Health Care Systems
A health system is the sum total of all the organizations, institutions, and resources whose primary purpose is to improve health (1). The U.S. health care system is a large and complex system with many components (eg, clinics, hospitals, pharmacies, and laboratories). These components are interconnected through the flow of patients and information with the aim of maintaining and improving health (2). Understanding a health care system perspective is critical to improving the delivery of care to women. Poorly structured health care systems disproportionately affect the delivery of care to underserved populations. A goal of the Patient Protection and Affordable Care Act (ACA) is to ensure effective system strategies to permit access for all, including underserved women.
Underserved women are those who are unable to obtain quality health care by virtue of barriers created by poverty, cultural differences, race or ethnicity, geography, sexual orientation, gender identity, or other factors that contribute to health care inequities. Underserved women are typically in need of more health services because of high rates of chronic conditions and unmet reproductive health care needs (3). Moreover, underserved women are at an increased risk of health problems related to limited access to quality health care in addition to elevated levels of poverty and geographic and social isolation. For example, Asian and Pacific Islander women, especially those who are Vietnamese; black women; American Indian and Alaska Native women; and Hispanic women have higher incidence rates of invasive cervical cancer than non-Hispanic white women (4, 5). Cervical cancer mortality rates are higher among black women (4.4 per 100,000) than among all racial and ethnic populations combined (2.4 per 100,000) (4). Cervical cancer rates for Hispanic women are nearly twice those of non-Hispanic white women and death rates are 48% greater (4). A comprehensive study indicates that inequities in mortality rates are due in large part to inequities in access to health care services (6).
Key Issues Important to Underserved Populations
Women have much at stake with the ACA. Currently, increasing health care costs disproportionately affect women with low incomes and minority women. More than one half of women report delaying or avoiding needed care because of cost (7). Additionally, some women experience challenges in receiving coverage for critical services, such as maternity care (8). For many, the challenges are due to their lack of insurance or inade-quate coverage, but educational, cultural, and logistical factors also can compromise access to care. In 2010, there were approximately 19 million uninsured women, aged 18–64 years (9). These women face risks, including lack of access to care, low quality of care, and poor health outcomes (10). Moreover, uninsured women are more likely than their insured counterparts to postpone obtaining necessary prescriptions and preventive services, such as screening for cervical cancer and breast cancer (3).
Preventive care services, preconception care, well-woman care, family planning, and subspecialty care are all critical to women’s health. The scope of care varies across the lifespan and specific aspects are of particular importance to underserved women. Local and national policies should ensure the delivery of culturally sensitive services to vulnerable populations, such as minorities and individuals with disabilities, and ensure the existence of a safety net. Safety net programs provide health care for individuals, regardless of their ability to pay. Moreover, coordination with other key services, including mental health care, results in the delivery of high-quality care. There are several mandated benefits in the ACA specific to women (Box 1). The ACA also encourages state expanded coverage of family planning (11). Health insurance coverage is a critical aspect of ensuring that health care is accessible to women. Additional strategies that must be incorporated locally to ensure that the health care system is responsive to the needs of women include timely identification of patient risk factors, effective coordination of care to allow linkages to appropriate levels of care (eg, specialty care), and the provision of opportunities to ensure comprehensive care (12). These additional strategies are especially important for underserved women.
Patient Protection and Affordable Care Act
The ACA has the potential to improve access to care for millions of underserved women across the nation. Generally, health insurance coverage will be granted to very low-income women, and insurers will be prohibited from denying coverage because of pre-existing conditions. Women will no longer face varying premium rates because of gender or health status (3). Through expansion of coverage, women up to age 26 years can be covered under their parents’ insurance policies. Additionally, the ACA allows direct access to obstetrician–gynecologists, which will facilitate women’s health care service delivery, including access to maternity care and preconception care. At present, several aspects of the law have been implemented, whereas others have yet to be determined (11).
