Policy Indicators

Women's Access to Health Care Services

The indicators in this section reflect whether a state has public policies and programs to support women’s access to health insurance and services. In particular, the Report Card identifies those policies that promote greater coverage through Medicaid because of the critical role this federal-state program plays in providing access to care for millions of low-income people nationwide. States can raise income eligibility thresholds, improve outreach to, and remove barriers to enrollment for, eligible populations, and pursue expansions for otherwise ineligible populations (i.e., childless, non-disabled, non-elderly adults). The Report Card also examines state policies that improve access to health care by regulating the private individual health insurance market and by aiding individuals with limited English proficiency to gain access to needed services.


Access to Health Insurance & Services

The indicators in this section reflect whether a state has public policies and programs to support women’s access to health insurance and services. In particular, the Report Card identifies those policies that promote greater coverage through Medicaid because of the critical role this federal-state program plays in providing access to care for millions of low-income people nationwide. States can raise income eligibility thresholds, improve outreach to, and remove barriers to enrollment for, eligible populations, and pursue expansions for otherwise ineligible populations (i.e., childless, non-disabled, non-elderly adults). The Report Card also examines state policies that improve access to health care by regulating the private individual health insurance market and by aiding individuals with limited English proficiency to gain access to needed services.

Medicaid Eligibility by Income

Medicaid is a critical source of insurance for women: ten percent of women who are not elderly are covered by Medicaid.1 While federal law requires states to cover specific categories of low-income adults, states may expand the pool of people covered by Medicaid, particularly by raising the income level at which people are eligible.2

Pregnant Women

States can expand Medicaid or Children’s Health Insurance Program (CHIP) coverage for pregnant women, a policy that has contributed to the nationwide increase in women receiving prenatal care in the first trimester.1


Working Parents

States can raise Medicaid income eligibility for working poor families. Currently, over 80% of the uninsured are in working families.1


Aged and Disabled

States can expand income eligibility for low-income elderly and disabled populations. Medicaid is already a crucial source of coverage for more than 8 million disabled individuals, and provides supplementary coverage for more than six million Medicare beneficiaries.1


Methods to Expand Medicaid Enrollment

Many people who are qualified for Medicaid do not enroll in the program, either because they do not know they are eligible or because they encounter barriers to enrollment. States can expand the pool of women insured by Medicaid by streamlining the enrollment process.

Presumptive Eligibility for Pregnant Women

States can adopt a policy that makes a pregnant woman “presumptively” eligible for Medicaid once she submits preliminary income information.1


Mail-In Application

States can simplify enrollment for families by allowing parents to apply jointly with their children using a simplified application.


Asset Test for Parents

States can cover more people by eliminating the “asset test” for parents.1 The asset test counts parents’ ownership of certain assets when determining the family’s eligibility for Medicaid. Eliminating this test serves multiple purposes, including easing the application process, streamlining and reducing administrative costs and increasing the pool of eligible people.


Access to Health Insurance & Services

Public Insurance for Childless Adults

There are many policies states can adopt to help all low-income women move out of the ranks of the uninsured. Although federal law does not require coverage for adults without children or disabilities, states can create a public program for this population through their Medicaid or CHIP programs via a waiver or with state-only funding. The Report Card examines states’ provision of publicly funded health insurance for otherwise uninsured, low-income adults, regardless of their parental status, age or disability.


Regulation of Insurance for Individual Coverage

The majority of American women have health insurance either through an employer or through a public program such as Medicaid, but a small percentage of nonelderly women purchase health coverage directly from insurance companies in what is known as the “individual market.” For the 18% of women who are currently uninsured—those who lack access to employer coverage, or who earn too much to qualify for public programs—the individual insurance market is often the last resort for coverage.

Buying insurance in the individual market is very different from getting health insurance through an employer. Women who get health insurance from their employer are protected by several important federal and state laws. For example, most employers cannot charge their employees different premiums for their health insurance.1 In contrast, states are left to regulate the sale of health insurance in the individual market; and in the vast majority of states, few if any such protections exist for women who purchase individual health coverage.

The Report Card examines whether states have enacted protections for people seeking to buy plans in the individual market. For example, states can require policies to be sold on a guaranteed issue basis, which guarantees access to coverage for all applicants regardless of health status. States can also mandate a minimum or standardized benefits package and establish rules prohibiting rate discrimination based on health status (known as community rated premiums). In addition, states that allow insurers to discriminate based on health status can create high-risk pools as a source of coverage for people who are turned down or charged more by private insurers because they have a “pre-existing condition.” The new federal health care law establishes high-risk pools in each state beginning in 2010 to help adults who are uninsured and have a pre-existing condition get insurance until the major coverage provisions of the new law come into effect in 2014.2 The Report Card gives credit to states that established high-risk pools before this new federal law was enacted.


Linguistic Access

Language barriers can inhibit a health care provider’s ability to diagnose and treat patients with limited English proficiency (LEP)—an obstacle to health care that affects millions of people who do not have the ability to proficiently speak, read, write and understand the English language.1 The Report Card examines states’ commitment to addressing the needs of this population.


Access to Specific Services

States can improve women’s health status by broadening access to specific services important to women. The indicators in this section address pharmaceutical costs, maternity care, long-term care issues, mental health care services, coverage of diabetes-related services, breast and cervical cancer services, family planning, abortion access and violence against women.

