The Past and Future in Women’s Health: A Ten-Year Review and the Promise of the Affordable Care Act and Other Federal Initiatives

Introduction

More than a decade ago authors at the National Women’s Law Center and the FOCUS program of University of Pennsylvania,1 advised by a group of women’s health experts from around the country, produced the first Women’s Health Report Card. At that time, the country lacked both a comprehensive set of standards for women’s health in the United States and a policy blueprint for supporting such standards. By coupling accurate health status information with data on a wide range of policies, investments, and resources, the Report Card provided a critical resource for health researchers, advocates, and policymakers to assess changes in women’s health and well-being at the federal and state levels. Now, ten years later and in its fifth edition, the Report Card continues to offer the most comprehensive federal and state-by-state assessment of women’s health to date. 

To mark the ten-year anniversary of the Report Card project, this special section of the 2010 edition considers changes over the past decade as well as what the future holds. It is divided into three parts: 1) a summary of how women’s health has changed since the publication of the first Report Card in 2000; 2) an analysis of the Patient Protection and Affordable Care Act, the new federal health care law that holds enormous potential for improving women’s health; and 3) an overview of the newly-launched Healthy People 2020 initiative and other initiatives that help point the way to improving the health of U.S. women.

A Ten-Year Look at Women’s Health

In the years since the release of the first Report Card, the nation has made notable progress on several women’s health indicators including lower death rates from coronary heart disease, stroke, and breast and lung cancer. The death rate from coronary heart disease has declined considerably, from 148.1 deaths per 100,000 women (average for 2000-02) to 118.9 deaths per 100,000 women (average for 2004-06),2 although it remains almost twice the 2010 Report Card goal of 60.9 deaths per 100,000 women. 

The steady decline in the proportion of women who smoke and the increase in the proportion who receive colorectal cancer screening represent two of the most significant improvements in women’s health indicators over the last decade.  The proportion of women who smoke has declined from more than one in five women (20.8%, 2000 Report Card) to roughly one in six (16.8%, 2010 Report Card), while the proportion of women who receive colorectal screening has increased by nearly two-thirds, from 37.7% (2000 Report Card) to 61.8% (2010 Report Card). Not surprisingly, federal and state policies have focused on these two areas over the last decade, resulting in considerable public attention and allocation of resources: 

  • The federal government’s efforts to reduce cigarette smoking have been widespread and include: passing laws to regulate production and marketing of tobacco products; funding research on nicotine addiction and cessation programs; and creating and disseminating materials on smoking health issues and cessation. As the decade progressed, more and more states adopted strong anti-smoking policies (see Table 1), most notably through tobacco excise tax policies.  Since 2000, the number of states with a tobacco excise tax has increased ten-fold.  At the same time, public awareness about the risks of smoking has grown, in large part due to successful mass media education campaigns such as the American Legacy Foundation’s national “truth” campaign. Public health researchers credit the “truth” campaign with helping to reduce the teen smoking rate from 25% to 18% over a three-year period.3,4
  • Since 1998, the federal government has required coverage of colorectal cancer screening for Medicare beneficiaries, and the Centers for Disease Control and Prevention (CDC) have supported a number of colorectal cancer education and screening programs—including the “Screen for Life: National Colorectal Cancer Action Campaign” and a demonstration program to improve screening among people with inadequate or no insurance coverage.  Also, the states have played an important role in implementing policies that support colorectal cancer screening: between  2000 and 2010, the number of states requiring private insurers to cover the screening increased from two to 29.  Increases in colorectal screenings have been attributed in part to greater public awareness of its importance—Katie Couric’s televised colon cancer awareness campaign, for example, has been associated with a significant increase in the number of colonoscopies performed.5 

Table 1: Number of States with Anti-Smoking Policy Indicators, 2000-2010

Policy Indicator Report Card Publication Year
2000 2010

Does the state’s Medicaid program cover comprehensive smoking cessation treatment?

Policy Goal: Coverage of all three forms of smoking cessation treatment: over-the-counter treatments, prescription treatments, and smoking cessation counseling

6 31

What is the state’s sales rate of tobacco products to minors?

Policy Goal: Below 10%

3 22

Does the state have an excise tax on cigarettes of one dollar or more per pack?

Policy Goal: Tax of $1.00 or more per pack*

3 30

* For the 2000 Report Card, a state received a "meets" policy if it had an excise tax of $1.00 or more per pack, but the 2010 Report Card uses a measure of $1.50 or more per pack as "meets" policy to account for inflation over time.  To allow for an appropriate comparison, this table considers an excise tax of $1.00 or more per pack as "meets" policy in the 2010 column.

Despite recent progress in addressing women’s health care needs, serious problems remain.  In a number of areas, women’s health status has declined over the course of the Report Card project. For instance, the 2000 Report Card showed that just over 5% of women had been diagnosed with diabetes—by the 2010 Report Card, this proportion had grown substantially, to over 8%. While this increase over time may be due to better detection, it is more likely to reflect a true increase in the diabetes rate nationally; according to a new analysis from CDC, as many as one in three adults could have diabetes by 2050 if current trends continue.6   Also, at the end of the decade, greater proportions of women had high blood pressure (23.6% in the 2000 Report Card vs. 27.7% in the 2010 edition) and were obese (19.8% vs. 26.4%).7 

There is much needed work ahead to improve women’s health status in this country.  At the same time, 2010 marks the beginning of a new chapter for women’s health, with the enactment of the comprehensive federal health care law and the launch of Healthy People 2020 and other initiatives to improve women’s health.  These developments are described in the sections that follow.

