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Correspondence to: Professor Sara Rosenbaum, George Washington University School of Public Health and Health Services, Department of Health Policy, 2021 K Street NW, Suite 800, Washington, DC 20006; Phone: 202-530-2343.
This article examines health insurance coverage among women of reproductive age and considers how national health insurance reform may affect access to high-quality, timely, and affordable preconception and interconception care. A focus on preconception and interconception care increasingly is understood as essential, not only to the health of women, but to that of infants as well, and thus, as a key part of a comprehensive infant health strategy. After a brief overview that examines the relationship between preconception and interconception health care and health insurance reform, the article examines the current state of health insurance coverage among women of childbearing age and the underlying causes of uninsurance and underinsurance in this population group.
The article then sets forth a proposed health insurance reform taxonomy in the context of health and health care generally, and preconception and interconception health care in particular. It is the underlying assumption of this article that preconception and interconception care can serve as bellwethers of the extent to which health reform achieves preventive results. Such results include coverage reforms that not only put acute treatments within financial reach, but that also help finance interventions that can help to achieve population-wide preventive results, in this case, long-term improvement in the health of both women and children.
This article examines health insurance coverage among women of reproductive age and considers how national health insurance reform may affect access to high-quality, timely, and affordable preconception and interconception care. A focus on preconception and interconception care increasingly is understood as essential, not only to the health of women, but to that of infants as well, and thus, as a key part of a comprehensive infant health strategy (
). After a brief overview that examines the relationship between preconception and interconception health care and health insurance reform, the article examines the current state of health insurance coverage among women of childbearing age and the underlying causes of uninsurance and underinsurance among this population group.
The article then sets forth a proposed health insurance reform taxonomy in the context of health and health care generally, and preconception and interconception health care in particular. It is the underlying assumption of this article that preconception and interconception care can serve as bellwethers of the extent to which health reform achieves preventive results. Put another way, preconception and interconception health coverage are emblematic of reforms that not only put treatment within financial reach, but also help to finance interventions that can help to achieve population-wide preventive results, in this case, long-term improvement in the health of both women and children.
Preconception Care
A special report on preconception care, issued jointly in 2006 by the Centers for Disease Control and Prevention (CDC)/Agency for Toxic Substances and Disease Registry Preconception Care Work Group and the Select Panel on Preconception Care (
), identifies the health of women of reproductive age as a critical aspect of population health, not only in relation to the health of women themselves, but that of their children as well. Given the relationship between health care and women's and children's overall health, the Work Group and Select Panel, in their joint recommendations, include 4 recommendations, 3 of which either directly or indirectly address health care access and quality: 1) improve the knowledge and attitudes and behaviors of men and women related to preconception health; 2) ensure that all women of childbearing age in the United States receive preconception care services (i.e., evidence-based risk screening, health promotion, and interventions) that will enable them to enter pregnancy in optimal health; 3) reduce risks indicated by a previous adverse pregnancy outcome through interventions during the interconception period, which can prevent or minimize health problems for a mother and her future children; and 4) reduce the disparities in adverse pregnancy outcomes (
The report thus draws a direct link between health and health care, thus making improvements in health care access and quality basic to the population goal of preconception health. In doing so, the report thereby establishes its relevance to a discussion of health insurance reform because of the indisputable link—demonstrated through an avalanche of studies—between health insurance coverage and the receipt of health care (
). These studies consistently show that insured individuals have higher rates of appropriate health care utilization compared with their uninsured counterparts. In view of this link, 3 basic questions move to the forefront:
1.
What is the current state of women's health insurance coverage and what are the underlying drivers of these patterns?
2.
What are the critical and relevant domains of any discussion regarding the design and operation of health insurance coverage? (Where this question is concerned, these domains, like any good taxonomy, are the same regardless of the population subgroup or health condition under consideration, even if their application to any particular problem might produce somewhat different results.)
3.
