Not that health programs are completely healthy anywhere. Over the past couple of years, the lackluster American economy has strapped many state budgets for cash, tightening the purse strings for programs involving women's health.
To get a clearer picture of how state-by-state spending for women has been affected, researchers at The Henry J. Kaiser Family Foundation and the National Women's Law Center in Washington, D.C., reviewed relevant health policies in 2001 and 2002. They have published the results online at statehealthfacts.kff.org.
"2002 was a difficult year for states," said review author Alina Salganicoff, vice president of the Kaiser Family Foundation, during a conference on the review. "Unless there's a major turnaround in the economy, the prospects for the future are grim."
The review emphasizes "the importance of monitoring what's going on at the state level," said Diane Rowland, executive vice president at Kaiser.
Researchers looked at several key areas in women's health, including private insurance, Medicaid, contraception, screenings, reproductive health care and abortion access. The goal, they said, was not to rank the 50 states but to construct a mosaic of the care women receive.
They found 60 percent of women have private insurance coverage primarily through their employers. However, state regulation of private insurance is uneven when it comes to mandating coverage of certain medical screenings. For example, 49 states plus the District of Columbia require coverage of mammography. Half of the states require screening for cervical cancer -- with roughly 13,000 new cases of cervical cancer developing each year. But only three states mandate chlamydia screening, the most common sexually transmitted disease. Only 15 states require insurers to cover routine costs associated with clinical trials and only eight mandate equal coverage for mental health.
Women receiving Medicaid, the federal health insurance program that assists more than 12 million low-income women, also struggle under inconsistent state policies. Medicaid largely is a woman's issue, the researchers said, because 70 percent of all Medicaid recipients are women.
Although Medicaid is partly financed by the federal government, it is run by the states and therefore constitutes an important state issue. The federal government wants to hand more control of Medicaid over to state regulators and, right now, states have control over who is eligible for Medicaid. However, the researchers report states are engaging in a piecemeal approach to improving Medicaid access.
Still, positive steps have been made, such as expanding coverage for pregnant women and working parents and adding family planning waivers to provide services to low-income women who do not qualify for Medicaid. However, there remain wide, state-to-state gaps in what is offered. Some Southeast and Midwest states have expanded Medicaid coverage for Medicare beneficiaries, for example, but there are large regional areas where this is lacking, particularly in the Northwest, Southwest and Ohio River Valley.
Another problem with Medicaid, according to the researchers, is each state is left to define family planning isues individually. This produces much variation in what family planning services Medicaid recipients can receive state to state. For example, a Medicaid program in one state might cover all Food and Drug Administration-approved contraceptive drugs and devices, while in another state it might cover only a limited number.
Calls by United Press International to the Department of Health and Human Services, which oversees Medicaid, were not returned.
One of the most disturbing findings for the researchers was how widely states vary in their approaches to the controversial issue of abortion.
Generally, abortion is highly regulated by states, the researchers found. Twenty-two states require a mandatory waiting period before proceeding with an abortion, and 43 states have enacted parental consent or notification laws for minors.
Forty states and D.C. have imposed post-viability bans, which restrict abortion after the time a fetus is considered viable -- able to survive outside the womb. Many states will not allow abortion after 24 weeks, because viability usually is estimated to begin around 22 to 24 weeks. A post-viability ban is different from a partial birth abortion, a rare procedure performed to protect the welfare of the mother should something in a late-term pregnancy go awry. Thirty-one states have banned partial birth abortions, while 19 have not.
Forty-five states allow insurance providers to exempt coverage for abortion services based on religious or moral objections. Twenty-four states permit insurance companies and health facilities to refuse family planning services. Just over half of state Medicaid programs cover emergency contraception.
Differences in treatment of the emergency contraception issue might be due to the states confusing emergency contraception with abortion, argued Judy Waxman, vice president for health and reproductive rights at the National Women's Law Center. That might explain why several states have refused to enact policies providing adequate emergency contraception coverage.
Emergency contraception consists essentially of birth control pills with extra dosages of hormones used to prevent pregnancy. The procedure is effective only when used within in the first few days after unprotected sex, so quick access is critical. The researchers found while access appears to be increasing, not all states require health facilities to make emergency contraception available to sexual assault victims. Only a handful of states allow women to obtain emergency contraception without a physician's approval -- a barrier that could delay a victim's access to the medication in time for it to be effective.
Emergency contraceptives will not harm a woman or her baby if she is already pregnant.
Waxman said she is perplexed why insurance plans, both government and private, still hesitate to offer full contraception coverage. "It really doesn't cost anything to add it as a benefit to the plan and in fact, it may even save money," she said.
On the consent issue, state legislators are debating whether college students should have parental permission before being given emergency contraception, said Viola Baskerville, a representative from the Virginia House of Delegates.
"We're still fighting very much a heavy battle," she told UPI. "Legislators don't understand the impact their policies are having on individuals."
The researchers also found five states with infertility treatment mandates have enacted exemptions for employers or insurance companies. These refusal clauses could limit a woman's access to infertility treatments, the report states.
Genevieve Kenney, principal research associate specializing in women's access to health care at The Urban Institute in Washington, said the Kaiser review "defines the landscape for low-income women" on the issue of Medicaid.
"We have a situation right now where the state tax revenues are lower and demand or need for Medicaid is up higher across the board. Yet states can't run deficits like the federal government can. If we really want to make a lot of progress in this area, we're going to have to take a more global approach rather than this episodic coverage during
pregnancy and you'll see some states have moved in this direction."
Kenney added: "I think there's a basic instability with having a big state component to Medicaid. Low-income women's access to public coverage ranges dramatically across this country. There are services that are at the discretion of the state. Depending on where you live, you might not have access to any public coverage, unless you're pregnant."
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