The Affordable Care Act and Women’s Health


Broad Protections against Sex Discrimination across the Health System

Prior to the passage of the Affordable Care Act, there was no federal law prohibiting sex discrimination in health care nor did the states provide broad protections against such discrimination. The ACA prohibits insurance companies, health care providers, and health programs that receive federal funding—as well as federally-administered health programs—from discriminating on the basis of race, national origin, age, disability, or sex. This protection applies immediately, broadly, and nationwide. The U.S. Department of Health and Human Services (HHS) is charged with issuing regulations to provide guidance on the interaction of this overarching provision with other aspects of the health reform law.

In March 2010, President Obama signed historic health care legislation—the Patient Protection and Affordable Care Act8 (hereafter called the “Affordable Care Act” or “the ACA”) and its companion Health Care and Education Reconciliation Act.9 This comprehensive legislation has significant implications for women’s health.  Although the most sweeping expansions in health care coverage and improvements in preventive care and other services begin in 2014, women and their families have already started to benefit from several provisions in the ACA that are taking effect this year.

Because the Women’s Health Report Card evaluates a broad set of public policies affecting women’s health, it is a valuable tool for assessing the expected benefits of the ACA for women. The legislation addresses, in some way, approximately two-thirds of the policy indicators examined in the 2010 Report Card (see Chart 1). While the following analysis is not exhaustive, it highlights a number of areas where women stand to gain from health care reform if properly implemented: protection from sex discrimination, improvements in Medicaid coverage, and expansions in private health insurance coverage.

Expansions and Improvements in Medicaid

Medicaid, the joint federal-state health insurance program for low-income people, provides a critical source of coverage for women; fourteen of the Report Card’s 68 policy indicators are related to Medicaid policies. The Affordable Care Act calls for a number of important changes in Medicaid with far-reaching implications for women and their families: women already enrolled in this important program will benefit from various provisions that strengthen and improve Medicaid, and due to an unprecedented expansion in income eligibility under health care reform, millions of women who are currently uninsured will become newly eligible for the program.

Medicaid Expansion to All Adults up to 133% of the Federal Poverty Level (FPL)

The ACA expands eligibility for Medicaid to all legal residents with incomes up to 133% of the Federal Poverty Level or FPL (currently about $14,000 for an individual or $29,000 for a family of four).10  All states are required to expand their programs beginning in 2014, but have the option of implementing this provision at an earlier time.   

This FPL-based expansion represents a major change for adult Medicaid coverage—prior to passage of health reform, states were required to meet minimum eligibility requirements only for certain categories of people, and the Report Card examines Medicaid eligibility limits separately for pregnant women, working parents, and the aged or disabled. Specifically, states were required to cover pregnant women and infants with family incomes up to 133% of the FPL, but could set much lower eligibility levels for low-income parents (in 2009, the median eligibility level for working parents across the states was 64% of the FPL).11  Also, the absence of coverage requirements for adults without dependent children or disabilities in most states prevented non-pregnant women in these circumstances from enrolling in Medicaid or other public insurance programs, no matter how poor. The 2010 Report Card finds that only four states provide comprehensive coverage to low-income adults without dependent children or disabilities.  By establishing a uniform Medicaid eligibility level for all low-income adults—regardless of whether they are pregnant, parenting, elderly, disabled, or none of these—the ACA expands coverage to millions of people. 


Will States Provide Medicaid to Populations above the New Federal Minimum?

The Affordable Care Act requires states, at a minimum, to maintain their current Medicaid eligibility levels for adults until 2014, when the new Health Insurance Exchanges go into effect (see discussion below).* After that point, states that currently cover adults with incomes higher than the new uniform eligibility level of 133% of the FPL must decide whether to keep these adults in Medicaid or transfer them into their state Exchange.  Adults who transition from Medicaid to the Exchange in or after 2014 will be eligible for private federally-subsidized coverage, which may provide different benefits and require payment of a premium and higher levels of cost-sharing (e.g., co-payments).   This could have a major impact on pregnant women with incomes above 133% of the FPL.  The Report Card shows that in 2010 nearly every state Medicaid program covers pregnant women with incomes beyond this level; both the District of Columbia and the state of Washington cover pregnant women with incomes up to 300% of the FPL. In making decisions regarding whether to maintain enhanced Medicaid eligibility levels beyond 2014, state policymakers must ensure that Medicaid enrollees do not lose access to health services or face new cost barriers.

* States are required to maintain their eligibility levels for children in Medicaid and CHIP through September 30, 2019.

Facilitating Medicaid Enrollment 

In the past, some states have taken steps to eliminate barriers to Medicaid enrollment and streamline the application process.  The Report Card evaluates state efforts to adopt a single “family” application form for children and parents, to eliminate asset test requirements for low-income parents, and to establish a presumptive eligibility process for pregnant women.  The problem is that states have been able to decide whether to adopt these measures or not.   

The ACA removes several barriers to Medicaid.  The law requires that states establish an Internet website by 2014 where individuals can apply for or renew Medicaid, the Children’s Health Insurance Program (or CHIP, which also covers some pregnant women), and the plans available through the new Health Insurance Exchanges.  States will be required to implement a single, streamlined application for several health insurance programs including Medicaid and the private insurance premium subsidy program (see discussion below).  In addition, the Affordable Care Act eliminates Medicaid asset tests for most Medicaid enrollees beginning in 2014, reducing the burden for applicants and increasing the pool of eligible people.  (The Report Card documents that the majority of states currently apply an asset test when low-income parents apply to Medicaid.

