Women's Health and Health Care Reform Report

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WOMEN’S HEALTH AND HEALTH CARE REFORM
The Key Role of Comprehensive Reproductive Health Care
Authors
Wendy Chavkin and Sara Rosenbaum in conjunction with Judith Jones and Allan Rosenfield, whose vision and support provided the impetus for this effort, and the following group of experts whose data, discussion and analyses informed this document.
Contributors
Alice Berger Vice President, Health Care Planning, Planned Parenthood of New York City Kathy Bonk Executive Director, Communications Consortium Media Center Vicki Breitbart Vice President, Planning, Research and Evaluation, Planned Parenthood of New York City Andrea Camp Consultant, Communications Consortium Media Center R. Alta Charo Warren P. Knowles Professor of Law & Bioethics, University of Wisconsin Law School Wendy Chavkin Professor of Public Health and Obstetrics-Gynecology, Mailman School of Public Health, Columbia University Ellen Chesler Distinguished Lecturer, Hunter College, City University of New York Vanessa Cullins Vice President for Medical Affairs, Planned Parenthood Federation of America Andrew Davidson Executive Vice Dean, Mailman School of Public Health, Columbia University Vanessa Northington Gamble University Professor of Medical Humanities, The George Washington University Simon Heller Legal Director, Alliance for Justice Silvia Henriquez Executive Director, National Latina Institute for Reproductive Health Mia Herndon Program Director, Third Wave Foundation Judith Jones Clinical Professor of Population and Family Health, Mailman School of Public Health, Columbia University Douglas Laube Professor, Obstetrics and Gyneology, University of Wisconsin Philip Lee Senior Scholar, Philip R. Lee Institute for Health Policy Studies, Medical School, University of California at San Francisco Herbert Peterson Professor and Chair, Department of Maternal and Child Health School of Public Health, The University of North Carolina at Chapel Hill Tina Raine-Bennett Associate Professor, Obstetrics and Gynecology, University of California San Francisco, San Francisco General Hospital Cory Richards Senior Vice President and Vice President for Public Policy, Guttmacher Institute Diana Romero Associate Professor, Urban Public Health, Hunter College, City University of New York Sara Rosenbaum Hirsh Professor and Chair, Department of Health Policy, The George Washington University Medical Center School of Public Health and Health Services Allan Rosenfield Dean Emeritus, Mailman School of Public Health, Columbia University John Santelli Professor and Chair, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University
ACknowledgements
We especially acknowledge Kathy Bonk and Andrea Camp for their role in shaping the final product, Carole Oshinsky and Stacey McKeever for their many contributions, and the Mailman School of Public Health at Columbia University.
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Executive Summary
Current debate over health care priorities and how best to pay for them presents a critical opportunity to improve women’s health throughout the life span—before pregnancy, during the child-raising years, and as productive seniors. We have a window of opportunity to establish a comprehensive standard of health for American women—a standard that enables women to attain good health in their childhood and adolescence, maintain good health during their reproductive years, and age well. A new analysis published by the Columbia University Mailman School of Public Health makes a case for a comprehensive “wellwoman standard of care” and underscores why such a standard must include reproductive health. The analysis makes a scientific, data-driven case that reproductive health is a key determinant of women’s overall health, and therefore, that the treatments and services that promote reproductive health should therefore be part of any national health plan. Society benefits from healthy women who can participate fully in family, workforce, and community life and therefore, must make health care investments that permit girls to grow into healthy women. Moreover, because a woman’s health in childhood ultimately affects her pregnancies, children also benefit directly from such health care investments. Some 62 million U.S. women are in their childbearing years (ages 15 to 44). Depending on their circumstances, women may have children at various and unpredictable times in their reproductive years, so they need to be healthy throughout their reproductive period. A well-woman standard of care can improve the likelihood that a woman will be healthy when she makes the important life decision to become a mother and that she will remain healthy thereafter. The typical American woman wants to have two children. That means she will spend roughly five years being pregnant, recovering from a pregnancy or trying to become pregnant, and three decades trying to avoid an unintended pregnancy. Without addressing reproductive health as part of overall health, the United States cannot move forward to redress its health disparities and the gaps in overall provision of health care. While both men and women have reproductive health needs, women have specific health concerns involving pregnancy and childbirth, preventing and addressing unintended pregnancy, access to safe and affordable contraception, and the severe consequences of sexually transmitted infections.
The analysis makes a scientific, data-driven case that reproductive health is a key determinant of women’s overall health, and therefore, that the treatments and services that promote reproductive health should therefore be part of any national health plan.
