Introduction
The health care debate has been at the center of a political firestorm for more than a decade. The last three American presidents all used the health care debate as a central focus in their campaigning and policy making. While each individual approached the issue in a different manner the underlying cause of this debate was the fact that many Americans do not have access to a private insurance plans. Women are disproportionately affected by lack of access to health care, because they face the additional health costs and risks associated with sexual reproduction. Nearly 20 percent of American women of childbearing age, defined as 14-44 years, or approximately 1.24 million are uninsured (Johnson et al. 2008, S3). Due to the aforementioned gap in access, both the government and not-for-profit sectors are faced with the task of providing essential reproductive health services. While both sectors provide a variety of services, I will be focusing on the quality and availability of services provided through Medicaid and not-for-profit clinics. Is there a difference in the quality and availability of women’s reproductive health services, when comparing Medicaid facilities and not-for-profit clinics in the United States? There are a variety of factors that must be examined when evaluating quality and availability of care. I will examine proximity, affordability, perceived quality, and potential road blocks to care. While there is no singular ideal measurement or factor that allows for a definitive comparison, there are numerous studies that provide invaluable insight into the quality and availability of care offered by Medicaid and not-for-profit organizations.
Background
The terms “reproductive health”, “government support” and” not-for-profit organizations” can be interpreted in a variety of ways, and for the sake of this comparative review, I will narrow the definitions based on the data found in my research. “Women’s reproductive health care” refers to, but is not limited to, counseling and testing for STDs including HIV, testing for cervical cancer, access to contraceptives, access to abortive services, and pre and post natal care. “Government support” will only refer to Medicaid for comparative analysis, and will not include other health care services provided by the government. “Not-for-profit clinics” will refer to clinics that receive Title X funds, as well as clinics that do not receive tax payer support. In addition, I will not be making a differentiation between not-for- profit clinics that offer a full range of services and the organizations categorized as “crisis pregnancy centers” that do not. This is due to a lack of differentiation in the available literature and does not negate the fact that many “crisis pregnancy centers” do not provide accurate information to their clients or comprehensive reproductive health services (Kulezyeki 2007, 339).
Geographic Proximity of Available Care
The most basic component of accessing care is the physical proximity of the available services. The availability of not-for-profit clinics varies from state to state. There are 3,141 counties in the United States, and there are clinics that offer reproductive services in 84.5 percent of those counties. However, those numbers are skewed slightly by counties with low populations. Ninety-eight percent of all women who need to access to reproductive services live in a county that has at least one clinic (Frost et al. 2004, 213). While this may seem like access to care is widely available, these clinics do not offer a full range of reproductive health services. Only 20 percent of the counties in the United States have someone who can provide abortive services. Due to the small number of abortion providers, approximately one-fourth of women who are seeking these services must travel more than 50 miles to access care (Ely, et al 2010, 661). This statistical evidence indicates that abortive services are not widely accessible, but it also suggests that other clinics that offer women’s health services are readily available. The geographic proximity however, does not necessarily prove that clinics are truly accessible. There are a variety of other factors including county size, availability and affordability of transportation, and the women’s knowledge of the clinic’s existence. Women who are on Medicaid can therefore expect to have access that is as good, or better, than those women who rely solely on clinics for care, because there are additional facilities that accept Medicaid vouchers, that are not classified as not-for-profit clinics. These additional facilities increase the likelihood of proximity, accessibility by public or private transportation, and visibility in the community.
