Reproductive Health Care for Women: Coverage, Access, and Financing
Usha R. Ranji, M.S. Senior Policy Analyst Kaiser Family Foundation KaiserEDU.org Tutorial October 2005
Figure 1
Background Reproductive health essential and integral component of women’s overall health and wellbeing Typically defined as contraception, STD and other screening, maternity care, abortion, and infertility Use of services affected by a broad range of federal and state policies and financing systems Private insurance also shapes access to certain reproductive services for women.
Prevention
Figure 2
Contraceptive Coverage
State Mandated Contraceptive Coverage, 2005
Coverage for contraceptives lags other prescription drugs
No federal mandate 22 states require coverage, but self-funded plans are exempt
Comprehensive
Limited* None
Federal court action reinforced coverage
* The state policy allows religious or ethical exemptions to the mandate. Source: Alan Guttmacher Institute, State Policies in Brief, August 2005.
Figure 3
Medicaid and Family Planning
Sources of Public Funding for Family Planning, 2001
•Assists ~6 million women of reproductive age
Medicaid 61%
Federal Grants 24%
•Pays for majority of publiclyfunded family planning care •Enhanced federal matching rate •Waiver programs extend family planning services to additional 2 million women
Other State Funds 15%
Note: Federal Grants includes Title X (15%), MCH Block Grant (4%), TANF (4%), and Social Service Block Grant (1%). Source: Sonfield, A. and Gold, R.B., Public Funding for Contraceptive, Sterilization and Abortion Services, FY 1980–2001, AGI, 2005.
Figure 4
Title X
• Publicly-financed Actual Dollars network of clinics and Constant Dollars (Accounts for inflation) providers for family 286 planning services 300
250 200 150 100 50 0
1980 1990 1999 2005 162 162 139.1 64 64 66 215
Annual Title X Appropriation Levels ($ millions)
• Serves ~ 5 million lowincome women annually • Funding levels have not kept up with inflation and demand
Sources: AGI, Fulfilling the Promise, 2000; NFPRHA, Title X Factsheet. Note: Figure for 2005 in Constant Dollars based on estimate that FY 2005 funding 59% lower than FY 1980.
Figure 5
Access to Emergency Contraception
Knowledge of EC:
• As far as you know, if a woman has just had unprotected sex or thinks her birth control may have failed, is there anything she can do in the following days to prevent pregnancy or is there nothing she • can do?
Awareness has grown, currently 2/3 of women are aware of EC -but gaps remain Currently, available only by prescription; application for OTC pending
• 7 states permit direct dispensation by pharmacists • 8 states mandate that sexual assault survivors be referred • or provided EC • Recent attention to reports of EC denials due to moral objections
Source: Among women ages 18 to 44; Kaiser Family Foundation, 2004 Kaiser Women’s Health Survey.
Figure 6
Access for Young Women
• Major policy proposals centered on access to information, preventive, and treatment services, including contraception and abortion • Declining rates of teen pregnancy but STDs remain public health challenge • Push for greater parental involvement (consent/notification laws for reproductive care) • Sex education – expansion of abstinence-only programs; debates over impact on youth
Figure 7
Women and HIV/AIDS
Women as a Proportion of Newly Reported AIDS Cases, 1986-2002
• Proportion more than tripled since beginning of epidemic
30%
26% 20%
15% 7%
13%
• Women of color, particularly African Americans, disproportionately affected • Heavy concentration in Southern region • Young women at particular risk
0% 1986 1991 1996 2002
Note: Includes reported cases among women 13 years of age and older. Source: CDC, HIV/AIDS Surveillance Reports, 1986-2002.
Pregnancy and Maternity Care
Figure 8
Pregnancy
Unintended Birth 19% Abortion 23%
Intended Birth 43%
Intended pregnancies
Unintended pregnancies
Miscarriage 9%
Miscarriage 6%
6.3 million total
Sources: AGI, Fulfilling the Promise: Public Policy and U.S. Family Planning Clinics, New York: AGI, 2000; Martin JA et al., Births: final data for 2002, National Vital Statistics Reports, 2003, 52(10); and Finer LB and Henshaw SK, Abortion incidence and services in the United States in 2000, Perspectives on Sexual and Reproductive Health, 2003, 35(1):6–15.
Figure 9
Major Federal Pregnancy-Related Legislation
Pregnancy Discrimination Act of 1978
Gradual expansion in employer-based health benefits – most workers covered for prenatal care, contraceptives, annual Ob/Gyn visit, maternity leave
Family and Medical Leave Act of 1993
Workplace protections for unpaid maternity leave and time off to care for family members First paid family leave law passed in CA in 2002
Newborns' and Mothers' Protection Act of 1996
Ban “drive thru” deliveries Hospital stay for childbirth may not be restricted to less than 48 hours following a vaginal birth or 96 hours for cesarean
Source: U.S. Equal Employment Opportunity Commission
Figure 10
Medicaid and Maternity Care
Medicaid income eligibility levels as a percent of the Federal Poverty Level:
200%
•
Covers all pregnancy-related care, including prenatal care, childbirth and delivery, and post-partum care Federal eligibility threshold higher than for other adults 133% of poverty Several states expanded up to 200% and facilitated enrollment Covers nearly four in ten births nationwide
Newborns eligible for one year; mothers eligibility limited to 60 days post-partum
133%
100%
133% 100% 42% 74% 0%
•
•
0%
Pregnant Pre-School SchoolWomen Children Age Children
Parents Elderly and Childless• Individuals Adults with • Disabilities
Note: The federal poverty level was $9,310 for a single person and $15,670 for family of three in 2004. Source: Cohen Ross and Cox, 2004 and KCMU, Medicaid Resource Book, 2002.
Figure 11
Trends in Abortion
Abortion Rates Among Women, Ages 15-44
Abortions per 1,000 women
30 25 20 15 10 5 0
• Half of unintended pregnancies end in abortion • Overall rate declining, but not among lowincome women • Majority occur within first trimester
• 74% are self-pay
29.3 20.9
1980
1984
1988
1992
1996
2000 2002
Source: Finer and Henshaw, AGI, 2005.
Figure 12
Access and Financing Abortion Services
Federal Policy - Hyde Amendment bans Federal financing of abortions except in cases of rape, incest, or to save the life of the woman Medicaid • Women in military
– “Partial birth” abortion ban – ruled unconstitutional, passed by Congress and signed by President • State Policy – “Partial birth” bans – Waiting periods
– Provider/Facility Regulations – Parental consent/notification for minors, – Health care provider refusal clauses
Figure 13
Infertility
Number (in thousands) of ART Cycles and Babies Born Using ART at Reporting Clinics, 1996-2002 120 115
108
• Broader range of treatments now available
• Use of ARTs estimated to have nearly doubled between 1996 and 2002
100
88
100 80 72 65
80 60 40 20 0
14 16
• Costs $12,000 on average per IVF cycle
33
20
22
25
29
• Relatively limited insurance coverage; 15 states mandate at least limited coverage for diagnosis and treatment
1996 1997 1998 1999 2000 2001 2002
Source: CDC, 2002 Assisted Reproductive Technology Report.
Figure 14
Conclusions
• Range of reproductive health services has expanded tremendously
• Access is central to women’s overall health and well-being
• Federal and state policies wield significant influence on reproductive health • Likely to continue to be at center of several policy debates