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Polls and voter analysis data consistently demonstrate that Americans value personal responsibility, but expect society and government to provide the information, services and options needed to foster it. The Columbia report outlines how national health care reform can improve access to the information, services and options American women need to be healthy and responsible as they make the important life decision of when to start a family. The report, “Women’s Health and Health Care Reform: The Key Role of Comprehensive Reproductive Health Care,” calls for a health reform agenda that has women’s reproductive health as a national goal. It holds that a national health plan should:
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Americans value personal responsibility, but expect society and government to provide the information, services and options needed to foster it.
link prenatal, family planning and medical care as part of a seamless continuum of care for women. ensure that Americans receive accurate health information and are assured of confidentiality so that they seek needed care. provide all individuals with lifetime comprehensive coverage. link reproductive health care with screenings and follow-up for health needs in later life, so that women’s care is integrated across their life spans.
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Health care reform must therefore achieve three core goals: 1) Health insurance coverage that makes care available, affordable, and stable with coverage of the right care at the right time, and in the right place. Quality and continuity are of paramount importance in reproductive health care. Effective coverage should be universal, affordable, rapid and continuous, maintaining high standards of care and medical necessity and aiming at achieving good health and eliminating disparities. 2) Direct investments in infrastructure and a qualified workforce. Investments should target the primary health care infrastructure in medically underserved communities and neighborhoods. Investments should also assure a supply of well-trained health professionals. A health workforce that is skilled in reproductive health care will improve quality and enable a full range of services to be provided. 3) Public health investments in community health promotion and surveillance. The health of the community should be promoted through information, education, monitoring and data collection, including: • using public awareness campaigns to promote reproductive health services and availability of health insurance.
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 • eliminating obstacles to enrollment. • eliminating restrictions to eligibility for low-income women. • monitoring changes in reproductive outcomes to highlight 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. Reproduction and sexuality are basic aspects of life, liberty, and the pursuit of happiness, guaranteed by the Constitution and by international 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.
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Introduction
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 national 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 coverage, 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 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.
Women’s Health and Health Care Reform
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.
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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 outcomes, children—and society—benefit directly from health care investments 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 pregnancy. 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 incorporated 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 mothers13 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.
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Having a Healthy Pregnancy
American women have children at varied stages of their reproductive 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 pregnancyassociated 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.
What We Know About Maternal Health Risks
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the u.s. has a higher maternal mortality 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 mortality 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 significantly 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
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Staying Healthy in the Reproductive Years
There is a 30-year period during which the average American woman 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 20th 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 pregnancies 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 percent less likely to use contraceptive methods requiring prescriptions.
Facts About Unintended Pregnancy
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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 unintended pregnancy have abortions.35
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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 pregnancies. 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 risks.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
Facts About Teenage Pregnancy
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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 contraception.38 more than 20 percent of adolescents receive abstinence education without receiving information about birth control.39 One fifth of adolescents lack any health insurance.40
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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 one in two 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
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A new national health plan should assure that Americans receive accurate health information and are assured of confidentiality so that they seek needed care.
Facts About Sexually Transmitted Diseases
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Cervical and Other Cancers
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At every age, women are more likely than men to contact herpes, chlamydia 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 inflammatory disease, ectopic pregnancy and infertility.51 Certain strains of human papilloma virus (hPV) are associated with cervical cancer.52
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 gynecological cancers.53 Cervical cancer death rates for African-American women are double that of all other groups (4.5 per 100,000 for blacks compared to 2.2 per 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 to 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 per 100,000 for white women compared to 32 per 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 one 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 to 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 woman is and the less her income, the less likely the provider will 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,
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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.
Coverage for family planning care is highly variable in the insured market.
Noncontraceptive Benefits of Contraception68
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 benign 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.
Facts About Contraception
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only half the states regulate contraceptive coverage as part of prescription drug regulation under state insurance law, and many of these plans contain exclusions of preexisting 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 waivers to expand medicaid coverage for contraception.72 Employee health benefits offered by self-insuring private firms are exempt from state insurance regulations, with coverage designed at employer discretion, 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 coverage of prescription contraceptives to the same extent and on the same terms that employers cover other types of drugs, devices and preventive care. the six percent of women who have private insurance face very uneven coverage of contraception.75
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, $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 per person for groups and benefited teenagers especially.77
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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 access to contraception increases the teen birth rate79 and, conversely, there are data demonstrating 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 requesting abortions.80
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Almost all health care workers support the notion of confidentiality, 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 safeguard 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.
Studies document the cost savings of providing health coverage for family planning services in terms of unintended pregnancies avoided.
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 percent 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 percent of American women received coverage through Medicaid, while 18 percent 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, 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.
Characteristics of Uninsured Women
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half of uninsured women have no regular doctor.95 40 percent do not fill 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 receiving care, including preventative care, and going to the emergency room.99 they are less likely to receive followup care.100
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Many experience periods without health insurance—called churning—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.
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:
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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.
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Reproductive health is a key determinant of overall women’s health, and should therefore be part of any national discussion about health care reform.
