This week, our In Focus section reviews highlights and major findings from the study, Beyond the Numbers: Access to Reproductive Health Care for Low-Income Women in Five Communities, conducted by The Kaiser Family Foundation (KFF) and Health Management Associates (HMA). The report, published in November 2019, was prepared by Sharon Silow-Carroll, Carrie Rosenzweig, Diana Rodin, and Rebecca Kellenberg from Health Management Associates; and by Usha Ranji, Michelle Long, and Alina Salganicoff from KFF.
The study examined access to reproductive and sexual health services in Dallas County, Alabama; Tulare County, California; St. Louis, Missouri; Crow Tribal Reservation, Montana; and Erie County, Pennsylvania. Through interviews with providers, community-based organizations, researchers, and advocates, as well as focus groups with low-income women, the study identified key factors affecting access, including cultural and social determinants of health; coverage; provider supply and distribution; sex education; and abortion restrictions.
Cultural and Social Determinants of Health
Across all communities, social determinants affected women’s ability and comfort in seeking preventative health care and family planning. Poverty, housing instability, food insecurity, limited education, and lack of employment contributed to women prioritizing food and shelter over their family planning needs. Women who were undocumented immigrants or not proficient in English were also less likely to seek family planning and other health services due to language barriers, fear of deportation, and concerns of jeopardizing immigration proceedings. Some focus group participants were discouraged from accessing care or using specific methods of contraception by providers and prior negative experience with the health care system, including feeling pressure to use contraception.
To address these barriers, interviewees suggested that providers could develop and train a more diverse group of doctors, co-locate clinics in workforce training sites or affordable housing, and use case management to address social and economic needs.
Availability of Coverage
Interviewees noted that Medicaid expansion was key in broadening access to coverage for low-income women and providing revenue to support safety net and rural hospitals that serve low-income populations. Two of the five communities in this study, St. Louis, Missouri, and Dallas County, Alabama, were in states where Medicaid coverage was not expanded under the Affordable Care Act. As a result, women had limited options for obtaining coverage for basic health care services. According to Kaiser Family Foundation, most low-income women have no coverage for preventive, acute, or chronic care outside of pregnancy in these states. In Dallas County, participants reported that they often would go to the emergency room when they needed health care. Additionally, participants reported that losing Medicaid eligibility at 60 days postpartum, or due to small changes in income, disrupted continuity of care and created barriers to family planning and reproductive health care. Medicaid and CHIP eligibility levels in the five states where the studied communities are located are shown on the chart below.
Certain Medicaid rules and low reimbursement rates limit the number of providers who accepted Medicaid coverage, creating additional barriers to care. Providers discussed Medicaid policies that limit their ability to provide long-acting revisable contraceptive (LARC) devices (e.g. IUDs and contraceptive implants) to their patients when they want them. These include policies that preclude same-day LARC insertions, tie LARC devices to specific patients, or do not reimburse providers for LARC immediately after delivery.
Provider Supply and Distribution
The five communities in this study are designated “Medically Underserved Areas” and “Health Professional Shortage Areas” according to the U.S. Health Resources & Services Administration (HRSA). These areas have too few primary care providers, high infant mortality, and high poverty, and face shortages of primary medical care, dental or mental health providers. Additionally, states that did not expand Medicaid have experienced rural hospital closures or a reduction in obstetrical units. These rural areas face severe provider shortages and persistent challenges in recruiting and retaining clinicians trained in reproductive and sexual health services. They reported insufficient numbers of providers offering STI testing and treatment, HIV care, obstetrical care, trans-competent and LGBTQ-friendly services, and a scarcity of abortion providers. Long travel distances and lack of public transportation in rural areas were also major barriers to care. Interviewees identified telemedicine as a possible solution to address these barriers, but upfront costs can hinder these efforts, and not all communities have access to broadband.
To address provider supply issues, interviewees suggested expanding provider training for IUD insertion and removal; collaboration with medical residency programs to identify and nurture providers who are interested in women’s health; training of nurse practitioners to initiate conversations about family planning; a platform for community providers to share “best practices” about what works in promoting family planning; and providers whose demographics reflect those of the community, including more female providers in certain areas.
Participants described availability and curricula of sex education as inconsistent among schools and often inadequate for high school-aged students. Most areas stressed abstinence in the curricula. Participants also felt that churches, which were central pillars of some of the communities examined, discouraged discussion of sexual health.
Access to abortion in the five communities was severely limited due to restrictive state policies and/or local pressures resulting in a shortage of abortion providers and long travel times, which was exacerbated by a lack of transportation options. Additionally, protestors and cultural stigma surrounding the procedure reportedly made women feel ashamed or afraid to seek an abortion. Participants also cited cost as a major barrier to abortion access.
The case studies and summary report revealed challenges and strengths that are not evident in statistics alone. Interviewees emphasized that much more needs to be done to eliminate the structural, cultural, political, and economic barriers to reproductive health services. However, multiple providers and community organizations were engaged in initiatives intended to address barriers to reproductive health care.
For more information, contact Sharon Silow-Carroll, Managing Principal, HMA.