Key Findings

The 2007 edition of Making the Grade on Women's Health: A National and State-by-State Report Card demonstrates beyond question that the nation and the states are not meeting the health needs of America's women. The 2007 Report Card makes two overarching conclusions. First, for the bulk of indicators of the status of women's health, the nation as a whole and the individual states are falling further behind in their quest to reach national goals for women's health. Significant improvements are needed for the nation to meet key health objectives by 2010. Health objectives set for the nation by the U.S. Department of Health and Human Services' Healthy People 2010 agenda provide a roadmap for assessing the status of women's health. Overall, the nation continues to be so far from the Healthy People and related goals that it receives a general grade of "unsatisfactory."

Unfortunately, of the 27 benchmarks assessed in the Report Card, the nation as a whole receives a grade of "satisfactory" in only three benchmarks that it meets, only one additional benchmark since the Report Card was last published in 2004 (see National Report Card for complete list of grades). The three goals met by the nation, the percentage of women age 40 and older across the country getting mammograms regularly, the number of annual dental visits, and the additional achievement of the percentage of women age 50 and older who receive screenings for colorectal cancer, represent important milestones for women. However, the nation now fails to meet 12 of the 27 indicator benchmarks, up from nine in 2004. The nation's performance still needs significant improvement on every other goal. Moreover, the disparities women experience nationwide 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 these overall numbers suggest.

When looking at each state, in none do women enjoy overall satisfactory health status, based on the Healthy People 2010 and related goals. All of the states missed ten benchmarks, primarily in key areas central to women's overall health, including access to health insurance (see chart 1). Two benchmarks previously met in the 2004 Report Card by some states are no longer met: no state now meets the goals for the percentage of women over 18 receiving annual Pap smears, nor of reducing obesity. As in 2004, the only benchmark met by all the states is annual dental visits. In 2007, 12 states received an overall failing grade because their performance was so weak, in contrast to the 2004 Report Card when seven states received an overall failing grade. Arkansas, Louisiana, and Mississippi continue to receive the lowest rankings.

The second overarching finding of this Report Card is that states have made more progress in adopting policies to advance women's health than they have in previous report cards, but still have a long way to go. A number of state governments have improved their policies across the broad range of 63 women's health policies evaluated in this report, although a number of states have lost ground in significant policy areas as well.Seventeen states improved in more than five of their health policies since the last Report Card, but only two improved more than 10 of their health policies.The policy most consistently improved was the provision of Medicaid coverage for smoking cessation—22 states made progress in this area. Twenty states improved their minimum wage provisions, bringing to 30 the number of states with a minimum wage at or above the July 2007 federal minimum. (See chart 2 for policies most widely improved.)

However, specific policy improvements varied considerably among the states, demonstrating that there is not consistent forward progress for women's health. Only two policy goals are met by all the states: Medicaid coverage for breast and cervical cancer treatment and participation in the Food Stamp Nutrition and Education Program (FSNEP) (see chart 3). Only 16 indicators total are met by a majority of states, including external review in managed care plans (46 states), choosing not to restrict the number of prescriptions covered by Medicaid (44 states), and requiring private insurance plans to include diabetes supplies and education as part of general coverage (43 states). This year, nine states meet a majority of the policy indicator goals (32 or more indicators each), up from just three states in 2004. New York (43), California (42) and Rhode Island (39) meet the most indicators.

These minimal gains were unfortunately offset by the weakening of other key policies. Eight states weakened a net total of one to three policies (total weakened minus total improved)—better than in 2004, when the majority of states had weakened one to three policies, but still inadequate. While the specific targeted policies varied among the states, 14 additional states increased co-payments to their prescription drug coverage under Medicaid. (See chart 4 for policies most widely declined.) In addition to these net declines, it is also important to note that on an additional 12 policy objectives, there was no progress made, and 14 of the policy indicators were met by only five states or fewer.

The three states that meet the fewest policy indicators are Idaho (9), South Dakota (11) and North Dakota (11), followed closely by Indiana (12), Mississippi (12), Alabama (13), and Nebraska (13).

These findings demonstrate that, while there has been some progress on implementing policies that support and advance women's health, that progress is piecemeal and inconsistent. Moreover, these policy improvements will take time to effect change in women's health status across the nation.

The 2007 findings help identify those priorities for women's health that must be tackled by policymakers and health care providers, and the serious systemic shortcomings in meeting women's health needs that persist as described below.

Women need better access to health insurance in order to get necessary health care.

