Health Policies Impacting Women’s Health: A Scoping Review
Nnennaya U Opara MD, MPH*
1Healthcare Administration, university of Phoenix, Phoenix, USA
2Emergency Medicine, Charleston Area Medical Center, Charleston, USA
3Charleston Area Medical Center Institute for Academic Medicine, Charleston, USA
*Corresponding author: Nnennaya U Opara, MD, MPH, Healthcare Administration, University of Phoenix, Emergency Medicine, Charleston Area Medical Center Institute for Academic Medicine, Charleston, West Virginia, 25304, USA
Received: 26 March 2022; Accepted: 05 April 2022; Published: 11 April 2022
Nnennaya U Opara. Health Policies Impacting Women’s Health: A Scoping Review. Journal of Women’s Health and Development 5 (2022): 125-131.View / Download Pdf Share at Facebook
Women face several challenges over the course of their lives in many aspects pertaining to their physical health, using the healthcare system, and the roles they play in society. Women make up over 50% of the US population and are projected to outlive men. Women are affected the most when it comes to changes in health policies because they use the healthcare system as patients (especially during childbirth), caregivers, and family representatives. In this review article, we aim to highlight and raise awareness regarding the several ways in which changes to health policies regarding abortions and breast cancer prevention, by either the Federal or State Governments, can impact women’s health in several U.S states.
Women’s Health, Health Policies, Healthcare System, Government, Abortion, Breast Cancer
Women, not the government, should have the right to make decisions about their health, but this is not the case in the state of Alabama. Women’s health policy includes family planning, reproductive health, and disease prevention, such as breast cancer screening coverage. The supplemental Title X, which is known as the National Family Planning program, was creat-ed in 1970 and is the only federal program designed specifically for the provision of family planning and preventive healthcare with priority given to persons with low socioeconomic status . Title X funding through Health and Human Services (HHS) awarded to grantees to promote a federal family planning program is not equally distributed across the country’s states. Further, the Gag Rule, which prohibits doctors from referring their patients to an abortion clinic as part of the anti-abortion law, went into effect in March 2020 .
Legislative officials restrict women’s access to abortions by restricting insurance coverage of abort-ions, establishing TRAP laws, which ban abortion after a specific week of pregnancy and non-surgical abortions, imposing mandatory ultrasounds and waiting periods before a woman can access an abortion, and imposing “personhood” measures . Alabama has fully adopted Title X, and as of October 9, 2019, there were only 82 Title X clinics fully dependent on Title X funding . In May 2019, Governor Kay Ivey signed the Alabama Human Life Protection Act into law, which outlawed abortions in all cases, including rape and incest, unless the mother’s life was at risk. Imagine a 13-year-old rape victim having to carry an unplanned pregnancy to full-term in Alabama because of this law. Women in Alabama are now forced to seek certain reproductive healthcare services in a neighboring state .
2. Impact of Alabama’s Law
Apart from Alabama, states like Ohio, Georgia, and Mississippi have passed strict anti-abortion laws which make it illegal for any woman to request an abortion past six weeks of gestation. This is a difficult law because not many women know they are pregnant at six weeks. Have these new anti-abortion laws reduced the need for abortion in these states? The answer is NO. In fact, the rate of unsafe abortion has increased threefold in these states, including Alabama. For example, there are an estimated 22,800 deaths each year from unsafe abortions. In 2014, the annual cost of post-abortion care from unsafe abortions totaled $232 million . The anti-abortion laws will result in an increased rate of abandoned and homeless children in the affected states. Forcing women to have babies conceived from a rape, whether by a family member or stranger, and babies with a congenital disorder, such as Down syndrome, or other developmental anomalies will increase the number of abandoned newborns. In time, caring for disabled children will drain the economy of the State of Alabama. For a state in which 70% of the population are low-income earners and the majority are on Medicaid or Medicare, a depleted economy will increase the number of people wishing to enroll. Additionally, Alabama’s law affects abortion providers by limiting the renewal of abortion clinic licenses and limiting new licenses to clinics, especially clinics within 2,000 feet of a K-8 public school. Alabama prohibits public funding for women who may be eligible for state medical assistance, except in situations in which the woman has life-endangering injuries or poor health.
