Our Bodies, Ourselves (163 page)

African Americans face the most severe burden of HIV in the United States. From 2005 to 2008, the rate of HIV diagnoses among blacks increased from 68 in 100,000 persons to 74 in 100,000—the largest increase in rates of HIV diagnoses during that time of any race or ethnicity.
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Women account for more than one in four new cases of HIV infection in the United States.
Of these newly infected women, about two out of three are African American.
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Approximately one in sixteen black men and one in thirty black women will be diagnosed with HIV at some point in their lives. The HIV prevalence rate for black women (1,122.4 per 100,000) is nearly four times higher than the rate for Hispanic/Latina women (263 per 100,000) and nearly eighteen times higher than the rate for white women (62.7 per 100,000).
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AIDS is now the leading cause of death for African-American women ages 25 to 34.
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And as with complications of pregnancy, lack of early detection and lack of access to treatment lead to a rate of death from AIDS-related illnesses among African-American women that is twenty-one times the rate among non-Hispanic white women.

Unprotected sex with an infected partner is the leading cause of HIV infection in women. The CDC cites lack of awareness of HIV status as one issue leading to ineffective efforts at prevention. The CDC and others also underscore that the “socioeconomic issues associated with poverty, including limited access to quality health care, housing, and HIV prevention education, directly and indirectly increase the risk for HIV infection and affect the health of people living with HIV.”
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To understand why the economic downturn has greatly reduced women's access to health care, it helps to understand the structure of the U.S. health care system.

The best way to be sure there is enough money to afford care for everyone is to cover everyone. Since everyone needs health care at some point, it is most affordable if everyone chips in, including those who are still healthy. Most other developed countries accomplish this, usually through systems of public and private coverage. They also use the negotiating power of the government to moderate health care prices, such as prices for drugs and for hospital care. They ensure a large supply of primary care services, to lessen the need for expensive specialty care. But the United States has historically done none of these.

The United States spends more than any country on health care, about 16 percent of gross domestic product in 2008. Despite this, it is the only industrialized country where not all residents are automatically covered for health care services. In 2010, close to 51 million Americans did not have health insurance coverage for some time during the year.
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In 2007, 45 percent of women, compared with 39 percent of men, had been underinsured or uninsured for a time in the past year.
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Even women with health insurance report problems affording health care. Unaffordable cost-sharing requirements and annual or lifetime limits on covered services have a disproportionate impact on women. More than half (52 percent) of working-age women report problems accessing health care because of costs, compared with 39 percent of men.
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Public programs guarantee coverage for some people. The federal Medicare program covers most people age sixty-five and older and people with certain disabilities, and the federal/state Medicaid program covers some of the very poor and disabled. Two public health services that pay for and provide care are the Indian Health Service and the Department of Veterans Affairs (VA). About 44 percent of personal health expenditures are covered by public programs, 36 percent by private insurance, and 16 percent by out-of-pocket payments.

Most people under age sixty-five who have private health insurance receive it through an employer. But there is no law requiring employers to provide coverage. Increasingly, workplace-based health care benefits have become a privilege enjoyed
by those in the largest workplaces with the highest-paid employees. Private insurance companies can make money on large groups, where expenses are somewhat predictable, and even more on large groups of healthy people.

But private insurers are reluctant to cover individuals and small groups, because it is difficult to predict who will have an expensive accident or illness. Without a large group of healthy people paying premiums, the insurer can lose out. And insurance companies calculate that if individuals don't have to buy insurance, only people who are already sick will do so. For these reasons, individuals and small employers have the hardest time finding a private insurance company that will agree to cover them, much less one that is affordable and pays claims reliably. In addition, insurance companies spend a lot of money trying to avoid paying claims and to exclude people who already need care—known in insurance-speak as those having a preexisting condition—or who might get sick.

As a result of this dysfunctional system, insurance premiums have risen, and employers have increasingly stopped offering coverage. Widespread job losses have led to equally widespread losses of employer-based health care for those who were fortunate enough to be covered in the first place.

