By Phil Galewitz | Kaiser Health News

For decades, doctors have been warned about the dangers of delivering babies early without a medical reason. But the practice remained stubbornly persistent.

by Michelle Andrews | Kaiser Health News

Even though they’re more effective at preventing pregnancy than most other forms of contraception, long-acting birth-control methods such as intrauterine devices and hormonal implants have been a tough sell for women, especially younger ones.

But changes in health-care laws and the introduction of the first new IUD in 12 years may make these methods more attractive. Increased interest in the devices could benefit younger women because of their high rates of unintended pregnancy, according to experts in women’s reproductive health.

IUDs and the hormonal implant – a matchstick-sized rod that is inserted under the skin of the arm that releases pregnancy-preventing hormones for up to three years — generally cost between $400 and $1,000. The steep upfront cost has deterred many women from trying them, women’s health advocates say, even though they are cost-effective in the long run compared with other methods, because they last far longer.

Under the Affordable Care Act, new plans or those that lose their grandfathered status are required to provide a range of preventive benefits, including birth control, without patient cost-sharing. Yet even when insurance is covering the cost of the device and insertion, some plans may require women to pick up related expenses, such as lab charges.

Long-acting reversible contraceptives (LARCs) require no effort once they’re put into place, so they can be an appealing birth-control option for teens and young women, whose rates of unintended pregnancy are highest, experts say.

Across all age groups, nearly half of pregnancies are unintended, but younger women’s rates are significantly higher, according to a 2011 study from the Guttmacher Institute, a reproductive health research organization. Eighty-two percent of pregnancies among 15- to 19-year-olds were unintended in 2006, and 64 percent of those among young women age 20 to 24 were unintended, the study found.

Although the use of LARCs has more than doubled in recent years, it is a small part of the contraceptive market. Among women who use birth control, 8.5 percent of women used one of those methods in 2009, according to the Guttmacher Institute. The use of LARCs by teenagers was significantly lower at 4.5 percent, while 8.3 percent of 20- to 24-year-olds chose this type of contraception.

In October, the American College of Obstetricians and Gynecologists reiterated its strong support for the use of LARCs in young women.

Yet many young women are unaware that long-acting methods could be good options for them, in part because their doctors may be reluctant to prescribe them, experts say. That is partly the legacy of the Dalkon Shield, an IUD that was introduced in the 1970s whose serious defects caused pain, bleeding, perforations in the uterus and sterility among some users. The problems led to litigation  that resulted in nearly $3 billion in payments to more than 200,000 women.

In addition, providers may hesitate because there’s a slightly higher risk that younger women will expel the device, experts say.

But expulsion is a problem more likely associated with the size of the uterus, which is not necessarily related to a patient’s age, says Tina Raine-Bennett, research director at the Women’s Health Research Institute at Kaiser Permanente Northern California and chairwoman of the ACOG committee that released the revised opinion on LARCs. “Expulsion is only a problem if it goes unrecognized.” (Kaiser Health News is not affiliated with Kaiser Permanente.)

The new IUD Skyla became available in mid-February. It is made by Bayer, the same company that makes Mirena, another IUD sold in the United States. Unlike Mirena, which is recommended for women who have had a child, Skyla has no such restrictions (nor does ParaGard, the third type of IUD sold here). Mirena is currently the subject of numerous lawsuits alleging some complications, such as device dislocation and expulsion.

Skyla is slightly smaller than the other two IUDs on the market and is designed to protect against pregnancy for up to three years, a shorter time frame than the others.

This shorter time frame may make Skyla more attractive to younger women who think they may want to get pregnant relatively soon, some experts say, although any IUD can be removed at any time.

“More providers are spreading the word that it’s okay, and more young women are demanding it,” says Eve Espey, a professor of obstetrics and gynecology at the University of New Mexico.

This article was produced by Kaiser Health News with support from The SCAN Foundation. Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

The United States has had a shortage of primary care providers for quite a while, and the doctor shortage is not expected to ease up anytime soon, with more people gaining access to health coverage along with the increased health needs of aging Baby Boomers.