The State government needs to amend this and ensure that all health insurance companies, including gover-nment insurance, cover Planned Parenthood for all women in Alabama as this will reduce the need for abortion. Restricting young women’s access to abortion will only increase the rate of teenage pregnancies . Parents and schools need to work together to educate students. Condoms should be available and free to all hospital visitors, and parents should ensure their daughters receive contraception irrespective of their healthcare coverage; it is better to be safe than sorry. A state in which most of the female population (reproductive age group) are forced to leave the state to seek medical attention in certain situations is a state with a high threshold of segregation against women. It is worth noting that the State of Alabama’s legislation committee is comprised of 99% men. It is void of logic to bring a disabled child into this world to suffer when a pregnancy clearly shows a congenital anomaly. A child with a congenital anomaly is a huge burden for the family and a financial burden to a poor state like Alabama. Communities in Alabama need to speak up and contact their local representatives or senators via social media, TV advertisements, or any means that will make their voices heard. Everyone deserves the right to make decisions about their own health.
3. Health Policy on Breast Cancer Prevention
Breast cancer is the third leading cause of death among women after colon cancer and lung cancer. There are over 3.5 million women with a history of breast cancer in the US, including women receiving treatment and those who have completed treatment . About 85% of breast cancer cases occur in women with no family history of breast cancer. This could be due to gene mutations consequence of aging and lifestyle, rather than inherited BRCA1/BRCA2 mutations. A woman’s risk of breast cancer doubles when she has a first-degree relative with breast cancer. Among women under the age of 45, the breast cancer incident rate is higher in Africa-Americans than in white women. Further, African American women are more likely to die of breast cancer than any other race. The Ashkenazi Jewish women have a very high risk of breast cancer due to a higher rate of BRCA gene mutations. The incidence of breast cancer in the US continues to rise. This year, there have been an estimated 276,480 new cases of invasive breast cancer (in which the cancer cells grow beyond the breast tissues and invade blood vessels resulting in the spread of cancer cells to other parts of the body, i.e., metastasis) along with 48,530 new cases of non-invasive breast cancer (in which the cancer cells do not metastasize, i.e., carcinoma in situ) .
4. Breast Cancer Prevention
There are a few approaches to breast cancer preve-ntion that an individual could undertake to reduce the risk of breast cancer (such as abstaining from alcohol consumption, not becoming obese or overweight, staying active, having children and breastfeeding, using birth control, avoiding hormonal replacement therapy after menopause, and in a few cases avoiding breast implants). Further, there are a few breast cancer risk factors that cannot be changed (such as being born a female, old age, inheriting the BRCA genes, a family history of breast cancer, race and ethnicity, being tall, having large/dense breasts, early Menarche, receiving chest X-rays, and exposure to Diethylstilbestrol (DES) in utero). Additionally, other factors could predispose a person to breast cancer (such as a high-fat diet, chemicals in the environ-ment, cigarette smoking, and possibly working night shifts as these prompts changes in the hormone Melatonin, but the research is ongoing ). There are health-related programs for breast cancer scree-ning approved by the government. One is employee health surveys. Companies collect employee inform-ation via health questionnaires and the information identifies who has received appropriate breast cancer screening. Women in the appropriate age group who have not received screening will be informed of the companies’ health coverage and encouraged to do so. One-on-one education, a second approach, is offered by healthcare providers in doctors’ offices or hospitals. The education focuses on the importance of breast cancer screening and the preventable risk factors of breast cancer . One-on-one education can also be accomplished using brochures, letters, and telephone reminders.
New findings of breast cancer prevention have shown that early detection saves lives, but many women with breast cancer do not show symptoms until it has metastasized. Accordingly, imaging tests such as mammograms, breast ultrasounds, breast MRIs, and newer experimental breast imaging tests are now used with women beginning at age 50 to screen for breast cancer. The American Cancer Society has stated that diagnosing breast cancer early and receiving treatment as soon as the diagnosis is made are the most important strategies to prevent breast cancer deaths. Women between the ages 40 and 44 have the option to screen with an annual mammo-gram. Women 45 to 54 should receive mammograms every year, while women 55 and older can receive mammograms every two years. A breast self-exam is another tool women can use to examine themselves, although it is not very effective. Failure to diagnose breast cancer at an early stage can lead to cancer metastasis and eventually death.