Gender Rating

“Gender rating” is the health insurance industry practice of using gender to decide how much to charge an applicant (whether an individual or a group) for health insurance.3

Gender Rating in the Individual Health Insurance Market

In most states, insurers are currently allowed to consider gender when setting premium rates in the individual health insurance market, where people buy coverage directly from insurance companies. As a result of “gender rating,” women are often charged more than men for the exact same coverage. In fact, a 2009 report on gender rating found that a 25-year-old woman may be charged up to 84% more than a 25-year-old man for identical coverage in the individual market. The same report also showed that gender rating is rampant in the individual market in states that do not prohibit it, with 95% of best-selling plans in those states practicing gender rating.

The Report Card examines whether states have enacted laws to prohibit or limit insurers from gender rating in the individual health insurance market. States that limit gender rating use a “rate band” to set limits between the lowest and highest premium that a health insurer may charge based on gender, e.g. a state with a 20% rate band can charge a woman up to 20% more (solely based on gender) than a man for the same health insurance.


Gender Rating in the Group Health Insurance Market

Many businesses obtain coverage for their employees in what is known as the group health insurance market. Though federal law prohibits employers from charging individual male and female employees different rates for coverage, insurance companies are allowed to consider the proportion of women a business employs when determining the group’s overall premium. As a result, businesses with predominately female workforces—such as child care centers, home health agencies, or non-profits—can end up paying significantly more for coverage.1

The Report Card examines whether states have enacted laws to prohibit or limit insurers from gender rating in the group health insurance market. States that limit gender rating use a “rate band” to set limits between the lowest and highest premium that a health insurer may charge based on gender.



The high cost of prescription drugs is a barrier to health care in the United States, creating financial hardship for many low-income women. In most cases, spending for prescription drugs accounts for one of the highest shares of individual out-of-pocket health care spending.4

Medicaid Prescription Number Limits

States can choose to cover an unlimited number of prescriptions under Medicaid. Although states must comply with federal guidelines for their Medicaid programs, they have some flexibility in determining the scope of coverage, including whether to limit the number of prescriptions covered during a specific time period.


Medicaid Prescription Co-payment

States can limit prescription drug co-payments. Co-payment requirements can seriously restrict Medicaid patients’ access to prescription drugs; even a minimal out-of-pocket cost may be too expensive for low-income women and prevent them from buying the prescriptions they need. Indeed, in 2007, 36% of non-elderly women did not fill a prescription because of cost.1


AIDS Drug Assistance Program

States can increase access for one vulnerable population by raising eligibility levels in their state AIDS Drug Assistance Programs (ADAPs). These programs provide access to HIV/AIDS drug therapies to low-income, uninsured and under-insured people living with HIV/AIDS who otherwise could not afford drugs which could improve the quality and length of their lives.1 Because women with HIV/AIDS are disproportionately low-income, it is especially important that states improve affordable access to drug therapies.2


Access to Specific Services

Maternity Care

State and federal anti-discrimination protections ensure that most employer-sponsored health insurance covers maternity expenses.1 However, it is very difficult—and sometimes impossible—for women to find coverage for maternity care in the individual health insurance market, where women buy coverage directly from insurers. In a study of the availability of maternity coverage in the individual market, the National Women’s Law Center found that the vast majority (87%) of individual health plans available to a 30-year-old woman across the country did not provide maternity coverage.2

A handful of states have recognized the importance of ensuring that maternity coverage—including prenatal, birth, and postpartum care—is a part of basic health care by establishing “benefit mandate” laws that require insurers to include coverage for maternity services in all group and individual health insurance policies sold in their state. Other states have adopted limited-scope mandate laws that require maternity coverage only for certain types of health plan carriers, certain types of maternity care, or for specific categories of individuals. Limited-scope mandate laws address the provision of maternity care but may fall short of providing women with full coverage for the care they need.


Diabetes-Related Services

Approximately 11.5 million women—10.2% of all women ages 20 or older—in the United States have diabetes,1 a condition requiring self-managed treatment. To manage their condition, patients need access to medical supplies (including test strips, insulin, and meters) and training to use these supplies. The Report Card examines whether states require private insurance plans to include diabetes supplies and education as part of general coverage.


Long-Term Care

Women constitute the majority of long-term care5 recipients—for instance, more than 70 percent of nursing home residents are women.6 There are many barriers to quality long-term care services, including cost. Medicare does not cover most long-term care services, and there are serious limitations on the coverage available through private insurance or Medicaid.7

Ombuds Staffing Levels

States can maintain adequate staffing levels of long-term ombuds. The federal long-term care ombuds program, administered and partially funded by the states, provides ombuds who act as advocates to help residents and their families obtain a better quality of life in long-term care settings.1


Medicaid Spousal Impoverishment

States can impose the most protective “spousal impoverishment” Medicaid eligibility rules. To prevent the high cost of long-term care from impoverishing the spouses of nursing home residents, federal law requires states to protect some assets and income of the non-institutionalized spouse (“community spouse”) through resource and income allowances.1


Mental Health

More than one in four American adults suffers from a diagnosable mental disorder8 in any given year,9 and women represent two-thirds of all users of mental health services.10 Yet historically, health plans have required higher cost-sharing and applied more restrictions to mental health benefits than physical health services.11 In 2006, an estimated 10 million adults reported that they needed, but did not receive, mental health services—and women were nearly twice as likely as men to report this unmet need.12

Mental Health Parity

States can enact mental health parity legislation that requires private insurers to cover mental health disorders on the same basis as physical disorders for individuals and groups of all sizes.