In addition, the ACA provides states with new opportunities to use the presumptive eligibility process, which allows health care providers to use preliminary income information to grant presumptive Medicaid eligibility to uninsured patients.  Previously, states only had the option of using presumptive eligibility with pregnant women and children.  Effective immediately, the new law allows states to use presumptive eligibility for women and men in need of family planning services and, beginning in 2014, states have the option of allowing hospitals to use presumptive eligibility for all Medicaid enrollees.

Access to Family Planning Services through Medicaid

The Report Card examines whether states have taken an important step towards improving women’s health by expanding access to family planning services under their Medicaid program. Previously, creating a Medicaid family planning expansion required the state to obtain federal approval to waive certain Medicaid laws. The Affordable Care Act includes a provision known as “the Medicaid Family Planning State Option”, which gives states the flexibility to expand family planning services without first having to obtain a federal waiver.  The provision took effect immediately upon signing of the ACA, reducing the burden on states that want to adopt this common-sense measure to improve women’s access to critical family planning services.

Medicaid Coverage of Smoking Cessation Treatment

Lack of health insurance coverage for smoking cessation is a barrier to receiving the treatment and support needed to quit, particularly for low-income women who have higher than average smoking rates. The Affordable Care Act requires Medicaid programs to cover comprehensive smoking cessation treatment (i.e., counseling as well as prescription and nonprescription remedies) without cost-sharing for all pregnant enrollees starting in October 2010. (Previously this was an optional benefit for state Medicaid programs.)

The ACA encourages states to cover smoking cessation treatments (and other preventive services recommended by the U.S. Preventive Services Task Force, or USPSTF) for additional Medicaid enrollees as well. Beginning in 2013, states that cover preventive services recommended by the USPSTF (without cost-sharing) will receive additional federal funding. The 2010 Report Card finds that more than half of the states covered comprehensive smoking cessation treatment in Medicaid.  With the extra financial incentive provided by the ACA to cover this service, additional states are likely to take up this option.

Expanding and Strengthening Private Coverage

The Affordable Care Act includes numerous provisions to strengthen protections under private health insurance, benefiting the more than 65 million women who currently have this type of coverage.12 In addition, the law creates a new health insurance marketplace and a federal health insurance subsidy program that will help millions of currently uninsured women and their family members obtain private health insurance that covers the services they need.  However, the ACA restricts coverage related to abortion, a basic reproductive health service (see discussion below).

Health Insurance Exchanges and Subsidies for Premiums and Out-of-Pocket Costs

The ACA establishes a state-based system of “Health Insurance Exchanges”:  easy-to-use  shopping places where individuals and certain businesses13 can compare and purchase the health plan that best fits their needs.  By 2014, every state will have an Exchange in place and federal subsidies will become available to help low- and moderate-income individuals and families afford Exchange-based coverage:

  • Premium subsidies will be available to women living in families with annual incomes up to 400% of the FPL (currently about $43,300 for a single person or $88,200 for a family of four)14 provided that they are not eligible for other acceptable coverage (e.g., most employer-sponsored coverage,15 Medicare, or Medicaid/CHIP).   Based on a sliding scale, subsidies will limit the amount that an individual or family pays for health premiums. The subsidies will be provided as tax credits that are both refundable (available even to very low-income women with limited or no tax liability) and advanceable (available at the beginning of a year for use whenever health insurance premiums are due).
  • Cost-sharing subsidies to reduce deductibles and co-payments will be available to low- and moderate-income women. Starting in 2014, the out-of-pocket spending limit for all new plans will be reduced for women living in families with incomes up to 400% of the FPL. Depending on a family’s specific income level, out-of-pocket spending will decline by two-thirds, one-half, or one-third—and women in families with incomes up to 250% of the FPL may qualify for further reductions in cost-sharing.

This new federal subsidy system will greatly expand women’s access to health care.  This type of widespread financial assistance with health insurance is unprecedented in the United States, and once it becomes available, far fewer women will be either uninsured or underinsured (i.e., have health insurance that jeopardizes their financial and physical health).


Insurance Programs for Specific Conditions under the New Health Care Law

Many uninsured and underinsured women rely on targeted insurance programs for specific conditions, most of which are funded with public dollars.  The Report Card evaluates several of these programs, including the Medicaid Breast and Cervical Cancer Treatment Program and the AIDS Drug Assistance Program.  It is important that these programs continue to operate with adequate funding so that women who continue to lack meaningful health insurance even after the coverage expansions can continue to get the care they need; this may include undocumented immigrants (who do not qualify for private insurance through the Exchanges) and women with health plans that do not cover the services they need.

Health Insurance Regulations that Protect Women from Discrimination

In most states, women face discrimination in the private health insurance market. The worst abuses exist in the individual market, where women buy coverage directly from insurers. Typically, states allow insurance companies in the individual market to deny a woman’s application because of her medical history, or to charge a woman more for coverage because of her gender, age, or health status. The Report Card’s policy indicator on state regulation of the individual insurance market demonstrates that only a handful of states have strong individual market protections.  Particularly disturbing is the fact that 37 states and the District of Columbia allow insurance companies to consider gender when setting health insurance premiums for individual policies.