Affordability of Services
With soaring health care costs and stagnant wage increases, affordability plays a large role in accessibility of care. The costs of medications and services can prohibit women from taking advantage of reproductive services. Consider that one year of oral contraceptives can cost, on average 300 dollars, or 25 dollars per month, while five-year contraceptive implants can cost 500 dollars, which averages out to a little more than eight dollars a month, but it carries a much greater initial investment (King et al. 1997, 9). These costs can be prohibitive, especially for women who are not eligible for Medicaid vouchers. Some not-for-profit clinics offer care at reduced costs or a sliding scale based on income. On its website, the Planned Parenthood Federation of America, a not-for-profit clinic, offers gynecological exams for 35 to 250 dollars and birth control pills for 15 to 30 dollars a month. In addition, the website lists the cost of abortive services, both pharmacological and surgical, as ranging between 350 and 600 dollars (Planned Parenthood Federation of America). On the U.S. Department of Health and Human Services website, the costs of prescription drugs are listed as one to three dollar co-pay per month (U.S. Department of Health and Human Services). However, Medicaid offers no reimbursement of abortive health services, due to the passage of the Hyde Amendment, which prohibits the use of federal funding when obtaining abortive services (Gius 2007, 497). Numbers alone do not indicate whether access to these services can be considered affordable; information on average salary must also be taken into account. The U.S. Department of Labor found that the median weekly income for women working full time was 657 dollars or 34,164 dollars per year, and that the median weekly income for women working less than 35 hours a week was 229 dollars or 11,908 dollars per year (U.S. Department of Labor). Reviewing these statistics, and calculating percentage costs by dividing the average monthly cost for birth control pills as 300 dollars by the median yearly salary, the cost of birth control would constitute .8 percent cost of total yearly salary for those women working full time, and a 2.5 percent cost of total yearly salary for those women working part time. While this certainly does not constitute a large percentage of salary, given the high costs of housing, food, and transportation, even the seemingly small percentage costs of access to birth control could be prohibitive. Given these statistics and the available research, it is difficult to come to a solid conclusion regarding the affordability of women’s reproductive services at not-for-profit and Medicaid clinics. While the Medicaid reimbursement certainly makes prescription coverage more affordable, the lack of coverage for other services, including abortion and treatments for infertility, can negate the positive impact of reduced prescription coverage. The sliding scale payment options at not-for-profit clinics could make various services more affordable, but if the cost of living is too high, even reduced cost care could be out of reach.
Quality of Care
The first factor that relates to the quality of care is the quality of services offered as compared to national medical standards and practices. All the data I was able to locate on comparative quality of care combines not-for-profit clinics with Medicaid vouchers, and then compares the quality of those services to private entities. Looking at survey data, the quality of care is largely determined by tests and services offered. When comparing those clinics that are public, to those that are private, researchers found that while the majority of both private and public clinics offered services such as pap tests, birth control counseling and prescription, STI and STD testing, the private clinics were more likely than the publicly funded clinics to offer the more accurate liquid pap test, at a rate of 47 percent versus 13-17 percent (Dubenstein et al. 2006, 141). However, clients at public clinics (encompassing both Medicaid and not-for-profit clinics) were more likely to receive contraceptive services, and counseling on STDs, including HIV, than those clients at the private clinics (Frost 2007, 1816). These differences can occur for a variety of reasons. Cost can affect the availability of newer and more advanced testing services. The lower rate of liquid pap tests at the public clinics could be a result of the increased cost of the test. Another factor that can affect availability of service could be client demand. The higher rates of receipt of contraceptive services, and counseling on STDs, including HIV at public clinics, could reflect the fact that the clients at public clinics are in a higher risk group than the clients at private institutions. The lack of comparative data between those receiving care through Medicaid and those receiving care through not-for-profit clinics, without government assistance, reveals a gap in current research. The two services are divergent and it could skew important health services statistics to ignore the potential differences between those who receive Medicaid vouchers and those who do not. It appears that additional research in this area could provide a clearer picture as to quality of care.
The second, and equally important factor when considering quality of care, is how the client perceives the quality of services offered. Again, I found a lack of data that compares Medicaid consumers to those who utilize not-for-profit clinics. Most of the research focuses on client perceptions of reproductive health care services without much differentiation between private, not-for-profit, and Medicaid sources. Communication is an extremely important factor in health care. If the client does not understand the medical information the physician or medical provider is sharing, they are less likely to follow directions and thus less likely to receive the optimal level of care. Based on general surveys that were distributed in 2002, nine percent of women who were pregnant reported that they were dissatisfied overall with their health care, while 16.2 percent of non-pregnant women reported dissatisfaction. The clients report the greatest level of dissatisfaction when it comes to the amount of time they spend with their health care provider. 16.9 percent of women who were pregnant reported that providers “sometimes or never spent enough time with them” and 18.6 percent of non-pregnant women had the same complaint (Ebrahim et al. 2009, 200). While this information gives a general idea of client satisfaction, it lacks detail based on provider type. In other studies, researchers generally found that public clinics and hospitals received lower quality ratings, while private doctors and hospitals tended to receive the highest quality ratings. Female providers received higher quality ratings than male providers, and non medical doctor (MD) providers received higher quality ratings that MDs (Becker et al. 2007, 209). The findings in these surveys make sense, because those facilities with fewer resources, such as not-for-profit public clinics and hospitals, are less likely to be able to provide the services that private hospitals with greater resources can provide. It would appear that both women who utilize Medicaid and not-for-profit clinics can expect to experience greater dissatisfaction and lower quality of care than those women who utilize private reproductive health resources. Additional research is needed not only in client satisfaction with all reproductive health services, but especially those clients who utilize clinics that are not-for-profit or accept Medicaid. Having a clearer idea of client satisfaction, would allow for greater understanding when examining utilization and effectiveness of reproductive health care services.
