Public Finance Policy Strategies to Increase Acces

Authors: Kay A Johnson

Publish Date: 2006/06/27

Volume: 10, Issue: 1, Pages: 85-91

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Abstract

Policy and finance barriers reduce access to preconception care and reportedly limit professional practice changes that would improve the availability of needed services Millions of women of childbearing age 15–44 lack adequate health coverage ie uninsured or underinsured and others live in medically underserved areas Service delivery fragmentation and lack of professional guidelines are additional barriers This paper reviews barriers and opportunities for financing preconception care based on a review and analysis of state and federal policies We describe states’ experiences with and opportunities to improve health coverage through public programs such as Medicaid Medicaid waivers and the State Childrens Health Insurance Program SCHIP The potential role of Title V and of community health centers in providing primary and preventive care to women also is discussed In these and other public health and health coverage programs opportunities exist to finance preconception care for lowincome women Three major policy directions are discussed To increase access to preconception care among women of childbearing age the federal and state governments have opportunities to 1 improve health care coverage 2 increase the supply of publicly subsidized health clinics and 3 direct delivery of preconception screening and interventions in the context of public health programsThe overarching goal of preconception care is to provide health promotion screening and interventions for the more than 62 million women of childbearing age 1 to reduce risk factors that might affect future pregnancies 2 3 4 As elsewhere in this supplement preconception care is defined as a set of interventions that aim to identify and modify biomedical behavioral and social risks to a womans health or pregnancy outcome through prevention and management emphasizing those factors which must be acted on before conception or early in pregnancy to have maximal impact It includes care before a first pregnancy or between pregnancies commonly known as interconception or internatal care 5 and care that would typically be delivered in primary care settings 4Health professional leaders and professional organizations’ guidelines have called for improvements in preconception care for more than 20 years 4 6 7 8 9 and several reviews of the literature have assessed the evidence for specific interventions and documented their effectiveness 10 11 Without changes in financing however it appears unlikely that the nation will improve its preconception health and thereby improve the health of women their children and their families Since federal and state policies are important drivers of health care financing this paper provides suggestions on how policymakers can improve financing for preconception care 12Although many observers have suggested that providers would deliver more preconception care if they could bill payers for the service 13 a closer look at the situation suggests that more complex changes in womens health care financing may be necessary to support widespread use of preconception care Affordability of care is a major concern for many women 14 Many women lack basic health coverage particularly nonpregnant lowincome women who do not meet of Medicaids low income eligibility levels 15 Securing private insurance coverage for additional preventive services may require more and better evidence about the effectiveness of interventions 4 Other barriers to financing are more mechanical Financing is required for an ongoing care process over a period of years and across the lifespan not a single visit Billing mechanisms and codes need refinement in addition costbenefit analyses and ongoing alignment with newly emerging approaches to care will also be required 16Financial barriers to health care access are widespread in the United States with many lowincome individuals having no or inadequate health coverage The Kaiser Family Foundation’s Womens Health Survey 17 does not focus on preconception care but some of its results are relevant to understanding barriers to womens health care Among women of childbearing age 18 to 44 years 30 percent reported that they delayed or went without care because of cost Moreover 21 of women of all nonelderly women 18 to 64 years in the survey reported that they did not fill a prescription for medication because of cost including 40 of uninsured women 17Millions of Americans live without health coverage Nearly 17 million American women are uninsured 17 Onethird of low income women with income less than 200 percent of the federal poverty level half of women with disabilities and 18 percent of all nonelderly women were uninsured in 2003 18 Younger women were more likely than older women to be uninsured Hispanic Asian and Black women were more likely than nonHispanic white women to be uninsured reflecting their income and employment status patterns ie more likely to have incomes below 200 percent of poverty and less likely to be employed in jobs that offer health insurance 17 Moreover recent data indicate that women are more likely to lose coverage than men Between 2002 and 2003 nearly 900000 women ages 18 to 64 became uninsured compared to 600000 men 53 and 47 percent respectively Such losses are attributed primarily to welfare reform policies and employerbased coverage trends 19Data for 2002–2003 reveal that the percentage of women ages 18–64 who were uninsured varies substantially ranging from 30 percent in Texas to 8 percent in Minnesota The proportion of uninsured lowincome adult women shows similar variation ranging from more than 50 percent in Texas to less than 25 percent in Massachusetts Minnesota Tennessee and Wisconsin Although to some extent these differences reflect Medicaid eligibility policy the statetostate variations also reflect employment patterns For example Minnesota had the highest percentage of adult women with private coverage and a fairly low proportion of women covered by Medicaid 83 percent and 8 percent respectively In contrast in Tennessee under policies in effect at that time 17 percent of adult women were Medicaid beneficiaries and only 70 percent had private coverage 20

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