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Building Effective Programs: Coping with the Patchwork Quilt of Women's Health Issues

Coverage & Access Issues


Alina Salganicoff, Ph.D., Vice President and Director, Women's Health Policy, Kaiser Family Foundation.

Concern is growing about the increase in health care disparities between men and women, especially for women of color. Research indicates that many health care disparities are a result of a lack of health insurance, which limits access to health care services. Concerns also have been raised about the impact that managed care arrangements, in which most insured women are now enrolled, have on access to care, particularly specialty services.

Current estimates place the rate of uninsurance among women ages 18 to 64 at 18 percent and rising. Risk factors associated with being uninsured include:

  • Age (27 percent of women ages 18 to 34 are uninsured).
  • Income level (32 percent of low-income women are uninsured).
  • Ethnicity (35 percent of Latina and 22 percent of African-American women are uninsured).

Among the barriers to care for uninsured women are: not receiving care when it is needed, not having a regular physician, and not receiving routine preventive services like mammograms or Pap tests.

Three major themes related to coverage and access disparities among women were addressed. These themes were:

  • Improving the reach and scope of coverage.
  • Meeting the health needs of vulnerable women.
  • Understanding women's roles in managing their health and the health of their families.

States have increasing latitude to expand coverage for low-income populations that have not traditionally been eligible for Medicaid because they fail to meet the income or categorical requirements. States have used authority provided under Sections 1115 and 1932 of the Social Security Act to help more low-income women qualify for coverage under Medicaid:

  • Section 1115 allows States to change provisions of their Medicaid programs, including: eligibility requirements; the scope of services available; the freedom to choose a provider; a provider's choice to participate in a plan; the method of reimbursing providers; and the statewide application of the program. States have used this approach to extend coverage to people who in the past were categorically ineligible.
  • Section 1931 allows States greater flexibility to extend eligibility to more low-income families using any of three mechanisms: income disregards, asset disregards, and increasing income and asset limits.

Kaiser Family Foundation data reveal that just 54 percent of health maintenance organization plans allow obstetrician-gynecologists (OB/GYNs) to serve as women's primary care providers, even though most women prefer to have these specialists manage their care. Many States have focused on improving OB/GYN access under managed care, but there is still much variation in access laws among States:

  • Some States have taken measures to eliminate the referral requirement.
  • Some States allow women to designate an OB/GYN as a primary care provider.
  • Other States have ensured that the number of annual OB/GYN visits is not limited.
  • Some States have restricted the surcharges or added co-pays for OB/GYN visits.

Another important issue is expanding health plan coverage of reversible contraceptive drugs and devices, the cost of which can be significant for women with low income. States' provisions vary, ranging from full coverage of all Food and Drug Administration (FDA)-approved contraceptive drugs and devices to coverage of only oral contraceptives. Related to this issue is Medicaid family planning expansions for women. States have used the Section 1115 waiver to extend Medicaid coverage for family planning to low-income women ineligible for full Medicaid assistance.

Dr. Salganicoff noted that expanding health care coverage for women is a critical issue, and State policies and programs can make a difference. Some of the key issues and challenges that States need to recognize are:

  • Women need coverage for a meaningful range of services throughout their lifetime. The scope of coverage makes a difference.
  • Vulnerable women need supplemental services and programs. Basic coverage is important, but unlikely to be enough to improve the health outcomes of these women.
  • Women play a key decisionmaking role in the health of their families, and it is important to take advantage of that in developing new programs and policies targeted at women.


Salganicoff A, Wyn R Access to care for low-income women: the impact of Medicaid. Journal of Health Care for the Poor and Underserved 1999;4(10):453-67.

Coverage of Gynecological Care and Contraceptives. Fact Sheet: Women's Health Policy Facts, December, 2000. Kaiser Family Foundation.

Health Insurance Coverage of Low-Income Women. Fact Sheet: Women's Health Policy Facts, February, 2001. Kaiser Family Foundation.

Medicaid's Role for Women. Fact Sheet: Women's Health Policy Facts, November, 2000. Kaiser Family Foundation.

State Estimates of Health Insurance Coverage of Women Ages 18-64, 1997-1999. Fact Sheet: Women's Health Policy Facts, February, 2001. Kaiser Family Foundation.

State Policies on Access to Gynecological Care and Contraception. Issue Brief: An Update of Women's Health Policy, December, 2000. Kaiser Family Foundation.

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