I ACCESS TO CARE
The American College of Obstetricians and Gynecologists (the College) supports access to quality, affordable health care for women, and since 1971 has called for universal access to maternity care.
The College believes a full array of clinical services should be available throughout a woman’s life, without delays or the imposition of cultural, geographic, financial, or legal barriers. The College and its members are committed to facilitating the provision of and access to high-quality women’s health care. The College focuses on the following principles as essential for meeting women’s lifetime health needs:• Health coverage should be accessible and affordable to everyone, with priority given to pregnant women and infants.
• A health care system should promote preventive care, provide continuity of care, and guarantee benefits regardless of employment, income, health status, or location.
• A successful health care system can build on the strengths of the private-public financing and delivery system.
• Coverage needs to be affordable for individuals, families, and businesses.
• Discrimination based on health status, gender, and other factors must be prohibited.
• Emphasizing prevention, reducing administrative costs, and enacting tort reform can help lower health care costs.
More than one half of women report delaying or avoiding needed care because of cost. Additionally, some women experience challenges in receiving coverage for critical services, such as maternity care. The Patient Protection and Affordable Care Act (ACA), the federal health care reform law passed in 2010, has the potential to improve access to care for millions of underserved women across the nation. Medicaid coverage is granted to very low-income women in most states, and subsidies are available for other low-income women to help purchase insurance coverage through health insurance exchanges.
Insurers are prohibited from denying coverage because of preexisting conditions. Women no longer face increases in premium rates because of gender or health status. Through expansion of coverage, women up to age 26 years can be covered under their parents’ insurance policies. Additionally, the ACA allows direct access to obstetrician-gynecologists, which facilitates women’s health care service delivery, including access to maternity care and preconception care, as well as contraceptive services.For many, the challenges to accessing health care are due to their lack of insurance or inadequate coverage, but barriers such as health care provider shortages and educational, cultural, and logistical factors also can compromise access to care. These obstacles to health care access, as well as proposed strategies to address them, are discussed in this section.
Increasing Access to High-Quality Care
The current lack of women’s health care providers in the United States, believed to be due in part to the increasing costs of liability practice insurance and changes in practice patterns, is a growing concern around the country. In 2010, the national ratio of obstetrician-gynecologists per 10,000 women was 2.1, the lowest ratio in more than 30 years (2.3 in 1978, 2.5 in 1988, and 2.7 in 1993). Approximately one half (49%) of the 3,107 U.S. counties lack obstetrician-gynecologists, and nearly 9.5 million Americans live in those predominantly rural counties. Although there are nonobstetrician-gynecologist clinicians who provide care, such as certified nurse-midwives and family physicians, this statistic speaks to the lack of access.
Under the ACA, more women have access to health care, which increases pressure for the provision of care by a wide range of trained health care providers. These changing needs will require seamless integrated health care provider relationships across specialties. Obstetrician-gynecologists provide women’s health care throughout the lifespan, often functioning as primary health care providers in a collaborative team.
The College has long supported collaborative practice in an integrated, patient-focused health care delivery system to help ensure high-quality care. Such high- quality care depends on appropriately trained and certified health care providers, open communication and transparency, ongoing health care provider performance evaluation, use of evidence-based guidelines, and patient education. Exemplary systems of care with these characteristics should be identified and replicated. To ensure access to high-quality programs that meet the health care needs of all women, Fellows of the College should exercise their responsibility to improve the health status of women and their offspring in the traditional patient-physician relationships and by working within their communities at the local, state, and national levels.Health Literacy
The problem of limited health literacy is widespread. Patient health literacy includes the ability to understand instructions on prescription drug bottles, appointment slips, patient education brochures, and consent forms and the ability to negotiate complex health care systems. Whereas approximately 10% of Americans have low general literacy (skills necessary to perform simple and everyday literacy activities), 50% of adults are estimated to have marginal health literacy skills to low health literacy skills. Patients with specific educational or linguistic challenges also may have limited health literacy. Senior citizens often have low health literacy skills and, therefore, poor comprehension of information on medication labels. On a broader level, a woman’s health literacy may determine how or if she attempts to access the health care setting. This alone can be a significant obstacle to access to care.
At the level of the patient-clinician interaction, it is critical that health care providers understand the broad variation in health literacy that may affect the evaluation of patients and their adherence to treatment. Health care providers need to be able to assess a woman’s health literacy and provide appropriate instructions and explanations about her care.
Specific strategies for making health information understandable and accessible to all patients are included in the U.S. Department of Health and Human Services’ Office of Disease Prevention and Health Promotion’s Quick Guideto Health Literacy (see Resources), as well as in the “Patient Safety” section in Part 1.
