-
https://clinton.presidentiallibraries.us/files/original/6ce80191486c138940afdfbe8da8e349.pdf
f4585ebe03082a89d2208ad72e1ce0df
PDF Text
Text
FOIA Number: 2006-0810-F
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Subseries:
OA/ID Number:
1232
FolderlD:
Folder Title:
Briefing Book on Reproductive Health Services [6]
Stack:
Row:
Section:
Shelf:
Position:
S
51
6
6
1
�i l WOMEN'S
HEALTH
A MODEL BENEFITS PACKAGE FOR WOMEN IN HEALTH CARE REFORM
Introduction
Health care reform offers an opportunity
care. While the public has understood for some
medical services, the system has not. Currently
for C A T s c a n s , while it ignores the essentials of
care and the importance of long term care.
to redefine the dimensions of health and health
time that health care is not the provision of
our health system is quick to pay expensive bills
primary care, the cost-effectiveness of preventive
Creating an appropriate standard under which a core benefits package is established is key
to the s u c c e s s of the entire system. Carefully reviewing current and proposed qualifying language,
the Campaign established the following standard: All services which are necessary or appropriate
for the maintenance and promotion of women's health should be included in a benefits package.
We do not recommend the application of a medically necessary standard because we
believe it is inconsistent with the promotion of good health. Although the term medically necessary
is not yet defined in pending legislation, many earlier proposals applied the medically necessary
standard embodied in Medicare. As defined Jby law, Medicare covers services necessary for the
diagnosis and treatment of illness or injury, or to improve the functioning of a malformed body part.
Defining a benefits package solely on the basis of medically necessary services could
contradict the goal of comprehensive health care reform and in some instances be contradictory to
provision of preventive services, a full range of reproductive services including abortion, and long
term care.
Primary a n d P r e v e n t i v e C a r e
The shift towards a cost-conscious
health care system which prevents illness, disease and
disability invites a strong emphasis on primary and preventive care for women.
The majority of
primary and preventive care services are low-cost, low-tech services which can be provided by a
range of health practitioners
in one-stop, out-patient
settings.
Most primary care services do not
require a physician,
other than for consultation and referral.
The provision of the primary and
preventive
care services for women listed in this summary would address the majority of common
health problems seen daily by primary care providers.
Equally important, these same services also
screen for cardiovascular
and infectious diseases, cancers, injuries and the other major causes of
death and disability in women.
Periodic History and Physical Exam. Including Blood Pressure Check, Urinalysis and
Cholesterol Screen. Personal health history and family history are reviewed to predict w h i c h
patients are at risk for disease. Screens for c o m m o n diseases such as diabetes and hypertension
prolong life and are cost-effective. A full physical exam also includes an eye exam, thyroid
evaluation and urinalysis. Blood pressure and weight checks as well as cholesterol screening
666 Eleventh 5;reet. NW. Suite 700. Washmaton. DC 20001
(202) 783-6686
FAX (202) 6:
356
�evaluate the patient for cardiovascular
disease, the leading cause of death for American
women.
Evaluations for nutrition, tobacco use, exercise, drug and substance use and violence, as well as
mental health status, are completed.
Regular, periodic primary care visits provide the most
important assessment of health status.
Osteoporosis. Osteoporosis is a major cause of death and disability in w o m e n . It is a
preventable, progressive disease w h i c h afflicts 5 0 % of w o m e n over the age of 4 5 and 9 0 % of
w o m e n over 7 5 . This bone-thinning disease results in 1.3 million fractures each year and over
5 0 , 0 0 0 deaths, costing an estimated $7-10 billion annually. Yet, the disease is largely preventable
b y alerting younger w o m e n to the importance o f dietary changes, weight-bearing exercise a n d
calcium. In w o m e n over age 3 5 bone loss may be arrested w i t h a combination of diet, exercise,
calcium supplements and, in high risk w o m e n , w i t h estrogen replacement therapy and other
treatments.
Mental Health Screen. Women suffer twice the rate of clinical depression as men.
However, three-quarters
of American women who experience clinical symptoms of depression
never receive treatment.
Some forms of anxiety disorder are also more common in women.
An
overwhelming
percentage (90%) of eating disorders occur in women.
And, in general,
women's
experience of mental illness differs from that of men, requiring appropriate screening and
treatment.
Over 20% of primary health care visits are mental health related. The American
Psychological Association states that parity of mental health benefits with medical/surgical
benefits
is cost effective.
Routine mental health screening for women would ensure improved detection of
mental illness in its earliest stages.
Domestic Violence.
Every 15 seconds an American woman is beaten in her own home.
Women are twice as likely to be injured by violence as to be diagnosed with cancer. Battering is
the single major cause of emergency room visits by women. The health consequences of violence
against women result not only in bruises, broken bones, infection and disease but, in long-term
mental health problems as well. The costs can be high - medical expenses are 2.5 times higher
and physician visits twice as high for victimized women versus non-victimized
women.
Emergency
room protocols to identify victims have been initiated in some hospitals but should be made
available nationwide.
Police arrest programs have demonstrated
that early intervention may be
effective in breaking the cycle of violence. However, routine domestic violence screening by health
professionals
- recently endorsed by the AMA - is still
uncommon.
Dental Check. Women are 2 0 times more likely than men to experience temporomandibular
joint dysfunction (TMJ). Pregnant w o m e n s h o w a significant increase in gingivitis and t o o t h decay.
Post-menopausal w o m e n are 9 0 % of individuals w i t h Sjogren's syndrome, an oral cavity disorder.
Failure to treat preventable tooth decay results in more than $ 1 6 billion in annual costs. Dental
screening w o u l d identify dental problems in w o m e n at early, preventable stages.
Vision Check. Diabetic retinopathy is a serious complication
of diabetes, leading to
blindness if left unchecked.
African- American women have twice the risk for diabetes as white
women.
Other populations, including Native American, Cuban, Mexican-American
and Puerto Rican
women also have a high prevalence of diabetes.
Women are a larger segment of the elderly, a
population also at risk for vision problems.
The National Eye Institute reports that over half the
cases of blindness due to diabetic retinopathy
could have been prevented if detected early.
Speech and Hearing Checks. Hearing loss is the most common health problem for older
women where hearing loss is associated with aging rather than physiologic dysfunction.
Older
women often inaccurately view hearing loss as an uncorrectable
consequence of aging.
Good
preventive care includes a periodic assessment for speech-language
and hearing
function.
�Limitations in independent living and functional status due to hearing loss can be reduced if
detected early.
Prescription Drugs and Devices. Prescription drugs and devices are an essential component
of some forms of diagnosis, prevention and treatment for women. They must be included as a
covered benefit for women so that primary and preventive care can be effective in slowing or
halting the progression to more serious conditions women may face. Appropriately prescribed
drugs and devices can improve health status and lower overall health cost.
Laboratory Tests and Immunizations. Specific laboratory tests and immunizations are
important diagnostic tools and serve to prevent illness and disease. For example, a fasting glucose
test for a woman with a prior history of gestational diabetes may alert her and her provider to the
onset of diabetes. Certain immunizations are known to be efficacious, such as DTP (diphtheriatetanus-pertussis) and hepatitis B vaccine. Infectious diseases such as polio were once widespread
-- there were more than 18,000 cases in 1954 -- and have now all but disappeared because of
basic and low-cost immunizations within primary care.
HIV Counseling and Anonymous Testing. Women are the fastest growing population with
HIV. An estimated 8 0 , 0 0 0 women aged 15 to 44 are currently infected. HIV seropositivity is now
nearly equal among men and women in several tested populations. By 1995, the Centers for
Disease Control (CDC) estimates that 7 5 , 0 0 0 women will have AIDS, compared to 2 6 , 0 0 0 today.
Universal anonymous testing with pre- a n d post-test counseling will ensure that women will choose
to be tested. Anonymous testing should be made accessible to women, in public health clinics,
family planning clinics and other settings where they seek primary care services. Studies by the
C D C have shown that persons who are tested at anonymous test sites are more likely to seek
additional care.
Primary a n d Preventive R e p r o d u c t i v e Health C a r e
Reproductive health services are an inseparable part of primary and preventive services for
women.
The full complement of reproductive services are linked to one another and are an integral
part of women's health and well being. Reproductive health services must be treated as a total
package of services for women. Reproductive health is part of the continuum of services over the
life course because women's reproductive
health needs precede, include and follow the
childbearing
years.
Periodic Gynecological
History and Exam, Including Pelvic Exam, Pap Smear and Clinical
Breast Exam. The gynecological
history and exam includes a survey of the woman's
reproductive
history, current sexual activity and contraceptive
use. The pelvic exam includes a check for
abnormalities
of the uterus, ovaries, rectum and abdominal organs. Screening for and counseling
about sexually transmitted
diseases is included. The Pap smear detects cancer in early stages cancerous cells can be detected up to 10 years before invasive cervical cancer develops.
The
survival rate of women with cervical cancer detected by Pap smear approaches 100%. The clinical
breast exam is performed to screen for breast cancer, the second most common cause of cancer in
women.
The exam is also an opportunity
for the practitioner to teach breast self-exam (BSE) and
to make a referral for mammography.
Regular, periodic gynecological
history and exam is essential
primary care for women.
M a m m o g r a m . More than 1 8 0 , 0 0 0 w o m e n were diagnosed with breast cancer in 1 9 9 2 and
4 6 , 0 0 0 w o m e n died from the disease. Reducing the mortality from breast cancer depends, in part.
�upon early detection. Mammograms are a p r o v e n screening t o o l for detecting breast cancer in
w o m e n . Research indicates that universal access to screening mammography w o u l d reduce breast
cancer m o r t a l i t y by 3 0 percent. However, many sub-populations of w o m e n including older,
African-American, Hispanic and poor w o m e n do not get screening mammograms. Physicians failing
to recommend mammograms for their patients and the lack of both public and private insurance
coverage contribute to the underutilization of mammograms.
Maternity Care. The full range of maternity care services, including prenatal, intrapartum
and postnatal care, are k n o w n to produce better outcomes for both mother and child. W o m e n w h o
lack access to prenatal care are t w i c e as likely to give birth to low-birth-weight or premature
babies. A n Institute o f Medicine study reported that for every dollar spent on prenatal care to l o w
i n c o m e w o m e n , savings o f $ 3 . 3 8 in medical care f o r their l o w - b i r t h - w e i g h t infants c o u l d be
achieved. Forty percent of w o m e n experience no complications during the prenatal or intrapartum
period. However, the remaining 6 0 % experience complications, about half being major
complications. Maternal mortality and morbidity including infection, hemorrhage, toxemia and
surgical interventions are reduced w i t h appropriate and timely maternity care.
Family Planning. Family planning services reduce the incidence of unplanned pregnancies -half of all pregnancies each year - by increasing access to contraceptive
services.
Family planning
also improves pregnancy outcomes for both mother and child by increasing the spacing
between
births. The National Commission on Infant Mortality estimates that 10 percent of all infant deaths
would be prevented if all pregnancies were planned. Every public dollar spent to provide
contraceptive
services saves an average of $4.40 that would otherwise be spent providing
medical
care, we/fare and social services to pregnant
women.
A b o r t i o n . Maternal mortality in New York State fell by 2 6 % after abortion was legalized in
the state in 1 9 7 0 . The availability o f safe abortion services is associated with declines in m a t e r n a l
mortality, l o w - b i r t h - w e i g h t infants a n d neonatal mortality. According to the Alan Guttmacher
Institute, the availability of legal abortion was the single most important factor in the decrease in
neonatal mortality between 1 9 6 4 and 1 9 7 7 .
Infertility. Infertility affects 2.3 million couples or 1 in 12 couples in the U.S. The National
Center f o r Health Statistics r e p o r t e d that 7.3 million women h a d one or more visits for infertility
treatment in 1988. Diagnosis of infertility in w o m e n includes determining when and if ovulation
occurs, the post-coital test, endometrial biopsy and laparoscopy. The majority o f infertile'couples
require conventional treatments, w i t h fewer than 2 % of couples using assisted reproductive
technologies. Infertility exacts an emotional toll on w o m e n , compounding the health consequences
of this condition. The American Psychological Association has reported that infertility is a major
risk factor for depression in w o m e n .
Sexually Transmitted Diseases. The major sexually transmitted diseases (STDs) include
gonorrhea, syphilis, genital herpes, chlamydia, human papillomavirus and AIDS. M a n y o f the
sexually transmitted diseases have no clear s y m p t o m s to alert women to seek treatment screening is vital. Untreated STDs can lead to pelvic inflammatory disease (PID), a serious
condition w h i c h can result in ectopic pregnancy and infertility. The Centers for Disease Control
(CDC) r e p o n that at least 7 forms of malignancy have been associated with STDs. Untreated STDs
can cause fetal and infant morbidity and death. One study in California estimated that $ 6 million in
treatment costs c o u l d be saved in one year i f patients in family planning clinics w i t h a s y m p t o m a t i c
chlamydial infections were screened. A CDC pilot chlamydia screening program led to a 51 %
decrease in the chlamydia rate among family planning clients between 1988 and 1 9 9 1 .
Menopause. A majority of American w o m e n spend up to one-third of their lives post-
�menopausally.
While menopause is a natural physiologic process, and not a medical condition, little
is known about it. Some of the health difficulties associated with menopause include hot flashes,
vaginal and urinary tract changes, thinning of bone and changes in mental health. Health providers
and educators can aid the majority of women to experience menopause without medical
interventions.
Long T e r m Care
Long term care integrates a continuum of home, community and institutional services.