Health Insurance Coverage
Quality and continuity are of paramount importance in reproductive health care. Effective coverage should be universal, rapid and continuous, affordable, maintain high standards of care and medical necessity 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 status or residence, entering independent adulthood, or movement in and out of the labor force.
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3) Coverage is affordable. Making sure that health care is affordable means more than just keeping premium rates low. It means that: • cost of obtaining and keeping coverage is reasonable and is pegged to a real-world estimate of what individuals and families can afford when considering premiums, deductibles and cost sharing. • premiums are reasonable in relation to family income, 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. • services essential to reproductive health, including routine 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. • health insurance plans set annual and lifetime out-of-pocket payment maximums so that when serious health problems do occur, families are not left uncovered. • total associated cost of coverage is kept sufficiently reasonable 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 task force recommendations 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 importance 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 Benefit Plans
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Clinical preventive services, contraceptive services and supplies medical, surgical and clinical care Prescribed drugs and biologicals, including all vaccines recommended by the Advisory Committee on immunization Practices diagnostic, outpatient and inpatient care health care items and services and patient supports that are used to treat and manage pregnancy, preexisting conditions that could complicate 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 necessity101
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Access to Care
Beyond the question of coverage reform lies the equally critical changes needed to eliminate the disparities in America with regard to access to health care services. This means:
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No community should remain medically underserved for primary health care.
Making investments in the primary health care infrastructure in medically underserved communities and neighborhoods. Communities should be helped to develop and staff primary health care service sites where needed, maintain locations and hours that are consistent with family needs, and allow community providers to furnish the types of direct patient supports such as transportation, care management, translation and cultural services that have been shown to reduce unequal access. In this way, no community will remain medically underserved for primary health care. Assuring a supply of well-trained health professionals. Investments to build a health workforce that is skilled in reproductive health care will improve quality and enable a full range of services to be provided.
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Community Health Promotion and Surveillance
The health of the community should be promoted through information, education, monitoring and data collection. This can be done in a number of ways:
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using public awareness campaigns to promote reproductive health services and availability of health insurance. eliminating obstacles to enrollment. eliminating restrictions to eligibility for low-income women. monitoring changes in reproductive outcomes to highlight needed interventions.
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Conclusion
The data are clear that reproductive health care is an essential component of basic care for women. If a new national health plan is to fulfill the goal of correcting our fragmented health system to effectuate improvement in America’s health, it must address these health needs of women. Moreover, reproduction and sexuality are basic aspects of life, liberty and the pursuit of happiness guaranteed by the Constitution and by international 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, access to reproductive health services should be a central and established part of health care to ensure that women can attain good health, maintain it through their reproductive years and age well.
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Suggestions for Further Reading and Resources
texts
Lila A. Wallis, et al. (Editor) (1998). Textbook of Women’s Health. Philadelphia, PA: Lippincott, Williams, & Wilkins. Linda L. Alexander, Judith H. LaRosa, Helaine Bader, & Susan Garfield. (2007). New Dimensions in Women’s Health 4th ed. Boston, MA: Jones and Bartlett.
orgAnizAtions