Within these key domains, what specific policies might, in turn, best position health insurance reform to make a difference where preconception health is concerned, by promoting access to health care;- that is—in the words of the IOM—safe, effective, patient centered, timely, efficient, and equitable (
The high cost of health care, coupled with competing social investment considerations, such as education, shelter, economic development, and public safety, result in a worldwide struggle to find the right balance between population health investments and health care finance. What makes the United States unique is the extent to which the nation—alone among all wealthy nations—has failed to systematically pursue this struggle on behalf of the population as a whole. Where health care and health insurance coverage are concerned, the United States has no “unified field theory” by which it balances health care finance and population health. Instead, the nation relies on an approach to health care finance that, when compared with other nations, leaves millions without coverage, produces health care of uneven quality, suffers from unusual complexity, exhibits extraordinary deference to powerful stakeholders in the health care marketplace, and lacks equity (
Schoen, C., Osborn, R., Doty, M.M., Bishop, M., Peugh, J., & Murukutla, N. (2007, October 31). Toward higher-performance health systems: Adults' health care experiences in seven countries, 2007. Health Affairs Web Exclusive, Available: http://content.healthaffairs.org. Accessed July 14, 2008.
In truth, the problem of health insurance coverage is not one that can realistically be approached by gender or by any factor unrelated to the social imperative of ensuring that everyone has access to health care when needed. Indeed, the Preconception Report itself recognizes the vital importance of partners’ health to women's and infants’ health. The importance of maintaining the health insurance discussion at a universal level is especially true in a nation in which health care is market driven. In such an environment, adequate health insurance coverage is an absolute prerequisite to a reasonable level of health care. Some communities are fortunate enough to have subsidized primary health care available through publicly funded clinics (
Shin, P., Finnegan, B., Sharac, J., & Rosenbaum, S. (2008, January). Health centers: An overview and analysis of their experiences with private health insurance. Washington, DC: Kaiser Commission on Medicaid and the Uninsured. Available: http://www.kff.org/uninsured/7738.cfm. Accessed July 14, 2008.
). US law also guarantees access to emergency examination and stabilization treatment at hospitals with emergency departments. But most medically underserved communities lack clinics (
), and hospitals’ emergency care obligations are in fact exceedingly constrained, limited to screening and the most basic stabilization interventions if an emergency medical condition is found (
Nonetheless, there is reason to focus on women as a group, as demonstrated by the following series of figures prepared by the Kaiser Family Foundation. Figure 1 shows that, compared with men, women report a greater likelihood of fair to poor health and a higher proportion of women report the presence of ≥1 chronic condition and use of health care. Women also experience a wage and income gap that persists over their lifetimes and that elevate the potential for health related access problems (
). Furthermore, experts primarily focus on women's (as opposed to men's) interaction with the health care system when considering the health care dimension of preconception health, thereby further elevating the importance of women's health insurance coverage.
Figure 1Why focus on women? Health status by gender, 2004. Note. Includes women and men, ages 18–64. (From The Henry J. Kaiser Family Foundation, Kaiser Women's Health Survey, 2004.)
Figure 2 compares health insurance coverage patterns for men and women. Women are more likely to have health insurance, but at the same time coverage patterns differ distinctly by gender. Figure 2 shows that family composition and labor patterns result in important distinctions between men and women: Women are less likely than men to have employer-sponsored health insurance coverage in their own name (38% vs. 49%), more likely to have employer coverage on a dependent basis (25% vs. 13%), and are nearly twice as likely to have Medicaid (10% vs. 6%).
Figure 2Insurance coverage patters differ between women and men. Health insurance coverage of adults ages 18–64, By fender, 2006. Note. Other includes Medicare, TRICARE, and other sources of coverage. (From the Henry J. Kaiser Family Foundation analysis of the March 2007 Current Population Survey, US Census Bureau.)