These services include medical services, health care, mental health services, personal care,
nutrition services and social services. These services are delivered over a sustained period of time
to persons who have lost or never acquired some degree of functional capacity.
Long term care is a w o m a n ' s issue and a family issue. Long term care is an
intergenerational issue:
• 6 2 % of w o m e n over age 85 either reside in nursing homes or need assistance to
live at home
• 4 0 % of all Americans w h o need long term care services are under age 65
• a majority of Americans have experienced a long term care crisis or expect to
w i t h i n five years
• almost 8 0 % of long term care is provided by unpaid caregivers, usually w o m e n
family members
Surveys show that Americans are willing to provide long term care for family members but,
they lack support services to help them sustain their caregiving responsibilities. Many long term
care support services can be provided in the community and in the home, including:
• for mental health care the older population needs to be better served by
c o m m u n i t y mental health centers, private practitioners and nursing homes than currently
• nutritional services, including meals, counseling and education, can be provided in
congregate settings and through home-delivered meals programs
• home care services, equipment and supplies, including home health aid, hospice
benefit, mental health care, speech, physical and occupational therapy can be offered in the home
• social support services, including respite care, social worker, homemaker, help
w i t h heavy chores, caregiver support and training programs enable families to provide long term
care
• community support services, including transportation, escort, adult day care,
senior centers and information and referral services
• for prescription drugs and devices older Americans make up 1 2 % of the
population but, purchase 2 5 % of all prescriptions written annually, paying 6 4 % of their prescription
drug costs out of pocket
• counseling services, including counseling for diet, exercise, injury prevention,
tobacco use, drug and substance use, dental care, violence prevention, vision, speech and hearing
care
H e a l t h C a r e D e l i v e r e d In A V a r i e t y of S e t t i n g s .
Although most Americans think of health settings as the doctor's office and the hospital, a
wide variety of settings already exist for the delivery of health care. Community health, rural
health and migrant health centers, public health and family planning clinics, school-based or -linked
�clinics and allied health practitioners
offices are existing settings where a range of health
services
are provided.
Health care reform offers an opportunity
to increase and support the
cost-effective
delivery of affordable services in these many
settings.
Health care reform also offers an opportunity to restructure consumer a c c e s s to health
services. Primary, preventive and long term health care can be delivered in convenient,
community-based and affordable settings such as the workplace, schools, day care centers and in
the home. In a restructured health care setting the hospital would no longer expend costly
resources to provide primary or chronic care but, would provide only acute care services.
Community-based care means primary, preventive and long term care would be more accessible
and less costly than it is today.
A n example of a community-based setting is a family health center, located near or at a
public school and meeting the health needs of families, including w o m e n ' s health care needs.
Community-centered care emphasizes family and individual health, convenient access and
utilization of existing community resources such as schools or worksites.
Health C a r e Delivered by a Range of Providers.
With health care reform, women should have the option of care from the health care
provider of their choice, including the choice of women providers.
Providers should include not
only physicians, but nurse practitioners,
clinical nurse specialists, certified nurse midwives,
lay
midwives, licensed clinical social workers, optometrists,
podiatrists, psychologists
and other allied
health
practitioners.
In our current system many barriers prevent many non-physician providers from being full
participants in the health care system. The major obstacle to their panicipation is the practitioner
limits set by Medicare, Medicaid and other federal and state laws. With a restructuring of the
health care system we can enable a range of providers to provide health services in an efficient,
affordable and coordinated manner.
M i d w i v e s are an example of accessible, appropriate and cost-effective providers of primary
and preventive care for w o m e n . Midwives work in a range of settings in the community —
hospitals, free-standing clinics, physicians offices, birthing centers and the home. Midwives offer
maternity care services w i t h a minimum of costly interventions. Yet, studies of midwifery care
demonstrate that mortality rates are equivalent to those of physicians, certain types of morbidity
are much lower, surgical procedures are fewer and breastfeeding rates are higher.
Conclusion
Health care reform is an opportunity
to simultaneously
provide health care to the 37 million
uninsured and to create a system which offers accessible, appropriate and affordable health care
for all our citizens.
It is a unique opportunity
to redress many of the inequities women have faced
securing health care for themselves and their families.
This model benefits package for women demonstrates that the majority of health care for
women does not demand complex technology or sophisticated
medical settings -- both at a high
cost. Rather, the majority of health care for women is basic care which can be provided in lowcost settings by a range of efficient
providers.
�C o m p i l e d b y t h e s t a l l of t h e C a m p a i g n f o r W o m e n ' s
Heallh:
A n n e Kasper
Joan Kuriansky
Vanessa Mitchell
Alice Weiss
W i t h Contributions f r o m the following:
C W H Health Care Strategy Core Group:
Stephanie Aaronson
I n s t i t u t e (or W o m e n ' s Policy Research
J o Blum
Planned Parenthood Federation of A m e r i c a
Chris d e V r i e s
A m e r i c a n Nurses A s s o c i a t i o n
Pat Ford-Roegner
Service Employees International U n i o n
Carolin H e a d
A m e r i c a n A s s o c i a t i o n of University W o m e n
Joanne Hustead
W o m e n ' s Legal Defense Fund
Donna Lenholf
W o m e n ' s Legal Defense Fund
A n n Kolker
N o t i o n a l W o m e n ' s L a w Center
Cindy Pearson
National W o m e n ' s Health Network
Julia S c o n
N a t i o n a l Black W o m e n ' s H e a l t h Project
Diane T h o m p s o n
N a t i o n a l A b o r t i o n Rights A c t i o n League
Claudia W a y n e
A m e r i c a n Federation of S t a t e . C o u n t y , and M u n i c i p a l Employees
C W H Benefits Task Force:
Rachel B e n s o n - G o l d
J o Blum
Carolin Head
Jody Hoffman
Joanne Hustead
Tracy Johnson
Lisa Kaeser
Katherine Kany
A n n Kolker
Lynne Lawrence
Cindy Pearson
Lois S c h o e n b r u n
Julia S c o t t
Other Contributors
Alan Guttmacher Institute
Planned Parenthood Federation of A m e r i c a
A m e r i c a n A s s o c i a t i o n of University W o m e n
A m e r i c a n Federation of S t a t e . C o u n t y , and M u n i c i p a l E m p l o y e e s
W o m e n ' s Legal Defense Fund
Bass & H o w e s
A l a n G u t t m a c h e r Institute
Federation of Nurses and Health Professionals
N a t i o n a l W o m e n ' s L a w Center
A m e r i c a n Fertility S o c i e t y
National W o m e n ' s Health Network
A m e r i c a n Medical W o m e n ' s A s s o c i a t i o n
N a t i o n a l Black W o m e n ' s H e a l t h Project
include:
Patti
Blumer
The American Dietetic
Ellen
Battestelli
Planned P a r e n t h o o d Federation of
Alice
Dan
C e n t e r f o r R e s e a r c h o n W o m e n a n d G e n d e r , U n i v e r s i t y o f Illinois at
Chris
Gallagher
A m e r i c a n A c a d e m y of
Jane
Gnmstad
Michelle
Linda
Harrison
Huss
Sarah
Gwendolyn
Jennifer
Keita
Knauss
America
Otolaryngology
C e n t e r for Health Policy. University of
U n i v e r s i t y of Pittsburgh School o l
N a t i o n a l Eye
Kayson
Association
Wisconsin
Medicine
Institute
American Heart
Association
American Psychological
Association
Illinois C a u c u s o n T e e n
Pregnancy
Donna
Kohlhepp
M a r y l a n d A s s o c i a t i o n of Innovative H e a l t h
Judith
Littlejohn
Older W o m e n ' s
Janet
Melantz
J a n e t Piatt
Judy
Norsigian
Kelley
Phillips
Dianna
Porter
Jennifer
Prouty
Rosemary
Carol
Norma
Gillian
Stoll
Swenson
Thomas
Tolcr
Susan
Joan
Ruelka
SaKala
Kathleen
Fran
McCarty
Wise
Zaro
Practitioners
League
American Speech-Language-Hearing
Association
American Speech-Language-Hearing
Association
Boston W o m e n ' s Health Book
American Psychological
Older W o m e n ' s
Collective
Association
League
Nursing Administration. Brigham and W o m e n ' s
A m e r i c a n A c a d e m y of
Women's
Hospital.
Institute for Childbearing
Policy
C e n t e r for W o m e n Policy S t u d i e s / W o m e n and A I D S
Boston Women's
Health Book
American Medical W o m e n ' s
Midwives
Alliance of N o r t h
N a t i o n a l Institute for Dental
American
Boston
Ophthalmoiogy
Pharmaceutical
Collective
Association
America
Research
Association
Coalition
Chicago
�C A M P A I G N
~W k T
F O R
WOMENS
H
E
A
L
T
H
A PROPOSAL TO THE CLINTON ADMINISTRATION:
WOMEN'S HEALTH IN HEALTH CARE REFORM
EXECUTIVE SUMMARY
Women's requirements for health and well-being have largely been ignored by the
current health care system. Medical research, health care delivery and payment systems
have failed to address women's changing needs. In addition to biological differences, social
and economic factors conspire to impede women's access to quality health care. Therefore,
the Campaign for Women's Health makes the following recommendations:
1. Develop a health care system which provides universal access as well as a
comprehensive benefits package which meets women's health needs and is affordable.
2. Include in this health plan preventive health services, a full range of reproductive
health services, and long-term care. Offer services from a wide range of providers, in a
wide range of settings and provide accessible community-based care.
3. Include in the national research agenda increased attention to the health needs of
women, accelerate appointments of women to senior research positions, and create
opportunities for young women in scientific research.
4. Solicit input from the women's health community for appointments to key health
positions in the executive branch.
5. Ensure that representatives of the women's health community, including those of
different races, ages, income levels, and sexual orientations are included in decision-making
boards, commissions, and other advisory and regulatory bodies.
A Project of O W L
666 Eleventh Street, NW, Suite 700, Washington, DC 20001
(202)783-6686
FAX (202) 638-2356
�CAIVIPAIGIM
WOMENS
H
E
A
L
T
H
A PROPOSAL TO THE CLINTON ADMINISTRATION:
WOMEN'S HEALTH IN HEALTH CARE REFORM
The Campaign for Women's Health is a broad-based coalition of more than 70 national,
state, and grassroots organizations convened to assure that women's voices are heard in the
current debate on health care reform. Our member organizations include women's groups,
labor unions, health care organizations and others concerned about women and their health.
The Campaign for Women's Health represents more than 8 million individuals nationwide.
I. Introduction: Health Is A Woman's Issue... and Everyone's Issue
For too long the health of women has been ignored or set apart from our
nation's concerns about its citizens' health. Women are the majority of Americans,
comprising almost 52% of the U.S. population. And yet, the health of more than half our
citizens has been treated as marginal, of little concern to policymakers and providers
alike. Until two years ago the world's premier research facility, the National Institutes of
Health, paid scant attention to women. Only after the General Accounting Office reported
that merely 13% of the NIH budget is allocated to women's health research did the NIH
begin its major initiatives for women.
The NIH is but one example among many of the country's failure to address
women and their health. Heart disease is the leading killer of both men and women and,
until the Women's Health Initiative, every major study of this disease had been
conducted on men only. Other smaller studies have evaluated the treatment women receive
for heart disease and concluded that women's symptoms are often either ignored or treated
too late. Women are the caretakers of family health. Yet, few services exist to help women
take care of sick older relatives at home or get children to health clinics in their
communities.
Currently, 12 million women have no health insurance of any kind.
Millions more have inadequate coverage, tenuously based on either their marital status or
their employment. Almost 60% of men have health coverage through their jobs, whereas
just 37% of women have employment-based health insurance. Many women work part time,
in small businesses, and in sales or clerical jobs where health benefits are most often
A Project of O W L.
666 Eleventh Street, NW, Suite 700, Washington, DC 20001
(202) 783-6686
FAX (202) 638-2356
�unavailable.
As we move to considerations of how to reform the health care system,
women and their health must be foremost in the minds of policymakers. By addressing
women's needs in a reformed system we will begin to meet not only the needs of women,
but the needs of all our citizens.
II. Diseases and Conditions Affecting Women and Their Health
Women's health is, like the health of men, the importance of maintaining good
health, preventing disease and disability, treating illness, and creating the
circumstances for the optimal well-being of every individual. Women's health also
includes diseases and conditions which affect women differently than men and which are
unique, more prevalent or more serious in women. A number of often-severe chronic and
acute diseases disproportionately affect women, such as lupus erythematosus, chronic fatigue
syndrome, arthritis, and depression among others. The following are a few examples from
the breadth of women's health diseases and conditions:
Breast cancer strikes one out of eight women in her lifetime and in 1993 more than
180,000 women will be diagnosed with the disease. In 1992 nearly 50,000 women will have
died of breast cancer. Yet, little is known about the causes of breast cancer. Mammograms
are important health services for women and yet, only 30% of older women get the annual
mammograms the National Cancer Institute recommends. As important as they are in saving
women's lives, mammograms do not prevent or treat, but onlyfindexisting breast cancer in
women.
Osteoporosis is a disabling disorder which affects some 24 million Americans, both
men and women. However, four out of five individuals with osteoporosis are women. The
lifetime risk of a hip fracture isfifteenpercent in women, while it isfivepercent in men.
Following hip fracturefiftypercent of individuals will require assistance with daily living,
while fifteen to twenty-five percent will require long-term institutional care. The costs of
osteoporosis are staggering, some $10 billion per year. Yet, the federal government spends
only $20 million per year on research.