Eating Disorder Parity

States can require private insurers to cover eating disorders—which overwhelmingly affect young women1—on the same basis as other health conditions. This treatment is particularly critical given that anorexia nervosa has one of the highest death rates of any mental disorder.2


Depression Parity

States can require private insurers to cover depression—which affects twice as many women as men1—on the same basis as other health conditions.


Breast and Cervical Cancer Treatment

Thousands of women each year are diagnosed with breast or cervical cancer. It is estimated that in 2009 in the U.S., 11,270 women will be diagnosed with cervical cancer and 192,370 women will be diagnosed with breast cancer, and about 44,240 women will die from both cancers combined.13

Medicaid Coverage

States can exercise their option under the Breast and Cervical Cancer Prevention and Treatment Act of 20001 to provide full Medicaid benefits to uninsured women under age 65 who were screened through the Centers for Disease Control and Prevention’s (CDC) National Breast and Cervical Cancer Early Detection Program2 and who are in need of treatment. States receive enhanced federal matching funds for the provision of these services.


Breast Reconstruction Surgery

States can help breast cancer patients by mandating coverage for breast reconstruction after a mastectomy. Many patients have trouble getting coverage because some insurance companies deem it “cosmetic” surgery that is not medically necessary. Although a federal law was passed in 1998 to combat this practice, state laws add the strength of state enforcement mechanisms.1


Mastectomy Hospital Stays

States can mandate that insurance companies allow physicians, in consultation with their patients, to determine how long a woman stays in the hospital following a mastectomy, based on the patient’s individual needs and circumstances. Such laws are necessary to prevent insurers from placing harmful restrictions on a hospital stay in connection with a mastectomy.


Family Planning

Family planning services provide numerous essential health benefits—including better spacing of pregnancies, which leads to healthier outcomes, and fewer unintended pregnancies, abortions and sexually transmitted diseases/infections. In fact, reducing negative health outcomes through the consistent use of effective family planning methods is one goal of Healthy People 2010.14

Contraceptive Coverage

States can require private health insurers to provide contraceptive coverage on the same basis as other prescription drugs.1 Contraceptives can be expensive, and without insurance coverage, many women are forced to either forgo using contraceptives completely or to use less effective methods.


Access to Emergency Contraception

States can facilitate access to emergency contraception (EC). EC provides women with a safe and effective way to prevent unintended pregnancies after unprotected sex or contraceptive failure.1 Studies show that EC works to prevent pregnancy in the exact same way that ordinary birth control pills do – mainly by preventing ovulation. Given that EC is most effective if used within the first 12 to 24 hours after unprotected intercourse, it is pivotal that women have quick and easy access to it.


Medicaid Waiver

States can expand access to family planning services for low-income women, who often face additional barriers to care. While Medicaid is the largest public provider of family planning services for low-income women, four in 10 poor women of reproductive age still lack insurance coverage.1 States can expand access to these critical health services by taking up a state option that allows them to provide family planning services only under Medicaid to women, and sometimes men, who would otherwise be ineligible for the program.


Infertility Treatment Coverage

States can require private insurers to cover infertility treatments. Infertility affects about 7.3 million women and their partners in the U.S.—about 12% of the reproductive-age population. In 2002, 2% of women of reproductive age went on an infertility-related medical visit, and 8% had had an infertility-related medical visit at some point in the past.1 However, private insurance companies do not always cover the costs of treatments, placing them out of financial reach for many families.2


Abortion Access

Reproductive health care, including abortion, is a vital component of women’s health care. While women in the United States have had a constitutionally protected right to abortion since the 1973 Roe v. Wade decision,15 actual access to abortion services is diminishing.16 State policies can have immense impact, both positive and negative, on women’s access to these services. 

Clinic Access

States can promote clinic access by banning violence, and by providing state police and prosecutorial authority in addition to that provided by federal authorities. Threats and violent attacks on reproductive health centers have had an extremely negative impact on women’s ability to obtain abortions.1 In 1994, Congress passed the Freedom of Access to Clinic Entrances Act (FACE),2 and a decline in such incidents followed immediately.3 Similar laws at the state level would provide further protection through state enforcement mechanisms.


Private Insurance Coverage of Abortion

States prohibit private insurers from covering abortions except in limited circumstances.1


Parental Consent/Notification

States create a serious barrier through parental consent and notification policies. These laws require involving one or both parents in a minor’s decision to terminate a pregnancy and often serve to limit young women’s access to abortion.1 Such requirements can endanger the health of young women—some may delay the procedure, and others may travel alone to another state to secure the abortion.2


Waiting Periods and Counseling Requirements

States limit access by passing laws requiring that women receive biased counseling and endure a mandatory delay before receiving an abortion. The type of information required by these laws goes beyond regular informed consent and often is medically inaccurate. Mandatory delays typically require a 24 hour wait between the time a woman receives state-mandated biased counseling and the abortion. These delays create unnecessary burdens and may increase the risk of complications.


Public Funding

States can use their own funds to provide medically necessary abortions to their Medicaid beneficiaries, many of whom are denied coverage of abortions due to the Hyde Amendment. Enacted in 1977, this amendment is a federal law which prohibits the use of federal Medicaid funds to cover abortion except in cases where the pregnancy is the result of rape or incest, or the life of the woman is endangered.1 Using states’ own funds to provide this access is critical for many low-income women.


Refusals to Provide Reproductive Health Care

Across the nation, patients are being denied health care services by individual health care providers and by institutions, such as hospitals, HMOs, and employers, who believe that their religious, ethical, or moral beliefs should come before patients’ needs.  Women are overwhelmingly the victims of refusals in health care settings because women’s reproductive health care services are the subject of the vast majority of refusals. Women denied needed services are forced to bear the additional costs, delays, and health risks incurred by going elsewhere or never receiving the services. These burdens fall most heavily on poor women and those living in rural areas, but the reduction of available health services adversely affect all women in need of reproductive health care.

