Alina Salganicoff

MAKING THE MOST OF MEDICAID Promoting the Health of Women and Infants With Preconception Care

This paper examines the evolution and current role of Medicaid in improving access to preconception care for low-income women. The authors review Medicaids eligibility policy and benefits of relevance to women of reproductive age and discuss various approaches to promote preconception care in Medicaid. The challenges facing the program and potential opportunities to use the program to promote preconception care to low-income women are discussed.

Health Coverage and Expenses: Impact on Older Women's Economic Well-Being

The health issues women face over the course of their lives, as well as policies that shape Medicare, Medicaid, and other supplemental coverage can affect retired womens economic well‐being. This study uses a nationally representative sample of Medicare beneficiaries aged 65 and older in 2002 to explore gender‐based differences in health and long‐term care use, spending patterns, and the financial burden of health and long‐term care out‐of‐pocket health expenses. Womens health care expenses were higher than mens; older women paid for a greater share of their total spending out of pocket and they faced a greater financial burden by shouldering these out‐of‐pocket costs with less income at their disposal. Low‐income women, those with Medigap or no supplemental coverage, and white women, who are less likely to qualify for Medicaid which covers long term care, faced the greatest financial burdens associated with health and long‐term care costs. The implications of these findings for women in the context of the current health policy landscape are discussed. Controlling health spending and developing options to finance long‐term care are key elements of the policy solutions that will need to be developed to preserve and support economic security for millions of retired women in the United States.

Medicaid managed care and low-income women: implications for access and satisfaction

Medicaid has provided critical health care coverage to millions of low-income women for over three decades and has been a major factor in improving their access to care. Following years of rapid spending growth, state Medicaid officials—like their counterparts in the private sector—have looked to managed care to help them reign in spending without compromising access. The move to Medicaid managed care has happened with unprecedented velocity. In 1991, less than 10% of Medicaid beneficiaries were enrolled in managed care; by 1997, nearly 50% of Medicaid beneficiaries were enrolled in a managed care plan.1 The shift to managed care has had a disproportionate effect on care received by low-income women and their children, because these are the population groups that have been targeted for initial enrollment. The elderly and people with disabilities have been enrolled to a much lesser extent. Despite this fast growth in enrollment, very little is known about how low-income women fare with Medicaid managed care generally.2 Much of the research on the effects of Medicaid managed care on access for women has focused on pregnancy and birth outcomes.3–5 Only a handful have focused on managed care and its impact more broadly on women for non–pregnancy-related services. Those studies were conducted to evaluate an earlier generation of managed care and did not find Medicaid managed care to be associated with better care and improved health outcomes for women in most cases.6 – 8 In this article we examine the impact of managed care on the adult women on Medicaid, who are the main adult Medicaid eligibility category affected by the transition to managed care. We use the Kaiser/Commonwealth Five-State Low-Income Survey to compare how low-income women with Medicaid managed care differ from women with traditional fee-for-service Medicaid and low-income women with private managed care with regard to personal and

Medicaid and managed care: meeting the reproductive health needs of low-income women.

State Medicaid programs have increasingly turned to managed care with hopes of controlling spending while improving access to care. The move to managed care has significant implications for the provision of reproductive health services--family planning, abortion, sterilization, sexually transmitted diseases, and maternity care. However, the delivery of reproductive health services in a Medicaid managed care environment is wrought with many difficulties. The complexity inherent in Medicaid policy, the changing world of managed care, and the health and social needs of the Medicaid population are compounded by the sensitive nature of reproductive health needs.

Medicaid at 50: Marking a Milestone for Women's Health

When Medicaid was enacted 50 years ago, no one could have imagined that this relatively modest program would become the backbone of coverage for millions of low-income women. Today, Medicaid provides health and long-term coverage to more than 1 in 10 women. For women inparticular, the program has served as a critical safety net by providing coverage for a wide spectrum of services that other government programs and private insurance did not, from contraceptives and pregnancy-related care to longterm care services and supports. Medicaid’s 50th anniversary is an opportune time to look back at some of the program’s achievements as they have affected women and to take stock of the challenges the program will continue to face in the coming years.