Women are the fastest growing segment of the population with HIV disease despite
public perception that it is a man's disease. The Centers for Disease Control report that
AIDS is now one of thefiveleading causes of death in all women agesfifteento forty-four.
AIDS disproportionately affects women of color throughout the country. Last year there was
a thirty-seven percent increase in the number of AIDS cases among women. Yet, women are
often misdiagnosed early on and clinical trials include few women. Men with AIDS have
access to more benefits, including Social Security Disability benefits which were designed for
men and not women. The June 1992 issue of the Journal of Infectious Disease reported that
women die more rapidly from AIDS than men because they are not tested, monitored and
treated adequately.
�Domestic violence is a serious health threat to women. Approximately one in four
women is attacked by a partner sometime in her life. Battering is the single largest cause of
injury to women, accounting for more emergency room visits than auto accidents, muggings
and rape combined. One in three women admitted to an emergency room has been seriously
abused as have almost a quarter of all pregnant women seeking prenatal care. Women who
have undergone violence are more prone to suicide and alcoholism, and battered women are
four to five times more likely to require psychiatric treatment.
The range of conditions and diseases affecting women and their health go well beyond
the above examples, from Alzheimers to urinary incontinence. By and large the majority of
this alphabet of illness affects men as well as women, although as the above examples
illustrate, women have special needs, as do men.
III. The Principles of the Campaign for Women's Health
The Campaign for Women's Health has developed a set of principles to meet the
health needs of women. The principles are a comprehensive approach to address the three
major areas in which reform is needed: treatment, access and research.
Treatment Needs
• Women require a full range of health care services to meet their unique health
needs, including comprehensive preventive, screening, diagnostic, and treatment
services.
• Pre-existing conditions must not be excluded from coverage.
•Preventive care services must include bur nor be limited to regular, appropriatelytimed check-ups, screening for cervical cancer (Pap resrs), breast cancer (clinical
breast examinations and mammography) and reproductive health services.
•A full range of reproductive health services must cover maternity care, prenatal and
postnatal care, family planning, abortion, and inferriliry.
•Services must be available in rhe home, in physicians' offices or other outpatient
senings, or in hospital, skilled nursing, long-term care or hospice facilities.
•Services should be appropriate to women and rheir health. Each woman should be
treated according to her individual needs. Sex role srereoryping and assumptions
about sexual orientation in the delivery of health care services must be eliminated by
means of public and, most imponant, provider education.
�Access to Health Care
• Ability to pay, employment status, marital status, public assistance (welfare) and
health status should not be barriers to eligibility for health services.
• The cost of health care services must be affordable. Cost sharing in the form of copayments and deductibles should nor constitute barriers to care. Medically necessary
preventive services should not be subject to cost-sharing.
• Eligibility for or enrollment in public programs or public assistance must not
preclude eligibility for health services or force a lesser standard of coverage, services
or care.
• Women musr have access ro full health care information as well as information
about treatment options and alternatives ro treatment in order to promote optimal
well-being and make informed choices regarding rheir health.
• Individuals enrolled in a health plan should have the option of extending health
insurance coverage to another family member or partner to parallel the coverage
available for married partners.
•Each individual should be covered from the moment of birth regardless of the form
the health care system takes. This can be accomplished either through a system that
covers everyone in their own right or one that covers dependents fully. Dependents
are to include all those individuals relying on an individual forfinancial,caregiving,
or other forms of tangible and intangible suppon.
• Services should be available through physicians, nurse practitioners, physician
assistants, and other appropriate health providers such as certified nurse midwives,
nurse midwives, health educators, licensed clinical social workers, clinical nurse
specialists, and others.
• Women should have the option of receiving care from women providers. Equitable
representation of women as physicians and health care providers ar all levels of care
should be achieved through expanded training programs.
• Primaiy care services should be community-based. Community health centers and
other forms of community-based care should be encouraged and expanded to meet the
needs of both rural and urban women.
• Primary care providers should be required ro provide comprehensive case
management to assure prevenrive health services, to make referrals to other providers,
and to provide for coordinated care for each individual based on each woman's
unique health needs.
• Where necessary, assistance to assure access ro needed care should be available
�including transportation, child and elder cure, caregiving arrangements and financial
assistance to pay out-of-pocket costs of needed care.
•Informal caregiving should be compensated and caregivers protected from workplace
job loss and employment discrimination because of caregiving responsibilities.
Research Needs
•Research should be conducted to redress the lack of data on the health of women.
New methodologies should be developed to account for women's reproductive
capacities and other gender differences as variables in rhe conduct of research.
• Women musr be included in clinical rrials in rhe same proportions as men and data
analyzed for gender differences. Research and analysis musr address sub-popularions
of women, including bur nor Urnired ro women of color, older women, minority
women, differently-abled women and women with specific health and medical
conditions.
• The research agenda should be expanded beyond traditional definitions of women's .
health to include issues related to the economic, social, and psychological
consequences of women's roles. These issues include bur are nor limited to: women
as caregivers, domestic violence, violence against women, sexually transmitted
diseases, workplace harassment and stress, occupational and workplace safety,
homelessness, housing, and lack of education, employment and job training.
• To increase the attention and sensitivity to women's health needs within the scientific
community a critical mass of senior women scientists musr be developed. Accelerated
appointment of senior women scienrisrs in rhe federal government and research
universities as well as the expansion of opportunities for young women in science must
be encouraged.
Any reform plan for the health care system must include the above principles if the
plan is to adequately meet the health needs of American women. By extension, a reform
plan which incorporates the principles of the Campaign for Women's Health
will also dramatically improve how the health care system meets the health needs of all our
citizens.
IV. Cornerstones of Health Care Reform for Women
A. A Comprehensive Benefits Package for Women
Universal access to health benefits must be a fundamental right, not a privilege. But,
access to a benefits package which includes only limited health services will fail to assure the
�health of all women. A basic benefits package, rather than a comprehensive benefits
package, will perpetuate the inequities of the current system: those who can afford it will pay
additional dollars for the health care they need and those less fortunate will go without. The
additional irony of a less-than-comprehensive benefits package is that those who can least
afford health care are those who frequently need it most.
Many recent health reform proposals have included hospital and physician care but,
have failed to include other essential services, including long-term care and even preventive
health services. All the proposals strictly limited coverage to "medically necessary" services.
Most of our older citizens have little protection against the high costs of long-term
care. And women are most vulnerable because they live longer and can least afford longterm care. Of the almost two million nursing home residents, 1.5 million are women.
Private long-term care insurance currently pays for just two percent of annual nursing home
costs. Less than one percent of home care costs are paid by private insurance. More than
half of nursing home costs and twenty percent of home care costs are paid out-of-pocket, by
those who can afford it.
Although some proposals have included mammograms and Pap smears, preventive
health for women goes well beyond these two tests. A range of preventive health services,
including blood pressure checks, colorectal screenings, glaucoma tests and diabetes work-ups
are but a few examples of the services women, and men, need to stay well and keep health
costs down.
Limiting benefits to "medically necessary" services may seriously compromise the
health of women in our country. Such a definition is both restrictive and unclear. What
does "medically necessary" mean and who decides? With such a definition in place women
may not have access to a range of important health services. Most important among these
are reproductive health services. Women are concerned that abortion, family planning,
contraceptive, and infertility services could be excluded in a benefits package limited to
"medically necessary" services.
A comprehensive benefits package for women will include the following:
Services
preventive health care
regular check ups
reproductive health care
long-term care
prescription drugs
mental health services
dental care
vision services
�Settings
hospitals
physicians offices
other outpatient settings
community health centers
clinics
specialized centers
skilled nursing centers
long-term care facilities
hospices
Providers
physicians
nurse practitioners
certified nurse midwives
nurse midwives
clinical nurse specialists
licensed clinical social workers
chiropractors
optometrists
podiatrists
psychologists
physical therapists
allied health practitioners
B. Reproductive Health Is An Important Part of Women's Health
Women's reproductive health has, for too long, either been ignored, denied, or
presumed to be all there is to women's health. Any reform of the current health system
must also include a renewed understanding of women's reproductive health: that it is an
important part of the overall health of women. This renewed perspective will enable
reform of our health system to include services for women's reproductive health in ways that
will benefit women's full health and well-being.
Prenatal, maternity, and postnatal care. Attention to these interrelated health
services is usually based on concern for the developing fetus and newborn. Yet, a woman's
health is as important as the health of the child she carries. While maternal mortality has
sharply declined, maternal morbidity from risks of pregnancy remains a serious threat to the
health of women. Insurance coverage for normal delivery has steeply declined, many
exclusions for obstetrical complications are used as cost-saving measures, and even some
aspects of normal maternity care are being excluded. A full range of prenatal, maternal, and
postnatal services for all women must be included in a reform proposal.
�Teen pregnancy. The United States leads all western countries in teen pregnancies.
One million teenage pregnancies occur each year, with 30,000 occurring in girls under age
fifteen. Underage pregnancies take a heavy toll on the health of young women and girls.
Pregnant teenagers have higher rates of maternal and obstetrical complications as well as
repeat pregnancies. Any reform of the health system must provide contraceptive, health, and
social education to limit the number of teen pregnancies and provide services specific to this
age group.
Abortion. The chilling effect of the politics of abortion has seriously eroded
women's access to this vital health service. The number of clinics, hospitals, and physicians
able to perform abortion has declined to the extent that twenty percent of American women
cannot get the abortions they want. Eighty-three percent of all U.S. counties no longer have
a clinic or hospital providing abortion. The number of abortion providers has declined more
than ten percent in the last five years. Fewer young doctors are receiving training in
abortion procedures. In 1991 only thirieen percent of obstetrics-gynecology residencies
provided abortion training for first-trimester abortions and only seven percent for secondtrimester abortions. Proposals for reform must assure women access to safe abortions by
trained health providers in community settings, with counseling, follow-up care,
transportation, and child care as needed.
Infertility. Infertility affects 4.9 million American women. Insurance coverage for
infertility is spotty at best. Infertility may be the first sign of underlying diseases, such as
pelvic inflammatory disease and endometriosis. Infertility is also a major risk factor for
depression. The emotional toll of the inability to conceive often takes a heavy toll on the
overall health of women.
Family planning and contraception. Family planning and contraceptive services
are an essential part of women's health for women to prevent unwanted and unintended
pregnancies. Again, the effects of abortion politics have forced a steady erosion of these
services and women's access to health education and counseling regarding reproduction. In
1992 cutbacks for family planning and contraceptive services forced funding to 1981 levels.
Additionally, women have fewer effective contraceptive choices now than in previous years.
Only one major private American company is doing contraceptive research, as compared
with thirteen in 1970. The NIH spent only $10 million on applied research in contraceptive
development in 1992. The ban on RU 486 is an example of the restrictions placed on
women's access to safe and effective contraception. Optimal health and well-being for
women cannot be achieved without reforms which assure that all women will have access to
a range of family planning and contraceptive services as needed.
Other Reproductive Health Services. Reproductive tract cancers, sexually
transmitted diseases, the dearth of information and services regarding the menstrual cycle and
menopause, and the excess of hysterectomies performed are just some of the other
reproductive health issues which must be addressed when including women's health in any
reform deliberations.
�C. Long-Term Care As A Part of Health Care Reform for Women
Long-term care is often the stepchild of health care reform. Most of the proposals
submitted to date have failed to include these important health services for women. Yet,
access to appropriate, comprehensive, and affordable long-term care services is as important
as any other segment of health care made available to our citizens.
The following principles should help guide the development of long-term care services
in a reformed health system:
•Access ro appropriare and affordable long-rerm care services for
all who need rhem
• Provision of a continuum of services, including home care services,
supportive social services, communin and institurional services
•Recognition of the role of all long-rerm care workers, including
adequare training, wages, working conditions, and benefits for paid caregivers
and assistance, respite, support services andfinancialsuppon where
appropriate for unpaid caregivers
• Comprehensive research in long-term care and chronic impairments to
improve the quality of long-term care now and in the future
V. Health Appointments In The Clinton Administration
The Campaign for Women's Health takes a strong interest in those individuals
chosen to fill the most important health positions in the federal government. These
individuals play vital roles as policymakers in the process of health reform and in the
implementation of the reforms that are made. Their selection is of great import to women
and the future of their health. To that end the Campaign for Women's Health is available
to offer recommendations for the following positions:
• Secretary of Health and Human Services
• Director of the National Institutes of
Health
• Administrator of the Health Care Financing
Administration
• Director of the Centers for Disease Control
and Prevention
• Commissioner of the Food and Drug
Administration
• Surgeon General
�VI. The Women's Health Community
The women's health community is extensive, diverse, and located throughout the
country. Members of this community include women's health organizations, health care
professionals, practitioners, and providers, activists and advocates, policymakers, consumers,
and academics. All the members of the community have a committment to improving the
health care system as it serves women. To that end, the Campaign for Women's Health
recommends the following:
•Recommendations for key health appointments in rhe executive branch
be sought from the women's health community
•Representatives of rhe women's healrh communiiy, including women of
different races, ages, income levels and sexual orienrarions be included on
decision-making boards, commissions, and orher advisory and regulatory
bodies establishing policies and procedures which affecr women's health
The Campaign for Women's Health welcomes the opportunity to work with the
Clinton Administration and offers its expertise on women and their health to the deliberations
on health care reform.
