Uninsured, exposed, and at risk, but not powerless

by Lourdes A. Rivera

Holes riddle the patchwork quilt that is the American Health Care system,leaving nearly 16 million women exposed to the dangers of being uninsured.¹ These dangers include a lower quality of care, preventable serious health problems, economic hardship and even death caused by their inability to access desperately needed health services.

Because they usually can't afford to pay for health care, uninsured women are less likely to access preventive care, such as mammograms, Pap tests and cervical screenings. They are more likely to postpone care and to forego filling prescriptions.¹ When they do seek out medical attention — often only when the condition has become very serious — it is likely to be of lower quality than the care delivered to insured women, more expensive and with worse health outcomes.² Some 18,000 uninsured American adults die each year because they can't get appropriate health care.2 Half of families lacking health insurance said they have used most or all of their savings to pay medical bills, according to the National Academy of Sciences' Institute of Medicine.³

Medicaid fills the insurance gap for nearly 12 million poor women. Millions more, however, do not meet the program's restrictive eligibility criteria, which also include categorical requirements such as being pregnant, having children or having a disability. Also, while Medicaid is the largest public payer of family planning services, coverage for abortion is limited.4 Under the Hyde Amendment, federal funds may be used to pay for abortions only in the case of rape, incest or to save the life of the mother.⁴ Just 17 states use their own funds to provide medically necessary abortions; four do so voluntarily; and 13 states do so under court orders enforcing the state constitution.⁵

Among the 16 million women who neither qualify for Medicaid nor have private health insurance, women of color, low income women, single mothers and immigrant women are especially vulnerable.

Income Status

Low-income individuals and families are most likely to be uninsured. More than a third of women between the ages of 18 and 64 have family incomes that qualify as low income.⁶ This group is 3.5 times more likely than higher-income women to be uninsured, and half as likely to have employment-based coverage. Low-income women also tend to be younger, less educated, less able to access resources and more likely to have childrearing responsibilities than more affluent women.⁶ All of these factors present obstacles to accessing health care.

Low-income women in rural areas are disproportionately uninsured. One in five uninsured people lives in a rural area, and more than 70 percent of uninsured people in states like Montana and Maine are from rural areas.⁷ Residents in remote rural areas have much higher uninsurance rates because they are far more likely to have low-wage jobs than urban residents, and are more likely to work in small businesses. Rural residents also have much less access to health care resources in their communities and few means to public transportation to reach service sites outside of their areas.⁷

Even more low-income women and families would be uninsured if it were not for Medicaid and SCIIIP (State Children's Health Insurance Program) Medicaid expansions and the implementation of SCHIP between 1997 and 2002 significantly offset the drop in employer-sponsored health insurance during that same period, especially benefitting children.⁸ For children from higher-income families and for adults, the public expansions only somewhat offset the drop in private health insurance.⁸

Employment Status

Most Americans are insured through their employment, and women, as is well documented, tend to have jobs that pay less and offer fewer benefits. Simply being employed outside the home is no guarantee of having health insurance. Only 39 percent of working-age women have health coverage through their jobs, compared to 53 percent of men. ¹ Women are less likely to be eligible for employer health plans because they are more likely to work part-time and to have lower incomes. Even workers who are eligible for employer-sponsored health coverage can't always afford their portion of the premium. Overall, of the nearly 44 million people who are uninsured, eight in 10 are in working families.²

Another factor behind this disparity is the fact that women are more likely to be insured through their spouses' jobs. Twenty-six percent of women have job-based insurance through dependent coverage, compared to 13 percent of men.⁹ This makes women more vulnerable to losing their coverage when they divorce or become widowed. (Men, however, are more likely to lose their employer-based insurance and be ineligible for Medicaid and other public programs that cover low-income pregnant women and low-income families. Because of this, more men than women lost health insurance between 2000 and 2002 - 2.5 million versus 1.3 million, respectively.¹⁰)

Race and Ethnicity

Latinos and African Americans are much less likely to be insured than whites, and Latinas and African- American women have the highest rates of uninsurance of all. Thirty-seven percent of Latinas are uninsured, compared to 20 percent of African-American women and 16 percent of white women.¹¹ Sixty-six percent of white women have job-based health insurance, compared to 52 percent of African-American women and 44 percent of Latinas.¹²

Similar patterns extend to men and children. Approximately 35 percent of employed Latino adults are uninsured, compared to 18 percent of employed African Americans and 11 percent of working white adults.¹² White children are more likely to have access to private health insurance, while African-American and Latino children are more likely to be covered by the public programs Medicaid and SCHIP or to be uninsured.⁸

Single Parents

Women are more likely to be single parents than men, limiting their ability to access job-based insurance. A California study found that 81 percent of the state's 1.4 million single parents in 1998 and 1999 were women.¹³ That study showed single mothers in California to have higher uninsured rates (28 percent) than women in every other family situation except single women with no children. Only 19 percent of married mothers were uninsured.