Medicaid and Women's Health Coverage Two Years into the Affordable Care Act

As Medicaid marks its 50th year, the program has unquestionably become the mainstay of health coverage for lowincome women in the nation. Since its inception, its role for women has continued to evolve and expand, but the passage of the Affordable Care Act (ACA) swung open the doors for Medicaid to serve even more low-income women who lack access to private or employer-based insurance. This is because the ACA enabled states to finally eliminate Medicaid’s historical “categorical” requirements, which had essentially shut out women and men without dependent children. The vision of the ACA’s proponents was that eligibility would be extended to all individuals with incomes up to 138% of the federal poverty level (FPL), creating a pathway to coverage for millions who previously could not qualify for the program, regardless of how poor they were. In 2012, a Supreme Court decision effectively made this expansion a state option (Supreme Court of the United States, 2012). As a result, 30 states plus the District of Columbia have opted to broaden eligibility, but 20 states have chosen to maintain historical eligibility categories with income thresholds that are far below the poverty level in many states. Despite this ACA implementation setback, millions of low-income women (and men) have gained coverage since the law was enacted (Office of the Assistant Secretary for Planning and Evaluation, 2015). Nearly 21% of nonelderly adult women and 16% of men now have public coverage, primarily Medicaid. Additionally, 4.8 million women and 3.7 million men have purchased a marketplace plan, with the majority qualifying for premium subsidies (Centers for Disease Control and Prevention, 2015). Considerable questions remain, however, about how to maximize the ACA’s potential to reduce the uninsured count, improve access to care, and how elements of coverage can be strengthened to better serve the needs of lowincome women.

Screening for Urinary Incontinence in Women: A Recommendation From the Women's Preventive Services Initiative

Urinary incontinence, the involuntary loss of urine, is characterized by 3 main types: urgency, stress, and mixed (1). Affecting an estimated 51% of women overall, urinary incontinence increases in prevalence with age, ranging from 13% in young, nulligravid women to 25% in reproductive-age, 47% in middle-age, 55% in postmenopausal, and 75% in older women (24). These rates are twice those reported in men (3). Of women with symptoms, 32% to 51% have episodes daily and 20% to 32% weekly (5). In a national survey, symptoms of incontinence were reported by 44% of white, 29% of African American, and 35% of Hispanic women (5). Urinary incontinence adversely affects a womans physical, psychological, and social well-being by limiting participation in social gatherings and work activities, interfering with sexual function, and reducing independence (6). Associated medical conditions include urinary tract infections, skin ulceration, and fractures resulting from falls occurring at night or while rushing to avoid urge incontinence episodes. Obesity (79) and a history of vaginal delivery (10) are important risk factors for urinary incontinence. Symptoms also are associated with potentially modifiable factors, such as smoking, caffeine consumption, diabetes, depression, vaginal atrophy, and constipation (11), as well as other factors, including menopausal status, hysterectomy, cognitive and functional impairment, and chronic medical conditions (12). In the United States, the direct cost of urinary incontinence care is approximately

Women, Private Health Insurance, and the Affordable Care Act.

19.5 billion (13), with direct medical and nonmedical costs of

The Importance of Strengthening Workplace and Health Policies to Support Breastfeeding

51.4 billion (14). Approximately 6% of nursing home admissions of older women are attributed to urinary incontinence (15), costing