�CAIVIPAIGIM
TT 4 T
F O R
WOMENS
H
E
A
L
T
H
SETTING PRIORITIES FOR WOMEN'S HEALTH RESEARCH
In October 1991 the Campaign for Women's Health met with Dr. Bernadine Healy,
director of the National Institutes of Health, regarding the lack of research on health issues of
concern to women. Dr. Healy stated that the federal biomedical agenda has never adequately
addressed women's health research. While Dr. Healy has turned much needed attention to
women's health research, a great deal remains to be done. Few research studies are conducted
on diseases and conditions that affect women, few women are included in clinical trials, and the
country has insufficient numbers of women as senior scientists in the research establishment.
To redress these inadequacies, the Campaign for Women's Health makes the following
recommendations:
1. Give statutory authority to the NIH Office of Research on Women's Health and
increase its scope of authority to initiate and fund research on women's health. Require an
advisory board to the ORWH, to include at least one-third consumer representation from the
women's health community.
2. Continue the committment and funding for the Women's Health Initiative, the
Women's Aging Study, and other recently developed projects now underway. Develop a longrange strategy for women's health research studies to fill existing omissions of data on women's
health, particularly data on chronic diseases and prevention. Review the PHS Plan of Action
for Women's Health for its adequacy in meeting these long-range strategy goals.
1
3. Include women in clinical trials in the same proportion as men and analyze the data
for gender differences. Assure the inclusion of women of color, older women, minority women,
lesbian women, differently-abled women and women with specific health and medical conditions.
4. Develop new research methodologies to account for women's reproductive capacities.
Expand the definition of women's health to include the health consequences of the economic,
social and psychological roles of women, including but not limited to the health effects of
violence against women, poverty, homelessness, women as caregivers, workplace harassment,
stress, occupational and workplace safety, and lack of education, employment and job training.
5. Appoint a director of NIH openly sensitive to and supportive of women's health
research. Accelerate the appointment of women senior research scientists in the federal research
establishment. Develop programs to expand the opportunities for young women to enter
scientific professions.
A Project of O W L.
666 Eleventh Street. NW, Suite 700, Washington. DC 20001
(202) 783-6686
FAX (202) 638-2356
�Health Care Reform
A Unique Opportunity to Provide
Balance and Equity to the Provision of
Reproductive Health Services
By Jeannie I. Rosoff
^7
The Alan Guttmacher Institute
�Health Care Reform
A Unique Opportunity to Provide
Balance and Equity to the Provision of
Reproductive Health Services
By Jeannie I. Rosoff
The Alan Guttmacher Institute
111 Fifth Avenue
New York, New York 10003-1089
212-254-5656
2010 Massachusetts Avenue, NW
Washington, DC 20036-1023
202-296-4012
©1993 by The Alan Guttmacher Institute, An Independent, Nonprofit
Corporation for Research, Policy Analysis and Public Education. All rights
reserved under the Universal Copyright Convention, the Berne Convention for
the Protection of Literary and Artistic Works and the Inter- and Pan American
Copyright Conventions (Mexico City and Buenos Aires).
�Jeannie I. Rosoff is president of The Alan Guttmacher Institute.
The Alan Guttmacher Institute is an independent, nonprofit corporation for
research, policy analysis and public education focusing on reproductive health
issues.
The author is indebted to Rachel Benson Gold and Terry Sollom for their
previous research on federal and state health reform initiatives and gratefully
acknowledges the contributions of other Alan Guttmacher Institute colleagues
Beth Fredrick, Jacqueline Darroch Forrest and Cory Richards.
Special thanks to Regina Toler for her invaluable assistance.
The Jessie Smith Noyes Foundation helped to support the research for and
preparation of this document.
Copy Editor: Dore Hollander
Production Director: Valerie Morris
�TABLE OF CONTENTS
I. Purpose and Scope
2
II. Background
5
III. The Need for Reproductive Health Services
Definition
Consumers of Reproductive Health Services
7
7
8
FV. Insurance Coverage of Reproductive Health Services
Public Insurance
Private Insurance
9
9
9
V. Special Considerations in
The Inclusion of Reproductive Health Services
The Need for Definitions, Specificity
Avoiding Bias in Coverage
Preventing Delays, Ensuring Continuity
Individual and Societal Costs
VI. Additional Considerations
Confidentiality
Freedom of Conscience: Individuals and Providers
Access
VII. Major Congressional Plans
Single Payer Plans
Play or Pay Plans
Managed Competition Plans
12
12
13
14
15
17
17
17
18
19
19
19
20
VIII. State Initiatives
23
IX. Conclusion
26
References
27
Figure 1
28
Figure 2
29
Appendix A
30
Appendix B
32
Appendix C
33
The Alan Guttmacher Institute
•1 •
Health Carr Rrtnrm
�I. PURPOSE AND SCOPE
The national health care plan President Clinton will announce in May will provide
the impetus and theframeworkfor a broad national debate. However, the
competing interests of various components of the health care industry,
professional and consumer groups, and the taxpayers at laige, will be difficult to
reconcile.
In the end, all of these interests will be brought to bear on Congress, and
Congress will have the final word through the enactment of the necessary
enabling legislation. Many leading members of Congress have been deeply
engaged in the consideration of health carereformin recent years, and their
proposals and predilections will no doubt shape the final product. In addition,
depending on the number of congressional committees intimately involved in
the consideration of the Clinton plan—at a minimum those concerned with
taxation and health care —the number ofrepresentativesand senators with
directresponsibilityfor shaping, orreshaping,the final product may exceed
125. Each will have a particular philosophy and interest and will be under
pressure from various constituents and sectors of the health industry.
1
The twin and often conflicting imperatives to expand coverage to all or most
of the population and to contain costs drive most plans. Thus, the content of the
basic benefit package, which is central to reform plans, hasreceivedrelatively
little attention although it is probably the one aspect of thereformdebate that
has the greatest import for the public at large. Nevertheless, one element of cost
containment—coverage of preventive health services—will likely be
highlighted in the Clinton plan.
Should the President's benefit package be based on the practices of Health
Maintenance Organizations (HMOs), however, little current and authoritative
information is available on how comprehensive or uniform these practices
might be in regard toreproductivehealth services. Scattered information
suggests that the plan would likely cover "family planning services" (with or
without the all-important provision of drugs and devices), various screening
services for sexually transmitted diseases (STDs) and cancers as well as prenatal
and maternity services and well baby and well child care. One can only
speculate about HMO coverage of contraceptive sterilization, abortion and
infertility services provided directly or "out of plan."
Despite much rhetorical support for prevention, coverage of preventive
health services is given limited scope in most of the congressional proposals
introduced to date. Generally, the only preventive health services specified
(mandated) are those that have been the previous objects of congressional
concern and attention—such as prenatal care, well-baby and well-child care
and cancer screening tests. Reproductive health services—with the exception of
prenatal care—receive short shrift and are mentioned only rarely or sketchily.
The Alan Guttmacher Institute
•2•
Health Carr Reform
�It is not dear whether the lack of specification ofreproductivehealth
coverage is accidental—due to the general lack of spedfidty of some of the
plans—or intentional—an attempt to avoid the controversy that reproductive
health issues inevitably engender, but that nevertheless will have to be
confronted eventually. If their coverage is spelled out, some of the components
will certainly encounter opposition, but probably much support, as well. If
matters are left ambiguous, or delegated to a nonlegislativebody charged with
defining a benefit package, "contentious"reproductivehealth services will be
prime candidates for attempts at preemptive exdusion by congressional
opponents. One way or another, these issues cannot be ignored, but they could
easily be compromised in the drive to achieve consensus on the overarching
aspects of the plan.
Nevertheless, the indusion of a standard benefit package of reproductive
health care under a national health plan offers a unique opportunity not only to
secure these services for all women of childbearing age, but toredressserious
biases in the existing system that prejudice true freedom of choice in
childbearing.
Since its inception in 1968, The Alan Guttmacher Institute (AGI) has followed
national health insurance and health care debates in the United States as they
have waxed and waned. At the same time AGI has developed an expertise on
the provision andfinancingofreproductivehealth services. As health care
reform has become more of a reality, and with the support of The Jessie Smith
Noyes Foundation, AGI has brought this knowledge to bear in reviewing
spedfic aspects ofreproductivehealth care that merit spedal consideration, and
in examining major proposals introduced in the last Congress, as well as
selected proposed or enacted state initiatives. With this review, AGI hopes to
seize the present opportunity and to keepreproductivehealth issues prominent
in whatever debates may be forthcoming.
Specifically, thisreportdoes the following:
• Defines the content of areproductivehealth "package" of services
needed to enable individuals and families to have children under
optimum health and medical conditions, or not to have children with due
regard to theirrightto make these dedsions free of government intrusion
• Reviews what is known—and not known—about the current coverage of
reproductive health services under public (primarily Medicaid) and
private health insurance
• Outlines spedal attributes of reproductive health services that must
receive consideration prior to their inclusion in a benefit package, if
�individuals and families are to be able to exercise effectively the choices
mentioned above
• Points to issues besides inclusion of reproductive health services in the
basic benefit package, such as the need for confidentiality and freedom of
conscience provisions, as well as the necessity to maintain appropriate
"access points" to underserved or poorly served populations
• Evaluates recent major congressional plans and selected state initiatives
in the light of the previous two conditions
• Evaluates selected state initiatives in light of the same criteria
Because of the multiplicity and complexity of the issues involved, this report
does not address the merits, or demerits, of various financing and
administrative schemes. Given its limited scope, neither does it touch upon
other important matters, such as the following:
• Theresultsof numerous studies and reports that demonstrate the
essential and positive relationships between the planning of births (and
birth control services, broadly defined) and optimum pregnancy and
birth outcomes
• The costs and benefits of including a reproductive health services
"package" available to all Americans in a national health care reform
plan
• The incentives that are necessary to encourage the participation of not
only patients (such as the waiver of deductibles or copayments), but
providers, as well (such as preferential reimbursement rates for
preventive health services)
• The need to put in place (or maintain) service delivery mechanisms that
would ensure the availability and accessibility of preventive health
services to varied populations with diverse needs
The Alan Guttmacher Institute
•4•
Health Care Reform
�II. BACKGROUND
In 1945 Harry Truman became the first president in U. S. history to propose
universal health insurance coverage for all Americans. It was not until 20 years
later, however, that the Congress enacted two partial, and very different,
measures to provide health insurance coverage to the elderly (Medicare) and to
welfare recipients and other low-income individuals, mainly impoverished
mothers and children (Medicaid). Despite sporadic proposals by various
presidents and congressional bodies to extend coverage to the rest of the
uninsured population, the issue—almost 30 years later—is stillfarfrom
resolved. However, the escalation of health care costs and the mounting
number of uninsured Americans, coupled with the election of a new president
pledged toreform,may finally provide enough impetus for its solution.
The facts are now well known:
• The Commerce Department recently announced that national
expenditures for medical care in 1992 reached $8385 billion, and no
measures undertaken in recent years have been able to halt their
unrelenting increases.
• Medical care absorbed 1 % of the Gross Domestic Product (GDP) in 1992,
4
a far higher proportion than in other industrialized countries; resources
spent on medical cane detracted from support for other pressing social
and education need*
• The Commerce Department expects medical spending to increase 12 to
15% each year for the nextfiveyears unless significant changes in the
health care system occur
• At the same time an estimated 35 to 37 million Americans are without
health insurance of any kind, and many millions are underinsured or
sporadically uninsured
• The record of the United States on a number of health indices is no better,
and in some cases is worse, than that of countries where medical
expenditures are considerably lower and access to health care is universal
or virtually so.
Theserealities,not surprisingly, are fueling a renewed national debate for a
thoroughreformof the health care system that would both contain costs and
ensure all Americans access to at least a minimum package of benefits. Another
goal, often mentioned as both a cost containment measure and a desirable aim in
itself, is toredirectthe nation's medical enterprise, to the extent possible, away
from a predominant emphasis oh the cure or treatment of illness, and toward its
prevention, early detection and less-intrusive—and less-costly—means of treatment.
The Alan Guttmacher Institute
•5•
Health Care Reform
�Indeed, a 1992 report prepared for the U. S. Centers for Disease Control and
Prevention (CDC), suggests that "there is considerable public and political
support for a comprehensive (prevention] strategy to be incorporated in health
carereformplans." However, according to the authors, the proposals
introduced to date "fall short" in a variety of ways. They warned, "Without a
comprehensive preventive strategy the U. S. runs the risk of continuing to be
the most costly health system in the world, while continuing to experience a
substandard health outcome performance."
2
The Alan Guttmacher Institute
•6•
Health Care Reform
�III. THE NEED FOR
REPRODUCTIVE HEALTH SERVICES
Definition
To define the components and conditions of a comprehensive and balanced
package of reproductive health services, AGI assembled, in early 1992, a widely
representative task force comprising women's groups, medical organizations
and health financing experts. The group's recommendations are embodied in a
resolution adopted by AGI's Board of Directors in March 1992 (Appendix A).
Of course, how reproductive health services are defined in any public or
private plan is subject to vastly different interpretations. Suffice it to say that the
AGI list of recommendations is generally limited to those services that are
needed by women in their childbearing years (usually defined as between the
ages of 15 and 44). These services have direct implications for women's ability
not only to maintain overall health, but to choose to become pregnant, or not; to
decide on the timing of the births they have; and to prepare for pregnancy by
identifying preexisting medical conditions or hazardous life-style behaviors
that may have an adverse impact on their own health and that of their infants.
In some areas, the recommendations include services for men as well as women
(sterilization, infertility screening and treatment, screening for sexually
transmitted d
(STDs) and cancers of the reproductive system).