Significant variations in health insurance coverage patterns are evident by race and ethnicity, chiefly as a result of the greater levels of poverty among women of color. Women of Hispanic origin are 3 times as likely as White non-Hispanic women to be completely uninsured (Figure 3); compared with White non-Hispanic women, Medicaid's role for African-American, Hispanic, and American Indian/Alaska Native women is 2–3 times as great. Employer-based and other private coverage, available to 80% of all White non-Hispanic women, is a factor for only 60% of African-American women and fewer than half of all Hispanic and Native American women.
Figure 3Differences in health coverage rates of women by race/ethnicity are significant. Health insurance coverage of women ages 18–64 by race, 2006. Note. Includes women ages 18–64. Other includes Medicare, CHAMPUS, and other sources of coverage. (From the Kaiser Family Foundation analysis of the March 2006 Current Population Survey, US Census Bureau.)
Figure 4 provides evidence regarding which women are at greatest risk for being uninsured. Poverty is the single most accurate predictor, placing women at a 4 in 10 risk for lack of coverage. Women who have certain demographic characteristics, such as membership in a racial and ethnic minority group, being a single parent, having limited education, or being foreign born, are also at elevated risk.
Figure 4Uninsured women: Who is at risk? (From the Kaiser Commission on Medicaid and the Uninsured and Urban Institute tabulations of 2007 ASEC Supplement to the Current Population Survey. The Federal Poverty Threshold for a family of 3 in 2006 was $16,277.
Figure 5 illustrates the extent to which women's uninsured rates vary among states. A total of 7 states show uninsured rates for nonelderly women of ≥23%; not surprisingly, these states exhibit the highest levels of noninsured rates among the nonelderly population generally. As Figure 6, Figure 5 shows, even in the states with the lowest proportion of women without health insurance, 1 in 11 nonelderly women was uninsured in 2006.
Figure 5Uninsured rates vary widely between the states. Uninsured rates among nonelderly women by state, 2005–2006. (From the Kaiser Family Foundation analysis of the March 2006 and 200 Current Population Survey, US Census Bureau.
Figure 6Improving reach of coverage: covering the uninsured. Note. Other includes Medicare, CHAMPUS, and other sources of coverage. (From the Kaiser Family Foundation of the March 2007 Current Population Survey, US Census Bureau.
Although the underlying details are almost incomprehensibly complex, the high proportion of women without health insurance is a function of a simple yet sensational twin failure of policy, whose consequences over the years have come into view like an unfolding mystery story: The nation's willingness—for political, economic, and social reasons—to rely on a voluntary, employment-based health insurance system that grows shakier with each passing decade and the concomitant failure to either replace this system or at least couple it with a universally available and sustainable alternative.
A library of books and articles have been written on the subject (
), and it is not the purpose of this article to explore the unending explanations for our failure. At the same time, it is worth recapping some of the ways in which the results of this failure manifest themselves.
Employer-sponsored coverage
For more than a half century the nation has relied principally on voluntary, employer-sponsored coverage arrangements to ensure coverage of working-age Americans and their families. In truth, this system never worked particularly well; indeed, even what historically is considered its height during the 1970s, employer plan arrangements excluded low-wage and part-time workers, workers employed by small firms with limited payrolls, and persons with limited or no attachment to the workplace (
Over the past 30 years, the voluntary system has eroded further in the face of several basic factors: a shift away from a strong and stable manufacturing base for the US economy with a highly unionized workforce; demographic shifts that have produced a rise in single parent households with more limited attachment to the labor force (2 parents are always better than 1 where the need to secure a link to an employment-based system is concerned); the rise of global economic competition that in turn has led to a vast squeeze on payrolls and jobs; and the enormous toll taken by uncontrolled health care costs (
), more than the annual income of full-time minimum wage work. Furthermore, offer rates (i.e., the percent of firms that even offer coverage as a job benefit) have fallen significantly in the face of these trends; between 2000 and 2007, the offer rate among small firms (which employ the majority of US workers) fell from 68% to 59% (
), and equally as dramatic, by 2007 employer contributions to coverage were low enough that a worker whose earnings stood at 200% of the federal poverty level would have been expected to pay >10% of her annual income toward the cost of employer-sponsored coverage (