At the systems level, responsibility for recognizing and addressing the problem of limited health literacy lies with all entities in the health care profession, from the primary health care team to public health care systems. Making information understandable and accessible to all patients involves a systematic approach toward health literacy in physicians’ offices, hospitals, clinics, national organizations, local health organizations, advocacy organizations, medical and allied health professional schools, residency training programs, and continuing medical education programs. Because nursing and support staff are often the ones who identify the level of health literacy among patients, it is extremely important to also provide them with the appropriate training and resources so they can help navigate these patients through the health care system. Community-based partnerships to help understand and address the needs of the local community and consumer health information organizations to focus on the issue of health literacy are needed in the effort to improve health literacy. The U.S. Department of Health and Human Services’ 2010 National Action Plan to Improve Health Literacy outlines goals and strategies to improve health literacy by engaging organizations, professionals, policymakers, communities, individuals, and families in a linked, multisector effort (see Resources).
Health Care for the Uninsured
Uninsured individuals often defer obtaining preventive and medical services, thus jeopardizing the health and well-being of themselves and their families. The need for universal health care coverage is urgent, given that a considerable and increasing portion of the U.S.
population does not have health insurance.The College supports universal coverage that is designed to improve the individual and collective health of society. The College has put forward the following five necessary principles to achieve universal health care that meets women’s lifetime health needs: 1) cover everyone; 2) guarantee benefits; 3) engage employers, individuals, and governments; 4) make coverage affordable; and 5) enhance quality and patient safety.
The ACA addresses many of these principles, expanding coverage options and access to minimum essential health benefits, such as preventive care. For example, as of 2014, the ACA gave states the option to expand Medicaid to include individuals younger than 65 years with incomes up to 133% of the federal poverty level but also included a provision to disregard the first 5% of income, effectively extending Medicaid to all individuals with incomes up to 138% of the federal poverty level. The expansion of Medicaid is expected to result in improved access to health care, less delay in obtaining health care, better self-reported health, and reductions in mortality. The percentage of uninsured women aged 19-64 years could decrease from 20% to 8% if all states implement the Medicaid expansion, with enormous anticipated health benefits to women. The ACA also provides subsidies for individuals with incomes between 100% and 400% of the federal poverty level to help them purchase private health insurance. Despite the promise of the ACA to improve health insurance coverage, some populations may be left out. It is estimated that with full implementation of the ACA, 23 million individuals living in the United States who are younger than 65 years will remain uninsured. Approximately 25% of these individuals will be undocumented immigrants. Up to 16.2% will be legal residents who may be exempt from the individual mandate to purchase health insurance because the cost of insurance may be found to be unaffordable, even with subsidies.
Accordingly, continued efforts to expand health coverage to all Americans must remain a high priority.Health Care for Undocumented Immigrants
Adequate provision of health care to undocumented, immigrant women remains a problem. In 2010, an estimated 11.2 million undocumented immigrants were living in the United States. Many immigrants are of Hispanic ethnicity, and approximately one third of Hispanics lack health insurance. This same group also reports linguistic and cultural barriers. There is great variation among communities and among states in policies that concern undocumented, immigrant women and access to health care providers. Health care providers can play an important role in improving access to needed health care for undocumented immigrants through implementation of the following strategies:
• Helping society understand the importance of universal health care access
• Advocating for local, state, and national policy and legislation to secure quality, affordable coverage for all
• Supporting the safety net system and provision of care in the community and office setting for the uninsured
• Providing a comfortable office atmosphere with translators and materials available in languages appropriate for the patient population
• Becoming informed and involved in the College’s government relations outreach activities. (For more information go to www.acog. org/About_ACOG/ACOG_Departments/Government_Relations_ and_Outreach.)
Health Care for Homeless Women
Homelessness continues to be a significant problem in the United States. Women and families represent the fastest growing segment of the homeless population. Lack of access to health care is a profound issue for the homeless population. As a result, homeless women lack preventive care, such as prenatal care, mammograms, and Pap tests, compared with women who are not homeless. In addition, they have higher rates of poor health status, mental illness, poor birth outcomes, and mortality.
The factors that contribute to homeless women being unable to obtain needed health care include the lack of health insurance, the inability to purchase or acquire medications, the lack of knowledge of where and when to obtain health care, long wait times at medical facilities, and the lack of transportation to and from medical facilities. Mental illness, substance abuse, domestic violence, and being too sick to seek care create additional obstacles in obtaining needed services. Medical providers who do not want to care for homeless individuals in their offices and the lack of available treatment facilities result in limited access to health care. Inadequate inpatient discharge planning and follow-up care and lack of referral to services available within the community for homeless individuals also act as barriers.
Health care for homeless women is a challenge but an important issue that needs to be addressed. Strategies to help health care providers address the needs of homeless individuals include the following:
• Identify patients within the practice who may be homeless or at risk of becoming homeless (ie, ask about living conditions, nutrition, mental health issues, substance abuse, and domestic violence).