Alliance for Health Care Reform www.allhealth.org American College of Obstetricians and Gynecologists www.acog.org ACOG Committee on Health Care for Underserved Women. Special Issues In Women’s Health. Center for Health Care Strategies www.chcs.org Committee on Economic Development Report, Quality, Affordable Health Insurance (Summary) www.www.ced.org/docs/summary/summary_healthcare200710.pdf (Full Report) www.ced.org/docs/report/report_healthcare200710.pdf The Commonwealth Fund www.cmwf.org Small But Significant Steps to Help the Uninsured (January 2003) Georgetown University Institute for Health Care Research & Policy www.healthinsuranceinfo.net Institute of Medicine www.iom.edu Insuring America’s Health: Principles and Recommendations (2004) Kaiser Family Foundation www.kff.org www.statehealthfacts.kff.org Kaiser Family Foundation The Kaiser Commission on Medicaid and the Uninsured www.kff.org/about/kcmu.cfm National Academy of State Health Policy www.nashp.org The Robert Wood Johnson Foundation www.rwjf.org www.covertheuninsured.com The Urban Institute www.urban.org Federalism and Health Policy (2003) U.S. Preventive Services Task Force (USPSTF) www.ahrq.gov/clinic/uspstfix.htm
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Endnotes
1. State Family Planning Administrator’s Project. (2001). Healthy People 2010 – Reproductive Health. Washington, DC: U.S. Department of Health and Human Services, Office of Population Affairs. Accessed December 23, 2007 from: www. hhs.gov/opa/pubs/hp2010_rh.html. 2. Communications Consortium Media Center & Women Donors Network. (2007). Moving Forward on Reproductive Health and a Broader Agenda: A Guide for Communications Strategies for Policy Change on Reproductive Health and Rights. Washington, DC: Communications Consortium Media Center and Women Donors Network. 3. Ibid. 4. See, for example, Vadala, G. (2007). Survey: Americans Worried about Health Care. CQ Healthbeat News, Jun. 4. Catholic Healthcare West. (2007). Health Security 2007. San Francisco, CA: Catholic Healthcare West. Teixeira, R. (2006). What the Public Really Wants on Health Care. Washington, DC: The Century Foundation and Center for American Progress. PollingReport.com. (2008). Problems and Priorities. [Summary of 2008 national opinion polls based on data from nationwide surveys of Americans 18 and older.] Accessed Mar. 24, 2008 from: www.pollingreport.com/prioriti.htm. 5. Lynch, D. J. (2008). 2007 trade deficit dips 6.2 percent as Americans buy less. USA Today, Feb. 14. 6. See Healthy People 2010 – Reproductive Health in Endnote 1. Grisso, M., A., Battistini, M., & Ryan, L. (1998). Women’s Health Textbooks: Codifying Science and Calling for Change. Annals of Internal Medicine, 129(11 pt.1), pp. 916-918. 7. Forrest, J., & Samara, R. (1996). Impact of Publicly Funded Contraceptive Services on Unintended Pregnancies and Implications for Medicaid Expenditures. Family Planning Perspectives, 5, pp. 188–195. 8. Ibid. 9. Kung, H., Hoyert, D. L., Xu, J., & Murphy, S. (2008). Deaths: Final Data for 2005. National Vital Statistics Reports, 56(10). Retrieved April 1, 2008 from: www. cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_10.pdf. The infant mortality rate is 2.4 times greater, and maternal mortality rate 3.3 times greater for the black population than that for the white population. The postneonatal mortality rate increased 3.1 percent between 2004 and 2005 and contributed to the observed but not statistically significant increase in the infant mortality rate 10. Chavkin, W. & Bernstein, P. (1999). Maternal-Fetal Conflict is Not a Useful Construct. In Marie C. McCormick & J. E. Siegel (Eds.), Prenatal Care: Practice and Potential. New York, NY: Cambridge University Press. 11. Boulet, S. L., Johnson, K., Parker, C., Posner, S. F., & Atrash, H. (2006). A perspective of preconception health activities in the United States. Maternal and Child Health Journal, 10(5 Suppl): pp. S13-20. 12. Chavkin, W., Breitbart, V., & Wise, P. (1994). Finding Common Ground: The Necessity of an Integrated Agenda for Women’s and Children’s Health. Journal of Law, Medicine, and Ethics, 22(3), pp. 262-269. 13. St. Clair, D. & Chavkin, W. (1990). Beyond Prenatal Care: A Comprehensive Vision of Reproductive Health. Journal of the American Medical Women’s Association, 45(2), pp. 223-225. Chavkin, W. (1995). Prenatal Care and Women’s Health. Journal of the American Medical Women’s Association, 50(5), p. 143. See also Chavkin, Breitbart, & Wise in Endnote 12. 14. Sattar, N. & Greer, I. A. (2005). Pregnancy Complications and Maternal Cardiovascular Risk: Opportunities for Intervention and Screening? The British Medical Journal, 325(7356), pp. 157-160. 15. See Kung, Hoyert, Xu, & Murphy in Endnote 9. 16. See Healthy People 2010 – Reproductive Health in endnote 1. 17. See Kung, Hoyert, Xu, & Murphy in Endnote 9.