• A troubling number of women in this country continue to lack health insurance. Nationwide, 18% of women ages 18-64 remain uninsured, falling seriously short of the national goal that every person should have health insurance and making no improvement since 2004. No state meets the Healthy People 2010 goal of access to health insurance, and health insurance is one of the status indicators in which a majority of states have, since 2004, grown increasingly distant from the benchmark, with greater numbers of uninsured women in 34 states (see chart 6). Moreover, the variation among the states was substantial: Minnesota had the lowest percent of women without health insurance (9.1%--a slight increase in the number of uninsured women since 2004), while Texas ranked last, with 28.1% of women without health insurance. Additionally, in the absence of federal health care reform, states are beginning to craft their own solutions to the health care crisis. States such as Massachusetts, Maine, and Vermont have fairly recently adopted health care reform plans, and others are currently debating alternatives. The ultimate impact of these reforms on women and their health care needs remains to be seen.

• The disparities between White women and women of color who have health insurance are alarming. Nationwide, 37.8% of Hispanic women, 35.9% of American Indian/Alaska Native women, and 22.7% of Black women do not have health coverage, compared to 16.9% of White women.
• Growth in state Medicaid programs has varied. While some states have increased the number of people eligible for Medicaid, others have taken steps to decrease eligibility, and/or enacted policies which make the process of obtaining or retaining Medicaid more complicated. In 2007, five states have decreased Medicaid income eligibility levels for working parents. Only four states now meet the income eligibility policy goal for working parents—one less than in 2004. This is especially troubling in light of recent research suggesting that children are more likely to be insured and use coverage effectively when their parents also have insurance.
• Only 17 states meet the goal for income eligibility levels for pregnant women in 2007, with no additional states added since 2004. Further, there are grave disparities that exist among women who receive prenatal care: only 70.8% of American Indian/Alaska Native women, 75.9% of Black women, and 77.5% of Hispanic women receive prenatal care beginning in their first trimester of pregnancy, compared to 85.7% of White women. Further, the infant mortality rate for Black women is significantly higher than that of women of other races (13.5 deaths per 1,000 live births, compared to 5.7 deaths among births to White women, for example).
• Women who are eligible for Medicaid are deterred from enrolling in the program because of complex enrollment procedures. Several states have made Medicaid enrollment procedures easier, although others revised their policies in ways that effectively limit enrollment. Two additional states, bringing the total to 27, have implemented simplified mail-in applications for families. No real progress has been made since 2004 regarding presumptive eligibility for pregnant women and asset tests: 31 states still provide presumptive eligibility, although Kansas dropped presumptive coverage since 2004 while Connecticut opted to provide it. The total of states that do not impose an additional limit on assets for parents remains the same at 21, with one state (South Carolina) implementing an asset test while another state (Virginia) eliminated it.
• Federal law does not require coverage for adults without children or who are not disabled, and few states have created public programs to enable these adults to obtain needed medical services. Overall, states have not moved towards more health coverage for childless adults. Only seven states meet the policy goal in 2007, with no change since 2004.

• Americans without employer-sponsored coverage or public insurance often turn to the individual insurance market. Only five states meet the goal of providing adequate protections for people seeking to purchase health insurance in the individual market, with no increase since 2004. The majority of states—38—have either minimal or no meaningful regulation of this market (up from 24 in 2004). Such regulation is even more important as the nation considers moving towards greater privatization of health insurance in the form of health savings accounts and consumer driven health plans. Recent research suggests that these kinds of plans may often end up costing women more money because they tend to have higher out of pocket costs and fewer savings to draw from, particularly for pregnant women.

Access to specific health care providers and services is insufficient, and the shortage is particularly severe for reproductive health providers and services.