• Provide health care for these homeless women without bias, including preventive care, and do not withhold treatment based on concerns about lack of adherence.
• Become familiar with and inform patients who are (or at risk of becoming) homeless about appropriate community resources, including local substance abuse programs, domestic violence services, and social service agencies.
• Simplify medical regimens and address barriers, including transportation needs, for follow-up health care visits.
• Advocate for initiatives to address homelessness, such as increased funding for housing, case management services, substance abuse treatment, mental health services, domestic violence programs, and primary and preventive care for homeless individuals.
• Volunteer to provide health care services at homeless shelters and other facilities that serve homeless individuals.
• Increase access to long-acting reversible contraceptives.
The ACA has the potential to improve the health care of homeless individuals. Although it does not directly address the homeless population, under the ACA, a portion of the homeless population will qualify for Medicaid in states that opt to expand their Medicaid programs. There are certain Medicaid benefits that can play an important role in assisting individuals who are at risk of or experience chronic homelessness, including behavioral health services (which include mental health and substance abuse services), case management, personal care and personal assistance services, and home-based and community-based services. Increased health care coverage may lead to improved access and coordination of care. Additionally, increased coverage could result in benefits such as less uncompensated care for physicians and emergency departments, thus, lowering the health care costs of caring for homeless individuals.
Health Care for Women in the Military and Women Veterans
An increasing number of women are serving in the military, and a greater proportion of United States veterans are women. Because obstetriciangynecologists may be the primary medical providers for women in the military and women veterans, they are in a position to interact with these women and intervene early and appropriately with their unique reproductive health care needs.
Women in the military and women veterans may seek primary and reproductive health care at military treatment facilities, through the U.S. Department of Defense’s TRICARE program, at the civilian sector (through Medicaid, Medicare, or private insurance), through the U.S. Department of Veterans Affairs (VA), or some combination thereof. Connecting women veterans to services available through the VA may facilitate needed comprehensive health care; VA facilities may be located by consulting a web-based directory (www2.va.gov/directory/guide/vetcenter_flsh.asp). Women who are honorably discharged from the military may qualify for a variety of benefits through the VA, including health care benefits. This eligibility is based on multiple criteria (details are available at www.va.gov/healthben- efits/apply/veterans.asp). Many mechanisms are in place to support the health needs of women veterans. Each Veterans Health Administration facility nationwide has a designated women veterans program manager who advocates for women and provides leadership in establishing, coordinating, and integrating quality health care services for women. Many VA sites have specialized women’s health clinics and services available to provide care for women veterans either onsite or through referrals to non-VA health care providers.
Partnerships between academic departments of obstetrics and gynecology and local branches of the Veterans Health Administration are encouraged as a means of optimizing the provision of comprehensive health care to women veterans. This will allow all health care providers who treat women veterans to ensure that veterans in their care are aware of health care resources offered through the VA and to provide referrals as needed. Such collaboration offers unique opportunities to share best practices, foster the development and implementation of a robust research agenda regarding the reproductive health care needs of women veterans, and enhance delivery and coordination of care.
Bibliography
Allen J, Bharel M, Brammer S, Centrone W, Morrison S, Phillips C, et al. Adapting your practice: treatment and recommendations on reproductive health care for homeless patients. Nashville (TN): Health Care for the Homeless Clinicians’ Network, National Health Care for the Homeless Council,Inc.; 2008. Available at: http://www.nhchc.org/wp-content/uploads/2011/09/ReproductiveHealth.pdf. Retrieved May 29, 2013.
American College of Obstetricians and Gynecologists. Health care for women, health care for all: a reform agenda. Washington, DC: ACOG; 2008. Available at: http://www.acog.org/~Zmedia/Departments/Resource%20Center/HCFWHCFA- ReformPrinciples.pdf?dmc=1&ts=20130905T1010044353. Retrieved September 5, 2013.
American Medical Association. Physician characteristics and distribution in the U.S, 2013. Chicago (IL): AMA; 2013.
American Medical Association. The Affordable Care Act. Available at: http://www. ama-assn.org/ama/pub/advocacy/topics/affordable-care-act.page?. Retrieved August 13, 2013.
Benefits to women of Medicaid expansion through the Affordable Care Act. Committee Opinion No. 552. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:223-5. [PubMed] [Obstetrics & Gynecology]
Berg CJ, Harper MA, Atkinson SM, Bell EA, Brown HL, Hage ML, et al. Preventability of pregnancy-related deaths: results of a state-wide review. Obstet Gynecol 2005;106:1228-34. [PubMed] [Obstetrics & Gynecology]
Buettgens M, Hall MA. Who will be uninsured after health insurance reform? Princeton (NJ): Robert Wood Johnson Foundation; 2011. Available at: http://www. rwjf.org/content/dam/farm/reports/issue_briefs/2011/rwjf69624. Retrieved July 22, 2013.