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18. Ibid. 19. Fiscella, K. (2004). Racial Disparity in Infant and Maternal Mortality: Confluence of Infection, and Microvascular Dysfunction. Maternal and Child Health Journal, 9(2), pp. 45-54. A large body of epidemiological, placental and pathophysiological evidence suggests that racial disparities in these disparate outcomes result from two distinct, but potentially converging, pathways: infection and vascular. 20. Murray, C. J. L., Kulkarni, S. C., Michaud, C., Tomijima, N., Bulzacchelli, M. T., Iandiorio, T. J., & Ezzati, M. (2006). Eight Americas: Investigating Mortality Disparities across Races, Counties, and Race-Counties in the United States. PLOS Medicine, 3(9), p. e260. 21. See Kung, Hoyert, Xu, & Murphy in Endnote 9. See also: Healthy People 2010 – Reproductive Health in Endnote 1. Wise, P. H. (1993). Confronting Racial Disparities in Infant Mortality: Reconciling Science and Politics. American Journal of Preventive Medicine, 9(6), pp. 7-16. Gortmaker, S. & Wise, P. H. (1997). The first injustice: socioeconomic disparities, health services technology, and infant mortality. Annual Review of Sociology, 23, pp. 147-70. Wise, P. H. (2003). The anatomy of a disparity in infant mortality. Annual Review of Public Health, 24, pp. 341-362. 22. See Wise, P. H. (2003), in Endnote 21. 23. Three years of data (2002-2004) were combined to get specific estimates of infant mortality rates by state, race and Hispanic origin. For the three-year period there were significant differences in infant mortality rates by state, ranging from a rate of 10.32 in Mississippi to 4.68 in Vermont. For infants of non-Hispanic black mothers, rates ranged from 17.57 in Wisconsin to 8.75 in Minnesota. For infants of non-Hispanic white mothers, the infant mortality rate ranged from 7.67 in West Virginia to 3.80 in New Jersey. Mathews, T. J. & MacDorman, M. F. (2007). Infant Mortality Statistics from the 2004 Period Linked Birth/Infant Death Data Set. National Vital Statistics Report, 55(14). 24. Swamy, G. K., Ostbye, T., & Skjaerven, R. (2008). Association of Preterm Birth with Long-Term Survival, Reproduction, and Next-Generation Preterm Birth. JAMA, 299(12), pp. 1429-36. National Center for Health Statistics. (2004). Preliminary Birth Data: Maternal and Infant Health Preliminary Births for 2004: Infant and Maternal Health (Health E-Stats). Accessed April 1, 2008 from: www.cdc.gov/nchs/products/pubs/pubd/ hestats/highlights/2004prebirth.htm. Wise, P. H., Wampler, N., & Barfield, W. (1995). The Importance of Extreme Prematurity and Low Birthweight to US Neonatal Mortality Patterns: Implications for Prenatal Care and Women’s Health. Journal of the American Medical Women’s Association, 50(5), pp. 152-155. 25. The U.S. Equal Employment Opportunity Commission. (2008). Pregnancy Discrimination. Accessed Oct. 6, 2007 from: www.eeoc.gov/types/pregnancy.html. 26. Kane, P. (2000). Reproductive Health Needs Worldwide: Constraints to Fertility Control. Reproduction, Fertility, and Development, 12(7-8), pp. 435-442. 27. Dudgeon, M. R. & Inforn, M. C. (2004). Men’s Influences on Women’s Reproductive Health: Medical and Anthropological Perspectives. Social Science and Medicine, 59(7), pp. 1379-1395. Kowaleski-Jones, L. & Mott, F. L. (1998). Sex, Contraception and Childbearing Among High-Risk Youth: Do Different Factors Influence Males and Females? Family Planning Perspectives, 30(4), pp. 163-169. 28. Mosher, W. D., G. M., Chandra, A., Abma, J. C., & Willson, S. J. (2004). Use of Contraception and Use of Family Planning Services in the United States: 1982-2000. Advance Data from Vital and Health Statistics (No. 30). U.S. Centers for Disease Control. Accessed Oct. 6, 2007 from: www.cdc.gov/nchs/data/ad/ad350.pdf. 29. U. S. Centers for Disease Control. (1999). Achievements in Public Health, 1900-1999: Family Planning. Morbidity and Mortality Weekly Report, 48(47), pp. 1073-1080. 30. Maine, D. & McNamara, R. (1985). Birth Spacing and Child Survival. New York, NY: Columbia University, Center for Population and Family Health.
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Westhoff, C. & Rosenfield, A. (1993). The Impact of Family Planning on Women’s Health. Current Opinions in Obstetrics and Gynecology, 5(6), pp. 793-797. Potts, M. & Thapa, S. (1991). Child Survival: the Role of Family Planning. Research Triangle Park, NC: Family Health International. Grundy, E. & Tomassini, C. (2005). Fertility History and Health in Later Life: A Record Linkage Study in England and Wales. Social Science and Medicine, 61(1), pp. 217-228. We found that nulliparous women and women with five or more children had significantly higher mortality than other women, and that in the oldest groups of women with just one child also had raised mortality. Women who had been teenage mothers had higher mortality and higher odds of poor health than other parous women. Mothers with short birth intervals, including mothers of twins, also had elevated risks in some cohorts. Late childbearing (after age 39) was associated with lower mortality. 