Reproductive health services identified include the following:
• Preconceptional risk assessment and care
• Contraceptive services and supplies
• Abortion services
• Voluntary contraceptive sterilization services
• Screening for STDs and cancers of the reproductive system, as well as
routine gynecological examinations
• Basic infertility services
• Maternity care, including prenatal, delivery and postnatal care
The indusion of STD screeningreflectsthe fact that, in the past 20 years, a
large number of diseases have become recognized as being sexually
transmitted. Often, STDs are asymptomatic in women; if undetected they may
lead to severe health problems, such as cancer or infertility, or to potentially
serious, if not fatal, health complications for the developing fetus and the infant
at birth. Basic infertility services are included because the inability to conceive
is a tremendous source of concern and anxiety for many couples, and because
The Alan Guttmacher Institute
•7•
Health Care Reform
�in many cases, infertility problems can be diagnosed and reproductive capacity
restored relatively easily. Including infertility services also serves the purpose
of dealing with all aspects of reproductive health in an evenhanded way, or
establishing, as a matter of public policy, a 'level playing field" in the decision
of whether to have a child.
Consumers of Reproductive Health Services
Most reproductive health issues affect women only, or women
disproportionately. Indeed, in 1985^ the number of women between the ages of
15 and 44 admitted to hospitals to have a baby or for other reproductive reasons
(4.9 million) exceeded the number of men admitted for any reason (4.1
million). However, both men and women need and utilize contraceptive
sterilization and infertility services, and the successful treatment of STDs
requires the extension of medical care to both partners if subsequent infection is
to be prevented.
3
Roughly 59 million American women are between the ages of 15 and 44. In
1990, more than six million became pregnant, and more than four million gave
birth. (The rest of the pregnancies ended in abortion or miscarriage. ) Some 90%
of the women in this age-group who are sexually active, fertile and not
currently pregnant or seeking to become pregnant use some form of
contraception and most use a method that requires formal medical
intervention. For example, they may rely on male or female sterilization (the
leading method of birth control in the United States), which entails surgery for
one partner, or on oral contraceptives (the second most popular method), which
requires a medical examination and prescription. In addition to the 27 million
current users of medical contraceptive methods (see Appendix B), some 500,000
women have received the long-lasting contraceptive implant Norplant® since
1990, according to its manufactunrs, Wyeth-Ayerst Laboratories.
4
5
Each year, some 1.6 million abortions take place, half are among the 10% of
women atriskof unintended pregnancy who did not use contraception at the
time, the other half are among women who experience a contraceptive failure
(of the method or the user) According to the CDC, 12 million American men
and women acquire an STD annually, and 8 of married couples are infertile or
%
have severe difficulty in conceiving and bearing a child.
4
The Alan Guttmacher Institute
•8•
Health Care Reform
�IV. INSURANCE COVERAGE OF
REPRODUCTIVE HEALTH SERVICES
In 1985 73% of women ofreproductiveage had some form of private insurance
and 10% relied on public insurance, primarily Medicaid. The remainder—or
one in six—were uncovered and had to assume the cost of their own medical
care, depend on publicly funded clinics if available, or forgo or delay care
altogether. This report describes Medicaid coverage of reproductive health
services first because the benefits are established by law and, in comparison
with those of private insurance, arerelativelywell documented.
7
Public Insurance
Medicaid eligibility is limited to low-income persons and is linked—in most
cases—to eligibility for welfare cash assistance. It is jointly financed and
administered by the states and the federal government, with variable eligibility
and benefits levels within broad national mandates. The provision of "family
planning services and supplies" is specifically mandated for all Medicaideligible recipients, and is reimbursable (by the federal government to the states)
at a preferential rate of 90 cents on the dollar. Federalregulationshave never
defined "family planning services and supplies," and the services provided
under this rubric may vary state by state. However, all states include coverage
of, and can identify expenditures for, contraceptive services, contraceptive
sterilization (under special federal regulations to guard against any potentially
coercive practices) and, according to recent reports, the relatively costly but
long-lasting contraceptive Norplant.
Although federal matching funds for abortions have been unavailable by law
since 1981 (except in cases of life endangerment), 12 states (California,
Connecticut, Hawaii, Maryland, Massachusetts, New Jersey, New York, North
Carolina, Oregon, Vermont, Washington and West Virginia) assume the cost of
abortions for their Medicaid-eligible populations entirely with state funds.
Infertility services might be covered under the rubric of family planning, but
since most Medicaid-eligible individuals in their childbearing years are single
mothers of young children, it is likely that few Medicaidrecipientssought such service.
Since the mid-1980s Congress has taken substantial steps to provide public
insurance for prenatal, maternity and child health services to low-income
persons. In a significant pohcy departure, these services—while administered
and financed under the Medicaid program—are no longer tied to the often
arcane eligibility provisions of the overall program. As of July 1,1990, all
women with family incomes below 133% (and in many states, 185%) of the
official poverty level are eligible for prenatal services, maternity and child
health care throughout the postpartum period (60 days after delivery).
Private Insurance
Another significant provision of federal lawregardingpregnancy and
maternity care, the Pregnancy Discrimination Act of 1978, applies to private
8
The Alan d l H m a r f c o r IncHh.t^
. O .
li I / - .
r ./
�health insurance. The act requires all employers with more than 15 employees
who provide health benefits to their employees (and dependents) to cover
pregnancy and delivery in the same manner they cover other medical care.
Nevertheless, in 1985-12% of the women of childbearing age who had private
insurance were not covered for pregnancy and maternity care, either because
they could not afford the premiums under individually purchased plans,
because they were nonspouse dependents of the policy holder (e.g., a teenage
daughter), because their pregnancy was treated as a preexisting condition and
thus a cause for exclusion, or for other reasons.
Privately insured individuals (and often their families) are most often
covered as a condition or benefit of employment. An employer can purchase
insurance coverage from a commercial insurance carrier, under a Blue
Cross/Blue Shield plan, from Health Maintenance Organizations (HMOs), a
Preferred Physician's Organizations (PPOs) and other organized networks.
Alternatively, an employer (usually a large enterprise or corporation) may
choose to "self insure." In many of these cases, claims processing and
administration may be delegated to a commercial insurer. Individuals (and
families) not covered by an employer-sponsored plan may purchase their own
coverage, although usually at a cost substantially higher than that of a
comparable group policy.
Overall, 7 % of Americans who are privately insured are enrolled in traditional
4
fee-for-service programs, 15% in HMOs and 10% in various forms of PPOs
usually referred to as "managed care systems." However, traditional insurance
programs have moved toward various ways of limiting utilization or linking
services needed by a particular patient or family, thereby blurring some
previously sharp distinctions between managed care and fee-for-service systems.
9
Lack of knowledge about the extent of insurance coverage for preventive health
services is pervasive, even asregardsservices for infants and small children,
which generallyreceivepreferential treatment by policymakers at the national and
state levels. According to the American Academy of Pediatrics, whichrevieweda
number of data sets from the public and private sectors, available information
tends to be poorly detailed, often lacking in definitions or specificity as to scope of
services provided or age groups covered. It is nevertheless dear that except in
HMOs even rudimentary coverage is often not available. Not surprisingly,
therefore, no comprehensive or current data exist on private insurance coverage
forreproductivehealth services, even for the coverage of prenatal and maternity
care (for which the latest information available dates back to 1985 before the bulk
of the Medicaid eligibility expansions).
10
There is little detailed information on insurance coverage of contraceptive
services, particularly the coverage of contraceptive drugs and devices, the cost of
The Alan Guttmacher Institute
• 10 •
Hmltfc Tor, RW^rm
�which may be prohibitive to many individuals. However, in 198$ four in ten
women used insurance (including Medicaid) to pay for all (24%) or some (17%)
of the cost of the medical visit itself. Higher income women were more likely to
have insurance even though the majority of insurance policies probably did not
cover nonsurgical contraception. But, even among women with family income at
200% of poverty, only 53% had coverage for contraceptive care." Since only one
health insurance participant in five appears to be covered for regular check-ups
it also seems doubtful that routine screening for STDs, which are often without
symptoms, particularly in women, would be covered in the absence of a specific
patient complaint. While most insurance plan participants may have coverage
for prescription drugs, it is not dear whether contraceptive drugs are typically
covered or are exduded as an adjund to preventive care. The extent of coverage
for contraceptive devices (as distind from prescription drugs), such as
intrauterine devices (lUDs) or Norplant, is unknown.
12
Information on coverage for sterilization and abortion is either sparse,
lacking or not contemporary. A1976 study showed that 34 of 37 major
commercial insurance companies surveyed induded coverage for female
sterilization, and 27 of the same 37 included coverage for vasedomies. In data
reported to the Commission for Professional Hospital activities, private
insurance was listed as the expected source of payment for 62% of all abortions
performed in 1985. However, only 10% of all abortions take place on an
inpatient hospital basis and thus arereportedin hospital discharge data.
13
14
According to the American Fertility Sodety, five states (California,
Connecticut, Hawaii, Illinois and Rhode Island) explidtly require some coverage
for infertility services, and six (Arkansas, Connecticut, Hawaii, Illinois,
Maryland and Texas)requiresome coverage for in vitro fertilization. The Health
Insurance Association of America estimates that 40% of individuals with private
health insurance have coverage for some servicesrelatedto in vitro fertilization.
The Alan Guttmacher Institute
• 11 •
Hr.alth Carr Rrform
�V. SPECIAL CONSIDERATIONS IN THE
INCLUSION OF REPRODUCTIVE HEALTH SERVICES
The Need for Definitions, Specificity
Generally, reimbursements under Medicare and Medicaid, and under most
health insurance plans, have been limited to "medically necessary" services or
forms of treatment. This term has been variously interpreted as meaning
measures strictly necessary to cure or alleviate illness, disease or disability or,
more broadly, what a physician determines to be necessary in view of his or her
training, philosophy or clinical judgment (subject to hospital utilization review
committees). Under this traditional definition, services meant only to prevent
illness or disability or, at least, to delay their onset or lessen their severity (e.g.
cancer or STD screening) would be excluded. Over time, of course, distinctions
between prevention and treatment have become blurred to a great extent.
Nevertheless, they still hold sway, particularly in the minds of insurers and the
health industry generally.
Moreover, most reproductive health services do not conform precisely to
either of these categorizations except if pregnancy, or the desire to avoid
pregnancy, is considered a disease or disability. Indeed, the insurance industry
has viewed them in the past as "elective" measures. "Elective" treatment, in
tum, is variously interpreted as a matter of choice for the physician or patient,
or as simply signaling that treatment is necessary but may be postponed for
cither's convenience without undue harm or hardship. In this context,
contraception, sterilization, abortion and infertility services are often described
as "elective," and, therefore, are excluded from coverage.
The definition of "family planning services" itself is a matter of much
confusion and controversy. For some, it means the provision of temporary or
reversible contraceptive methods of variable durations of effectiveness such as:
oral contraceptives, Depo-Provera (three months), lUDs (Progestasert, one year
or Paragard, eight years) and Norplant (five years). Others would add
contraceptive sterilization the purpose of which is also to prevent pregnancy,
albeit permanently. Still others would include abortion which, although strictly
speaking is not a modality of family "planning," is certainly a widely used
means of birth spacing and family size limitation. Indeed, in the 1970s, when
most states still paid for abortion under their Medicaid programs, a number
included their expenditures for abortion under the rubric of "family planning."
Clearly, ifreformplans are to cover preventive services, without ambiguity
and confusion, these definitions will have to berevised,sharpened or made
more inclusive.
Finally, since the effectiveness of preventive measures probably depends as
much on the patient's philosophy, background and perceptions of his or her
condition or risk potential as on the health care practitioner's "success" will
require a genuinely cooperative relationship between the two. That is, the
The Alan Guttmacher Institute
• 12 •
Health Carp Rrfnr
�selection of "treatment" will have to be as much the choice of the patient as that
of the service provider. Education, counseling and other support services, in
this context, are an integral part of the medical transaction and intervention. In
addition, as seen below, special provisions will have to be made if the choice of
the patient happens to conflict with the individual or "conscience"choice of the
health care practitioner or that of the practitioner's sponsoring institution.
Avoiding Bias in Coverage
A key factor in the formulation of health carereformplans is that they are likely
to be patterned after, or influenced by, the traditional structure and coverage of
private and public insurance plans. These plans (except for HMOs) are typically
geared to cover surgical and hospital costs and normally do not provide
coverage of most preventive health services. With the exception of prenatal
maternity care services, which must be included in most plans under the
Pregnancy Discrimination Act of 1978, sizable gaps exist in coverage.
There are substantial indications that, perhaps unwittingly, existing coverage
discriminates against the use of certain fertility control techniques and in favor
of others. For example, insurance probably often pays for surgical sterilization
regardless of whether the procedure is for therapeutic or "elective"
contraceptivereasons.On the other hand, coverage for lUDs, Norplant and
other expensive, long-lasting, but not permanent, contraceptives may be
exduded; coverage for the diaphragm, a contraceptive "device," and oral
contraceptive "drugs" (methods which, combined, account for some 12 million
contraceptive users each year) may also be exduded.
The indemnity plan offered under Hawaii's employer-mandated insurance
program is perhaps the best illustration of the bias toward coverage of surgical
procedures. The state Blue Cross/Blue Shield pays for the cost of both
contraceptive sterilization and abortion, but not for contraceptive services and
supplies or, for that matter, for preconceptional care. Other quirks of public
pohcy that need to be kept in mind result from the structure of public programs
such as Medicaid under which, for example, an indigent single mother is
eligible for family planning services and a free Norplant insertion in all states,
but a similarly indigent married woman (with spouse present) may not be
eligible.
