need to take a comprehensive, long-term approach to meeting women’s health needs and tackle this serious problem that plagues so many families."
Oregon Health & Science University associate professor Michelle Berlin says the outlook for women’s health is "grim and nowhere approaching the nation’s goals for 2010 set by the Healthy People initiative. There is a great distance to go with the nation meeting only two out of 27 benchmarks graded in this report. Failing to meet these goals undermines not only the health and well-being of women, but the well-being of our country, as well."
The researchers say the nation fails on nine benchmarks, including indicators measuring women’s access to health insurance, the prevalence of diseases such as diabetes, and deaths from coronary heart disease. "The two goals met by the nation . . . represent important but hardly adequate progress overall," they say. "The nation’s performance needs significant improvement on every other goal. Moreover, nationwide, the disparities women experience in the quality of their health related to race, ethnicity, sexual orientation, disability, and other factors underscore that the problems faced by many women are even greater than those overall numbers suggest."
In addition to a message that much remains to be done, the report says a second message is that the situation in the states is mixed, while overall there has been some serious slippage in the federal government. A number of state governments have improved their policies in some key areas to meet women’s health needs, Ms. Waxman and Ms. Berlin say, although a number of states have fallen backward in a few significant policy areas as well.
Twenty states improved at least five of their health policies since the last report card, with 29 states making progress in preventing tobacco sales to minors. Some 16 states improved their Medicaid enrollment process by adopting a mail-in application, and 13 states improved access to health services. "But as a general matter, the specific policy improvements varied considerably among the states," the researchers say.
"Moreover, unfortunately, these gains were offset to some degree by the weakening of other state policies. The majority of states weakened one to three policies, and three states weakened four or more policies. The 2004 findings help identify those priorities for women’s health that must be tackled by policy-makers and health care providers, and the serious systemic shortcomings in meeting women’s health needs that persist," they explain.
According to the report:
• Women need better access to health insurance to get the health care they need. Nationwide, almost 18% of women ages 18 to 64 are uninsured. No state met the Healthy People goal of access to health insurance. The variation among states was substantial — Minnesota ranked first with 7.9% of women uninsured, while Texas was last at 28.3%.
• Access to specific health care providers and services, particularly reproductive health providers and services, is insufficient. The report says women’s health suffers when family planning services are not available. Nationally, nearly half of all pregnancies are unintended, missing by a substantial margin the national goal to reduce unintended pregnancies to 30% or less of all pregnancies. Twenty states meet the Report Card policy goal of requiring that private insurers cover contraceptives as they do other prescription drugs; only three states have adequate laws to facilitate women’s access to emergency contraception. Some states actively limit women’s access to full reproductive health care services through policies such as parental consent and notification requirements, waiting periods, and funding restrictions for abortion procedures.
• Preventive and health promoting measures must be more available. Only a small number of states meet all the nation’s goals for screening for key diseases and states made only minimal progress in adopting policies to facilitate essential health screening by providing for insurance coverage for screening tests. "Given the importance of promoting wellness and preventing illness," the report says, "both the nation and the states should adopt policies and programs to help women engage in preventive behavior." Although the 2001 surgeon general’s report identifies smoking as a critical women’s health issue, only one state meets the national goal for achieving a low percentage of women who smoke. Smoking policies in the states have improved in some aspects but weakened in others since then. Medicaid smoking cessation treatment coverage policies have improved in 13 states, but only seven states have strong enough policies to meet the policy goal, and not one state mandates private insurers to cover smoking cessation. Although effective and comprehensive smoking prevention and cessation programs have been identified, only four states have allocated funds from their tobacco settlements to them, and that’s down from six states in 2001.
• Disparities and gaps in economic security continue to compromise women’s health because lower income women have more difficulty getting their health care needs met. Nationwide, 12% of women live in poverty, ranging from 7.4% in New Hampshire to 20.3% in Mississippi. Also, the gap between wages of men and women reflects the economic hurdles facing women, including those not living in poverty. Nationwide, women earn 72.7% of what men earn, and the states vary widely, from 89.2% in the District of Columbia to 64.4% in Wyoming.
The report puts a particular emphasis on the role the federal government can play in the health of women throughout the country. Through national programs and assistance to states, it can establish laws addressing private and public health care policies, fund health and ancillary services to individuals, and fund and conduct public education campaigns. But the report complains that the federal health policy agenda articulated in the 2001 Report Card has not advanced as it should, but rather has moved in the wrong direction in some critically important ways.
"According to the most recently available figures, almost 16.5 million women do not have any health insurance at all, representing an alarming increase in the number of uninsured women in the nation," the report adds. "Moreover, many women who are insured are particularly vulnerable. Millions of women, even more than men, rely on public programs for their health insurance. Both Medicare and Medicaid are two of the public programs that provide crucial health care services for women, yet proposals have been passed or are being forcefully pressed that would significantly weaken both programs and reduce critically important health care services to women most in need."
The report puts forth a new federal policy agenda for women’s health with 31 recommended federal policies it says would promote women’s health and well-being and allow the country to move forward.
[To see the report and additional information, go to www.nwlc.org. Contact Ms. Waxman at (202) 588-5180 and Ms. Berlin at (503) 494-5942.]
9th Annual Summit on the Medicaid Drug Rebate Program & Other Public Sector Reimbursement Programs, Sept. 20-22, 2004, Denver. Web: www.medicaiddrugrebates.com. Telephone: Shari Gelfand, (888) 670-8200.
National Association of State Medicaid Directors, Nov. 17-20, 2004, Washington, DC. Web: www.nasmd.org. Telephone: Sharon Thompson Henson, (202) 682-0100.