Canada-U.S.A. Women's Health Forum
Health care delivery

Women and The Health Care Delivery System

by Helen RodriguezM.D., FAAP.

Womens health involves their emotional, social and physical wellbeing and is determined by the social, political and economic context of their lives, as well as by biology. However, health and wellbeing elude the majority of women. A major barrier for women to the achievement of the highest attainable standard of health is inequality, both between men and women and among women in different geographical regions, social classes and indigenous and ethnic groups. In national and international forums, women have emphasized that to attain optimal health throughout the life cycle, equality, including the sharing of family responsibilities, development and peace are necessary conditions. 1

I. Introduction: Health Care Services And Womens Health Advocacy

A. Health Care Services and the Health Care Delivery System

Health care services can be defined narrowly as the services provided to individuals by persons trained and licensed to do so in designated facilities for the purposes of promoting health, preventing, diagnosing, curing illness and its consequences. In this definition, health care services are construed as personal services and do not reflect the community wide prevention and intervention strategies and activities that public health encompasses.

In the United States, people representing many sectors of the health care system and of the public carry on lively debates on the scope of health care. Those who accept the World Health Organizations definition of health as being a state of complete physical, mental and social welland not merely the absence of disease argue for a greater involvement of the health care system in the promotion of healthier communities as well as healthier individuals. At the other extreme are those who conceive health care as limited to personal health services for diagnosing and treating diseases and disabilities.

The organized systems of care include a wide variety of organizations, settings and associations such as hospitals, clinics, office based individual and group practices, diagnostic, treatment and rehabilitation facilities and hospices. Health care personnel provide levels of care, generally categorized as: primary, that is services widely available that meet most needs for prevention, early diagnosis and treatment; secondary, usually requiring services by specialists; and tertiary, requiring high level technology, expertise and facilities usually needed for rarer or more difficult to treat conditions.

Without departing from a basic premise that womens optimal health can only be promoted in a healthy society, this brief background paper will address health care services for women and the challenges and opportunities for improvement that current changes present. Here, health care services will be understood as personal health services plus those activities aimed at communitywide health promotion that can reasonably be undertaken by physicians, nurses, advanced level practitioners, social service workers, health educators and other professional and lay health care workers within the currently accepted organized systems of care.

The United States has a long tradition of government initiatives to provide health services to women of low income and living in specific communities known to be underserved, such as rural, migrant worker and inner city. Through Congressional appropriations, funds are designated for maternal and child health services, family planning and many public health services that serve women. Federal funding goes into Medicaid, health insurance for low income persons, and Medicare for those over 65 years of age, a majority of whom are women. A vast array of publicly funded hospitals and clinics serve women. Crucial as these services are, there is great concern that they are being severely reduced by cuts in Federal funding.

Womens access to quality health care services has been hampered by financial as well as cultural barriers. Health care in the United States is a commodity and not a service that is recognized as a right. As such, it is driven by market forces that are only slightly tempered by legislation, regulation and government controlled financing mechanisms. Health care providers are paid primarily on a fee for service basis by insurance companies that are the intermediary purchasers. Individuals usually purchase health insurance directly or as part of a group through their place of employment. If eligible for reasons of poverty, age or designated conditions, individuals are covered by Medicaid, Medicare or other publicly funded programs. Currently, there are an estimated forty million persons in the United States who are uninsured. Together, women and children form a majority of the uninsured and the underinsured. Blacks and Hispanic women are markedly over represented among those who are uninsured, with Hispanics being the most likely to have no coverage.

Recognizing the many deficiencies in the current system, President Clinton, with the active participation of Mrs. Clinton, initiated an ambitious reform effort to widen access to health care and contain health care costs in the first year of his presidency. Although these reform efforts did not lead to viable legislation, widespread participation and discussion among experts and the public served to educate many. As a result, members of various national organizations are committed to continuing efforts toward universal health care. A growing number of States have initiated their own reforms, several of them aiming at inclusion of previously uninsured persons. However, tensions over issues of cost, quality and access are growing.