31. See Endnote 29 and Healthy People 2010 – Reproductive Health in Endnote 1. See also: Moos, M. K. (2003). Unintended Pregnancies: A Call for Nursing Action. MCN American Journal of Maternal and Child Nursing, 28(1), pp. 24-30. Unintended pregnancies occur in all age groups and socioeconomic strata of our society and represent significant social, medical, and economic costs. Nearly 50 percent of all pregnancies in the United States are classified as unintended, and approximately 48 percent of all women ages 15 to 44 have experienced at least one unintended pregnancy. 32. See Healthy People 2010 – Reproductive Health in Endnote 1. See also: McCormick, M. C. & Siegel, J. E. (1999). Prenatal Care: Effectiveness and Implementation. New York, NY: Cambridge University Press. 33. See Moos in Endnote 31. 34. Finer, L. B. & Henshaw, S. K. (2006). Disparities in Rates of Unintended Pregnancy in the United States, 1994 and 2001. New York, NY: Alan Guttmacher Institute. Colker, R. (1991). An Equal Protection Analysis of United States Reproductive Health Policy: Gender, Race, Age, and Class. Duke Law Journal, 2 (Apr), pp. 324-364. 35. Henshaw, S. K. (2004). U.S. Teenager Pregnancy Statistics with Comparative Statistics for Women Aged 20–24. New York, NY: The Alan Guttmacher Institute. 36. Ibid. 37. Abma, J., Martinez, G. M, Mosher, W., Dawson, B. S. (2004). Teenagers in the United States: Sexual Activity, Contraceptive Use, and Childbearing, 2002. Vital and Health Statistics, 23(24), pp.1– 48. 38. Ibid. 39. Lindberg, L. D. (2006). Changes in formal sex education: 1995–2002. Perspectives on Sexual and Reproductive Health, 38(4), pp. 182–189. Santelli, J., Ott, M. A., Lyon, M., Rogers, J., Summers, D., & Schleifer, R. (2006). Abstinence and Abstinence-only Education: A Review of U.S. Policies and Programs. Journal of Adolescent Health, 38, pp. 72-81. 40. Alan Guttmacher Institute. (2002). In Brief: Sexual and Reproductive Health: Women and Men. Accessed Dec. 23, 2007 from: www.guttmacher.org/pubs/fb_1002.html. 41. Oakley, A. (2002). Gender on Planet Earth. Cambridge, UK: Polity Press. 42. Finer, L., Frohwirth , L., Dauphinee, L., Singh, A. & Moore, A. (2003). Timing of Steps and Reasons for Delays in Obtaining Abortions in the United States. Contraception, 74(4), pp. 334 – 344. Peterson, H. B., Grimes, D. A., Cates, W. J., & Rubin, G. L. (1981) Comparative Risk of Death From Induced Abortion of Less Than or Equal to 12 Weeks’ Gestation Performed with Local Versus General Anesthesia. American Journal of Obstetrics and Gynecology, 141, pp. 763-768. Lawson, H. W., Frey, A., Atrash, H. K., Smith, J. C., Shulman, H. B., & Ramick, M. (1994). Abortion Mortality, United States, 1972 through 1987. American Journal of Obstetrics and Gynecology, 171, pp. 1365-1372. 43. Harper, C., Henderson, J., & Darney, P. (2005). Abortion in the United States. Annual Review of Public Health, 261, pp. 501-512.
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44. Charo, R. A. (2007). Brief Summary of U.S. Law Regarding Reproductive Health. Unpublished paper prepared for the conference: Opening the Window for Reproductive Health, held Nov. 8-9, at Columbia University, Mailman School of Public Health. 45. See Healthy People 2010 – Reproductive Health in Endnote 1. 46. See Alan Guttmacher Institute in Endnote 40. 47. Alan Guttmacher Institute. (2006). In Brief: Facts on American Teens’ Sexual and Reproductive Health. Accessed Dec. 18, 2007 from: www.guttmacher.org/pubs/ fb_ATSRH.pdf. 48. Brindis, C. D. & English, A. (2004). Measuring Public Costs Associated with Loss of Confidentiality for Adolescents Seeking Confidential Reproductive Health Care: How High the Costs? How Heavy the Burden?. Archives of Pediatric and Adolescent Medicine, 158, pp. 1182–1184. English, A. & Ford, C.A. (2007). More Evidence Supports the Need to Protect Confidentiality in Adolescent Health Care. Journal of Adolescent Health, 40, pp. 199–200. Klein, J., Wilson, K., McNulty, M., Kapphahn, C., & Collins, K. (1999). Access to Medical Care for Adolescents: Results from the 1997 Commonwealth Fund Survey of the Health of Adolescent Girls. Journal of Adolescent Health, 25, pp.120–130. Ford, C., Bearman, P., & Moody, J. (1999). Foregone health care among adolescents. JAMA, 282, pp. 2227–2234. 49. See Alan Guttmacher Institute in Endnote 40. 50. See Healthy People 2010 – Reproductive Health in Endnote 1. 51. Ibid. 52. Cates, W. Jr. (1990). The Epidemiology and Control of Sexually Transmitted Disease in Adolescents. Adolescent Medicine, 1, pp. 409-28. Hampton, T. (2008). Researchers Seek Ways to Stem STDs: “Alarming” STD Rates Found in Teenaged Girls. JAMA, 299(16), pp. 1888-9. 53. See Healthy People 2010 – Reproductive Health in Endnote 1. 54. Ibid. 55. Fazekas, K. I., Brewer, N. T., & Smith, J. S. (2008). HPV Vaccine Acceptability in a Rural Southern Area. Journal of Women’s Health, 17(4), pp. 539-548. 56. Hung, C. F., Ma, B., Monie, A., Tsen, S. W, & Wu, T. C. (2008). Therapeutic Human Papillomavirus Vaccines: Current Clinical Trials and Future Directions. Expert Opinion on Biological Therapy, 8(4), pp. 421-39. 