Excerpt from Ourselves, Growing Older, by Paula Doress-Worters and Diana Laskin Siegal, in cooperation with The Boston Women’s Health Book Collective
National health reform may not address issues most crucial to women’s health, especially those affecting midlife and older women, unless we become much more active on our own behalf. In fact, basic structural reforms to the system, needed most by women, were not addressed by either the NIH research plans or the Women’s Health Equity Act of 1992. Women are bearing the greatest burdens in many instances.
Because of the growth of female-headed households and the “feminization of poverty,” low-income families pay more than twice their share of income for health care compared with high-income families. Poor families pay a greater share of earnings for both personal and family insurance premiums, and eight times more for out-of-pocket, unreimbursed medical expenses for office visits, drugs, and other services.6
Women are both uninsured and underinsured. The existing financing mechanisms are built around assumptions that we will be dependents of wage earners rather than workers or heads of households. The services women need most — reproductive health, screening, and preventive services — are frequently not covered.
- Basic Health Care.
Even when insured, women lack access to quality medical care.7 True primary care (see “Reformspeak” box) for women is almost nonexistent. Female-headed households — women and their children — are much less likely to have access to care, especially primary care.8
Women have an extremely difficult time obtaining good health- and medical-care information crucial for decision-making, for themselves or for family members. Frequently they feel frustrated and dissatisfied by the conflicting information they receive or the poor quality or inadequate amount of that information.9
We are obliged to use and learn about a system that is not designed by us or for us and frequently does not have our needs, interests, or communication requirements in mind. It is too difficult to get crucial information about technology and drugs, or about the true benefits of procedures and therapies — especially for women, older women in particular.10
More women than ever before are involved in the medical-care system at the professional level as physicians, researchers, and administrators, but most women are still clustered at the bottom of that system, doing underpaid practical, clerical, or housekeeping work in hospital systems.11
The NIH program and many women’s groups call for more professional women to be involved in policy and high-level decision making in the health system as a way to improve the systems accountability to women.12 Including the talents of trained professional women can never be a substitute for the input and direction that the health- and medical-care system needs from community women of diverse races and cultural backgrounds. Rarely do we hear a call for more women to be involved at the community and citizen levels.
We will have to demand those better systems of accountability, planning, evaluation, and information to be available to us as individuals, families, and community members. We will have to insist that a powerful community and citizen role for women be an integral part of any new system and all patients rights.13 Otherwise, we will be obliged to rely on experts, female or male, who have not been trained to see the situation from a laywoman’s point of view, and who frequently identify primarily with professionals and special interests.
SIDEBAR: SELECTED AGENCIES CONDUCTING WOMEN’S HEALTH RESEARCH
The Agency for Health Care Policy and Research (AHCPR) conducts research on a wide variety of subjects designed to help practitioners to be more effective in dealing with many different concerns, like urinary incontinence and managing pain. These guidelines and a patient brochure are available to consumers.
The Centers for Disease Control and Prevention (CDC) conducts studies and produces weekly reports on public health problems and infectious diseases like AIDS. Now they are looking at quality of life as well as disease and death, including the chronic diseases affecting older women. Now that smoking, breast and cervical cancer, tuberculosis, violence, and other life-threatening conditions are increasingly becoming problems for older women, CDC is expanding its activities.
The Food and Drug Administration (FDA) has many scientific advisory committees charged with evaluating new and existing treatments, primarily drug therapies and new devices, many of which directly affect midlife and older women. These committees are usually appointed and include consumers as well as clinicians. They review research and practice and make recommendations to the FDA Commissioner about which drugs to approve and/or remove from the market, as well as what information should be available to practicing physicians and to consumers.
Watchdog groups like the National Women’s Health Network are constantly monitoring the activities of these committees, often help identify knowledgeable clinicians and consumers, and regularly give testimony at the FDA’s public hearings. The Network reports its findings and analysis to press and public.
The Public Health Service (PHS) is the major agency concerned with issues affecting the public health system as a whole, especially how services are organized. They have proposed a “PHS Action Plan for Women’s Health,” thirty-eight goals for prevention, services, treatment, research, education, and policy, to be monitored by the Office of Research on Women’s Health in NIH.1
The Indian Health Service is supposed to establish at least one major Indian Women’s Health Center in each of its regions.
The National Cancer Institute (NCI) has focused on breast cancer as the death rate remains unchanged and the number of women diagnosed continues to rise. However, it also studies lung cancer, which now surpasses breast cancer as the most frequently fatal women’s cancer (mainly due to active or passive smoking), as well as reproductive cancers like cervical cancer, still prevalent in older women, and ovarian cancer.