The United States is undergoing a profound rethinking of the way in which health services are delivered and paid for both in the private and public sectors. The remarkable transformation of the health care system toward various forms of managed care is aimed at controlling costs by making primary care widely available, avoiding unnecessary, costly procedures and consultations, and delivering preventive services to keep individuals as healthy as possible. A new opportunity exists to improve the quality and efficiency of the health care system by expanding the scope of health care to include community wide prevention and health promotion efforts. This process can be facilitated by establishing links between traditional health care providers, public health workers, and community based health education projects. Nonetheless, concerns have been raised over issues of continuity of care, rapport between patients and physicians or other primary care providers, referrals to specialists, priority for coverage of mental and addictive disorders, length of hospital stays, and waiting time for appointments.

Among the many challenges facing health care reform efforts is a strong need to find new ways of delivering primary care and longhealth care services to an increasingly aging population and to young people engaging in behaviors that place them at risk. Women in both groups are represented in growing numbers. It is also important to find ways to ensure that health services are available to everyone in a society in which the disparities in ability to pay are widening and where women and children are markedly overrepresented among the poor. Ironically, mental health and substance abuse prevention and treatment services are being cut at a time when the social and behavioral dimensions of health are increasingly recognized.

Success in meeting womens health challenges will require a strong and continuing national effort from the Federal government. Since the early 1980s, various levels of government have acted to focus attention on womens health. In 1983, a Public Health Service Task Force on Womens Health Issues was convened and produced an important report that addressed behavioral as well as biologic determinants of womens health throughout their life cycle.2 Core recommendations included promoting a safe and healthful physical and social environment with women taking action to influence the personal and political processes that bear a relationship to their health. In 1990, the Womens Congressional Caucus was instrumental in the establishing an Office of Research on Womens Health (ORWH) at the National Institutes of Health (NIH). Other offices for promoting womens research and services have been established at the Substance Abuse and Mental Health Services Administration (SAMHSA), the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA). The Clinton administration has been particularly responsive to womens health issues. President Clinton appointed the first ever Deputy Assistant Secretary for Health to serve as the Director of the U.S. Public Health Services Office on Womens Health (OWH). The PHS OWH coordinates womens health activities across all Department of Health and Human Service agencies to forge a comprehensive agenda for womens health. This agenda includes activities to improve access and quality of health care services provided through the Indian Health Service, the Health Resources and Services Administration and the Agency for Health Care Policy and Research, and the Substance Abuse and Mental Health Services Administration.

B. Womens Health Advocacy

As important as federal efforts are on behalf of womens health, a discussion of health care for women today must recognize the tremendous contributions of womens health advocates who have been advancing progressive agendas for nearly three decades. Women activists and scholars have shaped the nature of discussion of what constitutes womens health and quality health care services. As public health analysts point out, the health agenda announced in 1985 by the Public Health Service Task Force only partially addressed these issues. Recommendations to increase the number of women and research on women became the basis for the ORWH, but the behavioral and social determinants of womens health were not addressed and still remain neglected.3 Bringing a feminist perspective to health issues, women health activists have helped integrate a holistic view of womens health in the context of womens lives, and laid the groundwork for emerging federal actions. Womens continuing involvement will be central to realizing the federal vision of making quality health care services available to all women regardless of health, marital or employment status, or ability to pay.

In recent years, when health care reform gained national attention, women played an active role in shaping new proposals to include adequate services for themselves and other underserved groups. Large coalitions, such as the Campaign for Womens Health convened by the Older Womens League, comprise hundreds of organizations representing millions of women, many of whom have longtime experience in advocacy and grassroots organizing. Their agenda for universal coverage and inclusion of comprehensive services for women in health plans receives active support from women at many local and state levels.4

Therefore, it seems fitting, that a major forum on womens health should take place on the year of the 25th anniversary of the publication of Our Bodies, Ourselves.5 The book, written from womens experiences and read by millions of women, clearly announced the birth of a womens health movement that has now spread worldwide. Over the past quarter century, women have organized, publicized, lobbied and impelled legislation and funding to address womens health issues. It seems equally fitting that a soon to be published major work edited by Ruzek, Olesen and Clarke, Womens Health: Complexities and Differences gathers much of the knowledge gained by scholars in the ranks of the womens health movement and poses serious challenges to what has been a narrow biomedical model of womens health in the past. The authors urge the development of a more inclusive view of health in the future, grounded in an agenda for equity in research and health care services.6

For the past twenty five years, feminist scholars and health activists have challenged the basic cultural core of medicine and its power structures by proposing that health care for women must be centered on womens concerns. 7, 8, 9, 10, 11, 12, 13, 14, 15 Some members of this group created a selfhelp movement that taught women how to care for their routine reproductive health. Their legacy persists in numerous organizations modeled after the self help clinics.16 Women activists succeeded in awakening a lasting interest in womens consciousness that is often reflected in the media. As a result, women have become more knowledgeable and demanding in seeking health care. The rising demands of women as advocates and as better informed consumers, coupled with cultural changes and market forces, have forced medical practitioners and health care institutions to change.