Public subsidization of alternative group health insurance markets, and publicly administered health insurance
Two strategies—by no means exclusive of one another—exist for at least compensating for the limits of employer-sponsored coverage. One would be to provide a subsidy to people without insurance to buy coverage in the individual insurance market, which in turn would be subject to very limited regulation in order to incentivize company participation. This is essentially what Senator John McCain has proposed in as part of his 2008 Presidential campaign. Another approach would be to incentivize employers to continue to offer group coverage and couple this incentive with the development of alternative, subsidized group health coverage arrangements for persons whose employers do not offer plans. This is essentially the approach taken by Senator Obama, who would also permit Medicaid and Medicare to continue to organize group coverage for their enrollees as well. Indeed, this is how most Medicaid agencies function at the present time in the case of their nonelderly, nondisabled beneficiary populations, and this is the approach that underlies Medicare Advantage and Medicare's “Part D” outpatient prescription drug benefit program (
What is not a viable alternative is reliance on an individual insurance market, with coverage purchased on the basis of after-tax income. Not only is the use of posttax earnings unaffordable, but the individual market is itself inherently exclusionary and unstable because of the extensive medical underwriting essential to maintaining such a market (
). The limits of individual insurance products for women of childbearing age is captured in a 2004 report on the individual market prepared by the Kaiser Family Foundation, which shows that in general women make extremely limited use of the individual market. The group most likely to do so are between ages 25 and 34, and 60% seem to retain this coverage for the long term (≥2 years;
). Because there is no tax subsidization, premiums must be paid out of after-tax income, and coverage is highly restrictive, with any significant use resulting in posttreatment underwriting (i.e., exclusion or new limits) in many states. Services such as pregnancy care and treatment for health conditions can be expected to be subject to heavy restrictions, assuming they are covered at all (
Medicaid offers a critically important pathway to coverage for millions of women of reproductive age, and its broad benefits and limited cost-sharing make it particularly suitable for low-income women. But Medicaid's reach is limited to only that portion of the low-income population that satisfies certain federally recognized eligibility categories; in the case of women, the most relevant categories are age (coverage of poor children is mandatory until age 18 and optional to age 21), pregnancy, disability, and parental status (
). As a result, neither a single 24-year-old single woman nor a low-income nondisabled adult woman with a spouse but no children earning twice the minimum wage ($6.55 as of July 24, 2008;
) would qualify. States certainly have the option of extending Medicaid (or some other form of government insurance) to categories of individuals for whom no federal financing is available, but few do so (
Kaiser Family Foundation. (2008c). States moving toward comprehensive health care reform. Washington, DC: Kaiser Commission on Medicaid and the Uninsured. Available: http://www.kff.org/uninsured/kcmu_statehealthreform.cfm. Accessed July 14, 2008.
Although the primary focus is on persons who lack coverage entirely, in recent years, the high cost of health care has caused the breadth and scope of insurance coverage to shrink through the use of high deductibles, high cost sharing, greater exclusions, or a combination of all 3. Thus, a growing focus has been given to the problem of underinsured persons. Using a measure of cost exposure in relation to family income, a 2008 study by the Commonwealth Fund estimated that in 2007 some 25 million insured people ages 19–64 were underinsured, a remarkable 60% increase since 2003. The authors found that the rate of increase was greatest for those whose incomes exceeded 200% of the federal poverty level. Among this group, the rate of underinsurance nearly tripled. Counted together, the uninsured and underinsured comprise some 42% of the nonelderly US adult population, and the economic stresses on the group are acute (
Any full assessment of health reform and its effects on a population must take into account all of the key domains of health insurance policy. Over the years, experts have attempted to delineate the principal domains of coverage policy (
Altman, D. (2008). Pulling it together: Critical path to health reform. Washington, DC: Kaiser Family Foundation. Available: http://www.kff.org. Accessed July 14, 2008.
Davis, K., Schoen, C., & Collins, SR. (2008). The building blocks of health reform: Achieving universal coverage and health system savings. New York: The Commonwealth Fund. Available: http://www.commonwealthfund.org. Accessed July 14, 2008.