The role of U.S. women’s diet in relation to breast cancer is being studied at last, following years of effort by health activists pointing to worldwide reports linking breast cancer rates to fat in the diet. Also, funds from the Department of Defense (DOD) were recently allocated for breast cancer research.2
More recently, activists have begun raising the issue of the contribution of pesticides, radiation, and other carcinogens to U.S. breast-cancer rates (and likely ovarian cancer rates as well). So far, the NCI has not undertaken any studies to investigate environmental causes of cancer in women.
National Institutes of Health (NIH). An increased amount of NIH research dollars are now allocated through the Office of Research on Women’s Health (ORWH) mainly for three major areas of chronic disease: heart disease, breast cancer, and osteoporosis. Programs in communities will attempt to encourage healthy habits in women of all ages and backgrounds by helping them to decrease smoking, improve diets, increase regular physical activity, and maintain optimum weight.
Most of these research trials are now under way, but the results will not be available for many years. Critics of these studies, however, suggest that their design is flawed and prepared without adequate peer review; they may not be able to “prove” what they set out to show. What most women need to know — how to prevent these diseases in the first place, and how to make treatment decisions once a disease is diagnosed — may not necessarily be forthcoming.
The second prong of the ORWH program is to get more professionally trained women onto the staffs of research projects at NIH and elsewhere. This will surely be helpful to the women researchers. But it is critical that we not confuse their increased involvement with improved participation of community women, and users of the system, in planning, decision-making, and accountability in the health- and medical-care system.
In the past, the NIH has held a number of Consensus Development Conferences, many of them on women’s health issues, but critics say these meetings have been too easily dominated by the drug industry and researchers viewpoints, which emphasize particular treatments more than prevention or alternatives.
The Office of Alternative Medicine at NIH was established in 1992 to study, gather, and disseminate information about “alternative” therapies of all kinds in the United States.3 Widespread national use of these therapies was recently revealed.4 While this office has no special focus on older women, the fact that chronic diseases are more common in older women and are less effectively treated by conventional medicine makes this development important to watch. Many women have already discovered the benefits of acupuncture, massage, and chiropractic treatments for long-term management and comfort as alternatives to drugs and surgeries.
The National Institute on Aging (NIA) is studying issues like frailty and through pilot programs is developing a set of guidelines that could potentially help reduce some of the falls and fracture to which women are especially vulnerable. (Not all fractures are a result of osteoporosis.) Without vigorous, community-based programs to implement these recommendations, however, women will receive little benefit from them.
The Office of Technology Assessment (OTA), an arm of Congress, has conducted a number of studies and reviews on key women’s health issues, most recently an excellent report on hormone treatments at menopause. Key among its findings was the lack of adequate information available to women making treatment decisions. OTA’s work is more objective and critical than some other federal agencies, but it is less well able to publicize its work, and often is under heavy attack from special interests.
Many of the other Institutes have programs of interest to women. One example is the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDKD), which studies a variety of chronic diseases affecting women such as osteoporosis, urinary incontinence, gestational diabetes, obesity, interstitial cystitis, urinary tract infections, gallstone disease, and nutrition deficiency anemia, especially in the elderly.5 (See Resources for this chapter.)
NOTES FOR THIS SIDEBAR
1. James O. Mason, “From the Assistant Secretary for Health, US Public Health Service.” Journal of the American Medical Association, Vol. 267, No. 4 (Jan 22/29, 1992) p. 482.
2. “Effective Lobbying Increases Federal Funds for Breast Cancer” The New York Times, Oct. 19, 1992.
3. “Exploratory Grants for Alternative Medicine.” NIH Guide, Vol.22, No.12 (Mar. 26, 1993).
4. David N. Isenberg, “Unconventional Medicine in the U.S.: Prevalence, Costs and Patterns of Use.” The New England Journal of Medicine, Vol. 328, No. 4 (Jan. 28, 1993), pp. 246-52; also see Editorial, pp. 382-83.
5. “Women’s Health Issues.” NIDDKD, August 1991. [END OF SIDEBAR]
ASSUMPTIONS ABOUT WOMEN
Women ages forty and over have the most to gain from changes in the way health and medical services will be financed and delivered, but only if those changes are designed to benefit us. Unless women get involved in fighting for what is needed, the new programs once again will be built around the old assumptions about women, namely that:
- Our labor is available free or at low cost, especially as midlife caregivers of ailing spouses or parents.
