The state’s 2006 health law expanded insurance coverage for women ages 18 to 64 from 91 percent the year the bill was signed to 97 percent as of 2009. It boosted access to maternity care and contraception, and it prohibited practices that blocked care for women, such as using gender as a factor in determining the price of a plan. But women in the state, particularly those who are low-income or immigrants, continue to face challenges.
Dr. Paula Johnson, director of the Mary Horrigan Connors Center for Women’s Health at Brigham & Women’s Hospital, last month brought a list of lessons learned to Washington, talking to lawmakers and speaking at a Senate briefing about what needs to be done locally and nationally to further improve care for women.
“In everything we do, if you don’t have people at the table thinking about that lens of women’s health, it will not routinely get addressed,” she said in an interview in her office last week. “It will not routinely be included in the discussion, and we have examples of that time and time again.”
The recommendations Johnson made in Washington grew out of a detailed report the Connors Center produced last year with the Massachusetts Health Policy Forum showing how women have benefited under the state’s law and identifying the remaining gaps in coverage:
1. Improve continuity of coverage: Because they generally have lower incomes than men, are more susceptible to changes in employment status, and are less likely to be the primary policyholder on a plan, women more often get stuck in what industry analysts call “churn.” They might get dropped from one plan and have a time lag before they can get enrolled in another, or they might get a new job and lose eligibility for a state-subsidized policy.
Not only does churn cause some women to experience gaps in coverage, but the turnover costs millions in administrative costs, Johnson said. She recommended that Congress encourage states to require that people verify their income eligibility for subsidized programs just once each year to reduce turnover.
2. Make care more affordable: This, of course, is a big, complicated issue and one that state lawmakers continue to struggle with. But Johnson outlined a few discrete steps that federal officials can take to help. They could require states to consider not only premiums but also out-of-pocket costs when making rules about whether a health plan meets affordability standards in state marketplaces, she said. This is particularly important because women often see multiple doctors in order to get basic care -- an internal medicine doctor and a gynecologist, for example -- and they are more likely to have chronic illnesses. Both factors lead to higher out-of-pocket costs.
3. Focus on access to primary care: Shortages in primary care providers, obstetricians, gynecologists, and psychiatrists are a problem for women in Massachusetts. Johnson said Congress could help by providing ongoing funding for programs that train new doctors in these areas.
4. Improve access to long-term care: This is a double-whammy for women. They are more likely to need it, because they live longer. And they are more likely to become the informal caregiver for a relative in need. Johnson is a supporter of the CLASS Act, a measure championed by Senator Edward Kennedy and put on hold by the Obama administration last month. That program would provide seniors with a cash to buy long-term care services. Johnson said Congress should pursue a similar model.
“This is a major women’s health issue in the baby boom generation,” Johnson said. “It will be one of the issues of our time.”
5. Improve health equity: Massachusetts has long been a leader in investing in public health. More will be needed here and nationally as the Affordable Care Act takes effect, Johnson said. Massachusetts created a council focused on identifying and addressing health care disparities, and the state has invested in advertising and outreach programs to groups who historically have had limited access to care. Johnson said Congress should set aside money to follow through on similar efforts outlined in the Affordable Care Act.
6. Track the effects for women: For years, Johnson has been pushing for more women to be included in clinical studies and for data from those studies to be evaluated according to both gender and race.
“It’s one thing to include women, but if you don’t know how women respond differently, that’s a problem,” she said. “That is something we see over and over again.”
The state’s track record on this issue is so-so, she said. As an example, she said, the state succeeded in driving down smoking rates among Medicaid enrollees when it expanded coverage of cessation programs in 2006. In the first two and a half years, smoking rates dropped about 10 percent. The state doesn't have that data available by sex, Johnson said. “And we should.”
Johnson encouraged Congress to pass the Health Equity and Accountability Act of 2011 and ensure that it includes routine reporting of data by sex and race.
Johnson’s center and partners are putting together a summit of women’s health experts to draft a plan aimed at helping states focus on women as they overhaul their health insurance systems under the Affordable Care Act.