ACOG Committee Opinion
Number 416, September 2008
(Replaces No. 308, December 2004)


Committee on Health Care for Underserved Women

The Committee on Health Care for Underserved Women would like to thank Kerry M. Lewis, MD, and Virginia C. Leslie, MD, for their assistance in the development of this document.

This information should not be construed as dictating an exclusive course of treatment or procedure to be followed.


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The Uninsured

ABSTRACT: The United States is one of the few industrialized nations in the world that do not guarantee health care for their populations. Access to health care for all women is of paramount concern to obstetrician–gynecologists and the American College of Obstetricians and Gynecologists. Pregnant women and infants are among the most vulnerable populations in the United States and the American College of Obstetricians and Gynecologists believes that providing them with full insurance coverage and access to health care must be a primary step in the process of providing coverage for all individuals within the U.S. borders. Health care professionals can play a pivotal role in improving access to needed health care by helping society and our political representatives understand the importance of broadening health insurance coverage.


The United States is one of the few industrialized nations in the world that do not guarantee health insurance for their populations. Of the 30 countries in the Organization of Economic Cooperation and Development, only Mexico and Turkey have a higher uninsured rate than the United States (1). There are more than 17 million uninsured women (aged 18–64 years) in the United States. This number has increased by 1.2 million since 2004, with one half of this growth occurring among low-income women (2). The number of women in the United States who are uninsured grew three times faster than the number of men without health insurance during the late 1990s and early 2000s (3). In 2006, one in five women of childbearing age—totaling 12.6 million women—was uninsured, showing no improvement from 2005 and accounting for 27% of all uninsured Americans (4). Nearly eight out of ten uninsured women (79%) are in families with at least one part-time or full-time worker (2). Most uninsured women do not qualify for Medicaid, do not have access to employer-sponsored plans, and cannot afford individual policies. Access to health care also is affected by other barriers, including health literacy and cultural differences along with proximity to health care facilities and lack of transportation. Women who are young and low-income are particularly at risk of being uninsured, as are women of color, especially Latina women (2). Most low income uninsured women are not eligible for public programs but cannot afford private coverage (5). This is a problem for both U.S and non-U.S. citizens.

Effect of Lack of Insurance on Women's Reproductive Health and Health Care

Having health insurance does not guarantee good health, but not having insurance is guaranteed to put Americans at higher risk for poor health outcomes and economic hardship. Acquiring health insurance reduces mortality rates for the uninsured by 10–15% (6). The uninsured receive less preventive care, receive diagnoses at more advanced disease stages, and, once diseases are diagnosed, tend to receive less therapeutic care (7). Lack of health insurance may affect women's health in the following ways:

  • Uninsured pregnant women receive fewer prenatal care services than their insured counterparts (1) (a total of 18% of uninsured pregnant women reported that they did not receive some needed medical care versus 7.6% of privately insured and 8.1% of Medicaid-enrolled pregnant women [8]).
  • Uninsured pregnant women are more likely to experience an adverse maternal outcome (1).
  • Uninsured newborns are more likely to experience adverse health outcomes and are more likely to die than insured newborns (1).
  • Uninsured women with breast cancer have a 30–50% higher risk of dying than insured women with breast cancer (1).
  • Uninsured women's options for contraception are limited (9).
  • Uninsured women aged 18–64 years are three times less likely to have had a needed Pap test in the past 3 years (10). This contributes to a 60% greater risk of late-stage diagnosis of cervical cancer among uninsured women compared with insured women (11).

Uninsured Non-U.S. Citizens

As efforts to expand coverage are pursued, assessing the coverage needs of low-income non-citizen adults, who have a high uninsured rate caused by limited access to both private and public coverage, will be an important consideration (12). Following the 1996 welfare reform law, almost all legal immigrants became ineligible for federally matched Medicaid coverage during their first 5 years of residence in the United States. Undocumented immigrants and temporary immigrants generally are ineligible for Medicaid regardless of their length of residence in the country, a restriction that has been in place before welfare reform.

Principles for Reform of the U.S. Health Care System January 2007

PREAMBLE: Health care coverage for all is needed to facilitate access to quality health care, which will in turn improve the individual and collective health of society.

