Changes in the organization and financing of the health insurance industry have converged to chip away at insurance coverage, especially for working-age women. Declines in coverage for those ages 18 to 64 (84 million women) have been dramatic; in fact, uninsurance rates rose from 14 percent in 1993 to 18 percent in 1998. The problem is particularly widespread and persistent among women who are younger and unmarried, or have low incomes and are less educated than others.
This rising uninsurance rate is due in part to a decline in private individual and employer-based coverage, according to a new report, Health Care Access and Coverage for Women: Changing Times, Changing Issues?, by The Commonwealth Fund Commission on Women's Health. The report, based on the Fund's 1993 and 1998 surveys of women's health and other national data, written and compiled by Deborah Lewis-Idema, Joan M. Leiman, Jane E. Meyer, and Karen Scott Collins, notes that seven of 10 uninsured women work full time or have a husband with a full-time job. In the five-year span from 1993 to 1998, the percentage of women covered by private insurance fell from 77 percent to 72 percent.
For low-income women—those earning less than $15,000 per year—the private insurance coverage rate dropped from 44 percent to 37 percent during the same time period. For those earning $15,000 to $35,000, the rate fell from 82 percent in 1993 to 72 percent in 1998. For women in the $35,001-$50,000 income range, private coverage slipped from 93 percent to 87 percent. Private coverage for women earning more than $50,000 stayed about the same, although their employer-based coverage rose from 83 percent to 88 percent.
"Our findings indicate the distressing reality that going to work can actually work against many women. They have jobs that simply do not provide health insurance, or they cannot afford the coverage that is offered," said Karen Davis, president of The Commonwealth Fund. "This disturbing trend will only continue in the absence of a concerted effort to assure the availability of affordable health insurance for women at every socioeconomic level."
Younger Women Are At Highest Risk of Being Uninsured
A major concern highlighted by the report is that women ages 25 to 34 are least likely to have health insurance. Further, women in this age group who do not have employer-sponsored insurance when they start working are not getting coverage as they grow older, even when they stay in the workforce. From 1986 to 1996, the coverage rate for women in this age group fell from 80 percent to 75 percent. Among working women in their early forties, employer-sponsored coverage fell from 72 percent in 1981 (when they were in their mid- to late-twenties) to 62 percent in 1996.
Social and Economic Changes Affect Insurance Status
Long-term social and economic changes, as well as new public policies, are reshaping women's access to health insurance. Of the approximately 55 percent of women who are in the labor force today, about 30 percent are employed in the retail and service sector—sectors where women have typically earned low wages and have limited health insurance options. Younger women are 50 percent more likely than older women to be working in sales and service occupations, making this already vulnerable group even more likely to lack health coverage.
"This report stresses a number of important issues and trends that, if they continue, may compromise women's health insurance and health status," said Karen Scott Collins, M.D., assistant vice president for The Commonwealth Fund. "This is a worrisome development that portends larger problems ahead if these trends are not reversed. Women's health care needs must be addressed to assure that they do not develop chronic or life-threatening conditions down the road."
The lack of insurance among older women is particularly troubling, given their greater need for health services: uninsurance rises to 17% for women ages 60 to 64. Single women are also at a disadvantage: they are nearly twice as likely as married women to be uninsured or to become uninsured when changing jobs. In addition, about one of three single women lose their health insurance coverage when they stop working, twice the rate for married women or married men.
However, married women with less than a high school education are worse off than their single counterparts. Half (51%) of married women 25 to 29 years old and with less than a high school education had health insurance in 1996, compared with more than three of five (64%) in 1986.
Gaps Persist Even for Insured Women
Lack of access to health care is also a problem, particularly for low-income women—even for those with health insurance. In 1997, insured women with incomes below 200 percent of poverty were twice as likely to report difficulty getting needed care and twice as likely not to have a regular doctor, compared with higher-earning insured women.
It is still too soon to gauge the impact of the growth of managed care on women's health. Roughly three of four women are in some type of managed care plan, and low-income women in these plans are almost twice as likely as higher-income women to report difficulty getting needed care (16% vs. 9%). Women enrolled in managed care, however, do report somewhat greater use of some preventive services than do women in fee-for-service. One barrier to preventive care persists, however: nearly one of four women enrolled in managed care are in plans that require a referral to see an OB-GYN.
Ultimately, the long-term impact of managed care on women's access to appropriate quality health care services will depend heavily on the nature and structure of managed care plans that emerge in the marketplace, according to the report. Close and continued monitoring will be necessary to assure that women's interests are not compromised.