57. Kaiser Family Foundation. (2007). Women’s Health Insurance Coverage (Women’s Health Policy Facts). Accessed Dec. 11, 2007 from: www.kff.org/womenshealth/upload/6000_05.pdf. Data from Kaiser Family Foundation 2004 Kaiser Women’s Health Survey. 58. U.S. Preventive Services Task Force (2003). Screening for Cervical Cancer: Recommendations and Rationale (AHRQ Publication No. 03-515). Summary of Recommendations. [Update of 1996 recommendation contained in the Guide to Clinical Preventive Services, 2nd ed.]. Rockville, MD: Agency for Healthcare Research and Quality. Accessed May 7, 2008 from: www.ahrq.gov/clinic/3rduspstf/ cervcan/cervcanrr.htm. 59. See Healthy People 2010 – Reproductive Health in Endnote 1. 60. Whitworth, A. (2006). New Research Suggests Access, Genetic Differences Play Role in High Minority Cancer Death Rate. Journal of the National Cancer Institute, 98(10), pp. 669. Blackman, D. J. & Masi, C. M. (2006). Racial and Ethnic Disparities in Breast Cancer Mortality: Are We Doing Enough to Address the Root Causes? Journal of Clinical Oncology, 24(14), pp. 2170-8. 61. American Center Society. (2007). Detailed Guide: Breast Cancer What are the Key Statistics for Breast Cancer? Accessed Mar. 31, 2008 from www.cancer.org/ docroot/CRI/content/CRI_2_4_1X_What_are_the_key_statistics_for_breast_cancer_5.asp 62. National Cancer Institute. (2007). Cancer Trends Progress Report–2007 Update. Accessed from: www.progressreport.cancer.gov/highlights.asp.
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63. Ibid. 64. Kagay, C. R., Quale, C., & Smith-Bindman, R. (2006). Screening Mammography in the American Elderly. American Journal of Preventive Medicine, 31(2), pp. 142-149. 65. Ibid. See also: Mcalearney, A. S., Reeves, K. W., Tatum, C., & Paskett, E. D. (2007). Cost as a Barrier to Screening Mammography among Underserved Women. Ethnic Health, 12(2), pp. 189-203. 66. Trivedi, A. N., Rakowski, W.& Ayanian, J. Z. (2008). Effect of Cost Sharing on Screening Mammography in Medicare Health Plans. New England Journal of Medicine, 358(4), pp. 375-383. 67. See Healthy People 2010 – Reproductive Health in Endnote 1. 68. Speroff, L. & Darney, P. D. (2001). A Clinical Guide for Contraception. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins. 69. Alan Guttmacher Institute. (2008). In Brief: Facts on Contraceptive Use. Accessed Jan. 11, 2008 from: www.guttmacher.org/pubs/fb_contr_use.pdf. 70. Pollitz, K. & Sorian, R. (2002). Ensuring Health Security: Is the Individual Market Ready for Prime Time? Health Affairs Suppl Web Exclusive, pp. W 172-176. Pollitz, K., Imhoff, D., Scott, C., Rosenbaum, S. (2003). New Directions in Health Insurance Design: Implications for Public Policy and Practice. Journal of Law and Medical Ethics, 31(4), pp. 60-62. 71. Gross, J. (2007). Must Employers Who Cover Prescription Drugs Cover Contraception? The EEOC’s Position, the Courts’ Recent Rulings, States’ Limited Overage, and the Need for a New Statue. Finlaw, Apr 27. Accessed Mar. 31, 2008 from: www.writ.news.findlaw.com/grossman/20070417.html. 72. Guttmacher Institute (2007). Insurance Coverage of Contraceptives. Accessed Oct. 6, 2007 from: www.guttmacher.org/statecenter/spibs/spib_ICC.pdf. 73. Rosenblatt, R., Law, S., & Rosenbaum, S. (2001-2). Law and the American Health Care System, Supplement. New York, NY: Foundation Press. See Pollitz, Imhoff, Scott, & Rosenbaum in Endnote 70. 74. Equal Employment Opportunity Commission Decision Available at http:// www.eeoc.gov/policy/docs/decisions-contraception.html. 75. Kaiser Family Foundation. (2007). Women’s Health Policy Facts: Women’s Health Insurance Coverage. Accessed Dec. 11, 2007 from: http://www.kff.org/ womenshealth/upload/6000_05.pdf. 76. Amaral G, Foster DG, Biggs MA, Jasik CB, Judd S, Brindis CD. Public savings from the prevention of unintended pregnancy: a cost analysis of family planning services in California. Health Serv Res. 2007 Oct;42(5):1960-80. 77. Levey LM, Nyman JA, Haugaard J. A benefit-cost analysis of family planning services in Iowa. Eval Health Prof. 1988 Dec;11(4):403-24. 78. Zavodny M. Fertility and parental consent for minors to receive contraceptives. Am J Public Health. 2004;94(8):1347–1351Erratum in: Am J Public Health 2005;95:194. 79. Dailard C, Richardson CT. Teenagers access to confidential reproductive health services. Guttmacher Rep Public Policy. 2005;8:6–11. 80. Kaiser Family Foundation. Statehealthfacts.org. Accessed Mar. 31, 2008 from: www.statehealthfacts.org/comparetable.jsp?cat=10&ind=460. 81. In: Morreale MC, Stinnett AJ, Dowling EC editor. Policy Compendium on Confidential Health Services for Adolescents. 2nd ed.. Chapel Hill (NC): Center for Adolescent Health & the Law; 2005;. 82. 42 U.S.C. §§ 300 et seq. 42 C.F.R. § 59.11. as quoted in: Association of Reproductive Health Professionals. (2007). Protecting confidentiality to safeguard adolescents’ health: Finding common ground. Contraception, 76(2). Accessed Mar. 31, 2008 from www.arhp.org/editorials/august2007.cfm.