In the group health insurance market, federal laws protect small groups (generally defined as those with up to 50 employees) from rejection by insurance companies.  But in most states, health insurance premiums for both small and large groups can vary depending on gender, age, or health status.  As a result, businesses employing more female, older, or sicker workers often end up paying significantly more for coverage. The 2010 Report Card finds, for example, that only one state prohibits insurance companies from using gender rating when determining health premiums for groups of all sizes.

The Affordable Care Act includes a number of reforms that prohibit discriminatory health insurance practices, making it easier for women across the country to find fair and affordable coverage. Beginning in 2014, insurers must accept every individual that applies for coverage (also known as “guaranteed issue”) and cannot exclude individuals from coverage based on pre-existing conditions. This reform is important for women who have faced rejection or coverage denials from insurance companies due to a previous C-section, a chronic disease, or any other condition.  Notably, the ACA allows health insurance companies to limit enrollment to special open enrollment periods. 


Explicit Protections for Domestic Violence Survivors

The Report Card examines whether states prohibit discrimination against survivors of domestic violence in health insurance as well as life, disability, and property/casualty insurance.   Without these prohibitions, insurers can deny coverage or increase premiums for women who have experienced domestic violence in the past.  Starting in 2014, the ACA prohibits discrimination by health insurance companies against individuals on the basis of health status including conditions arising from acts of domestic violence.  Importantly, this prohibition on discrimination only applies to health insurance companies, and does not prohibit discrimination against domestic violence survivors in the three additional lines of insurance examined in the Report Card

Additionally, by 2014 insurance companies will be prohibited from using gender or health status to determine (or “rate”) premiums for small group and individual health plans. Premiums may vary by age and tobacco use (although variation is limited for these factors), geography, and whether the coverage is for an individual or a family.

Standards for Essential Health Benefits and Other Coverage Requirements

Too frequently, women have health insurance that does not cover needed services. Some states have passed “mandate laws” requiring insurance companies to cover specific health services, thereby preventing them from excluding coverage for certain conditions and from placing stringent limits on covered services. The Report Card evaluates whether states require coverage in 2010 for maternity care, contraceptives, infertility treatment, mental health parity (including treatment for depression and eating-disorders), diabetes supplies and education, and participation in clinical trials.

In 2014, the Affordable Care Act requires all new health plans sold to individuals and small groups to cover a set of “minimum essential benefits”, which encompass ten broad categories of health services including maternity and newborn care, prescription drugs, mental health care, and preventive services.  The ACA requires the Secretary of HHS to further define the essential benefits package and stipulates that the Secretary must “take into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups.”16 Additionally, to ensure that the set of required health care services is comparable to the coverage available in a “typical” employer-sponsored health plan, the health reform law requires the Secretary of Labor to conduct a survey of the benefits currently covered under employer-sponsored plans.   


State Requirements for Benefits beyond the “Essential Health Benefits”

The Affordable Care Act stipulates that, if a state has one or more mandate laws for benefits that lie outside of the package of minimum essential benefits, the state must subsidize the premium costs of those additional benefits for residents receiving federal subsidies to purchase Exchange-based plans.  Since the essential benefits are still undefined, it is unclear how many states will be affected by this requirement.  It is possible that this ACA provision could encourage states to abolish certain mandate laws, if there is a significant cost associated with this provision.

While not part of the package of essential benefits, the ACA also includes requirements for insurance companies to cover participation in clinical trials and mental health parity beginning in 2014—two important mandate laws evaluated by the Report Card over the last decade. The ACA requires all individual and group health plans to cover participation in clinical trials. And the Act expands mental health parity requirements to certain populations that were not protected by previous federal laws—including anyone enrolled in an individual health plan—as well as to all those enrolled in Exchange-based health plans. Like the previous federal mental health parity laws, the ACA’s mental health parity provisions do not require coverage of all mental illnesses in the Diagnostic and Statistical Manual of Mental Disorders (DSM), meaning that health plans may be able to exclude specific conditions such as eating disorders

Coverage of Preventive Services without Cost-Sharing

Access to affordable preventive services is critical for women, who use more preventive care than men on average and who also are more likely to forgo key preventive services, such as a cancer screening or dental exams, due to cost.17 Even moderate cost-sharing (i.e. co-payments or coinsurance) deters women from screening services such as mammograms or Pap smears. 

The Report Card evaluates whether states have requirements that private insurers cover preventive services, including screenings for breast, cervical, and colorectal cancer; bone density (i.e. osteoporosis) screening; and testing for Chlamydia.  Approximately half of the states receive a “meets policy” for the various cancer screening mandates, but far fewer require private insurers to cover tests for osteoporosis or Chlamydia.  The Report Card does not evaluate states’ efforts to reduce cost-sharing for preventive care, as state policies generally do not address this barrier for the privately-insured.

The Affordable Care Act establishes both a requirement that new private health plans cover recommended preventive services and a requirement that those services be provided without any cost-sharing.  Beginning in September 2010, new health plans must cover the services recommended by the USPSTF, an independent panel of prevention and primary care experts that routinely assess and make recommendations for clinical preventive care. Current USPSTF recommendations include all of the preventive screenings examined by the Report Card (i.e., screenings for breast and cervical cancer, colorectal cancer, and Chlamydia as well as bone density tests) along with testing for high cholesterol and high blood pressure, obesity screening, annual influenza vaccinations, and smoking cessation treatment.  Also, the ACA requires new health plans to cover and eliminate cost-sharing for key preventive health services for women, to be defined by a designated federal agency.