Broad Refusals to Provide Reproductive Care

Currently, federal law provides protections for certain individual and institutional health care providers who refuse to participate in abortion or sterilization services.1 These laws do not contain critical patient protections that ensure access to reproductive health care in the event of a refusal.

Individual health care providers and health care entities who object to reproductive health care services also receive protection from state law. Forty-seven states have laws that explicitly allow health care providers and/or institutions to refuse to participate in abortion, sterilization, contraception, or other reproductive health care services. The content of these laws varies; some allow refusals with no patient protections, while others attempt to ensure that access to care is not compromised in the event of a refusal. The Report Card examines whether state laws permitting refusals to provide reproductive health care services also attempt to meet patients’ needs to access necessary care.


Pharmacy Refusals

In addition to broad laws permitting religious refusals to provide reproductive health care services, some states have enacted laws or policies that specifically govern refusals to dispense medication in the pharmacy. The Report Card examines whether states have a specific law or policy that protects women’s access to contraception at the pharmacy.


Violence Against Women Assistance

Violence against women presents a serious health problem in need of major attention.  In 2005, 1,181 women were murdered by an intimate partner,17 and women experience about 4.8 million intimate partner-related physical assaults and rapes every year.18 One in six U.S. women report experiencing an attempted or completed rape during their lives.19

Domestic Violence

The Report Card examines whether states have attempted to reduce the impact of domestic violence by requiring health care protocols, training, and screening for domestic violence for health care providers.  Early detection and intervention by health care providers can help domestic violence survivors escape abusive relationships. Health care providers need training not only to appropriately treat women who exhibit signs of domestic violence injuries, but also to screen for and recognize abuse in patients who do not exhibit recent injuries.


Family and Medical Support

Many women facing a serious health condition or caring for a family member cannot afford to take needed time away from work. Women are disproportionately responsible for family care giving—e.g., eight in 10 mothers are primarily responsible for their child’s health care, and one in ten mothers are also caring for a chronically sick or disabled family member.20 Yet many of these women also face their own health problems. Nearly one in five mothers are uninsured, and 25% suffer from a chronic health condition.21 Many women endanger their own health by struggling to meet the demands of both work and family care. While providing unpaid family and medical leave is an important step in helping Americans balance work and family responsibilities, enacting paid leave policies makes such leave more affordable and therefore feasible for lower-income families.

Family & Medical Leave

One way states can help women facing family and medical responsibilities is by adopting the policies reflected in the federal Family and Medical Leave Act (FMLA). The FMLA requires larger employers to allow workers to take up to 12 weeks of unpaid leave to recover from their own illnesses or to care for certain family members in certain circumstances.1 Unfortunately, nearly 40 percent of workers are not covered by the FMLA.2 The Report Card examines whether states have expanded family and medical leave coverage to cover more people (e.g., laws that apply to employers with fewer than 50 employees) and/or to provide more generous family and medical leave benefits than the federal law does (e.g., by allowing leave for participation in children’s education activities).


Temporary Disability Insurance

Because family and medical leave is typically unpaid, many women who may be eligible for leave cannot afford to take it. Indeed, an analysis by the Urban Institute found that 77 percent of employees who were eligible for and needed leave but chose not to take it made that decision for financial reasons, and 88 percent of this group said that they would have taken leave had some wage replacement been available.1 The Report Card examines states’ efforts to assist these women by providing some payment during family and medical leave periods through temporary disability insurance (TDI) laws. Such laws are usually provided through expansions of unemployment or disability insurance. Although limited, these laws provide partial wage replacement for employees who are temporarily disabled for non-work-related reasons and represent a first step toward making personal medical leave more affordable.2


Patients' Protections in Managed Care

Most insured women are enrolled in some form of managed care plan.22 Concerns exist about managed care practices that may impede access to needed treatment (especially higher cost care) and to fair grievance mechanisms. States can adopt many different protections to ensure women’s access to care under managed care plans.

Direct Access to OB-GYN

The Report Card examines state policies that provide direct access to reproductive and related health care without having to obtain a referral. This is particularly an issue for female enrollees if they do not select an OB/GYN as their primary care provider.


Clinical Trials

For patients with chronic, long-term, or terminal illnesses, access to clinical trials can be crucial in defining and treating life-threatening illnesses, especially when experimental approaches are the only treatment available. The Report Card examines whether states require managed care plans to pay for clinical trials.


External Review

A strong grievance and appeals process that includes the right to an external review—a review by an independent party—allows patients the ability to challenge limits on services. The Report Card examines whether state policy supports a patient’s right to challenge denial of care claims.


Addressing Wellness and Prevention

Given the importance of promoting wellness and preventing illness, the Report Card includes indicators that address key health screenings and prevention measures and the policies that support them. This section examines ways in which women and their health care providers can prevent and manage illness and maintain or improve health.


Screening Coverage Mandates

The Report Card examines screening coverage mandates for cervical cancer, Chlamydia, breast cancer, osteoporosis and colorectal cancer.  These tests (intended to be given when women do not have symptoms) were selected because the diseases for which they screen can effectively be treated with early interventions. Both Medicaid and Medicare cover some screenings, including Pap smears and mammograms.23 However, states can ensure that the majority of women have access to these and other preventive screenings by requiring private insurers to cover important screenings for women23

Pap Smear

Cervical cancer is one of the most successfully treatable cancers when detected early. The U.S. cervical cancer death rate declined by 65% between 1955 and 1992, in large part due to the effectiveness of Pap smear screening, and the death rate continues to decline each year.1 While the CDC’s National Breast and Cervical Cancer Early Detection Program covers pap smears for certain categories of underserved women,2 states can expand access to this key preventive screening by requiring coverage in private insurance.