Examples of some successes of the womens health movement in changing health care service delivery include:

Widespread use of patient information materials and detailed informed consent for women undergoing sterilization, hysterectomy, treatment for breast cancer and other procedures where choices and options are crucial patient rights.

Legalization and normalization of abortion services; establishment of women run, women centered family planning, breast care and other women specific services.

Increase in nurse programs and demand for midwife delivery.

Increase in prepared childbirth and participation of partners and family.

Increased support for breast feeding of infants.

Increased awareness of the health needs of women with disabilities.

Placing the problem of violence against women on the agenda of the medical community and instituting medical history to identify abuse as a cause of injuries. Achieving national public recognition that violence against women is a valid womens health concern.

Recognition of the differences in presentation and treatment of certain diseases such as human immunodeficiency virus/AIDS in women.

Increased recognition and valuing of womens role as health decision makers and as caretakers of elderly and family members afflicted by chronic conditions.

Womens health advocates have also successfully raised public awareness and help catalyze policy makers to respond to womens health care needs in the following ways:

Rallying Congressional support for a womens health research agenda through the establishment of an Office of Research on Womens Health at NIH. The Womens Health Initiative now underway at the National Institutes of Health is the largest study ever conducted on a number of diseases affecting women such as osteoporosis, breast and cervical cancer. The study should yield critical information that can be used to develop more effective methods of prevention and treatment and to alter health services to better serve women.

Gaining recognition for disparities in the use of major diagnostic and therapeutic interventions for women as compared with men. These are increasingly reported by researchers and recognized by clinicians.

Obtaining additional resources to address health problems of great concern to women such as breast cancer, osteoporosis, complications of menopause and violence at the hands of men.

Supporting NIH guidelines to redress biases against women in clinical trials by requiring researchers to include women, persons of color and others previously excluded from research studies.

Demanding medical schools to improve curricula to better address womens health concerns and issues of gender biases in medical practice and research.

Promoting womens health centers that offer comprehensive services to women in order to overcome the fragmentation of services. These are based in hospital centers, managed care programs or may be free standing.

ii. summary of the current knowledge and literature on delivery of services to women

Scholars link the adequacy of medical care insurance to use of health services and to health status. 17, 18, 19, 20 For women, service delivery is significantly affected by the factors discussed below: 1) differential access to insurance by race/ethnicity and social class; 2) inadequate coverage of preventive and longterm care services; 3) financial barriers to costbarriers.

1. Inadequate Insurance.

Health insurance coverage for women is woefully inadequate.21, 22, 23, 24, 25, 26, 27, 28 Although women in the U.S. are more likely than men to have medical insurance, this is largely because women are more likely than men to be enrolled in Medicaid, or Medicare, public programs for people with very low incomes, longterm disabilities or the elderly.29 Because women live longer than men in all racial/ethnic groups, the Medicare population is disproportionately female.

In 1993, about 67 percent of women aged 15 to 44 had some form of employerprovided insurance, 6 percent had other group or individual private insurance, and 8 percent had Medicaid coverage. Nearly 15 percent of were uninsured part of the year, and 8 percent had no coverage at any point during the year.30

The Commonwealth Fund (1994) emphasizes that summary statistics obscure the difficulties that certain groups of women experience in obtaining coverage, pointing out that women are more likely than men to be poor and unable to afford health coverage. Of the over 10 million women between 18 and 65 years of age who were poor in 1990, one third had no health insurance of any kind during the year. In 1992, more than 13 million women 18 years and older had no insurance. For women of color poverty is a particularly cruel fact of life. Thirty one percent of Black women, 29 percent of Native American women, 26 percent of Hispanic women, and 10 percent of white and Asian women are poor 31. Hispanic women are most likely to be uninsured, with rates of 22 percent compared with 16 percent of Black women and 13 percent of white women.31 Inadequate access to medical insurance is a particularly acute problem for widows and displaced homemakers who often have no coverage until they reach age 65 and become eligible for Medicare.32