), but in truth the domains evolve over time as health insurance, in both its structure and its relationship to the underlying health care and public health systems, also continues to evolve as a result of marketplace changes, fundamental technology changes, such as the introduction of health information technology, and economic considerations.
Based on my own involvement with national health reform over many years—in both large-scale efforts as well as in numerous smaller scale initiatives to achieve incremental improvements in coverage—I use a taxonomy that consists of 8 separate policy domains. The number of domains has expanded as health insurance has become more directly intertwined with health care, and as health insurance products have both proliferated in design and have become increasingly complex to understand.
In the mid-1970s, considered by experts to represent the zenith of employer-sponsored coverage arrangements (
), virtually all insured persons received coverage through what often is termed “fee-for-service” health insurance arrangements. These arrangements typically were sold by insurers that were captives of the health care industry itself, such as Blue Cross and Blue Shield plans. Coverage was broad and was effectuated typically through indemnification of policyholders, with direct payment of providers in the case of Blue Cross and Blue Shield. However, the financial transaction might occur (direct or via indemnity coverage), payment typically was at—or close to—the amount that a provider charged, and cost sharing was low. In essence, insurers essentially acted as conduits through which money passed, as passive payers that engaged in little if any active management of health care practice or costs (
Thirty years later, the landscape has completely changed. Three decades of skyrocketing cost, the enactment of the Employee Retirement Income Security Act (which freed employers from a provider-dominated insurance system), sweeping reforms in public insurance programs, and a fundamental reorganization of health insurance markets have combined to transform coverage. Today, all but a handful of nonelderly (publicly or privately) insured persons are members of health benefit plans that essentially deliver what they insure through loosely or tightly organized and managed provider networks (loosely in the case of more expensive plans, tightly managed in the case of public health insurance and less costly privately sponsored plans;
). Network providers are in turn selected by the plans in which they participate and are subject to plans’ operational rules. Payments are risk based, and cost sharing is steep.
Coverage itself has changed radically. In the 1970s, group health coverage was relatively loosely structured legally. Benefit classes and key coverage terms such as medical necessity were rarely defined. Insurers were only beginning to introduce utilization management, and payment formulas aimed at shifting risk and incentivizing provider conduct were generally nonexistent. In the odd chance that a claim was denied (after the fact of treatment), beneficiaries probably stood an excellent chance of winning in court, because of the legal rule of contra proferentem, which ensured that legal ambiguities in contractual documents would be construed against the drafter (
Today, privately sponsored group health benefit plans are awash in legalisms, with tightly drafted contracts that are structured solely at the discretion of the sponsor and are subject to very few external coverage standards (particularly in the case of self-insured plans). Whether self-funded or -insured, group benefit plans employ coverage documents that are dense with definitions, exclusions, and that—thanks to far better lawyering and an obscure but powerful US Supreme Court decision
Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989).
—vest broad discretion in health benefit plan administrators to interpret crucial contract terms as part of plan operations. This aggressive use of legal terms that favor the plan administrator, coupled with limited judicial review, means that in all likelihood (no definitive study ever has been done), most appeals involving individual coverage denials are decided in favor of the plan. Health benefit plans sold to state Medicaid programs continue to be subject to more robust coverage and performance standards, but even here, Congress has shown a penchant in recent years to loosen coverage requirements to permit states more discretion in the design and operation of the private sector plans they purchase (
Rosenbaum, S. (2007). After the Deficit Reduction Act: Using Medicaid to design accountable systems of care for people with complex and special needs. Hamilton, NJ: Center for Health Care Strategies, Inc. Available: http://www.chcs.org/publications3960/publications_show.htm?doc_id=468686. Accessed June 8, 2008.
In assessing the implications of insurance for improved access to preventive services, a series of essential domains must be considered, any 1 of which can significantly affect how health insurance ultimately performs in relation to health care access. These domains are as follows:
1.