  1. Health care coverage for all is needed to ensure quality of care and to improve the health status of Americans.
  2. The health care system in the U.S. must provide appropriate health care to all people within the U.S. borders, without unreasonable financial barriers to care.
  3. Individuals and families must have catastrophic health coverage to provide protection from financial ruin.
  4. Improvement of health care quality and safety must be the goal of all health interventions, so that we can assure optimal outcomes for the resources expended.
  5. In reforming the health care system, we as a society must respect the ethical imperative of providing health care to individuals, responsible stewardship of community resources, and the importance of personal health responsibility.
  6. Access to and financing for appropriate health services must be a shared public/private cooperative effort, with a system which will allow individuals/ employers to purchase additional services or insurance.
  7. Cost management by all stakeholders, consistent with achieving quality health care, is critical to attaining a workable, affordable and sustainable health care system.
  8. Less complicated administrative systems are essential to reduce costs, and increase efficiency.
  9. Sufficient funds must be available for research (basic, clinical, translational, and health services), medical education, and comprehensive health information technology infrastructure and implementation.
  10. Sufficient funds must be available for public health and other essential medical services to include, but not be limited to, preventive services, trauma care and mental health services.
  11. Comprehensive medical liability reform is essential to ensure access to quality health care.

 

American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American College of Cardiology, American College of Emergency Physicians, American College of Obstetricians and Gynecologists, American College of Osteopathic Family Physicians, American College of Physicians, American College of Surgeons, American Medical Association, American Osteopathic Association. Principles for reform of the U.S. health care system. Leawood (KS): AAFP; Rosemont (IL): AAOS; Washington, DC: ACC; Irving (TX): ACEP; Washington, DC: ACOG; Arlington Heights (IL): ACOFP; Philadelphia (PA): ACP; Chicago (IL): ACS; Chicago (IL): AMA; Chicago (IL): AOA; 2007. Available at: http://www.acponline.org/pressroom/health_ reform.pdf. Retrieved June 10, 2008.

The Capacity of the Health Care System to Serve the Uninsured

The cost of uncompensated care is staggering; in 2004, it was estimated to be $40.7 billion. Most uncompensated care expenses are incurred by hospitals, where services are the most costly. In 2001, hospitals spent 63% of total costs in uncompensated care. Office-based physicians and direct care programs or clinics accounted for 18% and 19% of uncompensated costs, respectively (13). A 2001 Common-wealth Fund study found that the value of care provided by academic health centers to those who were unable to pay for their services increased as a percentage of gross patient revenues by more than 40% in the past decade (14). The number of patients treated at hospitals who are unable to pay is increasing as the number of uninsured individuals grows, threatening the financial viability of some institutions. The proportion of private physicians providing care to the uninsured is decreasing and those who provide such care are spending less time doing so (15). Specifically, the number of physicians providing any care to individuals unable to pay decreased from 71.5% in 2001 to 68.2% in 2005 (15). A combination of higher office expenses, including professional liability insurance, and stagnant insurance payments reduces the ability of physicians to provide uncompensated care.

Covering the Uninsured

In recent years, there has been bipartisan interest in broadening access to health coverage to the nearly 47 million uninsured Americans. Although there has been relatively little activity at the federal level, a handful of states have recently adopted or are considering adopting proposals to expand coverage. States are using a combination of strategies, such as expanding public programs to cover most children in a state, mandating employers to cover all workers or contribute to a public financing pool, and requiring all individuals to carry health insurance with subsidies for those with lower incomes. Massachusetts and Vermont passed laws in 2006 to achieve nearly universal coverage as well as address cost and quality. On April 12, 2006, Massachusetts enacted legislation requiring that individuals have health insurance and that the government provide subsidies to ensure affordability (16). Vermont's law, which includes access to subsidized or low-cost insurance, relies on voluntary participation. Approximately 21 states introduced universal coverage bills in 2007 (17).

Conclusion

Access to health care for all women is a paramount concern of the American College of Obstetricians and Gynecologists (see box). Pregnant women and infants are among the most vulnerable populations in the United States and the American College of Obstetricians and Gynecologists believes that providing them with full insurance coverage and access to care must be a priority. Lack of health care coverage creates access issues that affect women, practitioners, and the health care system as a whole. A change in our currently fragmented health care system is warranted to expand coverage to the millions of uninsured individuals within the U.S. borders. Health professionals can play a pivotal role in improving access to needed health care by helping society understand the importance of universal health care access. For a listing of resources on the topic of the uninsured, go to www.acog.org/goto/underserved.