Health and the 2016 Election: Implications for Women

3 billion per year (15). Despite its high rates and adverse effects on health, well-being, and function, urinary incontinence is underreported by women and therefore infrequently recognized by clinicians. In a survey, approximately 55% of women with urinary incontinence did not report symptoms to their health care providers (6) because of embarrassment, stigma, or acceptance as normal. However, symptoms may be treated by behavioral, nonpharmacologic (16), pharmacologic (1618), and surgical interventions, depending on the type and severity of incontinence and patient preferences. Early intervention may reduce symptom progression, improve immediate and long-term quality of life, and limit the need for more complex and costly treatment (19). Womens Preventive Services Initiative The Womens Preventive Services Initiative (WPSI) is a national coalition of 21 health professional organizations and patient representatives that develops, reviews, updates, and disseminates evidence-based clinical recommendations for womens preventive health care services in the United States (20). The WPSI is supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), and is led by the American College of Obstetricians and Gynecologists (ACOG). It was launched in 2016 to continue the work of the former Institute of Medicine (IOM) (now the Academy of Medicine) Panel on Preventive Services for Women (21), which issued 8 clinical recommendations in 2011 that were accepted for coverage and implementation under the Patient Protection and Affordable Care Act (22). The prevention services mandate of the Affordable Care Act requires covered services to be incorporated into private and public insurance benefits, with no cost sharing or deductible charges to patients (22). Similar to the IOM panels guidelines, WPSI recommendations are intended to guide clinical practice and coverage of services for the HRSA and other stakeholders. Initial WPSI work focused on reviewing and updating the IOM recommendations, and these updates were adopted by the HRSA in December 2016 (23). The WPSI will review its recommendations every 5 years and at any time relevant new evidence becomes available. The WPSI focuses on gaps in current prevention recommendations for women. These include services that the U.S. Preventive Services Task Force (USPSTF) considered but for which it provided indeterminate recommendations, such as grade C (provide service for selected patients depending on individual circumstances) and I (insufficient evidence to assess benefits and harms) (24). Additional gaps include existing recommendations with a narrow scope, areas with new research, and topics not addressed by other guideline groups. The WPSI bases its recommendations on evidence of both benefits and harms of an intervention or service and an assessment of the balance between the two (25). Cost is not considered in assessing a service. The WPSI recognizes that many of the most important clinical questions regarding effective use of preventive services are not addressed by research studies, particularly those involving adolescents, pregnant and postpartum women, or elderly women. In these cases, compelling indirect data also are considered to determine benefits and harms. The WPSI based its rationale for urinary incontinence screening on several considerations. Screening has the potential to identify urinary incontinence in many women who silently experience its adverse effects but may benefit from appropriate evaluation and treatment. Effective screening may lead to earlier or more timely treatment, including behavioral, medical, and surgical interventions, depending on the patients age and the type and severity of symptoms. Recommendation Focus and Target Population This is a new recommendation based on evidence of the benefits and harms of screening for urinary incontinence in women, including a new systematic review of the accuracy of screening instruments (26) and recently published systematic reviews on the benefits and harms of treatments. The evidence on urinary incontinence screening was not evaluated previously in a scientific review, and no clinical practice guidelines exist for screening. Previous guidelines developed by different professional organizations (12, 16, 18, 27, 28) addressed women with symptoms who are referred for diagnostic evaluation and treatment, not screening. The target audience for this recommendation includes all clinicians providing preventive health care for women, particularly in primary care settings. This recommendation applies to women of all ages, as well as adolescents. Methods WPSI Topic Selection and Recommendation Development The Evidence-based Practice Center methods of evidence review (25) are adapted from the USPSTF (29) and the previous IOM Panel on Preventive Services for Women (21). Details on methods, processes, and funding are available on a public Web site (20). The WPSI is overseen by an advisory panel of representatives from ACOG, the American Academy of Family Physicians, the American College of Physicians, and the National Association of Nurse Practitioners in Womens Health, representing most womens health care providers in the United States (Figure). In addition, 3 experts in womens preventive health care and evidence review serve on the advisory panel. Members of the Multidisciplinary Steering Committee are invited representatives of 21 womens health professional organizations and patients who select topics and develop and vote on recommendations. A separate Implementation Steering Committee plans dissemination. Scientific review of evidence is conducted by the Pacific Northwest Evidence-based Practice Center Committee, and conflicts of interest are evaluated before appointment and annually by the advisory panel, which determines eligibility for participation after an ACOG process. Figure. Organizational structure of the WPSI. AAFP= American Academy of Family Physicians; ACOG= American College of Obstetricians and Gynecologists; ACP= American College of Physicians; EPC= Evidence-based Practice Center; HRSA= Health Resources and Services Administration; IOM= Institute of Medicine; NPWH= National Association of Nurse Practitioners in Womens Health; WPSI= Womens Preventive Services Initiative. The WPSI selects topics that fill gaps in existing screening and prevention guidelines and that meet eligibility criteria. Criteria include conditions that affect a broad population of women; that are specific, more common, more serious, or differ in women; and for which prevention would have a large potential effect on womens health and well-being. Additional criteria require that the health service be a primary or secondary prevention service feasible for practice in the United States, including screening, counseling, immunization, and preventive medication or therapy, and that the quality and strength of evidence directly or indirectly support its effectiveness. The topic of urinary incontinence screening was selected by a vote of the Multidisciplinary Steering Committee members. The scope and key questions were developed by the advisory panel with additional input from subject experts. A systematic review addressing the key questions was conducted by the Pacific Northwest Evidence-based Practice Center and presented to the WPSI Multidisciplinary Steering Committee at an in-person meeting (26, 29). Members discussed the strengths and limitations of the evidence for urinary incontinence screening, including weighing the benefits and harms. The committee considered the quality and applicability of direct evidence indicating benefits and harms of screening on health outcomes, indirect evidence of the validity of screening instruments, and the effectiveness and adverse effects of treatments for urinary incontinence. Health outcomes included improved symptoms, function, and quality of life. Indirect evidence was used to link screening and health outcomes in the chain of evidence that might support screening in the absence of direct evidence. The committee also considered the effect of screening on symptom progression and avoidance of costly and complex treatments, as