In an attempt to address this shortage, the Affordable Care Act includes provisions to train more primary care providers – including nurse practitioners (NP) and physician assistants (PA), not just MDs.

Many of us may have encountered an NP or PA at a Planned Parenthood or other women’s health clinic. Nurse practitioners typically have a master’s degree in nursing plus specialty certification, while physician assistants graduate from a 2- to 3- year physician assistant education program. Both NPs and PAs may specialize in areas such as family medicine, women’s health, pediatrics, emergency care, or other areas.

Michelle Andrews of Kaiser Health News provides a quick, basic overview of how NPs and MDs compare in the video below:

The American Academy of Nurse Practitioners offers a more detailed explanation of what NPs do:

NPs provide a variety of critical health services, including evaluating patients, making diagnoses, ordering and interpreting diagnostic tests, writing prescriptions, and managing acute and chronic health conditions—including the oversight of patients with multiple and complex chronic illness. NPs are providers of choice for millions of individuals and families. They are especially educated and prepared to care for vulnerable populations such as the elderly, the medically underserved, and those who live in rural areas that have more acutely experienced the primary care provider shortage.

Physician Assistants in practice do much the same work as nurse practitioners, as the American Academy of Physician Assistants explains:

PAs perform physical examinations, diagnose and treat illnesses, order and interpret lab tests, perform procedures, assist in surgery, provide patient education and counseling and make rounds in hospitals and nursing homes. All 50 states and the District of Columbia allow PAs to practice and prescribe medications [...]  PAs deliver high-quality care, and research shows that patients are just as satisfied with PA-provided care as they are with physician care.

So if you visit a primary care or women’s health clinic, a walk-in clinic, or other medical office, you might just find yourself in the care of a nurse practitioner or a physician assistant — and now you’ll know a bit more about their education and role.

Earlier this summer, when the House Subcommittee on Appropriations Bill for Fiscal Year 2013 was considered, Republicans included a provision (section 227) to get rid of the federal Agency for Healthcare Research and Quality (AHRQ).

The AHRQ conducts systematic reviews of medical evidence to better inform providers and patients about which treatments seem to work. It does so by evaluating how new treatments stack up to other existing therapies, and by evaluating whether there is good supporting evidence to recommend them. This research, then, helps people make smarter decisions about medical care by analyzing what is known and by making available information about the comparative effectiveness of different treatments.

Sounds like a useful thing, right? So why might Republican lawmakers want to defund an agency that helps us understand more about which medical care is most effective? I have a couple of ideas.

First, it allows Republicans to recycle anti-Obama talking points about both the stimulus bill and the Affordable Care Act. The provision in health care reform that makes preventive services available to insured patients with no copay — such as the many preventive services for women that are now covered — requires that that list of services be based on the U.S. Preventive Services Task Force’s evidence-based recommendations. Although AHRQ and USPSTF aren’t exactly the same thing, it gives opponents a chance to confuse voters by conflating evidence-based reviews to inform care with rationing to limit care.

Likewise, when funding for comparative effectiveness research — primarily conducted through AHRQ — was included in the 2009 stimulus bill, it kicked off conservative outcry about “rationing” of care. A political analyst for Consumers Union called that outcry ”a very clever effort by a bunch of well-paid lobbyists funded by people who don’t want the American people to know some pills work better than others.”

And that brings us to a second reason. Comparative effectiveness research can identify where highly advertised expensive new drugs or treatments aren’t any more effective than less expensive therapies or placebo. For example, a recent AHRQ review concluded that the heavily advertised drugs for urinary incontinence may help less than basic lifestyle changes and may not provide enough benefit compared to placebo to offset the cost and side effects for many patients.

For another example of hostility toward evidence-based reviews, it was a similar process that resulted in the recommendation that women in their 40s who are not at high risk for breast cancer don’t necessarily need regular mammograms – a finding that makes a lot of sense based on the medical evidence, but was controversial both among health care institutions getting paid for doing mammograms and the giant, screening-focused Komen organization.