Furthermore, while somereproductivehealth services affect only women,
others should involve both women and men. Thus, benefits should not be
structured, even inadvertently, in such a way as to exclude men and to put all
the burdens and responsibilities for seeking care on women (e.g., in the case of
contraceptive sterilization, infertility, and STD screening and treatment).
The Alan Guttmacher Instirute
• 13 •
Heallh Cure Rrform
�Preventing Delays, Ensuring Continuity
Experts agree that, ideally, a woman should start planning and preparing for
pregnancy with a preconceptional health assessment; should recognize the
signs of pregnancy early and should enroll swiftly in a program of health
supervision, which should continue throughout pregnancy and childbirth, and
indude postpartum care. In the case of an unplanned, unwanted pregnancy,
and if an abortion is contemplated, she should obtain the procedure as early in
the pregnancy as possible, when it is safest and generally least troubling.
Similarly, the use of contraceptives brooks no delays if an untended pregnancy
is to be avoided. Contraceptive use is not amenable to interruptions and must
be employed consistently over extended periods of time, normally for 25
years—assuming the average desired family size. The "immediacy" of need is a
feature of contraception, abortion and prenatal care. The need for continuity of
care over extended periods is substantial for pregnancy and considerable for
contraception.
Therefore, requirements and procedures that may delay initiation of care—
such as satisfying certain premivuns or meeting deductibles before care be
obtained or covered—are dearly contraindicated in the instance of most
reproductive health care as are, of course, waiting periods or exclusions for
preexisting conditions. Similarly, shifts in enrollment between plans (private
and public) with different benefit packages are likely to result in discontinuity
or interruption of care, with potentially harmful consequences (such as an
acddental pregnancy).
Additionally, assuming that "managed care" systems, of one kind or another,
are to become the norm rather than the exception, the triage system which is
basic to this form of organization may act to delay rather than fadlitate prompt
entry into care. Under this system, obtaining either a gynecological check-up or
contraceptive care may entail two separate appointments, one to the primary
care physician, and a second to a "specialist" who can provide the actual
service.
This arrangement is obviously burdensome, inconvenient and bound to
result in significant delays in obtaining needed medical care. It is also more
costly to the system than if only a single visit is required. The experience of
Great Britain's National Health Service (NHS) in regard to the provision of
abortion is instructive in this regard. Because women must/trst see their
primary care physician to verify a pregnancy and be referred to an obstetridangynecologist and then to a clinic or hospital, the proportion of abortions
performed after 12 weeks of gestation in England and Wales in 1988 was 13%
(residents only) versus 11% in the United States. An editorial in the British
Journal of Obstetrics and Gynecology, titled "Reducing Late Abortions," pointed
out that "referral and assessment for abortion takes longer within the National
15
16
Tlie Alan Guttmacher Institute
• 14 •
Health Care Reform
�Health Services (NHS) than in the private and charitable sectors. The NHS
carries only 21% of all its abortions before the 9th week as against 44% in the
private sector."
There are several ways, however, to avoid deleterious delays or needless
costs: providers of reproductive health services (induding the national network
of clinics that currently provide family planning services to over four million
women) could be recognized as primary care providers or, alternatively, they
could be designated as "gatekeepers" for the other health services needed by
the patient. In any event, insured individuals need direct access to reproductive
health services, induding the fadlities that provide abortion services to 1.6
million women each year.
Failure to spedfy coverage of reproductive health services or to take into
account their spedfic charaderistics has often required remedial action. For
example, the Medicaid Statute had to be amended in 1972 to guarantee the
provision of "family planning services and supplies" (emphasis added) to
Medicaid redpients, although theoretically, such services and supplies could or
should have been covered under the physicians' services, laboratory services
and prescription drugs authorized under the ad. Similarly, the Pregnancy
Discrimination A d of 1978 had to mandate the provisions of prenatal and
maternity care services since insurers, in general viewed them as "elective."
Failure to specify the provision of the various components of reproductive
health services in the basic benefit package could easily lead to de fado
exdusion at worst, and conflicting interpretations or misrepresentations at best.
Individual and Societal Costs
More generally, for the nearly 27million individuals who use medical methods
of contraception, insurance coverage for the method itself is an essential and
costly element of care (beyond continuing medical supervision and special
procedures, such as IUD or Norplant insertions, or hormonal injections, e.g.,
Depo-Provera), which require considerations in defining the reproductive
health package. Drug manufacturers tend to price their products to be rdatively
competitive. For example, in launching Norplant, Wyeth-Ayerst argued that the
high cost of the device (then $350) plus the cost of insertion and removal
(several hundred dollars) made this method very competitive with the use of
oral contraceptives over afive-yearperiod (the effective "life" of Norplant).
When, in fact, the cost of oral contraceptives over five years averages $1,180.
However, individuals are often not in a position to amortize their costs over a
long period of time or have sufficient resources to pay "up front."
Finally, provision of most reproductive health services (with possible
exception of delivery) can take place safely in dodor's offices or specialized
outpatient clinics, where it is less expensive, than in hospitals. And, it can
The Alan Guttmacher Institute
'IS*
Health Care Reform
�usually be theresponsibilityof specially trained health personnel working
under limited physician supervision. Thus, insurancereimbursementpolicies
should encourage the utilization of nonhospital-based facilities and trained
midlevel practitioners, both as a way to improve access to need and care and as
a cost control measure on its own.
The Alan Guttmacher Institute
• 16 •
Health Care Reform
�VI. ADDITIONAL CONSIDERATIONS
Confidentiality
Confidentiality is key to whether many, if not most, reproductive health care
services are really accessible to large numbers of women and men in need,
especially sexually active teenagers. The confidentiaUty in any health care
financing system where eligibility is based on a family unit must be a matter
of concern, and not only for teenagers. It is impossible for a family member
(particularly an adolescent) to obtain confidential services when he or she
has to obtain the family's insurance card or have a claim signed or
submitted by the policy holder (usually a husband or parent). To provide
effective access to reproductive health services, a health care reform plan
must ensure that individuals can obtain these services on a confidential
basis, whether from managed care plans, primary care physidans, or
freestanding clinics.
However, in many instances, individuals entitled to confidential services
under the plans may still fail to request them from a particular provider because
of fear of inadvertent disdosure, embarrassment or disapproval (real or
perceived). While this reticence may be most acute for teenagers, it may be a
potent source of discouragement for adults, as well, when seeking STD
screening, certain methods of contraception, abortion and even sterilization. A
reform plan must, therefore, allow for dired access to alternate providers on a
paid "out-of-plan" basis.
Freedom of Conscience: Individuals and Providers
There are well-founded concerns about the provision of reproductive health
care services in an environment dominated by managed care. These concerns
first arose around the provision of Medicaid-funded family planning services in
managed care programs when Medicaid enrollees began to face difficulties and
delays in services guaranteed to them by federal or state laws and regulations.
Not all care providers are able or willing—often for religious, moral, or even
individual attitudinal reasons—to offer all methods of contraception, or
abortion, or sterilization. As a result. Congress amended the Medicaid statute to
ensure that women enrolled in managed care plans under Medicaid waivers
remain free to seek family planning services from the provider of their choice,
such as a clinic or private physician.
To promote the provision of these services by managed care entities, a reform
plan should contain quality assurance requirements to ensure that they are
adequately providing fertility control services to their enrollees. First, plans
should be required to inform enrollees that all services (including sterilization,
abortion and STD screening) are available on a confidential basis to all
partidpants and provide a procedure to both prevent and redress problems
that would deter or delay beneficiaries from obtaining the services to which
they are entitled. Second, the data systems of managed care plans should
The Alan Guttmacher Institute
• 17 «
Health Care Rfform
�permit retrieval of utilization information to ensure that family planning
services are provided at appropriate levels.
However, despite the best of intentions, since it is unlikely that the full range
or services will be fully available to all in need, any health care reform plan
must retain the "freedom of choice" provisions currently embodied in the
Medicaid statute, and thus permit patients toreceiveservices "out of plan."
These provisions are necessary not only to protect the enrollees' entitlement to
services, but to avoid unnecessary and harmful conflicts and confrontations
when health personnel object, often for religious or moralreasons,to providing
the requested services. The insurer or entity managing the plan should bear the
ultimate responsibility for ensuring that covered services are provided
promptly and adequately—if necessary by making properreferraland other
arrangements on behalf of its enrollees with appropriate reimbursement for
services obtained "out of plan."
Access
While new and more adequate, and fair,financingmechanisms are a necessary
condition for reform, they are not sufficient to ensure the full availability and
accessibility of services to all. From earlier AGI studies of teenage (and adult)
pregnancy and childbearing in other industrialized countries, we know that in
spite of universal insurance coverage, supplemental mechanisms (clinics,
special education programs, etc.) have been necessary to address the needs of
specific populations, such as youth, disadvantaged minorities and immigrants.
Documentation of the experience of countries with national health insurance
systems, and of their need to ensure the availability of specialized services,
which are often beyond the ability or willingness of physicians to provide,
would complement, powerfully, the data that AGI attempts to maintain on the
operations of maternal and child health, family planning and other publicly
supported programs in the United States.
The Alan Guttmacher Institute
• 18 •
Health Care Reform
�VII. MAJOR CONGRESSIONAL PLANS
While members of Congress have introduced dozens of bills addressing the
issue of health care reform since 1991, the proposals are mostly variations on a
few central themes:
Single Payer Plans
Federally financed and administered plans that would cover all Americans (or
all U. S. residents) under one system of care with a standard benefit package are
considered as "single payer plans." Senator Paul Wellstone (D.-Minnesota)
introduced a prototype of the single payer plan which would subsume
Medicare and Medicaid and provide universal coverage and automatic
enrollment (the so-called Canadian plan). A variation on this scheme, proposed
by Representatives John Dingell (D.-Michigan) and Henry Waxman (D.Califomia) would also be federally funded and administered and provide a
uniform set of benefits. However, it would exclude individuals already covered
by Medicare and the military health benefit programs.
17
18
Play or Pay Plans
"Play or pay plans," in various ways, attempt to fill the gaps in coverage by a
combination of means: usually by requiring employers to provide a basic health
benefit package and by providing a new or enhanced public plan to cover the
partially employed, the unemployed or those not tied to the labor force. This
approach, the play or pay plans, would continue Medicare, but would require
employers to insure their full-time employees for a basic benefit package (or
have them pay premiums into a pool), and would devise new "public plans" to
cover most or all the rest of the uninsured.
Senator George Mitchell (D -Maine) and the Senate Democratic Leadership
offered a prototype of this proposal in 1991. It would require employers to
provide a basic benefit package and would create a new public plan to replace
Medicaid. The public plan would provide an "enhanced benefit package" for
all individuals currently eligible for Medicaid, as well as those with incomes
below 100% of the official poverty level; the package would cover any services
currently covered under Medicaid but not necessarily included in the basic
insurance package.
19
A 1992 variation, which Representatives Fortney Stark (D.-Califomia) and
Richard Gephardt (D.-Missouri) proposed, would also have employer plans
adhere to certain national standards. However, it would be based largely upon
an expansion of the current Medicaid program, with current benefits, to cover
all pregnant women and children up to age 19 with incomes below 200% of
poverty, and everyone else with incomes up to 133% of poverty. An optional,
supplemental plan for children would have benefits generally based on
Medicare, but with an extended preventive care package.
20
The Alan Guttmacher Institute
• 19 •
Health Care Reform
�Managed Competition Plans
This concept, first developed by a loosely knit group of economists and health
care leaders meeting in Jackson Hole, Wyoming, began to gain prominence
when the Conservative Democratic Forum introduced the Management
Competition Act of IWZ Under managed competition, individuals and
employees of all but the largest employers would be pooled into groups known
as Health Plan Purchasing Cooperatives (HPPCs, also known as Health
Insurance Purchasing Cooperatives), which would buy medical care coverage
on their behalf. HPPCs would negotiate with a range of payer/provider
networks, known as Accountable Health Plans (AHPs) (see Appendix C) that
would offer at least a standard benefit package, although they could offer
expanded benefits at an additional cost to the individual. Most of the plans
offered would likely have some managed care features (ranging from requiring
prior approval before hospitalization to structured systems such as HMOs).
Traditional indemnity plans would continue to be offered for individuals who,
at a greater out-of-pocket cost, wish to be able to continue choosing their
physicians.
21
Under this plan. Medicare would remain unaffected, but Medicaid would be
replaced by a hew federal program that would help individuals with incomes
below 200% of the poverty level to purchase coverage from competitive
managed care plans which would provide a minimum set of benefits. The plan
would indude federal subsidies for individuals below 100% of poverty for
services now covered under Medicaid but not included in the basic benefit
package. The basic benefit package itself would be set by a National Health
Board and would indude, among other things, "the full range of effective
clinical preventive services (including appropriate screening, counseling and
immunization and chemoprophylaxis)," i.e., the prevention of disease by
chemical or pharmaceutical means.
Under the preelection Clinton proposal, the benefit package would also be
determined by a National Health Care Board but would include, at least,
"ambulatory physician care, inpatient hospital care, prescription drugs, basic
mental health and important preventive care benefits, such as prenatal care and
an annual mammogram." Clinton also pledged to sign into law, among other
measures, the Women's Health Research Act as well as the Reproductive Health
Equity Ad, which would restore federal funding of abortions for Medicaid
redpients and a host of other Federal benefidaries. During the election
campaign, the candidate repeatedly pledged that his health care reform plan
would cover reproductive health services, including abortion.