Chlamydia Screening

In the United States, Chlamydia is the most common bacterial sexually transmitted disease (STD), particularly among sexually active adolescents and young adults. In 2006, over one million cases of Chlamydia were reported, and it is estimated that more than 2 million people ages 14-39 in the U.S. are infected.1  If not detected and treated, Chlamydia can lead to pelvic infection, infertility and tubal pregnancies in women, and increases risk for HIV infection.2 Babies born to women infected with Chlamydia can get infections in their eyes and respiratory tracts, and some evidence suggests that Chlamydia can cause early delivery in pregnant women.3 The CDC recommends that sexually active women under the age of 25 be screened for Chlamydia yearly. Screening for Chlamydia is also recommended for older women in high-risk categories, including those who have a new partner or multiple partners, and all pregnant women.4 States can expand access to this key preventive screening by requiring coverage in private insurance.



Research has shown that breast cancer screenings with mammograms reduce the number of deaths from breast cancer for women ages 40 to 69, especially for those over age 50.1 The CDC’s National Breast and Cervical Cancer Early Detection Program covers mammograms for certain categories of underserved women.2 However, states should require that private insurers cover mammograms, thereby giving all women access to this screening.


Osteoporosis Screening

Bone mineral density testing (also known as bone mass measurement) can predict a woman’s risk for bone fractures, one of the most common and debilitating consequences of osteoporosis.1 Medicare pays for bone density testing for five high-risk groups.2 States can help most women not on Medicare gain access to this screening by requiring private insurers to cover bone density testing for high-risk people.


Colorectal Cancer Screening

Although colon cancer is the second largest cancer killer in America,1 it has one of the highest survival rates with early detection and treatment.2 In order to detect colorectal cancer, the American Cancer Society recommends that all individuals over 50 get screened, either through a sigmoidoscopy or a colonoscopy.3 States can expand access to this important preventive screening by requiring coverage in private insurance.



Given the importance of promoting wellness and preventing illness, the Report Card includes indicators that address key health screenings and prevention measures and the policies that support them. This section examines ways in which women and their health care providers can prevent and manage illness and maintain or improve health.


The U.S. Department of Health and Human Services recommends that young people (ages 6–17) participate in at least 60 minutes of physical activity daily.1 Yet a 2007 survey by the Centers for Disease Control and Prevention found that a quarter of all high school students, and nearly one in three female students (32%), had not participated in 60 minutes of physical activity on even one day during the previous week. Young women are less likely than young men to have met recommended levels of exercise (44% compared to 26%), and Black and Hispanic females are even less likely than White females to have met recommended levels (21%, 22%, and 28%, respectively).2 And, while 40% of 9th grade students attended physical education class daily in 2007, fewer than one in four 12th grade students did.3 Promoting physical activity in school is crucial to encouraging girls to reap the health benefits of regular exercise and to develop good lifelong exercise habits. The Report Card examines states’ policies on physical education (PE) requirements for high school students.


Arthritis Program

A large number of women in the United States suffer from arthritis. In a 2005 survey, more than one in four adult women (ages 18 and over), compared to 17% of adult men, reported having been diagnosed with arthritis; and six in ten elderly women (65 and over) suffer from the condition. Arthritis is a particularly acute problem among Black women: one in two Black women ages 45 or over, compared to 40% of White women, has arthritis.1 States’ participation in a federally funded state-based arthritis program is critical to increasing awareness of arthritis as a public health problem and creating education, intervention and treatment strategies for people living with arthritis.


Maternal Mortality Review

More than two women in the United States die every day from complications of pregnancy and childbirth.1 The rate of maternal deaths in the United States has been rising, doubling from 6.6 deaths per 100,000 births in1996 to 13.3 deaths per 100,000 births in 2006.2 However, approximately half of these deaths could be prevented if maternal health care access and quality were improved.3

There are a number of factors that have led to the current state of maternal health, including unequal access, gaps in care, systemic failures, and financial, bureaucratic and language hurdles.4 There has been very little oversight of maternal health trends and a lack of documentation of maternal risk factors, which has made it difficult to implement consistent evidence-based standards.5 In response to these patterns, a number of states have set up maternal mortality review committees. While these committees vary in their approach, they maintain a common goal: to track maternal health patterns and effective develop responsive solutions to address the rising rate of maternal mortality.


Sexuality Education in Public Schools

Young people in the United States—particularly young women—need education and information to prevent unintended pregnancies and sexually transmitted diseases and infections (STDs/STIs). Each year, 750,000 adolescent females in the U.S. become pregnant,1 and teen pregnancy rates are far higher in the U.S. than in most other developed countries.2

Healthy People 2010 seeks to increase the number of young adults receiving school-based education on contraception and abstinence.3 The U.S. Surgeon General issued a report in 2001 emphasizing the important role of comprehensive school-based programs in promoting responsible sexual behavior and lessening some of the serious problems of sexual health experienced by the nation.4 In addition, numerous studies have found certain comprehensive sex education programs to be highly effective in delaying initiation of sex, reducing number of sexual partners, reducing incidence of unprotected sex and increasing condom usage among American youth, in addition to other positive results.5 The Report Card examines whether states are promoting sexuality education by requiring school-based sexuality education and enacting content requirements for these programs that include information about contraception.6


STD/STI/HIV Education in Public Schools

Each year, 15 to 24 year olds report more than 9 million cases of sexually transmitted diseases and infections (STDs/STIs).1 The Centers for Disease Control and Prevention (CDC) announced in 2008 that one in four young women, and one in two young black women, between the ages of 14 and 19 have an STI.2 Young women, particularly young women of color, bear the burden of unintended pregnancies and a disproportionate share of STIs.