Centers for Medicare and Medicaid Services. Affordable Care Act: eligibility. Available at: http://www.medicaid.gov/AffordableCareAct/Provisions/Eligibility. html. Retrieved July 22, 2013.
Community involvement and volunteerism. ACOG Committee Opinion No. 437. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114: 203-4. [PubMed] [Obstetrics & Gynecology]
Gusmano MK. Undocumented immigrants in the United States: demographics and socioeconomic status. Garrison (NY): Hastings Center; 2012. Available at: http:// www.undocumentedpatients.org/issuebrief/demographics-and-socioeconomic- status. Retrieved July 22, 2013.
Health care for homeless women. Committee Opinion No. 576. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:936-40. [PubMed] [Obstetrics & Gynecology]
Health care for undocumented immigrants. ACOG Committee Opinion No. 425. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009; 113:251-4. [PubMed] [Obstetrics & Gynecology]
Health care for women in the military and women veterans. Committee Opinion No. 547. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:1538-42. [PubMed] [Obstetrics & Gynecology]
Health care systems for underserved women. Committee Opinion No. 516. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;119:206-9. [PubMed] [Obstetrics & Gynecology]
Health literacy. Committee Opinion No. 585. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:380-3. [PubMed] [Obstetrics & Gynecology]
Passel JS. The size and characteristics of the unauthorized migrant population in the U.S.: estimates based on the March 2005 Current Population Survey. Washington, DC: Pew Hispanic Center; 2006. Available at: http://www.pewhispanic.org/files/ reports/61.pdf. Retrieved September 5, 2013.
Professional liability and gynecology-only practice. Committee Opinion No. 567. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013; 122:186. [PubMed] [Obstetrics & Gynecology]
Rayburn WF. The obstetrician-gynecologist workforce in the United States: facts, figures, and implications 2011. Washington, DC: American Congress of Obstetricians and Gynecologists; 2011.
Sommers BD, Baicker K, Epstein AM. Mortality and access to care among adults after state Medicaid expansions. N Engl J Med 2012;367:1025-34. [PubMed] [Full Text] The Henry J. Kaiser Family Foundation. Health reform: frequently asked questions: Who will be eligible for subsidies to make health insurance more affordable? Menlo Park (CA): KFF; 2013. Available at: http://kff.org/health-reform/faq/health-reform- frequently-asked-questions/. Retrieved September 5, 2013.
The uninsured. ACOG Committee Opinion No. 416. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008;112:731-4. [PubMed] [Obstetrics & Gynecology]
Resources
American College of Obstetricians and Gynecologists. Access to women's health care. College Statement of Policy. Washington, DC: ACOG; 2013.
American Congress of Obstetricians and Gynecologists. Government relations and outreach. Washington, DC: American Congress of Obstetricians and Gynecologists; 2013. Available at: http://www.acog.org/About_ACOG/ACOG_Departments/ Government_Relations_and_Outreach. Retrieved July 16, 2013.
American Congress of Obstetricians and Gynecologists. Health system reform: the law, your practice, your patients. Washington, DC: American Congress of Obstetricians and Gynecologists; 2010. Available at: http://www.acog.org/About_ ACOG/ACOG_Departments/Health_Care_Reform. Retrieved July 16, 2013.
American Congress of Obstetricians and Gynecologists. Practice management and managed care. Washington, DC: American Congress of Obstetricians and Gynecologists; 2013. Available at: http://www.acog.org/About_ACOG/ACOG_ Departments/Practice_Management_and_Managed_Care. Retrieved July 16, 2013.
Department of Health and Human Services, Office of Disease Prevention and Health Promotion. National action plan to improve health literacy. Washington, DC: HHS; Available at: http://www.health.gov/communication/HLActionPlan/pdf/ Health_Literacy_Action_Plan.pdf. Retrieved July 22, 2013.
Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Quick guide to health literacy. Available at: http://www.health. gov/communication/literacy/quickguide/Quickguide.pdf. Retrieved July 22, 2013.
Department of Veterans Affairs. Health benefits: veteran eligibility. Available at: http://www.va.gov/healthbenefits/apply/veterans.asp. Retrieved July 22, 2013.
Department of Veterans Affairs. Vet centers - locations. Available at: http://www2. va.gov/directory/guide/vetcenter_flsh.asp. Retrieved July 22, 2013.
Ethical considerations for performing gynecologic surgery in low-resource settings abroad. Committee Opinion No. 466. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:793-9. [PubMed] [Obstetrics & Gynecology] World Health Organization. Sexual and reproductive health. Available at: http:// www.who.int/reproductivehealth/en. Retrieved July 22, 2013.