Women are less likely than men to have jobs that offer employment-based private health insurance. This means, for example, that middle-age women who are single, divorced, or widowed and not yet old enough for Medicare are often uninsured. And even under Medicare, the long-term care that many women require is not covered. Women are more likely to be covered by Medicaid than men, owing to rules on eligibility during pregnancy, but the coverage frequently does not continue after the birth of the child. And in states where Medicaid payments are low, many providers do not accept Medicaid patients.

The spiraling cost of health care is attributable in part to administrative costs, which account for 25 percent of private insurance costs, compared with 3 percent in the federal Medicare program. Public systems like Medicare are much more efficient because they cover everyone over age sixty-five, even though older people generally need more health care as they age. Because they are public, they do not make profits. In addition, U.S. drug companies, hospitals, and other providers increase charges annually.
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Other countries use the power of the government to negotiate with these providers and hold down prices. In the United States, private insurance companies haven't done the job.

With the economy in decline, funding for many safety net programs, including local nonprofit food and housing programs, has been cut. And as unemployment insurance benefits run out, many of the unemployed have been unable to keep up health insurance payments on their own.

The situation is often worst for those workers who never had employer-based care to begin with. They often cannot even find an insurance plan that will take them, especially if plans detect preexisting conditions, which can include pregnancy and past medical treatment for domestic violence. They usually cannot afford the higher self-paid premiums. Poverty and poor health go hand in hand: An employment crisis becomes a health care crisis, while a health care crisis can drive a family into poverty.

People of color and people with low incomes are the least likely to have stable health insurance coverage. Black women age eighteen to sixty-four are nearly twice as likely to be uninsured as white women, while Hispanic women
are almost three times as likely not to have insurance.
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More than a third of low-income women age eighteen to sixty-four lack health insurance, compared with 18 percent of women overall.

Insurance access—or lack thereof—has a very real impact on health and quality of life. Low-income women are twice as likely as higher-income women to report problems getting health care, such as not filling a prescription, not seeing a specialist when needed, or skipping a recommended medical test, treatment, or follow-up visit.
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Other women who are more likely to lack health insurance include women who are divorced; who work in service jobs such as waitressing; who work part-time or as temps; or who provide full-time care for children, aging parents, or ill family members.

The economic decline and loss of health insurance coverage have had negative consequences for reproductive health care. The Guttmacher Institute found that the rate of uninsured women of reproductive age rose faster—and was
significantly higher—than the rate for the U.S. population overall.
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The share of women age fifteen to forty-four who were covered by private (mostly employer-based) insurance fell 4 percentage points between 2008 and 2009, from nearly 39 million to only 36.7 million. In 2009, 22.3 percent of all women of reproductive age were uninsured and 14.8 percent were covered by Medicaid, compared with 20.1 percent and 13.2 percent, respectively, in 2008. The analysis further noted:

[These] bleak new data confirm previous Guttmacher research on the severe impact of the recession. In 2009, we documented that because of economic hardship, nearly half of low- and middle-income women wanted to delay pregnancy or limit the number of children they have, but that many had to skimp on their contraceptive use—or forgo it entirely—to save money. We also found that publicly funded family planning providers were struggling to meet a growing need for subsidized contraceptive care, even as they had to make do with fewer resources.

Taken together, Guttmacher concludes, “the evidence paints a grim picture of fast-growing numbers of women struggling to afford contraceptives at a time when many say they can least afford to have a child (or an additional child).”

Yet while these data all underscore the critical importance of publicly funded family planning clinics as a crucial safety net for women who cannot otherwise afford the services and supplies they need to prevent an unintended pregnancy, those very services have become increasingly politicized.

In March 2010, President Obama signed the Patient Protection and Affordable Care Act (PPACA) into law. The act aims to expand health care coverage to 32 million uninsured Americans, mostly those who are locked out of the private insurance market because they are not part of a large group, already have a health condition, or can't afford coverage. They will be eligible either for the public Medicaid program or for new, private insurance options.

© Bill Hughes

Dr. Margaret Flowers speaks at a 2009 rally sponsored by the “Mad-as-Hell Doctors,” in Washington, D.C. Dr. Flowers is the Congressional Fellow of Physicians for a National Health Program, where she works on single-payer health care reform.