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83. Gudeman, R. (2003). Adolescent confidentiality and privacy under the Health Insurance Portability and Accountability Act. Youth Law News, July-Sept. 84. Alan Guttmacher Institute. (2008). State Policies in Brief: Restricting Insurance Coverage of Abortion. Accessed Jan. 11, 2008 from: http://www.guttmacher.org/ statecenter/spibs/spib_RICA.pdf. 85. Kaiser Commission on Medicaid and the Uninsured. (2007). Key Facts: The Uninsured and their Access to Heath Care. Accessed Dec. 11, 2007 from: http:// www.kff.org/uninsured/upload/1420_09.pdf. 86. See Kaiser Family Foundation in Endnote 57. 87. Ibid. 88. Glied, S., Jack, K., & Rachlin, J. (2008). Women’s Health Insurance Coverage 1980-2005. Women’s Health Issues, 18(1), pp. 7-16. 89. National Center for Health Statistics. (2006). Health Insurance Coverage 2006. Data from the National Health Interview Survey. Accessed Mar. 31, 2008 from: www.cdc.gov/nchs/fastats/hinsure.htm. 90. See Kaiser Family Foundation in Endnote 57. 91. National Center for Health Statistics. (2007). Health United States, 2007: With Chartbook on Trends in the Health of Americans. Table 144. Medicaid recipients and medical vendor payments, by basis of eligibility, and race and ethnicity: United States, selected fiscal years 1972–2004. Washington, DC: U.S. Government Printing Office. 92. Klein, K., Glied, S. A., & Ferryy, D. (2005). Entrances and Exits: Health Insurance Churning, 1998–2000. New York, NY: The Commonwealth Fund. 93. See Kaiser Family Foundation in Endnote 57. Based on Kaiser Family Foundation/Urban Institute analysis of March 2006 Current Population Survey, Bureau of the Census. 94. Kaiser Family Foundation. (2007). Health Insurance Coverage of Women Ages 18 to 64, By State (Fact Sheets: Women’s Health Policy). Accessed Oct. 6, 2007 from: www.kff.org/womenshealth/upload/1613_06.pdf. State-level figures based on Urban Institute and Kaiser Family Foundation estimates of pooled 2005 and 2006 ASEC Supplement to the Current Population Surveys. U.S. Total figures based on March 2006 Survey. 95. National Women’s Law Center. (2003). Women and Health Insurance. Washington, DC: National Women’s Law Center. Accessed May 7, 2008 from: www.nwlc.org/pdf/WomenAndHealthInsuranceApril2003.pdf. Institute of Medicine, Committee on the Consequences of Uninsurance, National Academy of Sciences. (2002). Care Without Coverage: Too Little, Too Late. Washington, DC: National Academy Press. Leatherman, S. & McQuarty, D. (2002). Quality of Health Care in the United States: A Chartbook. Hadley, J. (2002). Sicker and Poorer: The Consequences of Being Uninsured;. Blendon, , R. J. (2002). Trends: Inequities in Health Care: A Five-Country Survey, Health Affairs, 21, 182-191. 96. See Teixeira in Endnote 4. 97. See Kaiser Family Foundation in Endnote 57. 98. See Alan Guttmacher Institute in Endnote 40. Data is based on unpublished tabulations of the 1999 Current Population Survey 99. See Endnote 95. 100. Ibid. 101. A reproductive health standard of medical necessity is evidence-based and specifies that a treatment is necessary if its purpose is to: (1) achieve, promote, or maintain reproductive health or (2) threat and manage reproductive health and aging. See Bergthold, L. A. (1995). Medical Necessity: Do We Need It? Health Affairs, 14(4), pp. 181-190.
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