The availability of coverage;
2.
The stability of coverage;
3.
The accessibility of coverage;
4.
The affordability of coverage;
5.
The design of coverage;
6.
The ability of coverage to protect enrolled persons from high health care costs in relation to both what is covered and what is excluded from coverage;
7.
The extent to which coverage is administered fairly in relation to both the health needs of the population and those of any particular patient;
8.
The extent to which coverage payment policies help to foster health care access and the adequate distribution of health care resources among the population; and
9.
The extent to which the results of coverage are measured for their quality and equity, that is, whether the performance data collected are used to improve quality of care and reduce disparities in health and health care.
1 Availability of coverage
The question of availability focuses on who qualifies for coverage. Will populations be excluded and, if so, will the basis of the exclusion be factors unrelated to the need for coverage, such as legal status, state residence, or health status or preexisting condition?
2 Stability of coverage
Once available, will coverage be stable? If multiple sources of financing continue to be a presence (and both presidential plans as of the spring of 2008 assume a continuation of a multipayer approach to coverage), what safeguards exist to eliminate the potential for coverage breaks and lapses? For example, in a reformed system that retains employment-based coverage, what protections exist to avert a lapse in coverage for persons who become unemployed and must turn to an alternative coverage source such as a government-sponsored plan or one offered by a voluntary group association? What steps are taken to make coverage stable in the case of persons who travel interstate, such as migrant laborers and itinerant workers? The challenge of stability may be addressed through enrollment features, and it may also be a function of product availability. For example, a national coverage scheme that calls for state administration might include ≥1 national plans that are marketed in all states and that allow for portability for self-employed persons.
3 Accessibility of coverage
How accessible is coverage? Is enrollment automatic in relation to another status (e.g., automatic enrollment of all persons covered by the Social Security system and their families)? What steps must individuals take to secure coverage? The answer to this question may turn significantly on whether the reform model is both universal and compulsory, that is, whether coverage is not only widely available but also required, as in the case of the Democratic Presidential plan for children.
4 Affordability of coverage
Are enrollment fees or premiums affordable in relation to family income? Do the premiums adjust for family income, family size, and extraordinary expenses incurred by certain families, such as families headed by disabled workers or with special needs children?
5 The design of coverage
The issue of coverage design is enormous and one that is of particular interest to the specific topic of preconception coverage. Coverage design is a function of several key subdomains:
•
The classes of benefits covered (e.g., physician services, hospital inpatient care, prescribed drugs). Are service classes such as health and nutrition counseling recognized, and if so, under what circumstances?
•
The range and types of permissible exclusions and limitations that are built into coverage classes (e.g., excluding certain treatments from otherwise covered benefit groupings, such as cosmetic surgery from coverage of physician and hospital services);
•
Service definitions (e.g., the use of a service definition that inherently excludes certain treatments, an example of which would be a definition of physical therapy that defines the intervention in relation to the restoration of a body part to normal functioning rather than an intervention to maintain functioning or avert its loss);
•
The definition of medical necessity used by a health plan to make individual coverage determinations or assess whether or not to cover new treatments for all covered persons. Thus, for example, a medical necessity definition in the case of women that focuses on the attainment of health, and the maintenance of health during reproductive years would be considerably broader than a definition that focuses strictly on diagnosing and treating diagnosed medical conditions. The former definition emphasizes a preventive scope of coverage, and the latter allows limits tied to specific diagnoses and symptoms. Under this second scenario, preventive counseling, unless a specific service class, might not be considered covered, whereas psychiatric therapy in connection with a specific mental illness diagnosis would. Similarly, counseling to address weight-related problems might be considered necessary under a broader definition, assuming a health counseling coverage class. Under a narrower definition, counseling might be considered necessary only in connection with a diagnosis of diabetes or cardiovascular disease.
Coverage design is of particular interest where, as here, the focus is on a particular health care intervention. Applied to a health insurance discussion, the CDC's “Recommendations to Improve Preconception Health and Health Care” call for several major reforms in the design of coverage to create a comprehensive women's benefit for women of reproductive age:
1.