The Report Card examines whether states are requiring education about STD/STI/HIV—one of the best ways to reduce and prevent unintended pregnancy and the spread of sexually transmitted diseases, including HIV/AIDS.3


Rejection of Abstinence-Only Funds

Title V, Section 510 of the Social Security Act defines “abstinence education” and provides funds to states to promote abstinence-only messages.1  Programs are required to teach that “sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects,” and that “a mutually faithful monogamous relationship in [the] context of marriage is the expected standard of sexual activity.”2 In addition, federally funded abstinence-only programs are expressly prohibited from providing any information to adolescents about the proper usage of contraceptives or their proven efficacy in preventing unintended pregnancy and, for certain contraceptive devices, the transmission of STIs.3 At the same time, they are specifically required to inform participants of contraceptive failure rates.4 Furthermore, many abstinence-only programs promote stereotypes about gender and relationships that may compromise young women’s confidence in their ability to make responsible, pro-active decisions about their sexual health and alienate youths at especially high risk for problems relating to sexual health.5

As studies have increasingly demonstrated that abstinence-only programs fail to prevent adolescents from engaging in sexual activity outside of marriage—the primary objective of abstinence-only education—or to increase the likelihood that teens will practice safer sex methods when they do become sexually active,6 states have begun to reject the federal funds available to them for abstinence-education. The Report Card examines whether states have turned down Title V federal funding for abstinence-only programs.



One barrier to good nutrition for many low-income women is lack of information—both about the public benefits available to make nutritious food more affordable and about healthy eating.

Food Stamp Outreach

States can use federal matching funds to inform people that they are eligible for the Food Stamp Program, which helps eligible low-income people buy nutritious food. Outreach efforts are critical to ensuring that these eligible people participate.1 In the wake of the recession that begun in late 2007, enrollment in the program has reached record highs.2


Food Stamp Nutrition Education

States can help promote good nutritional habits in low-income communities through participation in the Food Stamp Nutrition Education Program (FSNEP). Through this program, states can receive federal matching funds as long as they demonstrate that their program educates recipients about healthy eating, handling food safely and managing a food budget.



Smoking-related diseases cause the deaths of about 178,000 women in the U.S. each year,24 yet the behavior persists. A 2008 survey by the Centers for Disease Control and Prevention found that more than one in six American women ages 18 years or older (18.3%) smoked cigarettes, and more than one in five women ages 25 to 44. While men are more likely to smoke than women overall, adolescent girls are just as likely to smoke as boys, with nearly one in five female high school students reporting smoking at least one cigarette in the past 30 days in 2008.25 State anti-smoking efforts are critical to ensuring both that non-smokers do not start smoking and that current smokers stop.

Medicaid Smoking Cessation Coverage

The Report Card examines Medicaid coverage of smoking cessation treatments. Health insurance coverage for cessation treatment increases successful quit attempts.1 This is particularly important for low-income women, who have significantly higher than average smoking rates.2


Tobacco Sales Rate to Minors

Each state is evaluated on its rate of tobacco sales to minors. All states have laws prohibiting the sale of tobacco to minors pursuant to a federal law known as the “Synar Amendment,” which they are required to enforce through random unannounced inspections of tobacco vendors.1 A state’s effectiveness in enforcing its ban is measured by a “tobacco sales rate” that reflects the annual percentage of merchants who break the law by selling tobacco products to minors.2


Excise Tax

The Report Card examines state excise tax policies. Increasing the excise tax on cigarettes is one of the most effective ways to reduce smoking and can have a particularly strong impact on certain populations, such as young adults.1 Moreover, when excise taxes support a comprehensive tobacco control program, decreases in consumption will continue even if tobacco prices are lowered to pre-excise tax values.2


State Funding for Tobacco Prevention

State comprehensive tobacco control programs are examined.1 These programs have been shown to be effective in preventing and reducing tobacco use, particularly among youth.2 The November 1998 multi-state settlement of the lawsuits against tobacco companies for over $200 billion over 25 years, as well as states’ individual settlements with tobacco companies, greatly increased the funds available to states for tobacco control. The CDC has studied states with successful comprehensive tobacco control programs to distill their essential elements and has made recommendations for how much funding is required in each state to implement such a program.3


Living in a Healthy Community

The community in which a woman lives affects virtually all aspects of her well-being. A woman’s inability to afford health care services, insurance, safe housing, nutritious food, and other basic necessities seriously compromises her health. To create healthy communities for women, states must implement policies to bolster women’s economic security, address discrimination, and reduce gun deaths and injuries.


Economic Security

On average, women still earn just 78 cents for every dollar men earn,26 and more women than men are poor.27 States can implement a variety of policies and programs to improve women’s economic security. 

