Poor Access to Abortion Endangers Women's Health

States can improve women's health by ensuring access to abortion services, but most states, and the nation as a whole, have failed to do so, according to a comprehensive state-by-state study. It grades 48 states “F.”

Doctor and patient

A newly developed Report Card on women's health gave 48 states an "F" because, it says, the lack of health care practitioners who provide abortion services in those states endangers women's health and lives.

Only Hawaii, Massachusetts and the District of Columbia received a passing grade. The nation, as a whole, flunked because almost one-third of all women live in a county with no abortion provider.

Released in August, the Report Card was created by the National Women's Law Center, the University of Pennsylvania School of Medicine's FOCUS on Health & Leadership for Women and The Lewin Group, a health policy consulting firm.

Abortion services are a critical indicator of women's health, said Sharon Levin, senior counsel for the National Women's Law Center. "The reality is that there are times when an abortion is necessary to protect the health and life of a woman, and if there is no abortion provider, that can and does put her health or her life at risk."

States were graded on the availability of abortion services by comparing the percentage of women living in counties without abortion providers to the percentage of women living in counties without an office-based obstetrician-gynecologist. The authors said abortion services should be as available as services for obstetrics and gynecology. Each of the 48 states that failed had at least 10 percent more women without access to an abortion provider in their county than the percentage of those without an office-based obstetrician-gynecologist.

Called "Making the Grade on Women's Health: A National and State-by-State Report Card," the report used various indicators besides abortion services to measure access to health care for women. These measures included family planning services, prenatal care, maternity care in hospitals and services for victims of domestic violence and sexual assault.

Far too many women have no health insurance

In addition, the picture of women's access to health care was bleak. Fourteen percent of American women have no health insurance, the report showed.

The goal, as defined by the federal government's Healthy People 2010 project, is for 100 percent coverage.

But no state has met this goal, the Report Card found. And, only eight states-Connecticut, Delaware, Hawaii, Massachusetts, Minnesota, Nebraska, Rhode Island and Wisconsin-have come within 10 percent of that benchmark.

As a result, those eight states received a "U" for unsatisfactory. The remaining 42 states and the District of Columbia received an "F" because they missed that benchmark by more than 10 percent. The nation as a whole also received an "F."

"Access to health care services is an area where almost all of the states did badly and the nation as a whole did badly," said Levin.

"We have a lot of work to do here to make sure women have health insurance. Even those women who are insured often do not have comprehensive insurance that covers all their needs."

Access to prenatal care still not widespread

The Report Card also looked at the availability of prenatal care because it is often seen as an indicator of whether women have access to general health care services. Prenatal care is also important because women who have prenatal care in the first trimester of pregnancy tend to stay healthier and have healthier babies, the authors noted.

But no state met the federal government's Healthy People 2000 goal of providing first-trimester care to at least 90 percent of all pregnant women, the Report Card found. Thirty-six states, however, were within 10 percent of the benchmark, thus earning a "U" for unsatisfactory. The other 14 states and the District of Columbia missed the mark by more than 10 percent, so they received an "F." The nation received a "U."

Two simple options for wider prenatal care

To offer prenatal care to more women, states have two simple options, said Lewin. States can extend Medicaid benefits to pregnant women who earn up to 200 percent of the federal poverty level and they can adopt a "presumptive eligibility" rule, which would allow pregnant women to receive prenatal care earlier in their pregnancies but before their applications for Medicaid have been processed.

On these two policies, the states have a mixed record. Ten states have raised the Medicaid eligibility criteria to 200 percent of poverty. Twenty-seven states and the District of Columbia have raised the eligibility level between 133 and 185 percent of poverty.

"The remaining 13 states are doing the bare minimum they need to do to participate in the Medicaid program," Levin said. The income ceiling for Medicaid eligibility in those states is 133 percent of this year's federal poverty level, which is $14,150 for a family of three in the 48 contiguous states and the District of Columbia. Thus, 133 percent of that is $16,031.

As for presumptive eligibility, 27 states and the District of Columbia have adopted it while 23 have not done so, the Report Card found.

Family planning services also found wanting

In analyzing access to family planning services, the Report Card found that only 11 states have required private insurers who pay for prescription drugs to cover the costs of all five federally approved prescription drugs and devices.

Six other states-Colorado, Idaho, Kentucky, Minnesota, New Jersey and Texas-require private insurers to provide limited coverage. The remaining 33 states and the District of Columbia have no laws requiring contraceptive coverage.

The availability of family planning services was another measure of general access. States can expand family planning services to more low-income women by securing a federal Medicaid waiver to broaden the eligibility requirements. Fifteen states have applied for such waivers. These expansion efforts have greatly increased the number of low-income women served by Medicaid family planning programs, the authors said. The other 35 states and the District of Columbia have not applied for the waivers.

More services needed for women subjected to violence

Recognizing that violence against women presents a serious health problem, some states have attempted to improve access to health care for these women by:

  • Requiring health care protocols, training and screening for domestic violence;
  • Prohibiting insurance discrimination against domestic violence victims; and
  • Requiring health care workers to follow protocols for sexual assault victims.

California is the only state to have all three policies, and only three states-Alaska, New York and Pennsylvania-have adopted both domestic violence policies and weaker versions of the sexual assault policy. The Report Card found that 34 states have had minimal policies. The other 12 states and the District of Columbia have had no such policies that include collecting and preserving evidence for trial and referring women to counselor.

Melinda Voss holds a master's degree in public health. A former reporter for The Des Moines Register, she now freelances and teaches journalism at the University of Minnesota.