A “well-woman” benefit (Recommendations 3 and 6), consisting of coverage of routine preventive visits (at unspecified intervals and including a prepregnancy checkup)
The Recommendations (Recommendation 3) express this as necessary in every “primary care” visit. However, most insurance plans may not cover routine primary care for women once they reach adulthood, except in connection with gynecologic care. A specific routine health examination would have to be recognized as either a specific benefit class or as a payable treatment within the subclass of medical and health professional services.
to assess risks, identify, for treatment, previously undiagnosed chronic illnesses and conditions, and provide health promotion counseling;
2The Recommendations (Recommendation 3) express this as necessary in every “primary care” visit. However, most insurance plans may not cover routine primary care for women once they reach adulthood, except in connection with gynecologic care. A specific routine health examination would have to be recognized as either a specific benefit class or as a payable treatment within the subclass of medical and health professional services.
2.
Comprehensive preconception treatment consisting of a broad array of otherwise covered benefits as well as a provision that would override otherwise applicable benefit limitations and exclusions in the case of diagnosed conditions in women of childbearing age that pose the potential to adversely affect maternal health and birth outcome (Recommendation 4). (Condition-related benefit limitation overrides are not uncommon under both publicly and privately sponsored health insurance plans. For example, Medicaid exempts from otherwise applicable “amount, duration and scope” limits medically necessary treatments in the case of individuals <21 and pregnancy-related conditions. Similarly, a private health insurer might permit a broader array of treatments for certain physical or mental conditions to avert an adverse outcome such as unnecessary institutional care). This type of expanded coverage of treatments for interconception risk can be thought of as the use of a special definition of medical necessity as well as an override of otherwise applicable benefit limits.
3.
Parallel to the second recommendation, comprehensive interconception treatment for women whose previous pregnancies have ended in adverse outcome (Recommendation 5). As with preconception treatment, this recommendation can be thought of as an array of treatments within covered benefit classes, using a special definition of coverage, as well as an exemption from otherwise excluded treatments when necessary in connection with interconception care.
4.
As with child health, interconception care is governed by a schedule that specifies examinations at periodic intervals. Thus, experts recommend visits in accordance with a specified schedule based on the best evidence.
6 Whether coverage protects against health care costs in relation to both covered and excluded services
A critical factor in coverage that, as previously noted, is receiving increased scrutiny is the problem of cost sharing, which in turn takes a number of forms: deductibles, the use of coinsurance or copayments, the imposition of annual or lifetime dollar limits on financed treatments, and the imposition of higher cost sharing for the use of health care providers who are not part of a health plan's recognized provider network. Optimally in the case of preconception care, well-women visits would be exempt from cost sharing, deductibles, and coinsurance or copayments would be low to minimal (in the case of low-income women), and the use of preconception/interconception care would not count against annual and lifetime maximums. Where medically necessary to address maternal risk, cost sharing for out-of-network treatments would be held to in-network levels.
7 Whether coverage is administered fairly at the population and individual patient levels
Fair administration encompasses a wide array of important factors, such as the use of utilization review techniques that are evidence based and transparent, the provision of prompt reviews in the case of treatment denials or exclusions, and a fair, rapid, and transparent appeals process that is evidence based and that permits access to an impartial and appropriately trained decision maker. Fair administration issues also focus on the accessibility of services in relation to language, disability, and special cultural or population considerations.
8 Whether coverage fosters access and the equitable distribution of health care resources
Coverage, although an end in itself, is also an intermediate point. The true goal is health care itself. Thus, several dimensions of coverage in relation to care become crucial, including the adequacy of provider networks in relation to the demand for care, payment levels that promote active involvement by qualified providers, special payments to health care providers who are located in low-income and medically underserved communities or who offer health care in multiple languages, additional health care “enabling” services, or other patient supports. Of crucial importance are enhanced payments to health care safety net providers in health reform models that are not universal and that continue to exclude certain classes of individuals, such as persons who are not state residents or who are not legally present in the United States.
