Women’s Health and Election 2008

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Women consistently cite health care as one of the top issues they want the Presidential candidates to address, reflecting their experiences with the health care system as patients, mothers, and caregivers for frail and disabled family members.  Women’s priorities for health care reform cut across many critical topics, including health insurance coverage and affordability, the cornerstones of the candidates’ health proposals, as well as long-term care, delivery system issues, and reproductive health.  This brief discusses each of these issue areas from a women’s perspective and summarizes the presidential candidates’ stated positions on these topics.

How do health care costs and coverage affect women’s access to care? 

Affordability.   The impact of health costs can be particularly acute for women, who are more likely to use health care services throughout their lives, yet have lower incomes and fewer resources than men.  Women are more likely than men to report that cost is barrier to care (Figure 1) Even among privately insured women, 17% report delaying or going without needed health care because they could not afford associated costs such as co-payments or non-covered services.¹ The effects of costs are particularly acute for low-income women.² 

Figure 1

Problems Accessing Health Care Due to Cost

Sources:  Kaiser Health Tracking Poll: Election 2008  (conducted April 3-13, 2008).

Coverage. Almost 17 million women are uninsured, (18% of women) most of whom are in low-income working families.  Many of these women lack access to employer-based coverage because they work part-time/year or in firms or industries that don’t offer insurance.  Many women cannot purchase insurance on their own because they have pre-existing health conditions or cannot afford the monthly premiums.   Nationally, 63% of women get insurance through their own (38%) or their spouses employer (25%), 10% are assisted by Medicaid, and 6 purchase coverage through the individual market.³

Scope of benefits. Maternity care, prescription drugs, contraceptives and mental health care are important benefits for women.  Many of these benefits, especially mental health and contraceptives are limited in many job-based insurance plans and are typically excluded in the individual insurance market, particularly maternity care.⁴ 

The Candidates’ Positions:
Senator McCain proposes providing tax credits to help individuals purchase insurance in the individual insurance market and reforming the tax code to include the value of employer sponsored health insurance plans as part of workers’ taxable income.   The McCain proposal would create a federally-supported “Guaranteed Access Plan” to assist people who are denied coverage due to pre-existing conditions. ⁵

The campaign has no stated official position on the benefits that are often limited in the individual market, including maternity care, mental health, and contraceptives.

Senator Obama would expand public program coverage of low-income families, particularly Medicaid and SCHIP, and broaden access to employer-sponsored coverage.  For uninsured women who still would not qualify for Medicaid, Senator Obama’s proposal would provide subsidies for families to purchase coverage and provide a choice of plans through a health insurance exchange with a structure and benefits that would be similar to that offered to federal employees.⁶ 

What are the special long-term care concerns facing older women and their families?

Long-term care. Women have a longer life expectancy than men and comprise the vast majority of the oldest and frailest group of seniors.  Half (49%) of women (compared to 28% of men) over 65 live on less than $20,000 a year, 17% have physical disabilities, one-fourth (23%) have cognitive limitations and 39% live alone.   As a result, more than 75% of nursing home residents and two-thirds of home health users are women.⁷ 

Medicare offers very limited long-term care benefits (only after a hospitalization) and Medicaid pays for long-term care only for very poor women or those who have become impoverished from high health expenses.  In the private sector, individually purchased long-term insurance policies can be unaffordable to most middle income families unless purchased well before there is need for assistance. 

Caregiving.  In the U.S., 12% of women are caregivers to frail or ill relatives, including children, parents, or other family members.   While many women have taken advantage of the job protection provided by the Family and Medical Leave Act (FMLA), which allows workers to take up to 12 weeks of leave from their job to care for a new child, sick family member or for their own medical care, this law does not provide for paid leave.  In addition, many women do not have paid sick leave and do not get paid when they need to stay home or care for a sick family member.  

The Candidates’ Positions:
Senator McCain has stated his support for a variety of state-based programs for delivering care to people in a home setting, and stated that he will take steps to provide individuals monthly stipends to hire care providers and purchase care-related services and goods.⁸  He would not expand the FMLA and argues that sick days should be negotiated between management and labor and opposes employer mandates.⁹

Senator Obama supports the creation of a national insurance program to provide people with functional needs the financial assistance to pay for the supports and services that will enable them to live independently in their communities.  He also supports improving the quality of elder care, including training more nurses and health care workers in geriatrics.¹⁰ He  would support a requirement that employers provide seven paid sick days per year and expand the FMLA to cover businesses with 25 or more employees (currently 50 or more) and broaden the eligibility for the leave benefit to include an expanded list of purposes including for parents to participate in school activities, elder care, and to address domestic violence and sexual assault.¹¹ 

How is women’s health affected by the health care delivery system?

Provider Shortages.  Experts predict that the current health care workforce will be insufficient to meet future health needs.  This is particularly a concern for services that are important to women such as primary care, mammography, obstetrics/gynecology, abortion and mental health.  Fewer medical graduates are choosing primary care specialties and in 2004, nearly 50% of U.S. counties had no obstetrician/gynecologist providing direct patient care, and 87% of counties (representing 35% of U.S. women) had no abortion provider.  In some parts of the country, women wait more than 40 days for their first-time mammograms.¹² 

Prevention and Chronic Disease.  Rising rates of chronic illness and other preventable conditions indicate critical gaps in health promotion and delivery.  The cost of managing chronic conditions, which has been estimated to account for over 75% of health spending,¹³ has emerged as a major health reform issue.  Women are disproportionately affected by many chronic conditions such as asthma, obesity, arthritis, autoimmune diseases, and certain cancers. ¹⁴ For women, wellness and prevention initiatives are most successful when they are tailored to their biological needs and societal roles.