4.1 Social, political, and economic implications of breast cancer prevention
4.1.1 Economic impact: The cost of cancer treatment is very high for both the patient and the government. The Agency for Healthcare Research and Quality (AHRQ) estimates that the direct cost for cancer treatment in the US in 2015 alone was $80.2 billion (52% of this cost accounts for hospital outpatient services and 38% for inpatient stays). Cancer is very expensive to treat, a lack of health insurance and other barriers, such as transportation to clinics, prevent many Americans from early and complete treatment. According to the US Census Bureau, about 28 million Americans (9%) were uninsured in 2016, ranging from 3% in Massa-chusetts to 17% in Texas . This year, an estimated 609,640 Americans are expected to die of cancer. Accordingly, reducing the barrier of cancer care is very important in the fight to eliminate suffering and death due to cancer.
4.1.2 Social impact: When cancer is not properly and effectively prevented, it costs people the loss of loved ones. Watching a loved one suffer through cancer is devastating and grief-inducing. Most who survive cancer always have a fear of recurrence and constantly suspect a simple headache or body ache to be cancer recurrence, which can prompt an illness anxiety disorder. Another social impact is depression. An estimated 70% of cancer survivors experience depression at some point in their life, constantly wondering why this terrible thing happened to them and what they did wrong to cause their cancer. Cancer destroys body image and self-esteem, especially among those who experienced breast removal, hair loss, or amputations. Further, relation-ships are challenged as life partners, coworkers, and friends treat these patients as “deadmen walking” or ”very sick people” .
4.1.3 Political impact: Breast cancer has been on the frontline of political debate in every election year. In 2010, the NBCC (National Breast Cancer Coalition) launched Breast Cancer Deadline 2020, a call to action for all policymakers, clinical researchers, breast cancer advocates, and stakeholders to imple-ment new research approaches to end breast cancer by January 2020 . The Department of Defense (DOD) Breast Cancer Research Program, which funds innovative research to eradicate breast cancer, has received full funding. Additionally, there is the Guaranteed Access to Quality Care for All, which ensures access to quality healthcare for people diagnosed with cancer. The NBCC works hard to protect and support all legislative efforts aimed at improving access to healthcare for breast cancer patients.
4.2 Current state and federal legislation addressing breast cancer prevention
4.2.1 Federal level: The Protecting Access to Lifesaving Screening (PALS) Act of 2019 (H.R. 2777, S. 1936) was established by Representative Debbie W. Schultz on May 15, 2019, and introduced by Senator Marsha Blackburn (R-TN) in the Senate on June 20, 2019. This bill ensures access to annual mammograms with insurance coverage without a co-pay starting at age 40 for all women. The bill was further introduced in the 115th Congress and 114th Congress. The Cancer Drug Parity Act of 2019 (H.R. 1730, S. 741) was introduced by Senator Tina Smith (D-MN) on March 12, 2019, in the Senate and Representative Brian Higgins (D-NY) on March 13, 2019, in the House of Representatives. This bill is designed to amend the Public Health Service Act to require group and individual health insurance coverage and group health plans to share costs for oral anti-cancer drugs . The Breast Cancer Patient Equity Act (S. 562, H, R. 1370) was intro-duced by Representative Judy Chu (D-CA) in the House of Representatives and by Senator Tammy Duckworth (D-IL) in the Senate on Feb. 26, 2019. This bill provides Medicare coverage for custom fabricated breast prostheses after surgical removal of the breast (mastectomy), including replacement of the prostheses when they become old. Unfortunately, not all states have funding to provide full coverage for breast cosmetic surgery after a patient’s mastectomy. The Federal Government needs to make funding available to Medicaid and Medicare to help states fully eliminate co-pays and other necessary expenses, such as childcare services. Cancer patients have endured enough pain and deserve financial relief.