References

  1. Institute of Medicine. Insuring America's health: principles and recommendations. Washington, DC: National Academies Press; 2004.
  2. Henry J. Kaiser Family Foundation.Women's health insurance coverage: December 2007. Menlo Park (CA): KFF; 2007. Available at: http://www.kff.org/womenshealth/upload/6000_06.pdf. Retrieved June 10, 2008.
  3. Lambrew JM. Diagnosing disparities in health insurance for women: a prescription for change. New York (NY): The Commonwealth Fund; 2001. Available at: http://www.commonwealthfund.org/usr_doc/lambrew_disparities_493.pdf?section=4039. Retrieved June 10, 2008.
  4. March of Dimes. Census data on uninsured women and children. Washington (DC): MOD; 2007. Available at: http://www.marchofdimes.com/Census.pdf. Retrieved June 10, 2008.
  5. Henry J. Kaiser Family Foundation. Characteristics of the uninsured: who is eligible for public coverage and who needs help affording coverage? Kaiser Commission on Medicaid and the Uninsured. Washington, DC: KFF; 2007. Available at: http://www.kff.org/uninsured/upload/7613.pdf. Retrieved June 10, 2008.
  6. Henry J. Kaiser Family Foundation. Sicker and poorer: the consequences of being uninsured. A review of the research on the relationship between health insurance, health, work, income, and education. Kaiser Commission on Medicaid and the Uninsured. Washington, DC: KFF; 2002. Available at: http://www.kff.org/uninsured/upload/Full-Report.pdf. Retrieved June 10, 2008.
  7. American College of Physicians–American Society of Internal Medicine. No health insurance? It's enough to make you sick. Philadelphia (PA): ACP-ASIM; 1999.
  8. Bernstein AB. Insurance status and use of health services by pregnant women. Washington, DC: Alpha Center; 1999. Available at: http://www.marchofdimes.com/files/bernstein_paper.pdf. Retrieved June 10, 2008.
  9. Sonfield A, Gold RB. New study documents major strides in drive for contraceptive coverage. Guttmacher Rep Public Policy 2004;7(2):4–5, 14.
  10. Ayanian JZ, Weissman JS, Schneider EC, Ginsburg JA, Zaslavsky AM. Unmet health needs of uninsured adults in the United States. JAMA 2000;284:2061–9.
  11. Ferrante JM, Gonzalez EC, Roetzheim RG, Pal N, Woodard L. Clinical and demographic predictors of late-stage cervical cancer. Arch Fam Med 2000;9:439–45.
  12. Henry J. Kaiser Family Foundation. Health insurance coverage and access to care for low-income non-citizen adults. Kaiser Commission on Medicaid and the Uninsured. Washington, DC: KFF; 2007. Available at: http://www.kff. org/uninsured/upload/7651.pdf. Retrieved June 10, 2008.
  13. Henry J. Kaiser Family Foundation. The cost of care for the uninsured: what do we spend, who pays, and what would full coverage add to medical spending? Issue update. Kaiser Commission on Medicaid and the Uninsured. Washington, DC: KFF; 2004. Available at: http://www.kff.org/uninsured/upload/The-Cost-of-Care-for-the-Uninsured-What-Do-We-Spend-Who-Pays-and-What-Would-Full-Coverage-Add-to-Medical-Spending.pdf. Retrieved June 10, 2008.
  14. The Commonwealth Fund. A shared responsibility: academic health centers and the provision of care to the poor and uninsured. A report of The Commonwealth Fund Task Force on Academic Health Centers. New York (NY): Commonwealth Fund; 2001. Available at: http://www.commonwealthfund.org/usr_doc/AHC_indigentcare_ 443.pdf?section=4039. Retrieved June 10, 2008.
  15. Center for Studying Health System Change. A growing hole in the safety net: physician charity care declines again. Tracking Report No. 13. Washington, DC: HSC; 2006. Available at: http://www.hschange.com/CONTENT/826/ 826.pdf. Retrieved June 10, 2008.
  16. Henry J. Kaiser Family Foundation. Massachusetts health care reform plan: an update. Kaiser Commission on Medicaid and the Uninsured. Washington, DC: KFF; 2007. Available at: http://www.kff.org/uninsured/upload/7494-02.pdf. Retrieved June 10, 2008.
  17. National Conference of State Legislatures. Health reform bills. Denver (CO): NCSL; 2007. Available at: http://www.ncsl.org/programs/health/universalhealth2007.htm. Retrieved June 10, 2008.

Copyright © September 2008 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. Requests for authorization to make photocopies should be directed to: Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400.

The Uninsured. ACOG Committee Opinion No.416. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008;112: 731–4.