The new health reform law does not in any way restrict insurers from covering preventive services beyond those recommended by the USPSTF. For example, insurers can still choose to cover a colonoscopy for a 30-year-old woman at risk of cancer due to family history, even though the USPSTF guidelines only recommend routine colon cancer screening for people ages 50-75.  

“Grandfathered” health plans—those that existed before passage of the ACA—are exempt from requirements to cover preventive services without cost-sharing, although plans will lose their grandfathered status if they significantly cut benefits, increase out-of-pocket spending, or change insurance carriers. The state mandates evaluated by the Report Card (such as requirements that private insurance companies cover cancer screening, bone density screening, and testing for Chlamydia) continue to provide meaningful protections for women, since grandfathered health plans are still subject to these state laws. 


The United States Preventive Services Task Force (USPSTF) Recommendations for Mammography and the New Health Care Law

The ACA requires new health plans to cover mammography for women ages 40 and over, without cost-sharing. During the debate around healthcare reform, the USPSTF updated its recommendation for mammography, which created some confusion and controversy.  Since 2002, the USPSTF has recommended regular breast cancer screening for women of average risk ages 40 and older. However, in November 2009, the Task Force revised its guidelines to recommend that women aged 40-50 discuss the risks and benefits of mammography with their provider before embarking on regular screening while women ages 50 and older consider screenings every two years rather than annually.  The final health reform law mandates that the 2002 USPSTF recommendations on mammography screening be retained until the Task Force releases any new recommendations on breast cancer screenings. 

Restrictions on Abortion Services

Unfortunately, the Affordable Care Act treats abortion coverage differently from all other medical services. The law stipulates that abortion cannot be included in the required benefits that all plans must cover in order to participate in the Health Insurance Exchanges.  The decision about whether or not to cover abortion services is left to each health plan.  The ACA does not preempt state laws prohibiting or requiring abortion coverage, which means that states can enact laws that prohibit or require coverage of abortion in their Exchange-based health plans.  

As noted in the Report Card indicator on private coverage of abortion, five states currently prohibit abortion coverage in all private health plans (whether sold in or outside of the Exchange)—Idaho, Kentucky, Missouri, North Dakota, and Oklahoma. In addition, five states already have established bans on abortion coverage specifically for plans sold through the Exchange, including one of the states (Missouri) with a broader ban on abortion coverage in all private plans—Arizona, Louisiana, Mississippi, and Tennessee.  This means that in nine states, women will not be allowed to use their own private money to purchase an Exchange-based health plan that covers abortion services.18

In the remaining 41 states and the District of Columbia, insurers selling plans in the Exchanges can decide whether or not to cover abortion services. Plans that include coverage for abortion services must follow certain requirements in order to ensure that no federal subsidy dollars pay for abortion coverage except in the case of rape or incest, and/or if the woman’s life is endangered.  The ACA requires private Exchange-based insurance plans that cover abortion services to collect two payments from enrollees and to segregate one portion of the private premium payments. It is not yet clear if these segregation requirements will prompt some insurance companies to drop the abortion coverage currently provided.

Protections in the New “Patient’s Bill of Rights”

Concerns that managed care practices may impede access to needed treatment led to the inclusion of several policy indicators in the Report Card focused on state efforts to protect women’s access to care under managed care plans.  These include requiring managed care organizations (MCOs) to give women direct access to obstetric and gynecologic care (i.e., without referral) and to provide patients with a right to external review of health plan decisions. The ACA extends these two protections to all types of new health plans, managed care and otherwise, beginning in September 2010 as part of a bundle of protections called the “Patient’s Bill of Rights.”  Also included in these protections are prohibitions on lifetime limits for health plan benefits and on health plan rescissions (i.e., ending the practice of insurers cancelling an individual’s coverage after she becomes ill or develops a chronic condition). 

“Grandfathered” health plans in place before passage of the ACA are exempt from both the direct access to OB/GYN care and the external review requirements, although plans that significantly cut benefits, increase out-of-pocket spending, or change insurance carriers will lose their grandfathered status.  Since state laws regarding direct access to OB/GYN care and external review still apply to grandfathered health plans, women will continue to benefit from these important protections. 

Improving Long-Term Care Services and Supports

Because long-term care is particularly important for women—who account for the majority of recipients and caregivers of this type of care—the Report Card includes policy indicators measuring states’ commitment to expanding access to high-quality and affordable long-term care.  The ACA takes several steps to strengthen the long-term care system in the United States. It creates a voluntary national long-term care insurance program—known as Community Living Assistance Services and Supports (CLASS)—to help the functionally disabled continue living independently in the community by paying for needed care.  The Act provides new opportunities and support for “direct care workers” (many of whom are women) who provide long-term care services by establishing a workforce advisory panel and providing grants to develop training and certification programs.

The ACA also makes several improvements in long-term care services through changes in the Medicaid program, which provides the primary funding for long-term care services in the United States.  Currently, Medicaid is structured to favor institutional care although most people would prefer to receive long-term care services at home or in the community.  The Act takes several steps to expand access to home- and community-based services in Medicaid.  In addition, the law extends protections against “spousal impoverishment” (rules that protect spouses from becoming impoverished in order for their partner to qualify for Medicaid-funded long-term care) to beneficiaries of community-based Medicaid services. 

The Report Card assesses the strength of state rules against spousal impoverishment for individuals whose partners need nursing-home care. For five years starting in January 2014, the ACA requires states to extend spousal impoverishment protections to the spouses of recipients who receive Medicaid long-term care services at home or in the community.  This ensures that women are not pressured to institutionalize a spouse who needs long-term care in order to receive the important spousal impoverishment protection.