Medicaid Roadblocks
There are several different factors that might prevent a woman from accessing reproductive health care through the Medicaid system. A lack of understanding when it comes to the requirements and the application process for Medicaid could prevent eligible women from accessing benefits. Eligibility for program access is not only based on income, but other factors: “These may include your age, whether you are pregnant, disabled, blind, or aged; your income and resources (like bank accounts, real property, or other items that can be sold for cash); and whether you are a U.S. citizen or a lawfully admitted immigrant. The rules for counting your income and resources vary from state to state and from group to group” (U.S. Department of Health and Human Services 2). Therefore, if you were a woman, with a lower income, who had difficulty paying your medical expenses, you would not automatically qualify for coverage under Medicaid. In addition, if you were a woman who qualified for Medicaid in one state, and you moved to another state, you would not necessarily still qualify for aid. These complicated rules regarding eligibility could easily discourage someone from applying for Medicaid, especially if there were other factors involved, including educational background, English language proficiency, and general knowledge of government aide. A complicated set of rules for qualification can stop women from applying for Medicaid. The application process itself may also affect the likelihood that a woman would obtain Medicaid and thus have access to reproductive health services. Medicaid requires that all potential recipients go through an application process, and provide proof of eligibility. This process takes time, and requires that the recipient either go to a specified office to fill out the paperwork, fill out an application online, or fill out an application at a point of care clinic in cases of urgent care (U.S. Department of Health and Human Services 2). If a woman had a job that would not allow her to take time off, did not have internet access at home, or had children, it could be difficult for her to complete the application process. If a woman were eligible, and was able to complete the application process, there are still potential road blocks to receiving care. Not all medical facilities accept Medicaid, so even if there is a women’s reproductive health provider in the area, a woman on Medicaid might have to travel farther to access a Medicaid eligible provider.
Medicaid does not automatically cover all costs or all services associated with women’s reproductive health services. Co-pay is often required for medications, such as birth control pills, and services, such as routine gynecological exams. If a Medicaid client is unable to pay for these services, this could deter a visit to the care provider. There are also certain services that are prohibited to be covered by Medicaid funds. Medicaid has placed bans on funding for both abortion and infertility treatments. Medicaid specifically prohibits clients from obtaining abortions using Medicaid, unless they are the victim of rape or incest, or if going through labor presents a danger to the woman’s health. These rules, along with state mandates regarding bans on partial birth abortions, have been found to have a “significant negative impact” on the number of abortions performed in the United States (Gius 2007, 498).
Political changes can also cause road blocks for woman accessing care through Medicaid. Expansions in Medicaid funding have been, for the most part, at the discretion of an individual state. Individual states can apply for a federal waiver, and once that waiver has been approved, the federal government will reimburse the cost to the state, up to 90 percent (Sonfield, et al 2008, 3). That means that each state chooses to allocate resources to Medicaid based family planning services, and some states allocate more resources than others. These changes can be based on financial constraints, but it is also likely that they reflect the political beliefs of those in power. Many of the states that do not provide expanded services are those that can be considered more conservative politically. These states include Georgia, Tennessee, Ohio, Montana, and South Dakota, among others (Sonfield, et al 2008, 4). Women who live in states without expanded services can find that they are not eligible for services that they can qualify for in other states and can therefore expect to receive fewer services. Because the power to allocate resources lies in the hands of elected officials, it can be assumed that as political power shifts and policy changes, so too can allocations to Medicaid. Thus, changes made to allocations can have both a positive and a negative impact on those women seeking reproductive health services through Medicaid.