2. Inadequate Preventive and Long Services.

Health insurance benefits do not necessarily take into account womens needs and patterns of service use.33, 34, 35, 36 Coverage for preventive services used by women varies with sociostatus. For lower income women, preventive services range from poor to nonexistent. Largely as a result of childbearing, women between 15 and 44 years of age are hospitalized two and a half times more often than men. The long term care needs 37, 38, 39, 40 and the mental health needs 41, 42, 43 of women are not met. Women are traditionally the caretakers of spouses and other family members and are likely to outlive their spouses; therefore, women 65 and older are nearly twice as likely as men to spend time in a nursing home. 37

3. Financial Barriers to Cost Sharing.

Costand outspending is greater for women. 44, 45, 46 Women make up 51 percent of all people between 15 and 44 years, yet they pay 63 percent of total outpocket expenses for that group. Poor women fare worse; one quarter spends more than 10 percent of their income on health care. Only 5 percent of highwomen spend an equally high proportion of their salary to pay health care costs. 30 Greater expenditures do not guarantee women access to necessary health care. For example, a survey on womens use of clinical preventive services in 1991 showed that four out of ten women over 40 years of age had not had a clinical breast exam within the past year, and 46 percent had not had a mammogram within the two preceding years. Not surprisingly, low income women were less likely to be screened. Sixty four percent of women with incomes below the poverty level have not had a mammogram within the past two years, compared with 33 percent of women with incomes 300 percent of poverty or above. 35

4. NonBarriers.

Access to services is also impeded by other than financial barriers. An estimated 30 million Americans face sometimes insurmountable barriers to needed care 47 because of circumstances of culture, race, ethnic identity 48, 49, 50, 51, 52, 53, place of domicile 54, 55, 56, sexual preference 57, 58, 59, or immigration status. Other personal challenges, such as the nature of their disease or disability also determine access to quality care in a system that is fragmented and unevenly developed. 60, 61 Persistence and aggravation of a multitiered, unevenly distributed health services system creates great gaps in access and quality of services for women. Among other services and supports, women may need transportation, child care, translating services, assurances of confidentiality and sensitive, culturally competent providers in order to access care.

5. Limitations of Medicare and Medicaid.

Proposed changes in public programs currently under Federal management and supported by public monies, including Medicaid and Medicare, are particularly threatening to women with low incomes and elderly women. Even prior to contemplation of reductions in coverage and numbers of eligibles, Medicaid and Medicare posed problems of access for beneficiaries based on relative reimbursement rates. Medicaid on average pays physicians only 47 percent of what they would receive through private insurance, and Medicare pays on average 59 percentdisincentives to most office based physicians. A paucity of providers in areas where reimbursement for services is low drives uninsured women and women with Medicaid coverage to hospital emergency rooms and outpatient clinics for regular care. Thirtyfive percent of uninsured women and 24 percent of women with Medicaid have no regular source of care. 62

6. Quality of Services.

Quality of care is acknowledged as a fundamental element that is difficult to measure. Clinicians, researchers and administrators strive to develop tools that can quantify outcome measures for various health interventions. Still, the capacity to measure quality lags behind in several areas. The satisfaction of users with health care services provided is an area that has been neglected, and is an issue that is extremely important to women. 24, 63 A recent Harris survey documented widespread dissatisfaction with health care services. Women report greater communication problems with their physicians than men, and are more likely to change physicians because of their dissatisfaction. Forty one percent of women changed their physicians because they were dissatisfied. One in four women said that she had been talked down to or treated like a child. Nearly one in five women had been told that a reported medical condition was all in your head. 63 Further problems with establishing and monitoring quality services relate to the limited goals that most health care systems set for themselves. Optimally, the promotion and maintenance of the health of individuals and populations should be the focus of health services. In reality, health services are better geared to diagnosis and treat diseases, and take little responsibility for preventing illness and maintaining health.