Immigration Status

Women who are non-citizens, the majority of them in the United States legally, are disproportionately uninsured. They are as likely as citizens to have a full-time worker in their families, but their jobs tend to be low paying and not to offer health insurance. In 2001, the United States had n million low-income non-citizens. Sixty percent of them had no health insurance, compared to 28 percent of low-income citizens.¹⁴

Non-citizens also are less likely to qualify for Medicaid, especially after the passage of the Personal Responsibility and Work Opportunity Act of 1996 (the"welfare reform" law), which placed a five-year ban on public benefits for new immigrants.¹⁵ In 2001, only 13 percent of low-income non-citizens received Medicaid, compared to 30 percent of low-income citizens.¹⁴

Affordable Access for All

Even women who have health insurance often must pay out of pocket for many health needs. Insurance plans routinely exclude contraceptive drugs and devices, although they generally cover prescription drugs. Some states have responded to this inequity, according to the Alan Guttmacher Institute.¹⁶ Twenty states, for instance, require health insurers that cover prescription drugs to also cover contraceptives and related services. But there are exemptions within these and other mandates. Twelve states, for instance, exempt religious employers from including contraceptive coverage in their plans.

Without a national response, millions of women, men and children will continue to lack health insurance and needlessly suffer poor health outcomes. Medicaid and SCHIP are the closest programs we have to national health insurance for low-income people. While the need and demand for these and other programs are increasing, they face severe budget cuts. States buffering fiscal budgetary crises are looking to impose aggressive cost-cutting measures by freezing enrollment, rolling back eligibility and increasing out-of-pocket costs for those in the program. The Bush administration also has proposed to combine Medicaid and SCHIP and provide states with "block grants" capped amounts that will not increase in response to economic downturns. In addition, the administration continues to propose budgets that severely underfund the Title X Family Planning Block Grant, which provides access to comprehensive family planning services and reproductive health counseling, while doubling funding for ineffective "abstinence-only" programs. These policies fail to address comprehensive community health needs. A system that guarantees affordable access to quality health care, including comprehensive reproductive health care, is long overdue.

What Can Women Do?

The 2004 general election provides an opportunity to focus national attention on the lack of health access for so many women, their families and communities. Concerned women can take the important steps of registering to vote, going to the polls on November 2 and encouraging others to do the same. Without a strong showing of civic participation, women lose a fundamental right – one for which many before us fought — and forego an opportunity to hold politicians accountable for failing to address health access issues. Regardless of who is elected to the White House, Congress or the state houses, women can demand that elected officials preserve public programs that provide critical lifelines for so many people, and develop a system that extends comprehensive health services to all.

Imagine if each of the 16 million uninsured women in this country cast their vote on Election Day, and then called and or wrote the president and their representatives At the 2004 March for Women's Lives, many thousands of people chanted, "Show me what democracy looks like! This is what democracy looks like!" It is incumbent upon women to answer that call. Register. Vote. Use your power to advocate for health care.

Lourdes A. Rivera is managing attorney of the National Health Law Program, a private nonprofit law firm working to ensure access to quality health care for low-income individuals and communities. She is former chair of the NWHN and a current member of the SisterSong Women of Color Reproductive Health and Sexuality Rights Collective Management Circle.

REFERENCES

1. Henry J. Kaiser Family Foundation. Fact Sheet: Women's Health Insurance Coverage. June 2004.

2. www.covertheuninsurecl.org. Health Care Coverage in America: Understanding the Issues and Proposed Solutions. 2004. Henry J. Kaiser Family Foundation, The Cost of Not Covering the Uninsured. June 2003

3. As cited in Health Care Coverage in America: Understanding the Issues and Proposed Solutions.

4. For an overview of Medicaid reproductive coverage, see National Health Law Program, Medicaid Coverage of Reproductive Health Services. June 2001. www.healthlaw.org pubs 2OOIo625reprohictsheet.html

5. Alan Guttmachcr Institute, State Policies in Brief: State Funding of Abortion Under Medicaid. May 3, 2004.

6. Henry J. Kaiser Family Foundation. Health Coverage and Access Challenges for Low-Income Women: findings from the 2001 Kaiser Women's Health Survey. March 2004.

7. Henry J. Kaiser Family Foundation, The Uninsured in Rural America. April 2003.

8. Finegold K, Wherry L, Race, Ethnicity and Health. The Urban Institute: Snapshots of America's Families III. No. 20. March 2004. Holohan I. Wang M. "Changes in health insurance coverage during the economic downturn: 2000 - 2OO2." Health Affairs January 28, 2004. (Web exclusive.)

9. Henry J. Kaiser Family Foundation. Fact Sheet: Women's Health Insurance Coverage. July 2OOI.

10. Holohan and Wang.

11. Henry J. Kaiser Family Foundation. Racial and Ethnic Disparities in Women's Health Coverage and Access to Care: Findings from the 2001 Kaiser Women's Health Survey. March 2004.

12. Robert Wood Johnson Foundation, "Study Shows One in Three Working Hispanics Have No Health Coverage, Suffer Flcalth Gaps as a Result" (press release). May 10. 2004.

13. Wyn R. Ojeda V. Single Mothers in California, Understanding Their Health Insurance Coverage UCLA Center for 1 lealth Policy Research, Policy Brief. May 2002.

14. Henry J. Kaiser Family Foundation, Immigrants' Health Care Coverage and Access. August 2003.

15. For an overview of immigrant health access rules, see The Access Project and the National Health Law Program, Immigrant Access to Health Benefits: A Resource Manual. August 24. 2002.

16.  Alan Guttmacher Institute. State Policies in Brief: insurance Coverage of Contraceptives. May 1, 2004.