Box 1. Mandated Benefits in the Affordable Care Act Specific to Women*
Comprehensive lactation support and counseling from trained health care providers and renting breastfeeding equipment
- Access to women’s preventive health services without cost sharing, including the following:
Counseling for a healthy diet
Counseling for tobacco use
Counseling for sexually transmitted infections in sexually active women
Counseling and screening for human immunodeficiency virus (HIV) in sexually active women
Full range of U.S. Food and Drug Administration approved contraceptive methods and contraceptive counseling
Screening for cervical cancer, including high-risk human papillomavirus DNA testing in women older than 30 years with normal cytology results
Screening and counseling for interpersonal and domestic violence
Screening and counseling for obesity
Screening and counseling to reduce alcohol misuse
Screening for depression
Screening for gestational diabetes in pregnant women between 24 weeks and 28 weeks of gestation and at the first prenatal visit for pregnant women identified to be at high risk of diabetes
Screening for gonorrhea and chlamydial infection in certain populations of sexually active women
Well-woman visits, including preconception care and prenatal care, for adult women to obtain recommended preventive services, allowing for additional visits, depending on the women’s health status, needs, and other risk factors
- Maternity coverage
- Medicaid coverage of accredited free-standing birth center services
- Medicaid coverage of smoking cessation
*Catastrophic plans will be able to be offered through the exchanges for individuals younger than 30 years or if other plans are deemed to be unaffordable. These plans are exempt from having to meet the essential health benefits standard, which includes maternity care.
Department of Health and Human Services. Affordable Care Act rules on expanding access to preventive services for women. Washington, DC: DHHS; 2011. Available at: http://www.healthcare.gov/news/factsheets/womensprevention08012011a.html. Retrieved September 21, 2011.
Department of Health and Human Services. U.S. Preventive Services Task Force recommendations: grade A and B recommendations of the United States Preventive Services Task Force. Available at: http://www.healthcare.gov/law/resources/regulations/prevention/taskforce.html. Retrieved September 27, 2011.
Department of Health and Human Services. Affordable Care Act expands prevention coverage for women’s health and well-being. Washington, DC: DHHS; 2011. Available at: http://www.healthcare.gov/law/resources/regulations/womensprevention.html. Retrieved September 27, 2011.
Department of Health and Human Services. Recommended preventive services. Washington, DC: DHHS; 2011. Available at: http://www.healthcare.gov/law/resources/regulations/prevention/recommendations.html. Retrieved September 27, 2011.
Patient Protection and Affordable Care Act, Pub. L. No. 111–148, § 1302, 124 Stat. 119 (2010).
Patient Protection and Affordable Care Act, Pub. L. No. 111–148, § 2301, 124 Stat. 119 (2010).
Patient Protection and Affordable Care Act, Pub. L. No. 111–148, § 4107, 124 Stat. 119 (2010).
Workforce and Health Systems
A key aspect of a well-designed health system is a well-trained workforce (13). Women must have access to a multidisciplinary, culturally competent health care provider workforce that includes professional specialty and primary health care providers for women (eg, obstetrician–gynecologists) and certified, trained, and qualified allied health care providers. Accredited education, professional certification, and licensure are essential to ensure skilled health care providers at all levels of care.
Because of geographic maldistribution, there is a relative shortage of obstetrician–gynecologists for the U.S. population (14). Under the ACA, more women will have access to health care, creating increasing pressure for the provision of care by a wide range of trained health care providers. These changing needs will require seamless integrated health care provider relationships across specialties.
Obstetrician–gynecologists provide women’s health care throughout the lifespan, often functioning as primary health care providers in a collaborative team. The American College of Obstetricians and Gynecologists has long supported collaborative practice in an integrated, patient-focused health care delivery system to help ensure high-quality care. Such high-quality care depends on appropriately trained and certified health care providers, open communication and transparency, ongoing health care provider performance evaluation, use of evidence-based guidelines, and patient education. Exemplary systems of care with these characteristics should be identified and replicated.
Health System Models
Currently, a number of health care systems provide for underserved women. These include hospitals, publicly funded clinics, community health centers, federally qualified health centers, Title X Family Planning centers, managed care delivery systems, and accredited free-standing birth centers. Emergency departments also serve as a vital component of the health care system by providing care 24 hours a day, seven days a week to all who seek care, thereby addressing logistical and financial barriers faced by underserved women attempting to access care (15, 16). Under health reform, underserved women must continue to have access to these existing sites of care and also to new models of care that improve continuity of care and incorporate health information systems that support integrated service delivery and improved care coordination.
Health systems should be designed to achieve the fundamental goal of improving the health of the population served with an emphasis on fairness and responsiveness (17). Underserved women have a disproportionate share of adverse outcomes, such as higher breast cancer mortality rates among black populations than among any other racial or ethnic group (4). Underserved women also encounter challenges in interactions with the health care system that pertain to cultural, educational, and logistical factors. As implementation of the ACA moves forward, stakeholders must advocate for expansion of access for underserved women. Key areas include the following:
- Provision of culturally competent care
- Tracking of outcomes with attention to racial and ethnic minorities and other populations who experience health inequities
- Coordination of key services, such as mental health care and reproductive health care
- Funding of comparative effectiveness research to develop effective interventions for underserved women
Despite the promise of the ACA to improve health insurance coverage, some populations may be left out. It is estimated that with full implementation of the ACA in 2014, the rate of uninsured Americans younger than 65 years will decrease from 18.9% to 8.7%. Of the remaining Americans younger than 65 years, approximately 25% will be undocumented immigrants and 16.2% will be legal residents who qualify for the affordability exemption (18). Safety net health care providers, including Federally Qualified Health Centers and emergency departments, must continue to offer care to populations who may not benefit from the ACA.