7. The Effects of Changes in Financing.

The financing of health care services and the rapid changes that are taking place in funding for hospitals and other institutions and programs that serve low income persons are particularly troubling to women and minority communities. In poor communities, publicly funded hospitals, health centers and clinics are often the mainstay of care. Yet severe cuts in funds and downsizing measures are forcing smaller hospitals in many communities to close. Health maintenance organizations and other managed care programs appear to compete for people displaced by hospital shrinkage, but in fact, most do not enroll any but those covered by adequate financial backing. Financing issues are especially crucial to reproductive health services. For several decades, Federal funds under the authorization known as Title X of the Public Health Service Act and Medicaid have enabled private and public family planning organizations to provide services to low income women. A decrease in funding would threaten the survival of many of the traditional family planning providers. Whether managed care organizations will serve the needs of poor women without specific financial incentives from government remains to be seen.

III. Major Challenges and Issues That Women Confront In Their Attempts To Change The System.

In spite of progress, have serious inadequacies in health care services for women still pose challenges to womens health advocates, policy makers and health care professionals. Some of the most important challenges will be: a) shifting the focus and orientation of health care systems from profits to services; b) adopting a public health perspective; c) eliminating gender biases in the marketing of services; d) illustrating the need for national health reform; and e) making services relevant, accessible and acceptable to diverse groups of women.

A. Moving Health Care Systems From Profit Motivated to Service Driven

Womens advocacy and government responses notwithstanding, the rapid changes in the health care delivery system are directed not necessarily toward improving what health care does, but toward lowering costs for employers and other major purchasers and maximizing profits for investors and owners. The market driven changes in the health care system create uncertainties among the public and researchers. 64, 24, 38 A major challenge for women will be to capitalize on the opportunities that these changes provide to make the system become more responsive to consumers. Changing health care from a commodity to an individual right will require time and a major change in national will. Changes in the delivery system reflect a growing trend toward the organization of services in capitated prepaid programs which may place restrictions on benefits to subscribers. Although very diverse and lacking a common set of goals and principles, these prepaid programs are currently lumped under the term managed care. Women are concerned with the restrictions on the choice of provider, site and services that some of the managed care programs impose. 65 Yet at the same time women recognize the positive features that these changes can bring about. 66, 67

Managed Care

Managed care in its various modalities emerged primarily as a response to the widely acknowledged duplication and waste of a health care system in which individual health providers, mainly doctors, frequently determined what services to provide and at what cost. There is some evidence of the cost reduction success of managed care plans, which now cover 71 percent of all workers who have insurance provided by their employers. According to two recent surveys, health care costs for participants in managed care networks fell for the first time last year, down 3.8 percent from 1994. In contrast, traditional health insurance plans had a rise in costs of 4.4 percent. Critics point out that cutbacks in coverage, for example in services for mental health, alcohol and other substance abuse problems that are typically severely limited in managed care programs, are not documented in the surveys. 68 In addition, the rising out of pocket costs for workers is a major issue for women who are disproportionally among the lowest paid.

On the promise of cost reductions and perhaps greater efficiency in delivery of care, most States have implemented managed care organization for Medicaid recipients. Still to be evaluated, posing great methodological problems in their great variability, Medicaid managed care is nevertheless becoming the dominant trend in reorganization of publicly financed health care.

Many foundations and other institutions that engage in policy analysis have issued reports and position papers recommending rational directions for health care reform (see appendix B for list of recent publications). Highlights from recent surveys and reports illustrate a litany of deficiencies in the current health care systems and the hazards of changes to managed care for women and people of color.

B. Adopting a Public Health Perspective

A serious weakness in the current debates on health care is the narrow focus on personal health services, that is, services provided by doctors and other health professionals at their offices, clinics or hospitals. The health of women and of all people is ultimately more a function of public health policies and services than of personal health services. In no way does public health diminish the importance of personal health services for women. Public health emphasizes prevention and concerns itself with developing an environment, social and economic as well as physical, that fosters health. For almost all preventable diseases, poor people fare worse. Indicators of the public's health in a State by State comparison show clear correlation between poor health and poverty. 69 Women of color are over represented among the poor, and are disproportionately adversely affected. Failure to acknowledge that health promotion and illness prevention must be foremost and to commit the resources toward reducing social and economic inequities to ensure healthier environments will continue to result in increasing the burdens and costs of health care.