22
However, until the President actually submits his health care reform proposal
to Congress, one can only guess to its overall structure, cost containment
features and basic benefit package, as well as how its implementation will be
The Alan Guttmacher Institute
• 20 •
Health Care Reform
�phased in. The different approaches to health care reform outlined above were
selected for study either because they proposed a radical restructuring of the
U. S. health insurance system (Wellstone), their authors were likely to be
particularly influential in the congressional debate (Mitchell, Dingell/Waxman,
Stark/Gephardt) or their approach appeared to be dose to that envisioned by
the President (Conservative Democratic Forum). Each was in tum examined for
the following features, which would diredly affect the provision of preventive
health services in general and reproductive health services in particular:
• Populations covered, and not oovered, for different benefit packages, so
that change in insurance status could result in temporary or permanent
disqualification for certain services
Potential impact of the abolition of Medicaid and itsrelativelyfavorable
coverage ofreproductivehealth services
• Provision and spedfidty of preventive health services in general and
reproductive health services in particular
• Coverage of contraceptive drugs and devices
• Requirements, or lack thereof, for premiums or yearly deductibles to be
satisfied before services can be obtained or covered
The summary presented in Figure 1 of the speciallyrelevantprovisions
regarding reproductive health care is hardly encouraging in regard to these
criteria. To the degree that preventive services are mentioned as part of the
proposed congressional benefit packages, they are generally limited to prenatal
services and well-baby and well-child care, which Congress mandated (under
Medicaid) in the middle and late 1980s, and to mammography and cervical
cancer tests, which have been the subjed of special congressional consideration
in recent years. In most cases, benefits for low-income individuals and families
would continue according to current Medicaid policies. However, only the
Dingell/Waxman proposal specifies the provision of "family planning
services" (however defined) to all Americans. Of course. Department of Health
and Human Services or other standard-setting bodies could spedfy them. Still,
it is worth noting that under the Mitchell proposal, at least, private plan
coverage would explidtly exclude all preventive services (other than prenatal
and well child care, mammograms and Pap tests).
Most of the plans, fortunately, waive copayments or deductibles or provide
for sliding scales to fadlitate access to covered preventive health services.
Nevertheless, employer-imposed premiums and deductibles, which must be
satisfied before preventive health services may be obtained or covered, could
The Alan Guttmacher Institute
• 21 •
Hnlih rnr, R,fnr~,
�militate against early and timely utilization. On the other hand, a matter of
special concern regarding the provision of contraceptive services relates to the
coverage of prescription drugs and medical devices that the major
congressional plans do not cover, specify or are, at best, phased in.
While it is true that in most proposals, the categories of services to be covered
in the basic benefit package are very broad and their final specification is
delegated to various standard-setting bodies, the fact that some services (e.g.,
well-child care) are specified and others are not must reflect some order of
priority on the part of the authors of legislation. It is also notable that while all
basic benefit plans cover physicians' (and other health care providers') services,
as well as in-hospital services, reproductive health services are not
automatically covered under these rubrics. Even coverage of physicians'
services cannot be automatically assumed to indude preventive care.
The Alan Guttmacher Institute
• 22 •
Health Care Rrform
�VIII. STATE INITIATIVES
As increasing numbers of people lacked or feared losing health coverage in the
middle and late 1980s, states took a number of initiatives to improve access to
care for the uninsured. However, first local economic recessions and then the
national economic downturn forced the states to curtail expenditures and slow
the pace of health care reform. Still, infiscalyear 1991 and 1992 according to a
nationwide survey, 44 states took at least one action to increase access to health
care, while 22 states reduced access by restricting eligibility or decreasing
funding to health care programs for poor or low-income people.
The most common steps intended to increase access did not involve any state
expenditures; rather, they tended to try to decrease the cost of insurance by
waiving mandated benefits for state-regulated health insurance plans sold to
small groups or individuals or through other means. However, increases in
enrollments were small, and these steps do not appear to hold much promise
for achieving universal or even wide coverage. Most of the expansions occurred
in small demonstrations or other narrowly targeted programs serving relatively
few people. Other state initiatives were targeted at improving insurance
coverage for children. For example, 11 states established state-funded insurance
programs for pregnant women and children. Nine states and the District of
Columbia now mandate the provision of preventive health services to children
under state insurance policies; however, at least in California, which requires
coverage of all health supervision services from birth through age 16
preventive health services are still subject to deductibles and copayments.
23
24
Moreover, the 1974 Employee Retirement Income and Security Act (ERISA)
severely constrained states' ability to advance more comprehensive measures to
provide universal health insurance to their residents. The law prohibits states
from requiring that all employers offer health insurance, regulating the terms
and conditions of self-insured employee benefit plans and taxing plans to fund
high-risk pools.
25
Nevertheless, five major plans were enacted prior to 1992. The first (in Hawaii)
dates back to 1974. Two were intended to provide universal access but their
implementation has been postponed indefinitely (Massachusetts) or were
delayed until very recently (Oregon). Two more (in Maine and Washington) are
among demonstration programs that could eventually lead to universal
coverage. Five other measures were enacted in 1992; four of these (in Colorado,
Oklahoma, Florida and Vermont) established mechanisms for the development
and implementation of plans by specified dates through 1995. Minnesota, which
started in 1992 to expand health coverage to low-income groups as a first step
toward state universal coverage, had a partially operational plan in place by the
end of 1992. At year's end, many other legislatures were considering more or
less ambitious plans that would have, in most cases,requireda waiver of the
ERISA or Medicaid laws and regulations. It is not yet dear how the perception of
The Alan Guttmacher Institute
• 23 •
Health Care Reform
�impending national action will affect the states'reformmomentum, but it is
clear that these plans coverreproductivehealth services selectively, if at all.
Prior to the 1980s, Hawaii adopted its Prepaid Health Care Act, an employerbased insurance mandate that (accompanied by other coverage for those not tied
to the labor force) achieves virtually universal coverage. Some 88% of state
residents are covered by employment-based insurance. Two insurers cover most
Hawaiians: Blue Cross/Blue Shield (also called Hawaii Medical Services
Association) with the majority of enrollees in its fee-for-service plans; and Kaiser
Permanente, accounting for about 20% of the total in its HMO plans. When
Medicaid is also taken into account it is estimated that 98% of the population has
insurance of some sort. Under SHIP, the state purchases insurance from Blue
Cross/Blue Shield and Kaiser Permanente and then pays the entire premium for
those individuals and families with income less than 100% of the poverty level.
Those between 100% and 300% of poverty contribute to their own coverage on a
sliding scale.
In 1988y Massachusetts adopted its Health Security Act, a variant of employermandated insurance intended to extend universal coverage by 1992. However,
this "play or pay" plan has not been implemented (and no basic benefit package
has been established) because of the state'sfiscaldifficulties, and the election of a
new governor strongly opposed to the plan makes its eventual disposition
uncertain. Meanwhile, other components of the act have been implemented: to
subsidize COBRA payments for the continuation of insurance for individuals
who haverecentlybecome unemployed and to provide managed care to other
uninsured individuals with family incomes below 200% of poverty.
The Oregon Health Plan, enacted in 1989, was intended to provide universal
access by 1995 through a four-part program, hinging on federal approval of its
Medicaid component. This approval was denied in 1992, but the Clinton
Administration has now allowed the program with some modifications. The
Medicaid component of the program would cover more people but curtails
some services viewed by the state as being of low priority or effectiveness. A
"play or pay" mandate that wouldrequireemployers to provide basic insurance
coverage or contribute to an insurance pool fund is on hold. A basic benefit
package has not yet been established for the employer-mandate component.
Two other components of the plan, which have been implemented, guarantee
coverage to those unable to obtain private insurance because of preexisting
conditions and assists small employers in providing group health insurance.
It is the Medicaid-priority setting feature of the Oregon plan that had created
controversy. On the basis of available medical information and the views of
Oregonians as expressed in polls and public forums, the plan ranked several
hundred conditions and treatments as to their effectiveness. Each year, the
The Alan Guttmacher Institute
• 24 •
Health Care Reform
�annual budget will determine how far down the list the ranked services could
be funded. Some observers have argued that the plan constitutes rationing of
health care, others that it offers a more rational and equitable allocation of
scarce resources.
The Maine Health Program was enacted in 1990 and demonstration funds
were awarded for its implementation in 1991 by the Health Care Financing
Program (DHHS). The plan uses state funds to provide Medicaid-like coverage
to adults with income at or below 95% of the federal poverty level and to
children with family incomes up to 125% of poverty. Washington's Health Care
Access Act, adopted in 1987 and revised in 1992, subsidizes a number of
demonstration programs to enroll persons not covered by Medicaid whose
income is below 200% of poverty in selected managed care systems. The state
sets premiums according to a sliding scale. The minimum premium is set at $10
a month and the average premium was $34 in 1991.
Minnesota Care, enacted in 1992, takes yet another approach. It finances its
planned expansion of health care, with a strong emphasis on preventive care,
through a variety of taxes—^including taxes on providers (hospitals, other forprofit and not-for-profit health fadlities and HMOs). The taxes are being
contested in the courts. By January 199^ enrollment was open to families with
children with incomes up to 275% of poverty and by January 1994> all other
adults should be able to participate. While enrollees (other than those who are
Medicaid-eligibles) can still pick their own provider, the essential goal is to
move to a network of managed care providers, with additional charges to those
opting for services "out of plan."
Figure 2 summarizes the provisions of the two statewide insurance coverage
programs currently operative, although it should be kept in mind that Hawaii's
has been in existence for an extensive period of time and Minnesota is still in its
inception. The provisions of the other three plans, summarized in the table,
either have just been approved (Oregon) or are onlyrepresentativeof
demonstration programs. The detailed provisions of the four components of
Hawaii's near universal insurance coverage illustrate the inconsistendes of
coverage between plans, particularly the exclusion of contraceptive services,
STD screening and preconceptional care in the fee-for-service plans. Minnesota,
on the other hand, apparently places great emphasis on preventive care, but
exdudes abortion, as it does under its Medicaid program. Meanwhile,
Washington, which does pay for abortions under its Medicaid program,
apparently exdudes it in its trend-setting demonstration project. All in all, the
plansreveallittle conformity, even in states that may be considered in the
vanguard of comprehensive reform.
The Alan Guttmacher Institute
»25»
Health Care Reform
�IX. CONCLUSION
The formulation of a health care reform plan for the nation presents an historic
opportunity to guarantee equitable protection to all Americans against the
unavoidable costs of illness, disease and injury. At the same time, it offers a new
and unique opportunity to restructure the health care system so as to prevent,
postpone or alleviate these conditions to the maximum extent possible, to help
contain runaway national medical expenditures and to improve the quality of
life and functioning for all.
Some health needs are specific to certain age groups or certain subsets of the
population. One set of special needs is easily identifiable: they relate to the
processes of sexual behavior, pregnancy and human reproduction, generally
grouped under the heading of "reproductive health." These needs affect the
health, well-being and functioning of women in their childbearing years in a
singular way; but they affect the health and well-being of men as well. Their
impact extends to individual children, individual families, and, more broadly,
to the health and well-being of future generations.
Pregnancy, STDs, infertility, pregnancy prevention or termination, and
cancers of thereproductivesystem have often been viewed and treated in the
past as isolated and unrelated events. The time has now come to look at
reproductive health needs in a comprehensive manner as a set of
complementary and interconnected conditions, services and programs.
The task, unfortunately, is not simple, as has been pointed out in this report.
New definitions are needed, specificity isrequired,obstacles must be identified
and overcome, and new insights and stronger political will has to be developed.
The goal, however, is clear a more consistent, fair and pluralistic approach to
the provision of reproductive health services in the United States. The reality is
still to come.
The Alan Guttmacher Institute
• 26 •
Heahh Care Reform
�REFERENCES
1. Senate Finance, Senate Labor and Human Resources Committees; House Ways & Means and
House Energy and Commerce Committee (and the la tier's Subcommittee on Health and
Environment)
2. K. Davis, et.al.. Health Care Reform and Preventive Services, Centers for Disease Control and
Prevention, Atlanta, August 21,1992.
3. R.B. Gold, A.M. Kenney, S. Singh, Blessed Events and the Bottom Line: Financing Maternity Care in
the United States, The Alan Guttmacher Institute, New York, NY, 1987.
4. Facts In Brief. Pregnancy and Birth in the United States, The Alan Guttmacher Institute, New York,
NY, 1993.
5. Facts In Brief. Contraceptive Use, The Alan Guttmacher Institute, New York, NY, 1993.
6. S.K. Henshaw, J. Silverman, "Characteristics and Prior Contraceptive Use of U.S. Abortion
Patients," Family Planning Perspectives, 20:158,1988.
7. Op. cit. 3.
8. PL 95—555
9. N. DeLew, G. Greenberg and K. Kincheu, "A Layman's Guide to the U.S. Health Care System,"
Health Care Financing Review, Vol. 14, No. 1.
10. Child Financing Report, American Academy of Pediatrics, Vol. 4, No. 3, Winter, 1993.
11. J.D. Forrest, Norplant and Poor Women, The Henry J. Kaiser Family Foundation, Menlo Park,
CA,1992.
12. A Profile of Group Major Medical Expense Insurance in the United States, Health Insurance
Association of America, Washington, DC, 1986.
13. CF. Muller, "Insurance Coverage of Abortion, Contraception and Sterilization," Family
' 'lanning Perspectives, 10:71,1978.
14. S.K. Henshaw, J. Van Vort, Abortion Factbook, 1992 Edition: Readings, Trends, and State and Local
Data to 1988,The Alan Guttmacher Institute, New York, NY, 1992.