Promoting Healthy Communities

The quality of life in the community where a woman lives has a major impact on her overall health and well-being. For this reason, the Report Card examines a number of state policies addressing community-level factors—including efforts to improve women’s economic security, eliminate discrimination, and reduce gun violence.

The Affordable Care Act includes several provisions to improve community health.  The innovative “Community Transformation Grant Program” helps local communities address racial and ethnic health disparities and reduce chronic diseases by promoting healthy living and tackling the social and economic causes of poor health. Grant activities may include increasing access to nutritious foods, encouraging physical activity, and improving community safety.19 Another grant program provides funding for Community Health Workers, individuals from the community who are trained to provide culturally and linguistically appropriate health and nutrition education, give referrals and help coordinate care, advocate for individual and community health, and provide other important services.   However, the health reform law does not directly address most of the community-level indicators in the Report Card such as policies related to child support collection, the minimum wage, and gun safety measures.

Health Care Reform: Summing Up

The fact that the Affordable Care Act addresses, in some way, the vast majority of the Report Card’s sixty-plus women’s health policy indicators is a testament to the law’s scope and potential for improving women’s health and overall well-being.  Even with its limitations, the Act will undoubtedly benefit millions of women by making it easier for them to get the care they need, where and when they need it.  However, much work remains to be done to ensure that the enormous promise of the Affordable Care Act becomes a reality. 

Although federal policymakers play a major role in implementing health care reform, states are also critical to this effort.  States must make decisions about how to design their Health Insurance Exchange, when to implement the Medicaid expansion, and whether to transfer Medicaid enrollees into the Exchange in 2014.  State policymakers must determine when to apply the ACA’s various insurance market reforms (i.e., the deadline of 2014 or before) and whether to retain health insurance benefit mandates for services that are not part of the federally-defined package of minimum essential benefits.  Also, states have a major role to play in assuring that the insurance programs are well-run, and that new policies that advance women’s health continue to be adopted. 

Women’s Health Status: Healthy People 2020 and Beyond

Over the last decade, increased interest and concern about women’s health has changed the language, landscape, and approach to women’s health research—particularly concerning health disparities and the importance of a “life-cycle approach” that promotes quality of life, healthy development, and healthy behaviors across all life stages. Various government and quasi-government agencies have focused their attention on women’s health by creating strategic plans to improve health and well-being, developing new ways to measure women’s health status, and identifying critical gaps in research.


Lack of Data is a Setback for Women’s Health

The utility of the Report Card, to researchers and policymakers alike, rests upon the quality, comprehensiveness, and applicability of the health data underlying its findings.  From its inception, the Report Card has highlighted areas where data are available, missing, or incomplete.  Still, critical gaps in women’s health research remain. The availability of women’s health data is limited by budget constraints that prevent researchers from completing the data management process.  And while electronic systems have increased access to existing data, significant gaps in data collection still exist—e.g., for women with disabilities. 

The new health care law—the “Affordable Care Act”—provides opportunities for improved data collection, with the goal of identifying and eliminating health disparities among all populations. The law requires that data on patients’ race, ethnicity, sex, and primary language be collected for all federally supported and public health care programs. It specifies that this data should be collected on the smallest geographic level possible, be sufficient for useful analysis, and be made available to federal agencies, nongovernmental organizations, and the public. However, the law does not appropriate funding for this provision. In fact, it prohibits data from being collected until funding has been appropriated. Given how important this provision is to understanding and eliminating health disparities, and to improving women’s health, it is necessary for Congress to act to ensure data collection is fully funded. Read more about the importance of data collection to address health disparities among women. 

Healthy People Goals

Starting in 1980, HHS has provided a set of national public health objectives for the ensuing decade, called the Healthy People objectives. With each new Healthy People initiative, the government continues to redefine its goals for national health.  When setting goals for women’s health by which to measure state and national progress, the Report Card project has utilized Healthy People 2000 (for the 2000 and 2001 Report Card editions) and Healthy People 2010 (for the 2004, 2007, and 2010 Report Card editions).  All but four of the 26 health status indicators graded for the 2010 Report Card are drawn from Healthy People objectives.

The newest set of objectives for the nation’s health, Healthy People 2020, calls for a new conceptual approach, as well as increased accessibility and relevance to all potential stakeholders and users.20 In addition, Healthy People 2020 recognizes the importance of the social determinants of health as well as a life course view of health promotion and disease prevention.  The mission statement of Healthy People 2020 incorporates these changes:

“To improve health through strengthening policy and practice, Healthy People will: 

  • Identify nationwide health improvement priorities; 
  • Increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress; 
  • Provide measurable objectives and goals that can be used at the national, state, and local levels; 
  • Engage multiple sectors to take actions that are driven by the best available evidence and knowledge; 
  • Identify critical research and data collection needs.”

The limited progress made in achieving health goals over the last three decades has prompted this important re-evaluation of Healthy People.  The number of objectives or targets achieved during this period has markedly decreased from 32% for the 1990 objectives, to 21% for the 2000 objectives, to 6% for the 2010 objectives (as of the 2005 mid-course review). The Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for Healthy People 2020 addressed these shortcomings in its Phase I and Phase II Reports, which outline recommendations for the framework and format of Healthy People 2020 and key data considerations.