• Nationally, as in 2004, nearly 12% of people continue to live in a "medically underserved area," with reduced access to primary care physicians. There are large disparities among states in providing access: in New Jersey, 2.8% of the population live in medically underserved areas, while in Mississippi, 29.3% of the population live in these underserved areas. Almost 34% of women—including those who need abortions to address medical emergencies—reside in a county with no provider available.
• Coverage for specific conditions affecting women is often excluded from general insurance plans. In 2007, Medicaid pharmaceutical coverage decreased, as 14 states weakened their policies and adopted high co-payments for prescription drugs and only two made improvements. In 2007 only 11 states meet the policy goal, a decrease from 12 states in 2004 and 19 states in 2001. However, 22 states improved their Medicaid coverage of comprehensive smoking cessation treatment, with 18 states meeting the policy goal in 2007, as compared to only seven states in 2004. Despite these setbacks, it bears noting that all 51 states continue to cover breast and cervical cancer treatment through Medicaid for uninsured women under 65 identified by the Centers for Disease Control and Prevention (CDC) Early Detection Program or other programs.
• In any given year, one in four Americans suffers from a mental disorder. The number of days in the past 30 that women reported that their mental health was "not good" varies substantially: from North Dakota where women report an average 2.8 such days, to Kentucky where women reported an average of 5.5 days. While seven states improved their parity laws relating to coverage of mental health conditions, only five states meet the policy goal of equal coverage (compared to four states in 2004). ;Six states improved their parity laws for eating disorders, with 17 states now meeting the policy goal as compared to only 14 in 2004. Significantly, ten states improved their parity laws for coverage of depression, and 32 states now meet the policy goal, compared to only 24 states in 2004.
• Women's health suffers when family planning services are not available. Nationally, nearly half of all pregnancies are unintended, thereby missing by a substantial margin the national goal to reduce unintended pregnancies to 30% or less of all pregnancies. The states' adoption of policies and programs to reduce unintended pregnancies varied widely. Twenty-seven states now meet the policy goal of requiring that private insurers cover contraceptives as they do other prescription drugs, as opposed to only 20 in 2004. For emergency contraception, progress remains slow. While ten states improved their policies, only four states have adequate laws ensuring access to emergency contraception, one more than in 2004.
• 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. By 2007, many states increased obstacles for women seeking these services. Now, only 15 states have no requirement for parental involvement, a continued decline from 16 in 2004 and 19 in 2001. Only 27 states do not require a waiting period in 2007, again a decline from 31 states in 2004 and 35 states in 2001. Only 17 states - the same number as in the 2004 and 2001 Report Cards - provide public funds for safe abortion procedures for women who could not otherwise afford them. With the 2007 Report Card, a new policy objective was added, measuring whether states place restrictions on the ability of insurers to cover abortions: 39 states currently meet the policy objective of no restrictions.
• Most insured women are enrolled in managed care plans. Due to concerns about coverage of expensive and/or experimental treatments and the patient grievance process, some states have enacted patient protections to ensure access to treatment. Twenty-one states now require managed care programs to cover the cost of participating in clinical trials as compared to 17 in 2004. Forty-six states provide patients with the right to external review of a managed care company's decisions, as compared to 44 states in 2004.
• Limited English proficiency (LEP) is a barrier to health care for the millions of people who do not read, write or understand the English language. In 2007, two states improved their policies on interpretation and translation services for this population. One more state now meets the policy goal of having a comprehensive legal requirement that health care providers address the language needs of individuals with LEP.

Preventive and health promoting measures must be more available.

• Only a small number of states meet the nation's goals for screening for key diseases. Thirty-nine states meet the national goal for mammograms for women age 40 and older, down from 43 in 2004, and no states meet the national goal for women receiving annual Pap smears—the primary screening test to help detect cervical cancer (three states met this goal in 2004). However, 37 states now meet the national goal for colorectal cancer screening, compared to only 19 states in 2004.
• While in all states death rates from stroke and coronary heart disease have decreased, the country as a whole still receives a failing grade on these benchmarks because much progress remains to be made.
• It is also clear that policies must be implemented that address the higher death rates of Black women from these diseases. Black women are significantly more likely to die from coronary heart disease (190.2 per 100,000 Black women, for example, compared to only 138.2 for White women and 120.4 for Hispanic women), breast cancer (33.4 per 100,000 Black women compared to 24.5 White women and 15.8 Hispanic women), and stroke (69.1 per 100,000 Black women compared to 50.4 for White women and 37.5 for Hispanic women).
• Four states now meet the benchmark for the maternal mortality rate, up from three in 2004; however, 42 states have moved further away from the benchmark and now have higher levels of maternal mortality than in 2004.
• The percentage of women who are obese increased in all 51 states, the only status indicator on which every single state's performance got worse. This has serious consequences for women's health, since obesity is often associated with illness and death from cardiovascular disease, high blood pressure, diabetes, and others. Indeed, nationally the number of women with diabetes has also increased: 46 states declined in this indicator, and only three states improved.
• States made only minimal progress in adopting policies to facilitate essential health screening by providing insurance coverage of screening tests. Only 20 states—one less than in 2004—require private insurers to cover annual mammograms for women over 40. Since 2004, only three more states—20 states in total—require coverage for colorectal cancer screenings. Eleven states, compared to eight in 2004, mandate coverage for osteoporosis screening. Pap smear and chlamydia screening policies saw little change since 2004. Twenty-five states mandate coverage of annual Pap smears (the same as in 2004), and there are still only two states that require coverage of recommended screening for chlamydia.
• Given the importance of promoting wellness and preventing illness, both the nation and the states should adopt policies and programs to help women engage in preventive behaviors. States have seen significant improvements in adopting nutrition policies that promote healthy habits. States are also doing better in the provision of nutrition education programs: all 51 states now meet the policy goal in 2007 for Food Stamp Nutrition Education Programs. However, outreach programs have slightly declined with now only 22 states—two less than in 2004—meeting the policy goal. Further, all but one state fail to meet the status benchmark for nutrition (eating five fruits and vegetables a day), with five states declining since 2004.
• Preventive health policies that address the high prevalence of AIDS among Black women are desperately needed. The AIDS rate for Black (non-Hispanic) women is 49.9 per 100,000, compared to a national rate of only 9.4. Overall, in the District of Columbia, the AIDS incidence rate is 100 new cases per 100,000. This is by far the highest rate of any of the other states, with Maryland being the next highest at 24.2 per 100,000. Further, four states had policies on HIV and STD education which declined, with only one state improving.
• Over half of the women in the United States are likely to report having been raped and/or physically assaulted in their lifetime. Vast improvement is needed to curtail the excessive violence experienced by American women. In particular, culturally sensitive policies that address the higher rates of violence experienced by Native American and Alaska Native women are needed, as 64.8% are likely to report having been raped and/or physically assaulted in their lifetime, compared to 54.5% of White women. Given the difficulties experienced by all women in reporting such incidents, the actual number of Native American/Alaska Native women experiencing violence is likely to be even higher.