Not-for-profit Clinic Roadblocks
Women who utilize not-for-profit clinics for reproductive health services also face certain roadblocks when accessing care. In addition to previously discussed issues related to accessibility and cost, there are other factors that can affect a woman’s choice to utilize a not-for-profit clinic. Studies have shown that over the last ten years, there has been a great amount of turnover in not-for-profit clinics. While the number of available clinics has remained relatively stable, there has been an effort to consolidate some services, and clinics come and go based on funding, client base, and other factors (Frost et al. 2004, 214). These changes can create instability for women seeking care. If the clinic they use closes, they may not feel comfortable going to another clinic, or the quality of care may drop due to a lack of continuity in service providers.
State mandated laws can also create difficulty for women attempting to utilize not for profit clinics specifically for abortive services. In 32 states female patients under the age of 17 are required to obtain parental consent before obtaining pharmacological or surgical abortions. While 28 of the 32 states allow for judicial intervention that allows for access without parental consent, the consent laws can cause delay or denial of services (Ely, et al 2010, 662). In addition to parental consent laws, there are other laws on the books that can also delay or effectively deny access to care. There are thirty-two states that require counseling and twenty-four states require a twenty-four hour waiting period, before a woman can receive abortive services (Ely, et al 2010, 665). The state mandated counseling can create a roadblock to care, because it is not necessarily created or provided by an objective individual. If the counselor provides biased information, or presents the counseling in a manner that promotes fear or guilt, they could create a situation where care is essentially blocked. The twenty four hour waiting period can also cause roadblocks to care. Earlier, it was noted that one fourth of women have to travel more than fifty miles to access a clinic that offers abortive services. If any woman has to make more than one trip to a clinic, it is likely to result in increased transportation expenses and loss of wages, particularly for those women who have to travel greater distances. The additional expenses associated with the mandatory waiting periods could create a situation where access to services at not for profit clinics become unavailable for women with limited financial resources.
Another factor that may negatively affect access to care is more difficult to quantify. I was unable to find any research related to the affects of protesters and access to care but, it is possible that there is a negative correlation. Some not-for-profit clinics face protests and acts of violence, such as bomb threats, bombings, personal attacks on physicians and threats of personal harm to all staff, for providing abortive health services to women. In addition to these threats of violence, there are also groups that protest outside of clinics that provide reproductive health services. It is possible that the history of violent attacks, verbal threats and the physical presence of protestors outside of not-for-profit clinics have a negative influence on women accessing care. This is an area that requires more research, to make any determination as to the possible effects that protesters may have on access to not for profit clinics.
Conclusions
There are numerous factors that can affect access to women’s reproductive health services, for women utilizing both Medicaid and not-for-profit clinics. Those women using Medicaid face limited access, complicated and confusing application processes, and changes in service based on political policies. Women who utilize not-for-profit clinics face challenges due to financial limitations, physical proximity, and the instability that can be inherent in the not-for-profit arena. In addition to the easily quantifiable factors listed above, there are social and political factors that can also affect perceptions of healthcare, government services, and reproductive health. Government policies regarding not only reproductive health services, but sex education, and international outreach can affect our perception of sexuality and reproduction. Social factors, like education, race, religion, can also impact the utilization of various reproductive health services.
I believe that more research needs to be done to reach a conclusion in regards to which sector provides better women’s reproductive health services. In much of the current research there is little to no differentiation between services provided by not-for-profit clinics and services provided by Medicaid. It seems that much of the research that has occurred up to this point focuses on the difference between private and public healthcare. While this research has been invaluable in providing information that has improved advocacy for those women without health insurance, it has not shed light on the more subtle differences between government and not-for-profit care. Perhaps because there is so much overlap in these areas, for example: not-for-profit clinics receive federal funding and Medicaid patients are seen at not-for-profit clinics, no one has seen the need to research the outcomes separately. However, I believe that investigating these services would provide valuable insight into quality of care. The government and not-for-profit sectors could learn from each other, and improve partnerships to provide better health care for all women.
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