E. Use of Health-Care System

Women’s use of health care differs from men’s. Women are more likely than men to visit the doctor and more likely than men to have an annual examination. Even excluding pregnancy-related visits, women are 33% more likely to visit a doctor than men are. Women made about 4.6 visits a year in 1997-1998, ranging from 3.8 for women age 15-44 to about double that for women age 65 and over. Women make key health care decisions for themselves and for their families. A recent study by the National Centers of Excellence in Women’s Health explored women’s level of satisfaction with primary-care services in an effort to improve use of health care services (Scholle et al. 2000). In addition to better access to diagnosis and treatment, better education about, access to, and use of preventive health measures is important to improving the quality of life of Indiana women.

Ambulatory visits by women were paid for by private insurance (50%), Medicare (22%), and Medicaid (9%). Private insurance paid for 1.3 times as many visits among white women as among black women. Medicaid paid for more than three times as many ambulatory visits among black women as among white women. In 1999, 15.2% of American women age 18-64 and 19% of all Americans age 18-64 were uninsured. Women age 18-29 are most likely to be uninsured and the least likely to have job-based coverage. “Women in their peak reproductive years—ages 18 to 29—are the most likely age group to have Medicaid (12%). This is because they are more likely to qualify for Medicaid if they have low-incomes and children or are pregnant” (Henry J. Kaiser Family Foundation Fact Sheet: “Women’s Health Insurance Coverage”).

In Indiana during 1997-1999, private insurance (employer-based coverage, other private insurance, and other public insurance, such as Medicare and military-related coverage) paid for 81.1%, Medicaid paid for 4.4%, and 14.5% of women age 18-64 were uninsured. Nearly one-fourth of women age 18-24 in Indiana are currently without health insurance (2000 BRFSS).

According to Catherine Hoffman et al., fewer Americans are covered by health insurance through their employer than just a decade ago. Health insurance either is not offered or is unaffordable. Children are well covered by the State Children’s Health Insurance Program (CHIP), and the elderly are nearly all covered by Medicare. A significant gap in coverage exists for working-age adults in the United States, impacting access to health care services. “Uninsured low-income working age adults were particularly at risk of having problems getting needed care” (Hoffman et al. 2001, p. 283).

For women of childbearing age, access to health care impacts their own health as well as the health of their children. According to Bernstein, “women with no children are equally likely to be uninsured as women with children. . . . Women with children, however, have the added burden of obtaining medical and other care for their children, as well as for themselves” (Bernstein 2001, p. 183). Barriers to care impact prenatal treatment as well as children’s health care, given that women remain primary consumers and advocates for family health care.

Ten states offer Medicaid benefits to uninsured women who are diagnosed with breast or cervical cancer (Rhode Island, New Hampshire, West Virginia, Maryland, Utah, Idaho, South Dakota, Illinois, Montana, and Indiana) through the federal Breast and Cervical Cancer Prevention and Treatment Act, signed into law in October 2000. To qualify for this program, women must be under age 65, not eligible for Medicaid, and lack creditable health care coverage.

The Office of Primary Care at the Indiana State Department of Health maintains the list of health professional shortage areas (HPSAs) and medically underserved areas (MUAs). These designations were established under the U.S. Public Health Service Act. They designate a county, collection of townships, or census tracts as needing additional primary health care services. As of June 2001, Indiana has 16 whole counties designated HPSAs: Benton, Blackford, Brown, Crawford, Daviess, Jennings, LaGrange, Newton, Ohio, Owen, Pike, Randolph, Spencer, Starke, Steuben, and Warren. Twenty other counties contain townships and census tracts designated as HPSAs. As of June 2001, 12 whole counties are designated MUAs: Brown, Clay, Crawford, Daviess, Franklin, Ohio, Pike, Scott, Spencer, Starke, Sullivan, and Switzerland. Thirty-six partial counties (townships and census tracts) are designated as MUAs.

Mammography in the United States is about 29% lower for women age 65 and over than for women age 45-64. Of women aged 50 years and older, 29% reported not having had a mammogram within the last two years. High blood pressure screenings were performed in over half of all visits; pelvic exams and urinalysis were performed in about 14% of visits. Uninsured women were less likely to get a Pap test than were insured women (Henry J. Kaiser Family Foundation Fact Sheet: “Women’s Health Insurance Coverage”). Of women age 18 and over with intact cervix, 5.7% in Indiana have never had a Pap smear.

In Indiana, 20.3% of women age 40 and over have never had a mammogram or breast exam. Women age 50 and over who have not had a mammogram and breast exam within the past two years amount to 63.5%; 13.5% have not had a mammogram or breast exam in two or more years. Women age 40 and over who have never had a mammogram comprise 13.5% of all Indiana women (2000 BRFSS). Comparing 1997 data, 84.4% of American women age 40 and over had a mammogram, compared to 80.8% in Indiana.

Colorectal cancer screenings in Indiana lag behind national percentages, but women exceed men in having fecal occult blood testing. Of all states, Indiana had the fourth highest percentage of adults age 50 years and older who reported not having had a sigmoidoscopy in the last five years.