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, 12.6% of women live in poverty, ranging from top-ranked New Hampshire, where 6.3% of women live in poverty (compared to 7.4% in 2004), to bottom-ranked Mississippi, where 20.2% of women live in poverty (the same as in 2004), and Louisiana, where 19% of women do so (an increase from Louisiana's rate of 17.3% in 2004).
• Poverty rates for many women of color are also markedly higher than those of White women, with 27.1% of American Indian/Alaskan native women, 23.8% of Black women, 20.9% of Hispanic, and 10.5% of Asian/Pacific Islander women living in poverty compared to 10.8% of White women. Further, women of color are also less likely to have completed high school than White women (only 62.2% of Hispanic women, 76.6% of Native American/Alaska Native women, and 82.4% of Black women compared to 87.1% of White women).
• Only Washington and Oregon have a minimum wage that allows a family of three to reach the federal poverty threshold. The gap between the wages of men and women also reflects the particular economic hurdles facing women at every income level. Nationwide, women earn 77% of what men earn (an increase from 72.7% in 2004), but the states vary widely.
• The District of Columbia has the highest percentage of earnings for women as compared to men—women earn 85.5% of what men earn (a decline from 89.2% in 2004). The state with the largest wage gap remains Wyoming, at 60.7% (a decline even from 2004, when the gap was at 64.4%).
• Child support payments can make a substantial difference in the financial well-being and health of a woman and her family. Unfortunately, states have made relatively no progress towards implementing policies that allow Temporary Assistance for Needy Families (TANF) recipients to keep some of the child support collected on their behalf. Only 21 states meet this policy goal in 2007, the same number as in 2004 (with one state declining and one state improving). Overall, the states have shown improvement in their child-support collection rates, with 11 states improving their policies while two declined, bringing the total to 18 states collecting child support in 60% or more of their cases.
• States can also help women secure access to health care for themselves and their families through paid leave policies. In 2002, California was the first state to enact a paid family leave policy, allowing workers to take partially paid leave in order to care for a new child or ill family member. In 2007, only one additional state, Washington, meets this policy objective.
• Discriminatory practices can affect women's health by creating barriers to securing health care services and health insurance, by creating stress that contributes to adverse physical and mental health and by creating barriers to financial achievement. States have made progress in adopting strong legal protections against some forms of discrimination. Twenty-one states—six more than in 2004—prohibit employment discrimination based on sexual orientation, and 33 states—five more than in 2004—prohibit employment and health insurance discrimination based on genetic information.

Conclusion

The health status of women all across United States must be improved. Far too many states fail to meet the Healthy People 2010 and related goals for satisfactory health status, yet states are only slowly grappling with policy changes that can make improvements in women's health. Since 2004, more states have made positive changes in their policies, but there is still a great distance to go. Much more needs to be done to improve access to health insurance, health care providers and services, and to increase access to reproductive health services. Additionally, women need help attaining economic security, which if achieved would greatly improve their health and the health of their families. This Report Card shines a light on the problems and possible solutions to create a nation of healthy women, for the benefit of themselves, their families, and their communities. Now is the time to take giant steps toward that goal.