Even if the ACA is never fully implemented, the benefits expected to be achieved by its passage should still be sought. We have an obligation to address the issue of underserved women with or without the ACA. A well functioning health care system responds in a balanced way to a population’s needs and expectations by (19)
- improving the health status of individuals, families, and communities
- defending the population against health threats
- protecting the population against the financial consequences of ill-health
- providing equitable access to patient-centered care
- ensuring patient participation in decision making regarding health
These health system characteristics are important elements of ensuring quality care to all women, including underserved women.
- World Health Organization. What is a health system? Geneva: WHO; 2005. Available at: http://www.who.int/ features/qa/28/en/index.html. Retrieved September 21, 2011. ⇦
- Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001. ⇦
- Henry J. Kaiser Family Foundation. Women’s health insurance coverage. Menlo Park (CA): KFF; 2010. Available at: http://www.kff.org/womenshealth/upload/6000-09.pdf. Retrieved September 21, 2011. ⇦
- Altekruse SF, Kosary CL, Krapcho M, Neyman N, Aminou R, Waldron W et al, editors. SEER cancer statistics review, 1975-2007. Bethesda (MD): National Cancer Institute; 2010. Available at: http://seer.cancer.gov/csr/1975_2007. Retrieved September 27, 2011. ⇦
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- Freeman HP, Wingrove BK. Excess cervical cancer mortality: a marker for low access to health care in poor communities. NIH Pub. No. 05–5282. Rockville (MD): National Cancer Institute, Center to Reduce Cancer Health Disparities; 2005. Available at: http://crchd.cancer.gov/attachments/excess-cervcanmort.pdf. Retrieved September 19, 2011. ⇦
- Rustgi SD, Doty MM, Collins SR. Women at risk: why many women are forgoing needed health care. An analysis of the Commonwealth Fund 2007 biennial health insurance survey. New York (NY): The Commonwealth Fund; 2009. Available at: http://www.commonwealthfund.org/~/ media/Files/Publications/Issue%20Brief/2009/May/Women%20at%20Risk/PDF_1262_Rustgi_women_at_risk_issue_brief_Final.pdf. Retrieved September 21, 2011. ⇦
- National Women’s Law Center. Still nowhere to turn: insurance companies treat women like a pre-existing condition. Washington, DC: NWLC; 2009. Available at: http://www.nwlc.org/sites/default/files/pdfs/stillnowheretoturn.pdf. Retrieved September 27, 2011. ⇦
- Henry J. Kaiser Family Foundation. The uninsured: a primer. Supplemental data tables. Menlo Park, CA: KFF; 2011. Available at: http://www.kff.org/uninsured/upload/7451-07-Data-Tables.pdf. Retrieved October 20, 2011. ⇦
- Henry J. Kaiser Family Foundation. The uninsured: a primer. Key facts about Americans without health insurance. Menlo Park (CA): KFF; 2010. Available at: http://www.kff.org/uninsured/upload/7451-06.pdf. Retrieved September 21, 2011. ⇦
- Henry J. Kaiser Family Foundation. Impact of health reform on women’s access to coverage and care. Menlo Park (CA): KFF; 2010. Available at: http://www.kff.org/womenshealth/upload/7987.pdf. Retrieved September 21, 2011. ⇦
- American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care. 6th ed. Elk Grove Village (IL): AAP; Washington, DC: ACOG; 2007. ⇦
- World Health Organization. Health systems. Available at: http://www.who.int/topics/health_systems/en. Retrieved September 21, 2011. ⇦
- Rayburn WF. The obstetrician–gynecologist workforce in the United States: facts, figures, and implications. Washington, DC: American Congress of Obstetricians and Gynecologists; 2011. ⇦
- Richardson LD, Hwang U. Access to care: a review of the emergency medicine literature. Acad Emerg Med 2001;8:1030–6.
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- World Health Organization. Key components of a well functioning health system. Geneva: WHO; 2010. Available at: http://www.who.int/healthsystems/EN_HSSkey components.pdf. Retrieved September 21, 2011. ⇦