Information Technology. Enhanced use of information technology could benefit women by improving communication and coordination of care between providers. Women are more likely than men to rely on different providers, and women with multiple chronic conditions may visit as many as 16 different specialists in a year, often leading to duplicative diagnostic testing and confusion over care plans.¹⁵  Electronic records can also facilitate the transfer of sex- and gender-specific knowledge between researchers and clinicians, and enable tracking of individual patient outcomes.  For women who make the overwhelming majority of family health decisions, access to a comprehensive medical record may enhance record-keeping and clarify choices. 

Research.  Sex- and gender-based clinical research continues to find major differences in how men and women experience many aspects of disease, including risk factors, symptoms, detection, and treatment.  In addition to improving diagnosis and treatment, the identification of these differences can help shape effective policies on issues such as health care workforce development, prevention and chronic care initiatives, and the use of technology that better meet the health care needs of women. 

The Candidates’ Positions:
Senator McCain would promote public health initiatives that would include changing behavior, incentives to encourage screenings, and payment mechanisms that would reward outcomes and patient compliance.  He also supports more federal research on chronic disease.  He supports the rapid deployment of information systems and technology that will allow doctors to practice across state lines and argues that the market will respond to system demands and provide the health information technology infrastructure. ¹⁶

Senator Obama would expand funding to improve the primary care provider and public health practitioner workforce and would also establish community outreach programs to improve health care access in underserved areas.  He supports legislation to encourage research examining gender and health disparities.¹⁷ He maintains that the broad adoption of standards-based electronic health information systems will generate large savings in the health care system which will help fund his coverage expansion proposals. ¹⁸

How do federal policies affect women’s access to reproductive health services? 

Abortion. Federal and state laws have been used to restrict access to abortion services by banning intact D&E abortions (so-called “partial birth” abortions), imposing parental consent and waiting laws, exempting health care providers from performing abortions, restricting the use of public funds, and limiting services provided by U.S. funded non-governmental organizations.  It is likely that the next President will be faced with the selection of at least one new Supreme Court justice as well as several lower court federal judges, with these appointments possibly tipping access to abortion in either direction.

Contraception.  Contraception is one of the most widely used preventive care services for women.  Insurance coverage of contraceptives increases access for women.  Today,  27 states require private health plans to cover contraceptives, but a change in federal law would be needed to require that all employer-sponsored provide coverage.  For low-income women, public financing of family planning services through Title X, the federal family planning program, and Medicaid provides both access to contraception and primary care.  However, the level of Title X funding has not kept pace with medical inflation, straining the ability of providers to serve low-income women and teens. 

Education and information.  There have also been longstanding debates about the scope of information in teen sex education programs.  Federal funding for abstinence-only sex education which prohibits information about contraception and condoms has more than tripled since 2001. In the wake of the recent rise in teenage births ¹⁹ and with increasing evidence that sexually transmitted infections are a significant health concern for many teens, new attention is being directed to these issues. 

HIV.  As women account for a growing share of the HIV epidemic, there is greater emphasis on HIV testing and knowing one’s status.  The American College of Obstetricians and Gynecologists now recommends that all adult women be screened routinely for HIV.  Given the epidemic’s disproportionate impact on minorities and the effectiveness of treatments in slowing the progress of AIDS, there is also greater emphasis on encouraging women of color to be screened. 

The Candidates’ Positions:
Senator McCain supports overturning the Roe v. Wade decision and allowing states to decide on abortion legality.  He maintains that government should empower and strengthen pro-life organizations and efforts and supports the ban on the use of federal funds for abortion. ²⁰ He also supports a complete federal ban on certain abortions (so-called “partial birth” abortions). ²¹

Senator Obama supports upholding Roe v.Wade and opposed the ban on use of federal funds for abortion.²² He contends that state-level bans on certain abortions (so-called “partial birth” bans) should include exceptions for the pregnant woman’s health.  He supports requiring insurance companies to cover prescription contraceptives and would increase funding for the federal Title X program.  He also supports comprehensive sex education that teaches about abstinence as well as contraception. ²³

Included below are a series of questions to help further evaluate the candidates’ proposals.

• What strategies will the candidate employ to improve the affordability of health insurance for families? 
• Will plans be required to cover services such as maternity care, mental health, and contraceptives?
• How would the candidate's health reform program affect Medicaid and SCHIP coverage for low-income women and kids?
• How would the availability and affordability of long-term care services be improved?
• What efforts would the candidate undertake to address existing and future health care workforce shortages especially in the areas of primary care, mental health, obstetrics and gynecology, and radiology for mammography?  
• How would the candidate encourage further research on gender and health disparities?  
• How would the candidate address the impact of the AIDS epidemic on women, particularly  women of color of in the U.S.? 

Prepared by the Kaiser Family Foundation and the Connors Center for Women’s Health and Gender Biology at the Brigham and Women's Hospital.