C. Eliminating Gender Biases In The Marketing Of Services To Women.

Gender biases in the social construction of womens health pervade the culture of health care for women. 70, 71, 72, 73, 74 Established medical practice in many areas of womens health, reproductive and mental as prime examples, has been based less on scientific grounds and more on presuppositions about womens needs and nature. Socially promoted standards of beauty, definitions of womens sexuality, sexual attractiveness and relations to men have led to a huge industry of cosmetic surgery. Many unnecessary, costly, and sometimes risky interventions have become the norm. 75

D. The Need For National Health Reform

President Clintons initiative in health care reform captured the attention of the public for more than a year. Vigorously debated, the Administrations plan, a complex reorganization of the delivery system based on the new construct managed competition, fell into a politically unfeasible category shortly after its unveiling. Nevertheless at state, city and local levels advocates and others remain organized around health care reform. In the House of Representatives, the McDermottWellstone Conyers single payer plan received the largest number of sponsors. Patterned after the Canadian system, it called for universal, comprehensive coverage financed primarily through payroll taxes. Its proponents pointed to the savings potential of reducing current administrative costs by at least half as a mechanism to gain funds to cover uninsured Americans. 76, 18 Although women health advocates suffered a serious setback when health care reform came off the national agenda, coalitions supporting single payer initiatives have continued to organize and in several states are gaining momentum. Womens groups have largely endorsed reform toward the single payer model. In addition, growing numbers of consumer groups are participating in State health care reform efforts to expand services to underserved groups. Consumer groups continue to analyze alternatives to the current unmanaged changes. Most would seek a guided transition with a greater role for government in oversight of quality and assurance of universal coverage. 77

Womens gains in establishing family planning, abortion and other reproductive health services have suffered serious setbacks in the past decade due to strong antisentiment and violence by some very vocal and well funded groups. Attacks on providers of abortion services have resulted not only in a marked decrease of availability of such services to women, but also in a reduction of other essential services, such as prenatal care, sexually transmitted disease prevention services and cancer screening. No other area of health care has been politicized to the degree of abortion and related services, a grim reminder that womens health care is not determined by womens best interests. Health care reform that would provide universal coverage and mandate minimally acceptable standards and scope of services may go a long way toward establishing reproductive health services as a right.

IV. The Future / Emerging Trends

Increased Consumer Education and Participation

To become active and determinant participants in guiding the change in health care, women must utilize multiple strategies. Perhaps foremost among them is forging alliances among broader sectors of women and their allies concerned about health care. Such partnerships must include: health care workers, from entry level to highly placed professionals; women in academia; women researchers and researchers on women; women consumers of services, particularly those vulnerable to exclusion in current plans, including the elderly, women of color; and women with low income, disabilities, mental health needs, or HIV/AIDS and other chronic conditions. A broadly based effort to do ongoing consumer education will result in pressure groups that will effectively demand better care from their providers. Promulgation of standards and other quality measuring tools to the public at large may be a useful way of educating consumers. Several efforts to develop quality assurance measures, standards and methods in reproductive health are well underway. 78, 79, 80 Women must demand that quality tools and results of quality assessments be made accessible to the public in usable ways.

Assuring accountability in public policy and in health care delivery

Accountability is a major emerging issue in health care delivery. Women as major users of health care are invested in obtaining the best possible quality of care for themselves and their families. The development of quality assurance tools that provide information to policy makers, providers and consumers is an emerging trend that is very promising. There is an emphasis by public health to develop outcome measures of effectiveness that will foster preventive interventions.

VI. Minority, Diversity Issues

Minority and diversity issues cannot be properly addressed without a commitment to universal access to health care as a baseline. Additional issues that must be addressed include ensuring cultural competence among providers and increasing the diversity of the health workforce.

V Bringing Beijing Home

The Plan of Action adopted at the Fourth World Conference on Women held in Beijing in 1995 is very clear in establishing that:

Women have the right to the enjoyment of the highest standard of physical and mental health. The enjoyment of this right is vital to their life and welland their ability to participate in all areas of public and private life. 1

The challenge to our governments and to our peoples is to declare health care a right, and to structure a reform effort toward guaranteeing universal high quality services for all.

*** Special thanks to Sheryl Burt Ruzek for her thorough review and complete references. Equally thankful for the incisive comments of Ellen R. Shaffer. Thanks to all of the other reviewers.

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