How well the 2020 objectives will reflect the current and anticipated health needs of women in the United States remains to be seen. In some respects, Healthy People 2010 presented challenges in objective applicability for women, compared to Healthy People 2000. For example, the laudable goal of setting overall targets as an indication of the importance of equity rendered it difficult to apply the targets to specific populations; whereas Healthy People 2000 contained targets for lung cancer death rates by gender, Healthy People 2010 objectives did not. The Report Card 2010 benchmark, therefore, was based upon a modification of the Healthy People goal [Healthy People 2010 Objective 3-2] to make it more applicable to women. The final Healthy People 2020 objectives are currently due to be released in early December 2010, just after the 2010 Report Card goes to print.

Other Developments Relevant to Women’s Health

Other agencies and offices within HHS have recently prepared, or are currently preparing, documents highlighting the need for research and performance measures on a variety of women’s health measures. These efforts continue to provide useful guidance for advocates, policymakers, and researchers working to improve the health of women in the U.S.  

  • The HHS Coordinating Committee on Women’s Health (CCWH) conducted a multi-phase initiative to identify opportunities and strategies to advance the health status of women and girls beyond 2010. The process included gathering feedback from more than 1,000 key informants including experts from government, academia, and health services as well as consumers, researchers, and advocacy groups. This year-long initiative concluded with a Summit for Action: The Health of Women and Girls Beyond 201021 that identified a number of priorities including the need to: eliminate access barriers; deliver prevention; mobilize knowledge for health; teach healthy lifestyle skills; promote wellness; marshal collective action; communicate informed policies; conduct, translate, and apply research; and integrate health systems and services.
  • The National Institutes of Health Office on Research in Women’s Health released its strategic plan for the upcoming decade in Moving into the Future with New Dimensions and Strategies: a Vision for 2020 for Women’s Health Research.22 This report is the culmination of a two-year strategic planning process, which involved five regional scientific meetings with more than 1,500 leading scientists; women’s health advocates; public policy experts; health care providers; federal, state, and local elected officials; and the general public. In keeping with the concept of a life course and comprehensive view, this new plan is not disease specific but articulates six broad goals: to increase research on sex differences in basic science studies; to incorporate findings of sex/gender differences in the design and application of new technologies, medical devices, and therapeutic drugs; to actualize personalized prevention, diagnostics, and therapeutics for girls and women; to create strategic alliances and partnerships to maximize the domestic and global impact of women’s health research; to develop and implement new communication and social networking technologies to increase understanding and appreciation of women’s health and wellness research; and to employ innovative strategies to build a well-trained, diverse, and vigorous women’s health research workforce.
  • The Health Resources and Services Administration, Maternal and Child Health Bureau is exploring the potential development of a national performance or outcome measure for women's health for state-level reporting under the Title V Block Grant Program. This process began with a consultative meeting in September 2009, which had four goals: to assess state efforts to report existing and new women's health measures; to determine areas of emphasis at the state and national levels; to identify data sources and the states’ capacity for data collection and reporting; and to set a future course for women's health performance outcome measures. This effort is ongoing, and continues to assess women’s health status in the context of a life course model of health, health equity, and the social determinants of health.

In addition, the Institute of Medicine (IOM) recently released Women’s Health Research: Progress, Pitfalls, and Promise23 in conjunction with the strategic plan of the NIH Office of Research on Women’s Health. This report reviewed conditions where research has contributed to major progress (breast cancer, cardiovascular disease, cervical cancer), some progress (depression, HIV/AIDS, osteoporosis), or little progress (unintended pregnancy, autoimmune disease). The authors of the report, the IOM Committee on Women’s Health Research Board on Population Health, provide seven key findings and recommendations:

  • Continued research is needed, “including…[research on the] genetic, behavioral, and social determinants of health and how they change during one’s life”.
  • Investigations to address issues that affect disadvantaged women disproportionately are needed.
  • Over-emphasis on mortality outcomes leads to lack of study on conditions and treatments that affect quality of life and wellness.  Better ways to evaluate these effects are needed.
  • Attention to key determinants of women’s health (including behavioral and social determinants) is needed. Governmental research agencies should work together to address these issues.
  • Analyses by gender should occur in all research conducted in both men and women. Medical journals could require such analyses for publication when relevant.
  • Communicating research results, and the uptake of diffusion and application to public health and clinical medical care, should occur more quickly. As more evidence accumulates, evaluation of effectiveness is needed.
  • Better communication strategies to the public are needed. Research results, as currently disseminated, can be confusing (and often contradictory). Establishing a task force of media experts and developing appropriate plans to communicate research results should be considered.

CONCLUSION 

Since the publication of the first Report Card in 2000, the nation has made notable progress in several women’s health indicators including lower death rates from coronary heart disease, stroke, and breast and lung cancer—as well as a decline in women’s smoking rates and an increase in the number of women receiving colorectal screening.  Still, as Report Card 2010 shows, the nation is failing to meet most of the goals for women’s health drawn from the U.S. Department of Health and Human Services Healthy People agenda. 

The passage of comprehensive health care reform this year holds great promise for women’s health.  With its emphasis on access to health care, including the critical preventive services that women need to stay healthy, the Affordable Care Act will make an enormous difference in addressing many of the problems identified in the 2010 Report Card.  However, there is still much work to be done.  Women’s health advocates have a critical role to play in monitoring the implementation of ACA to ensure that women receive the benefits, expansions, and improvements included in the new law.  In assessing progress made under the ACA, advocates can draw on the 2010 Report Card as well as Healthy People 2020 and other federal blueprints for women’s health.  It is also important to continue seeking improvements in health care policy for women at the federal and state levels.