4.2.2 State level: Maryland awarded grants to every jurisdiction in the state for local health departments to provide breast cancer screening, outreach, and education, while hospitals and private practices offer follow-up services. Additionally, the state provides patient navigation services to eligible women, which help schedule breast cancer screening appointments, provide transportation to appointments, explain the test results, arrange further appointments, and provide language interpretation services for non-English speaking patients . The state provides outreach and education to create awareness of breast cancer in the community. Maryland provides quality assurance ensuring every breast cancer patient receives high-quality program services delivered in a timely and standardized manner. Further, the state established the Medical Advisory Committee, which created the Minimal Clinical Elements for Breast Cancer Detection and Diagnosis (Breast MCEs), which guides other health programs regarding patient screening and follow-up services. Maryland depart-ment of Health Breast and Cervical Cancer Prevention (BCCP) partners with many coalitions at the state and local levels and have created cancer coalitions in 23 Maryland counties. To strengthen their programs, the State of Maryland needs to allow Medicaid patients to receive the benefits provided at the federal level, such as coverage for breast pros-theses, which is not currently available for women on
women on Medicaid in this state.
Abortion laws vary across the U.S states and is constantly changing. These changes ranges from abortion being freely available upon request, to regulation and restrictions of various kind (like in the state of Alabama with the harshest abortion law yet). Few other U.S states have signed into law, a new abortion law. For example, Texas abortion law, which was signed on May 19th, 2021, which went into effect September of 2021, effectively banning abortions following the ultrasound detection of the fetal heartbeat. The United Nations Human Rights Committee (UNHR) states that anti-abortion laws violate basic rights to health, privacy, and to some extent, the right to be free from cruelty, inhumane and degrading treatment. Anti-abortion laws do not reduce the rates of abortion, rather, they increase the rates of unsafe abortions resulting in young women use of dangerous methods/drugs in their desperate efforts to terminate a pregnancy. The American College of Obstetrics and Gynecologists (ACOG) had discovered that over 1.2 million women in the U.S had unsafe abortions which resulted in over 5000 deaths, and left tens of thousands more with permanent uterine damages and other severe health complications.
This article proposes four recommendations to address the shortcomings of women’s health policy at state and federal levels:
- The Government needs to eliminate all forms of deductibles, co-pays, and cost-sharing for breast cancer patients.
- Terminal breast cancer patients should have the ability to choose where they wish to spend their remaining days. Medicare and Medicaid do not cover in-home hospice care, referring patients to hospice or rehab facili-ties. The Government needs to cover the cost of home health-aid and hospice nurse services without cost-sharing and allow dying patients the comfort of their home.
- The Government needs to provide insurance coverage for women with a family history of breast cancer. Rather than wait for women to be diagnosed with cancer before providing coverage, choosing to undergo a mastec-tomy as a preventive measure and breast reconstr-uctive surgery should be covered for these patients. Prevention is more cost-efficient than treatment.
- Every woman should have the right to the healthcare service she wants and that include abortion rights. Also, access to contracep-tion should be always made available to all at no cost especially to women who do not have healthcare coverage.
- Family Planning Annual Report. US Department of Health and Human Services (2019).
- What is Title X? An explainer. Physicians for Reproductive Health (2019).
- Federal and state bans and restrictions on abortion. Planned Parenthood (2019).
- The status of participation in the Title X federal family planning program. KFF (2019).
- Trautwein C. After abortion ban attempt in Alabama, a flood of confusion and phone calls. FRONTLINE (2019).
- S.’s extreme anti-abortion policies put women’s lives at risk – in the U.S. and around the globe. Global Fund for Women (2019).
- State Laws Alabama. NARAL Pro-Choice America (2017).
- S. breast cancer statistics. Breastcan-cer.org. (2020).
- Breast cancer statistics. Centers for Disease Control and Prevention (2019).
- Breast Cancer: potential risk factors. American Cancer Society (2020).
- Breast cancer interventions. Centers for Disease Control and Prevention (2019).
- Social & emotional impacts of cancer. MD Anderson Cancer Center (2020).
- Visco F. Breast Cancer is a Political Issue. HuffPost (2016).
- Federal health legislation. National Cancer Institute (2020).
- Maryland Breast and Cervical Cancer Program. Maryland.gov. (2019).