Child Support Pass-Through

Child support payments can make a substantial difference in the financial well-being of single mothers and their children. Under federal law, families receiving income assistance, known as Temporary Assistance for Needy Families (TANF), must assign their rights to child support payments to the state.1 When a state collects child support on behalf of a TANF recipient, the state is permitted to keep the money to reimburse itself and the federal government for TANF assistance. States, however, have the option of allowing some of the child support payment to be “passed through” to the parent and child.2 By providing this additional income, the “pass-through” allows low-income mothers and their children to better meet their daily needs.


Child Support Collection

States can aid low-income families by improving the actual collection of child support. Since 1998, states have made significant progress in their child support collection rates, due to increased enforcement activity and legislative reforms.1 Nevertheless, states still fail to collect in nearly 40% of child support cases.2 Moreover, the Deficit Reduction Act of 2005 reduced federal matching funds to states for child support enforcement beginning in 2008.3 Fortunately, the American Recovery and Reinvestment Act of 2009 temporarily restored federal funding to its earlier levels for 2010,4 but the reduced levels are scheduled to go back into effect in 2011—which could significantly complicate states’ ability to collect the child support that low-income families sorely need.


State Supplement of SSI Grant

States can aid low-income families receiving SSI by supplementing these payments with state funds. Women account for nearly 60 percent of the recipients of Supplemental Security Income (SSI).1


Minimum Wage

States can pass minimum wage laws that are above the federal minimum.1 This action is particularly important for women’s economic security as women ages 16 and over make up more than 68% of hourly wage workers earning the federal minimum wage or less.2



Discriminatory practices can affect women’s health by erecting barriers to services and insurance, by creating stress that contributes to physical and mental health problems and by establishing obstacles to financial achievement. State policies can combat these negative effects.

Domestic Violence in Insurance

States can protect survivors of domestic violence who face discrimination in all “lines” of insurance: health, life, disability and property/casualty.1 Insurance companies have used a history of abuse to deny coverage or to increase premiums, and have refused to cover abuse-related medical conditions and claims.2 These practices can discourage survivors from seeking help for fear of losing their insurance coverage if the abuse is discovered; they may also have the effect of penalizing survivors of domestic abuse for the violence they have experienced—by denying them coverage or treating domestic abuse as a pre-existing condition. Although federal law offers some protections against discrimination,3 several states offer more comprehensive protection by enacting laws that explicitly prohibit insurance discrimination against domestic violence survivors.


Sexual Orientation in Employment

States can prohibit discrimination based on sexual orientation in employment. Employment discrimination affects women’s health and well-being, not only because access to employment affects women’s financial status, but also because employment discrimination blocks one of the key avenues to health insurance. Although the federal government and the vast majority of states prohibit employment discrimination based on sex, race, religion, ethnicity, age and disability, few states prohibit employment discrimination based on sexual orientation.



States can pass genetic nondiscrimination laws that reinforce and expand upon federal law to ensure that people do not face genetic discrimination in health insurance or employment. While the federal Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits certain forms of discrimination based on genetic information by group health plans, health insurers, and employers based on genetic information, gaps remain.1 For example, most of the law’s employment protections do not apply to employers with fewer than 15 employees, and the law does not prohibit health insurers or health plan administrators from obtaining and using genetic test results in making health insurance payment determinations.2


Gun Control

Women lose their lives and survivors face serious health problems as a result of violent crimes. Between 1999 and 2006, nearly 33,000 females were killed by guns.28

Waiting Period/Licensing

States can require licensing and waiting periods to reduce unauthorized and illegal access to guns and give local government the authority and time to conduct thorough background checks on potential handgun purchasers.


Safe Storage and Locks

States can have policies requiring owners to either store guns in places that are inaccessible to children and/or use safety locks to help protect women and their families from guns kept in homes.


Restrictions on Carrying Concealed Weapons

States can prohibit concealed handguns, as this type of law has been shown to reduce the rate of violent crime.1



1 National Women’s Law Center analysis of 2008 data on health coverage from the Current Population Survey’s 2009 Annual Social and Economic Supplement, using CPS Table Creator, available at http://www.census.gov/hhes/www/cpstc/cps_table_creator.html, accessed August 26, 2010. 

2 42 U.S.C. §§ 1396 et seq.; 42 C.F.R. §§ 430-498; 45 C.F.R. §§ 1-199.

3 Edward L. Martinez and others, Language Access in Health Care Statement of Principles: Explanatory Guide (Los Angeles: National Association of Public Hospitals and Health Systems, National Health Law Program, 2010), 8.

4 The Henry J. Kaiser Family Foundation, “Trends in Health Care Cost and Spending,” March 2009, available at http://www.kff.org/insurance/upload/7692_02.pdf, accessed August 27, 2010.

5 “Long-term services and supports” are provided in the home, in assisted living settings, in nursing homes and elsewhere. Services can include various medical and social services and assistance with daily living activities (e.g., dressing, bathing, and eating) for people with chronic long-term conditions that reduce their ability to function independently. AARP, The Policy Book: AARP Public Policies 2009-2010 (Washington: AARP, 2009) available at http://assets.aarp.org/www.aarp.org_/articles/legpolicy/2008/Chapter8.pdf, accessed August 27, 2010. 

6 Ari N. Houser, AARP Public Policy Institute “Women and Long-Term Care,” April 2007, available at http://assets.aarp.org/rgcenter/il/fs77r_ltc.pdf, accessed August 27, 2010.

7 State-mandated nursing home staffing levels are also important to ensuring women’s access to quality long-term care, but there are only limited ways to evaluate state commitment to adequate staffing in this area.   AARP, The Policy Book: AARP Public Policies 2009-2010: Discussing Limitations of Medicaid and Private Insurance Coverage for Long-term Care (Washington: AARP, 2009), available at http://assets.aarp.org/www.aarp.org_/articles/legpolicy/2008/Chapter8.pdf, accessed August 27, 2010. 