9 Quality improvement, performance measurement, and public reporting
In recent years, policy makers increasingly have moved to the forefront the question of performance measurement in relation to overall quality and the effects of health care financing on overall costs as well as on the reduction of disparities in health and health care. The topic of quality improvement is multitiered and considers performance at the individual clinical level, the health care system level, the plan level, and at geographic levels that permit comparison of the relationship of place, community, and geographic location to health and health care expenditures and outcomes.
Prospects for Reform
The proposals of presidential candidates invariably are only partially formed and remain sufficiently hazy in their features so that a true assessment of impact is difficult. Nonetheless, the roadmap to health insurance reform effectively creates a classification system under which reasonable judgments can be drawn regarding whether a particular candidate's recommended plan will advance or limit prospects for improving preconception health. Specifically, these factors allow assessment of certain basic questions:
1.
Does the plan seem to move toward universal, equitable, and stable coverage without interruptions and lapses based on age, employment status, health, or wealth?
2.
Does the plan acknowledge the relationship between health care financing on the 1 hand and health care access and quality on the other by specifying a level of coverage that is preventive, evidence based, and in line with population health considerations?
3.
Does the plan, in its payment and coverage features, acknowledge the need for direct investment in certain community health care providers whose special activities for members at risk of poor health and medical underservice are essential in achieving population equity in health and health care?
4.
Does the plan emphasize equitable administration and broad transparency and accountability?
Whether the preconception health of women becomes a specific goal of reform will depend in great measure on the extent to which thought leaders and reform stakeholders perceive women's health generally—and preconception health in particular—as a central aim of reform. Regardless of where the key stakeholders in health reform may come down on the question of abortion rights, their voices are essential in advocating for primary and preventive reforms that advance preconception and interconception health that are fully integrated into comprehensive coverage that is sufficient to address the full spectrum of health needs.
References
Altman, D. (2008). Pulling it together: Critical path to health reform. Washington, DC: Kaiser Family Foundation. Available: http://www.kff.org. Accessed July 14, 2008.
Davis, K., Schoen, C., & Collins, SR. (2008). The building blocks of health reform: Achieving universal coverage and health system savings. New York: The Commonwealth Fund. Available: http://www.commonwealthfund.org. Accessed July 14, 2008.
Kaiser Family Foundation. (2008c). States moving toward comprehensive health care reform. Washington, DC: Kaiser Commission on Medicaid and the Uninsured. Available: http://www.kff.org/uninsured/kcmu_statehealthreform.cfm. Accessed July 14, 2008.
Rosenbaum, S. (2007). After the Deficit Reduction Act: Using Medicaid to design accountable systems of care for people with complex and special needs. Hamilton, NJ: Center for Health Care Strategies, Inc. Available: http://www.chcs.org/publications3960/publications_show.htm?doc_id=468686. Accessed June 8, 2008.
Schoen, C., Osborn, R., Doty, M.M., Bishop, M., Peugh, J., & Murukutla, N. (2007, October 31). Toward higher-performance health systems: Adults' health care experiences in seven countries, 2007. Health Affairs Web Exclusive, Available: http://content.healthaffairs.org. Accessed July 14, 2008.
Shin, P., Finnegan, B., Sharac, J., & Rosenbaum, S. (2008, January). Health centers: An overview and analysis of their experiences with private health insurance. Washington, DC: Kaiser Commission on Medicaid and the Uninsured. Available: http://www.kff.org/uninsured/7738.cfm. Accessed July 14, 2008.
Sara Rosenbaum is the Harold and Jane Hirsh Professor of Health Law and Policy and Chair of the Department of Health Policy, The George Washington University School of Public Health and Health Services.
Article info
Publication history
Accepted:
July 25,
2008
Received in revised form:
July 15,
2008
Received:
July 1,
2008
Footnotes
The author has no direct financial interests that might pose a conflict of interest in connection with the submitted manuscript.
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