- We must be dependent on spouses/partners or employers for access to insurance and care even though working women pay into the system.
- Poor women and women of color are liabilities.
- Insured women are markets and “billable” resources.
- Our ignorance of how the system works and how technology and drugs are misused can be exploited.
- Our major dependence on government programs means women’s services will be the first to be cut or scaled back.
Women, especially women over forty, will have to take the lead in pointing out how these assumptions work now, and why they must not be built into health- and medical-system reform proposals.
“REFORMSPEAK”: SOME TERMS
YOU SHOULD KNOW
Fee for Service. Medical-care providers bill for each medical visit, treatment, service, etc. as a separate item, and unless restrained, may increase the amount billed from one visit to the next. Conventional insurance companies now handle the majority of health insurance this way under the “indemnity” insurance principle. Most government sponsored health services are billed and paid this way. Fee for service gives the maximum incentive for medical-care providers to do more and charge more, whether or not services are necessary or beneficial. It maximizes profits for clinics, labs, doctors, hospitals, and insurers but speeds up cost increases for employers, consumers, and tax-payer- supported government programs.
Global Budget. This is the annual, government-established target or spending limit for the country’s health expenditures. In its most extreme form, specific limits would be set for each state as well as for the nation.
Health Maintenance Organization (HMO). An HMO is a medical-care-provider corporation organized to deliver both office-based medical care and necessary hospitalization for subscribers who pay one prepaid monthly or annual fee (packages vary). HMOs have their own staff of primary-care doctors and nurses, and expensive visits, procedures, and hospitalization are restrained. Subscribers who seek care outside the HMO will have to pay for bills they incur. HMOs may be for-profit or nonprofit, and can be set up by government, insurance companies, unions, or other groups. HMOs are the oldest type of managed care.
Independent Practice Association (IPA). An IPA contracts with doctors who are in private practice to care also for some patients in different HMOs and other health plans, presumably for less cost.
Managed Care. This is any system that controls costs by monitoring and controlling decisions made by doctors and hospitals under various types of health planes. HMOs and PPOs are two types. Managed care may set up specific guaranteed services of doctors and hospitals to subscribers based on fixed prepaid fees or premiums. A key component of any type of managed-competition plan, managed care is usually profit motivated but may also reduce unnecessary or risky treatments.
Managed Competition. This is an untested theory combining health care services and financing mechanisms. It is tied to employment and based on the profit-making insurance principle, but with vastly expanded regional markets. A few very large health-insurance plans would be forced to compete for large pools of subscribers in each region. Groups of employers or other subscriber offering benefits, variously called health insurance purchasing cooperatives, or alliances (HIPCs, HIPAs), would “shop” for the best plan. Insurers would be obliged to offer (defined) basic coverage packages to everyone in a prepaid managed-care system with global budgets (package price set in advance) and capitation (a fixed fee to care for each person for a fixed time). Theoretically, the best plan would be the cheapest and would win the competition, keeping prices down and avoiding price control.
PAC Money. Political action committees, special interest groups, give funds to members of Congress to finance their campaigns, securing their loyalty in key legislation battles. (see box, “Political Action Committee [PAC] Contributions and Women”)
Play or Pay. This is a “carrot and stick” approach to employers that would require them to either provide health-insurance coverage for their employees (“play”) or else “pay” the federal government, which would provide it through payroll taxes.
Primary Care. Primary care is generally defined by health experts to mean health or medical care given by a generalist, someone with broad training who is skilled in recognizing special problems and who will refer a patient to specialists if needed. Nurses with additional training, like nurse practitioners, midwives, and physician’s assistants, now function as primary care practitioners in doctor’s offices, public health systems, and managed care programs, as do many physicians, such as family-practice doctors, internists, and geriatricians. The obstetrician-gynecologist, a surgical specialist, is not trained as a primary-care provider and should not be so designated, although many women use them for primary care.
Preferred Provider Organization (PPO). In a PPO, which is one of several managed-care approaches, doctors and hospitals form corporations to give volume discounts to insurance companies to help lower copayments for subscribers who choose from a large list of providers in private practice. PPOs are rarely nonprofit.
Provider. Any health worker or health facility eligible (by license or other mechanism) to receive payment for a medical visit or service, regardless of who pays the bill.
Public Interest. This describes the viewpoint of consumers or citizens, especially to benefit or protect the most vulnerable members of the public, including the poor, the elderly, people with disabilities.