8  A “mental disorder” is “a health condition marked by an alteration in thinking, mood, or behavior (or some combination thereof) that is associated with distress and/or impaired functioning.”  U.S. Department of Health and Human Services, Mental Health: A Report of the Surgeon General (Rockville: U.S. Department of Health and Human Services, National Institute of Mental Health, 1999) available at http://www.surgeongeneral.gov/library/mentalhealth/chapter1/sec1.html, accessed August 27, 2010.

9 National Institute of Mental Health, “The Numbers Count: Mental Disorders in America,” 2008, available at http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml, accessed August 27, 2010.

10 U.S. Department of Health and Human Services, Women's Health USA 2008, “Mental Health Care Utilization” (Rockville: U.S. Department of Health and Human Services, Health Resources and Services Administration, 2008) available at http://mchb.hrsa.gov/whusa08/hsu/pages/309mhcu.html, accessed August 27, 2010.

11 U.S. Department of Health and Human Services, Mental Health: A Report of the Surgeon General “Chapter 6: Organizing and Financing Mental Health Services” (Rockville: U.S. Department of Health and Human Services, National Institute of Mental Health, 1999), available at http://www.surgeongeneral.gov/library/mentalhealth/chapter6/sec3.html#patterns, accessed August 28, 2010.

12 Women’s Health USA 2008, supra note 3.

13 American Cancer Society, Estimated New Cancer Cases and Deaths by Sex (Atlanta: American Cancer Society, 2009), available at  http://www.cancer.org/Research/CancerFactsFigures/estimated-new-cancer-cases-and-deaths-by-sex-us-2009, accessed September 23, 2010.

14 U.S. Department of Health and Human Services, Healthy People 2010, 2nd Edition (Washington: U.S. Department of Health and Human Services, 2000) 9-14, available at http://www.health.gov/healthypeople, accessed August 27, 2010.

15 Roe v. Wade, 410 U.S. 113 (1973).

16 The Guttmacher Institute, “An Overview of Abortion in the United States,” undated, available at http://www.guttmacher.org/media/presskits/2005/06/28/abortionoverview.html, accessed September 1, 2010.

17 U.S. Department of Justice, Bureau of Justice Statistics, Intimate Partner Violence in the United States (Washington, D.C.: U.S. Department of Justice, December, 2007), available at http://bjs.ojp.usdoj.gov/content/pub/pdf/ipvus.pdf, accessed September 2, 2010,

18 U.S. Department of Health and Human Services, Center for Disease Control and Prevention, “Understanding Intimate Partner Violence,” 2006, available at http://www.cdc.gov/ncipc/dvp/ipv_factsheet.pdf, accessed September 2, 2010.

19 U.S. Department of Health and Human Services, Center for Disease Control and Prevention, “Understanding Sexual Violence,” 2007, available at http://www.cdc.gov/ncipc/pub-res/images/SV%20Factsheet.pdf, accessed September 2, 2010. Citing: Tjaden P, Thoennes N. “Extent, Nature, and Consequences of Intimate Partner Violence: Findings from the National Violence Against Women Survey,” Publication No.: NCJ 181867 (Washington: Department of Justice; 2000) available at www.ojp.usdoj.gov/nij/pubs-sum/181867.htm, accessed September 2, 2010.

20  Alina Salganicoff et al., Women and Health Care: A National Profile (Menlo Park, CA: Kaiser Family Foundation, July 2005), 40, available at http://www.kff.org/womenshealth/upload/Women-and-Health-Care-A-National-Profile-Key-Findings-from-the-Kaiser-Women-s-Health-Survey.pdf, accessed September 21, 2010.

21 Ibid.

22 In 2009, 99% of individuals with employer-sponsored health insurance were enrolled in a managed care plan.  Kaiser Family Foundation and Health Research and Educational Trust, Employer Health Benefits: 2009 Annual Survey, “Exhibit 5.1,” 63, available at http://ehbs.kff.org/pdf/2009/7936.pdf, accessed September 21, 2010.

23 42 U.S.C. §§ 1395l, 1395m, 1395x, 1395y (2009) (mammograms and Pap smears – Medicaid); 42 C.F.R. §§ 410.34, 411.15(k)(6) (mammograms – Medicare); 42 C.F.R. §§ 410.56, 411.15(k)(8) (Pap smears – Medicare).  

24 American Cancer Society, “Women and Smoking,” 2009, available at http://www.cancer.org/docroot/PED/content/PED_10_2X_Women_and_Smoking.asp, accessed September 23, 2010.

25 Ibid.

26 U.S. Census Bureau, “Men’s and Women’s Earnings for States and Metropolitan Statistical Areas: 2009” (American Community Survey Brief, Issued September 2010), available at http://www.census.gov/prod/2010pubs/acsbr09-3.pdf.

27 In 2007-2008, 12.7% of women, compared with 9.2% of men, had incomes below the federal poverty level. National Women’s Law Center analysis of 2007 data on health coverage from the Current Population Survey’s 2008 Annual Social and Economic Supplement, using CPS Table Creator, http://www.census.gov/hhes/www/cpstc/cps_table_creator.html, accessed September 24, 2010.

28 Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File 1999-2006. CDC WONDER On-line Database, compiled from Compressed Mortality File 1999-2006 Series 20 No. 2L, 2009, available at http://wonder.cdc.gov/cmf-icd10.html, accessed September 24, 2010.

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