 

NOTES:

1 When the Report Card was first produced, the lead author from Oregon Health & Science University, Michelle Berlin, was on the faculty of FOCUS/University of Pennsylvania.  Therefore, FOCUS/University of Pennsylvania is listed as a partnering organization for both the 2000 and 2001 Report Cards. The Lewin Group was also involved in producing the first (2000) Report Card.

2 The data in the original Report Card for deaths from coronary heart disease, breast cancer, lung cancer, and stroke are not comparable to the 2010 Report Card data, due to changes in methodology.  To allow for an appropriate comparison, this section cites alternative and comparable data from early in the decade.  These data are available at the U.S. Department of Health and Human Services Office on Women’s Health’s Quick Health Data Online, http://www.healthstatus2010.com/owh/.  

3 Guide to Community-Preventive Services. The Effectiveness of Mass Media Campaigns to Reduce Initiation of Tobacco Use and to Increase Cessation.  January 2003, available at http://www.thecommunityguide.org/tobacco/cessation/massmediacampaigns.ht...

4 MC Farrelly et al. “Evidence of a Dose-Response Relationship between ‘Truth’ Antismoking Ads and Youth Smoking Prevalence,” American Journal of Public Health 95(3), March 2005.

5 P Cram et al. “The Impact of a Celebrity Promotional Campaign on the Use of Colon Cancer Screening,” Archives of Internal Medicine 163(13), July 2003.

6 JP Boyle et al. ”Projection of the Year 2050 Burden of Diabetes in the US Adult Population: Dynamic Modeling of Incidence, Mortality, and Prediabetes Prevalence,” Population Health Metrics 8:29, October 2010.

7 The data in the original Report Card for obesity are not comparable to the 2010 Report Card data, due to changes in methodology.  To allow for an appropriate comparison, this section cites alternative and comparable data from early in the decade.  These data are available at the U.S. Department of Health and Human Services Office on Women’s Health’s Quick Health Data Online, http://www.healthstatus2010.com/owh/.  

8 Public Law 111-148.

9 Public Law 111-152.

10 Although states are not required to implement the Medicaid expansion until 2014, the examples provided here are based on current (2010) federal poverty levels to illustrate the required income level for women and families to qualify for Medicaid after the expansion.

11 VK Smith et al.  Kaiser Family Foundation’s Commission on Medicaid and the Uninsured, Hoping for Economic Recovery, Preparing for Health Reform: A Look at Medicaid Spending, Coverage and Policy Trends—Results from  a 50-State Medicaid Budget Survey for State Fiscal Years 2010 and 2011.  September 2010, available at: http://www.kff.org/medicaid/upload/8105.pdf. 

12 National Women’s Law Center analysis of 2009 health insurance data from the U.S. Census Bureau Current Population Survey’s (CPS) 2009 and 2010 Annual Social and Economic (ASEC) Supplements, available at http://www.census.gov/hhes/www/cpstc/cps_table_creator.html. 

13 Exchanges must be open to businesses with up to 50 employees in 2014-15. States have the option to allow businesses with 51-100 employees to participate until 2016, at which point groups of this size must be allowed into the Exchanges.  Beginning in 2017, states also have the option to open their Exchanges to even larger (101+ employees) businesses.

14 Premium credits will not be available until 2014; the examples provided here are based on current (2010) federal poverty levels to illustrate what women and families would pay under their current income levels.

15 A woman who is eligible for employer-sponsored insurance (ESI) is ineligible for health insurance subsidies, unless the ESI is deemed “unaffordable”,  in which case she can opt to receive subsidies to buy coverage through the Exchange.  To qualify, a woman’s share of the ESI premium must exceed 9.5% of household income, or the ESI plan must have a significantly lower value than the plans available through the Exchange.

16 Patient Protection and Affordable Care Act, Section 1302.

17 SD Rustgi et al. The Commonwealth Fund, Women at Risk: Why Many Women are Forgoing Needed Health Care 2009, available at http://www.commonwealthfund.org/Content/Publications/Issue-Briefs/2009/M...

18 The bans in Arizona, Idaho, Kentucky, Mississippi, Missouri, North Dakota, and Oklahoma include limited exceptions (e.g., in the instance of rape or incest, and/or if the woman’s life is endangered).

19 It is expected that the first grants will be awarded in 2011. See Community Catalyst, Community Transformation Grants (fact sheet), available at: http://www.communitycatalyst.org/doc_store/publications/community_transf....

20 U.S. Department of Health and Human Services, Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020.  Phase I Report: Recommendations for the Framework and Format of Healthy People 2020, available at: http://healthypeople.gov/hp2020/advisory/PhaseI/default.htm.  

21 Concept Systems Inc.  Summary of Discussion and Recommendations from A Summit for Action: The Health of Women and Girls Beyond 2010, Prepared for the U.S. Department of Health and Human Services Coordinating Committee on Women’s Health, available at: http://www.womenshealth.gov/pub/owh/womens-summit-summary-060810.pdf

22 U.S. Department of Health and Human Services, Office of Research on Women’s Health at the National Institutes of Health. Moving into the Future With New Dimensions and Strategies: A Vision for 2020 for Women’s Health Research (Strategic Plan), available at: http://orwh.od.nih.gov/ORWH_Strategic-Plan_Vol_1_508.pdf.

23 Institute of Medicine. Women’s Health Research: Progress, Pitfalls, and Promise. Washington, DC: The National Academies Press. 2010.

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