Single Payer. This is a principle similar to public utilities in which one national, centralized nonprofit utility, or a government agency like the Social Security Administration, would be responsible for both collecting and disbursing the money needed to pay medical-care bills. Canada works on this principle and covers everyone for less, with agreed fee schedules for providers and systemwide access for consumers. A single payer would replace the approximately twelve hundred (mostly profit-making) U.S. insurance companies now handling medical claims. Two independent federal agencies agree this saves the most money and is the fairest way to expand coverage. As we go to press, the Health Security Act of 1993 is the most popular single-payer bill before Congress.
Utilization Review. This is the practice of regularly examining all the processes of medical care—tests, treatments, hospitalizations, and other services—so as to limit the unnecessary ones.
WOMEN’S INSURANCE NEEDS
Millions of women currently lack health insurance, and are the majority of those dependent on government programs for health and medical care.14 Most uninsured women are women heading families of dependent children or are caring for dependent adults, or both. They are uninsured because they:
- Are caring for dependent family members and cannot work outside their homes;
- Are working or have worked in small companies that cannot afford to provide health benefits or group coverage;
- Work part-time and are not eligible;
- Are retired without health benefits; or
- Lost whatever benefits they once had as dependents of a working or retired spouse.15
Because of changes in the law, employers will be less obliged to provide retirement benefits in the future, so women will be even less likely to have health coverage in retirement.16
Too many women are paying a higher and higher percentage of their incomes to buy insurance because they are not part of an employer group.17 Many women are now “locked in” to jobs they might rather leave, or take jobs they might not like, in order to keep or obtain employer-covered health insurance.
If you are divorced or widowed while part of a group plan, federal legislation may allow you to continue in the plan for a period of time if you can afford the high premiums. Too large a percentage of women still do not have this protection.18
Ironically, while most women’s health-and medical-care needs, especially at midlife, are often ignored, trivialized, and undertreated, our status as insured women often creates an incentive or “magnet” for unnecessary tests, and surgical or other procedures, resulting in overtreatment.19
1. Rassell, J. Bernstein, and K. Tang. The Impact of Health Care Financing on Family Budgets. Washington, DC: Economic Policy Institute, 1993. (As cited in Health-care Trends Report, Vol 7, No 7 [July 1993], p. 5). The 28-page report is available from Public Interest Publications (800) 537-9359 for $5 plus shipping.
2. “One-third of Women Do Not Receive Basic Health Service, U.S. Study Finds.” The Boston Globe, July 15, 1993; Judy Norsigian, “Women and National Health Care Reform: A Progressive Feminist Agenda.” Journal of Women’s Health, Vol. 2, No. 1 (1993), pp. 91-94; Carolyn M. Clancy and Charlea T. Masson, “American Women’s Health Care.” Journal of the American Medical Association, Vol. 268, No. 14 (Oct. 14, 1992), pp. 1918-20.
3. “Less Access to Care if Family Headed by Woman.” Ob-Gyn News, Vol. 18, No.13 (July 1-14, 1993). Article announced publication of “A Growing Crisis: Disadvantaged Women and their Children” by the U.S. Commission on Civil Rights.
4, “The Menopause, Hormone Therapy and Women’s Health,” Background Paper for the Office of Technology Assessment, May 1992, p.101; “Report Finds Health Information not Easily Available to Women.” Update, Aug. 12, 1992, p.19.
5. Doug Podolsky and Joanne Silberner, “How Medicine Mistreats the Elderly.” US News and World Report, Jan. 18, 1993, pp. 75-79.
6. The Boston Women’s Health Book Collective, op. cit., pp. 651-98.
7. “Women’s Health Research: Prescription for Change,” op. cit.
8. George Annas, et al,. “Legal and Ethical Issues, Tort Reform, and Consumer Protection and Participation Working Group Consensus Report.” Report to Senator Edward Kennedy, Chair, Committee on Labor and Human Resources, April 9, 1993.
9. “Women Without Health Insurance.” National Women’s Law Center Report, Washington, DC, April 1993.
10. Older Women’s League Report, op. cit.
11. Lawrence O. Gostin and Alan Widiss, “What’s Wrong with the ERISA Vacuum?” Journal of the American Medical Association, Vol. 269, No. 19 (May 19, 1993), pp. 2524, 2527, 2544.
12. Older Women’s League Report, op. cit.
13. National Women’s Law Center Report, op. cit.
14. Judy Norsigian, op. cit.