15. Office of Population Censuses and Surveys, Abortion Statistics, 1988, England and Wales, Her
Majesty's Stationery Office, London; and S.K. Henshaw, J. Van Vort, Abortion Factbook, 1992
Edition: Readings, Trends, and State and Local Data to 1988, The Alan Guttmacher Institute, New
York, NY, 1992, p. 180, Table 5.
16. February 1989,96:135-139.
17. S 2320, introduced March 5,1992.
18. HR 5514, introduced June 3,1992.
19. S1227, introduced June 4,1991.
20. HR 5502, introduced June 26,1992.
21. HR 5926, introduced September 15,1992.
22. "Putting People First: Health Care Our Families Can Afford," Journal of American Health Policy,
September/October 1992.
23. D.J. Lipson, S.D. Gold, State Budget Crises and their Effects on State Health Care Access Initiatives,
National Academy for State Health Policy, Portland, ME, 1992.
24. Op. cit. 9.
25. P.A. Butler, Taxing Choices: ERISA and State Health Care Financing Strategies, National Academy
for State Health Policy, Portland, ME, 1992.
The Alan Guttmacher Institute
• 27 •
Health Care Rrform
�FIGURE 1
SELECTED FEATURES OF MAJOR HEALTH REFORM PLANS
(introduced in the 102nd Congress)
Wallstorw
All legal US residents.
Dingell/Waxman
Mitchell
Stwfc/Gephardt
Democratic Conservative Forum
All legal US residents
All legal US residents except
Expansion of Medicaid benefits
Voluntary participation of
except those covered
those covered by Medicare.
to an < 133% of poverty wHhout
employers In AHPs* and of small
by Medicare or
Coverage through employment
private health insurance, <200% employers and individuals In
Military health plans.
or under a "Public Plan."
for pregnant women and low-
H P P C S " and Public Plan to help
income children under 19 and
those <200% of poverty puchose
an optional new program for all
coverage. Subsidy for < 100% of
children.
poverty for items now covered
' Coverage
under Medicaid but not in basic
benefit package (see p. 9).
Uncovered: adults with incomes Optional coverage of full - time
> 133% poverty or pregnant
employees
women with Incomes >200% of
Uncovered: less than full-time
poverty without private health
employees and others with
insurance.
Incomes >200% of poverty.
Continues: Medicare
Eliminates: Medicare,
Continues: Medicare
Continues: Medicare
Continues: Medicare
Medicaid
Eliminates: Medicaid
Bimimtes: Medicaid
Expands: Medicaid
Eliminates: Medicaid
To be set by DHHS.
To be set by Nat'l Health Board.
Limited under private plan to:
To be set by DHHS for
To be set by Nat l Health Board.
Specified:
Specified:
Specified:
private plans. Same
Specified:
o "the full range of effective
Preventive 4
o Prenatal and well-child care
o Prenatal and well-child care
o Prenatal and wed-child care
coverage under Expanded
Reproductive Health
o Mammograms
o Family planning services
o Mammograms
Medicaid Program as cirrent
Services
o Bap tests
o Mammograms
o Pap tests.
Medicaid (see p. 9).
o Colorectal and prostate
o Pap tests.
Excluded: all others
those < 100% of poverty
"Enhancecf coverage under
(see p. 9).
cancer examinations.
preventive services"
Same as current Medicaid for
public plan same as curerrt
Medicaid (see p. 9).
description
Covered
Covered, phased in over time.
Not covered under basic plan.
Unspecified, to be set
Unspecified, to be set
Could be covered by states in
Drugs
by DHHS.
by National Health Board.
the "enhanced" package.
Premiums
None
None
Generally 20% for full-time
Unspecified, to be set by DHHS. No provisions, except subsidy for
employees.
Deductibles
None
$250 per Individ. $500 per fam.
None for preventive services.
Generally 20%, with sliding
Reduced for low-income.
None
Subsidies for low-income.
$250 per Individ. $500 per fam.
Copayments
None for preventive services.
scale for low-income.
low-Income.
Unspecifed. to be set by DHHS.
Unspecified, to be set by
National Health Board.
Unspecified, to be set by DHHS. Unspecified, to be set by
National Health Board , no c o payment for preventive services.
"Accountable Health Partnerships **l
th Plan Purchasing Cooperat
�FIGURE 2
S E L E C T E D FEATURES OF STATE HEALTH REFORM PLANS
Hawaii
Employer - Mandate
Blue Cross/
Massachusetts* * '
Medicaid
SHIP*
Recently
Unemployed
Blue Shield
Preconceptional
1
Maine
Washington
(Demonstration)
Minnesota
(Demonsfration)
Unirmired
Program
Kaiser
Low-Income
Oregon* •
Program
(Medicaid)
No
Yes
Yes
Not specified
No
Yes
Not specified
Yes
Yes
Not specified
No
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
and Supplies
No
Yes
Yes
No
Yes
No
Yes
Yes
No
No
Voluntary
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes, 1 in vtoo
Yes
Diagnosis,
Yes
Diagnosis,
No
Yes
No
Care
Contraceptive
Services
Sterilization
Screening for STDs
and Cancers
Basic InfertHrty
Yes. 1 In vitro
Service
procedure per
procedure
lifetime
per lifetime
Abortion
Yes
Yes
no treatment
Yes. limited
freatment
limited
treatment
Yes
Yes
Yes
No
Yes
No. only for life
No
endangerment
Maternity Care
Yes
Yes
Yes
Yes
Counseling and
No
Yes
Yes
Yes
Yes
Premiums
Deductibles
Vary by
Vary by
employer
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Not
None
Not
specified
None
Sliding scale
None
None
None
Sliding scale
None
Sliding scale
None
None
$100/person.
None
None
None
None
None
$ 3 - 8 per vis It
None
Yes
None
employer
Copayments
Yes
employer
Vary by
June. 1992
Yes
specified
Education
No, after
None
$200/lamHy
None far pre-
$5 per visit
None for
maternity care,
none for pre-
children <6,
ventive care or
family planning
$4 per visit
ventive care
$5 per visit
maternity care
None for
•State Health Insuance Plan
"Health care reform act delayed, not operative, except for limited provisions.
'Applies only to a) subsidize private insurance for the recently unemployed, and b) provide managed care to the uninsured <200% of poverty; Medicaid in effect, 'play or pay" plan stalled.
2
Applies only to new, expanded, priority setting Medicaid program; "play or pay" plan pending.
�APPENDIX A
The Alan Guttmacher Institute
Board of Directors'
STATEMENT ON HEALTH CARE REFORM
WHEREAS, the ability to dedde whether and when to have a child is a
fundamental human right and responsibility, and the exercise of that right and
responsibility:
• is essential to women's self realization as individuals, and to their full
partidpation in and contribution to sodety,
• promotes the health and well being of families, their individual members
and the community at large, and
• is highly beneficial and cost effective to sodety.
Therefore, the Board of Directors of The Alan Guttmacher Institute
RESOLVES that any proposals for health care reform must:
Cover the full range of reproductive health services for all individuals
covered under the plan(s), induding:
• contraceptive services and supplies,
• abortion services,
• voluntary sterilization services,
• basic infertility services,
• screening for sexually transmitted diseases and cancers of the
reproductive system,
• preconceptional risk assessment and care,
• maternity care, including prenatal, delivery and postnatal care; and
• appropriate education and counseling services necessary to render the
services listed above effective.
And further guarantee that:
• no deductible or copayment be imposed on the preventive services
covered under the plan(s),
• services appropriately provided by either physidans or trained nonphysidan providers such as nurse midwives, nurse practitioners and
other health personnel bereimbursableunder the plan(s).
�• coverage for services be portable and not restricted as a result of
preexisting medical condition or waiting period,
• services be provided expeditiously and confidentially to all covered
individuals, induding minors, and
• individual practitioners be free to refuse to provide services contrary to
their ethical or religious beliefs but that requested services be made
available to the beneficiaries of the plzm(s) through other providers.
RESOLVES, further that:
• in the implementation of any health reform plan(s), priority be given to
the maintenance, expansion or modification of existing communitybased public health and other health care fadlities unless and until it can
be demonstrated that these systems are no longer needed to ensure
universal availability and accessibihty of the services covered.
DIRECTS The Alan Guttmacher Institute staff:
• to conduct research and policy analysis, engage in outreach to other
concerned organizations and provide assistance to policymakers as
necessary to further the goals established herein.
March 5 and 6,1992
�APPENDIX B
Contraceptive Use in the United States
by Method, Number and Percentage of Users
# of users
On thousands)
% of users
13,686
39.2
Tubal
(9,617)
(27.5)
Vasectomy
(4,069)
(11.7)
Pill
10,734
30.7
Diaphragm
2,000
5.7
703
2.0
27,123
77.6
5,093
14.6
Periodic Abstinence
806
2.3
Withdrawal
778
2.2
Spermicides
637
1.8
Sponge
399
1.1
Other Methods
76
0.4
Medical Methods
Sterilization
IUD
Subtotal
Non-Medical Methods
Condom
TOTAL
SOURCE: The Alan Guttmacher Institute
34,912
100.0% '
�APPENDIX C
MANAGED COMPETITION
Individuals
Oversee heahh market
Standardize accounting and
paperwork
Source: Democratic Conservative Forum
Small Businesses
Provide consumer information on the
quality of AHPs
Large Businesses
Adjust for risks among AHPs
�Infertility:
T * T7 C / ^ \ T A TT?
IV Jl
National Office
1 3 1 0 B l
Education
Advocacy
Support
o a d w L l v
'
' Somerville. MA 02144-1731
Business Office 6r/6J3-1156
HelpLinc 6r/'623-Cr-H Fax 617/623-0252
March 22, 1993
Hillary Rodham Clinton, Chairperson
Task Force on National Health Care Reform
The White House
Washington, DC 20510
Dear Ms. Clinton,
RESOLVE is a national non-profit consumer group that supports those suffering from
the medical concerns of infertility. Our organization has become increasingly concerned
about the widespread lack of education and sensitivity about infertility.
As you review any health care reform, we implore you to consider that one in six
couples are infertile and striving to have a family. Infertility is the abnormal functioning of
the reproductive system and needs to be evaluated as any other health care problem.
I am enclosing Rationale for the Inclusion of Infertility Treatment in a Health Care
Benefits Package. Please consider the nearly 5 million Americans who suffer from the
disease of infertility.
Sincerely,
Diane D. Aronson
Executive Director
Enclosure
�U -M-I ^ / ^ V T \ 7 1 7
J t V i l ^ V y J ^ V JC
National Office
1 3 1 0
Broadway, Somerville, MA 02144-1731
Business Office 617/623-1156 Fax 617/623-0252
Helpline 617/623-0744
Rationale for the Inclusion of Infertility Treatment in a
Health Care Benefits Package
• Infertility, a disease that affects 1 in 6 couples, is the abnormal
functioning of the reproductive systems of both men and women (1/3 women,
1/3 men, 1/3 a combination or unknown cause).
• Infertility treatment coverage is an issue of fairness. How can other
medical problems such as hip replacements or hernias be included for coverage
and the problems of an abnormally functioning reproductive system be left out of
a benefits package?
• There is a misconception that infertility treatment is costly. This is
due primarily to the mass media's focus on the new technology for treatment. In
fact, only 1.6% of those seeking treatment move on to address their infertility
through procedures such as in vitro fertilization. For women who have had
diseases that caused the destruction of their fallopian tubes, IVF can be an
appropriate and less expensive treatment than tubal surgery.
• There is a perception that infertility treatment is elective and it is
often compared to cosmetic surgery. This is an insult to the many who are
suffering with the disease of infertility, experiencing this major life crisis, and
who are struggling to build a family.
• Why don't people just adopt? Individuals start off with a life-vision
of having their own biological children. It is important to resolve all medical
problems before moving on to other ways of achieving this life-goal. Adoption is
not always an easy option to pursue and it can cost upwards to $30,000. Most do
not have thisfinancialresource and for some individuals an inexpensive treatment
can solve their infertility.
• Finally, our country places a great deal of emphasis on its acknowledgement of the importance of families. Infertile individuals are striving to be a
part of this basic element of our society.
�
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Health Care Reform
Identifier
An unambiguous reference to the resource within a given context
2006-0810-F
Description
An account of the resource
<p>This collection consists of records related to Hillary Rodham Clinton's Health Care Reform Files, 1993-1996. First Lady Hillary Rodham Clinton served as the Chair of the President's Task Force on National Health Care Reform. The files contain reports, memoranda, correspondence, schedules, and news clippings. These materials discuss topics such as the proposed health care plan, the need for health care reform, benefits packages, Medicare, Medicaid, events in support of the Administration's plan, and other health care reform proposals. Furthermore, this material includes draft reports from the White House Health Care Interdepartmental Working Group, formed to advise the Health Care Task Force on the reform plan.</p>
<p>This collection is divided into two seperate segments. Click here for records from:<br /><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0810-F+Segment+1"><strong>Segment One</strong></a> <br /><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0810-F+Segment+2"><strong>Segment Two</strong></a></p>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Briefing Book on Reproductive Health Services [6]
Creator
An entity primarily responsible for making the resource
Health Care Task Force
General Files
Identifier
An unambiguous reference to the resource within a given context
2006-0810-F Segment 1
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 58
<a href="http://clinton.presidentiallibraries.us/items/show/36144" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12090749" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Medium
The material or physical carrier of the resource.
Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
5/5/2015
Source
A related resource from which the described resource is derived
42-t-2194630-20060810F-Seg1-058-010-2015
12090749