So the pharmaceutical industry, health care lobbyists, and other associations with vested interests might have a pretty strong interest in minimizing research that could negatively affect industry bottom lines. Both major political parties take a lot of money from pharmaceutical companies, which might be why we haven’t heard as much political opposition to this move as you might expect.

Some expert health professionals, though, have not been so quiet on the proposed elimination. The American Academy of Family Physicians wrote a letter urging Congress not to defund the agency, calling the move, “pennywise and pound foolish,” and pointing out that “this research helps Americans get their money’s worth when it comes health care. We need more of it, not less.” The president of the Association of American Medical Colleges has also spoken out against the provision.

In a recent op-ed in the Philadelphia Inquirer, Jeffrey C. Lerner, president of the ECRI Institute (a center that does evidence-based medicine research for AHRQ), explains the value of AHRQ’s work for patient safety and effective health care and notes that this isn’t the first political attempt to kill the agency. He asks an essential question — “Why is objective information so threatening?” — and goes on to write:

The answer is that objective information shakes up the status quo. Many constituencies think objective information is information that supports their perspective, and are resistant to change, no matter what the evidence shows. So, truly objective information is a very dangerous weapon.

But it is tough to argue publicly that objectivity is bad, so a time bomb is buried in this House bill in an attempt to avoid having to first openly engage the public in a national debate on the best ways to improve quality and reduce unnecessary expenditures.

How will we find out what quality is and how will we find out what unnecessary expenditures are? Without AHRQ, we won’t.

It’s not completely clear what will happen next in the effort to defund AHRQ, as the 2013 spending decisions will be delayed until after the presidential election. It’s worth keeping an eye on, though, and we’ll update as this moves forward.

[Disclosure: some of my work involves systematic reviews/comparative effectiveness research funded by AHRQ.]

Countdown to Coverage is a campaign to help women understand the concrete ways that the Affordable Care Act can improve our health. This blog entry is the first in a series designed to answer the question, What’s in it for women?

by Leana S. Wen, MD

As an emergency physician, I tend to work on the other side of preventive care services. I see what happens when women don’t know about safer sex and birth control, and end up with complications from sexually transmitted infections. I see what happens when women do not get routine screening for cervical cancer and struggle with life-threatening cancer. I see what happens with out-of-control hypertension and diabetes, and the heart attacks and strokes that are detected far too late.

These experiences have shown me that prevention is the best medicine. That’s one big reason why the Affordable Care Act provision requiring new insurance plans to cover women’s preventive care without any extra charges or co-pays is a real victory for women. These requirements, which go into effect Aug. 1, will be phased into existing insurance plans over time.

Because of this change, women will be able to obtain complete contraceptive care, screening for sexually transmitted infections, and screening and counseling for intimate partner violence. This builds upon earlier requirements that insurance companies cover — at no additional cost to women — mammograms and screenings for cervical cancer. It’s clear to me that these mandates will significantly improve women’s health and lives and ultimately lead to a reduction in health care costs.

The Well-Woman Visit
One of the easiest ways to obtain preventive services is through a well-woman visit. These visits, which will soon be covered with no co-pay, give you the opportunity to ask key questions about birth control, sexually transmitted infections, and other reproductive issues, along with questions about diet and exercise and any health concerns you may have. You can also discuss changes in your family’s medical history that are important for your health care provider to consider. For example, when my mother was diagnosed with breast cancer, my doctor recommended that I get earlier screenings.

Along these same lines, your health care provider may have questions or issues to discuss with you. Smoking, drinking and recreational drug use can create and contribute to health problems, and often need to be discussed and addressed multiple times before change happens. Well-women visits also give your health care provider a chance to screen for potential high blood pressure, diabetes, depression, domestic violence, and more.

The well-woman visit is important for another reason: It gives you and your health care provider a chance to get to know each other. Most people go to their provider or to a clinic only when there’s a problem, but the best time to get to know your provider isn’t when you’re in distress from a painful or troublesome condition. Studies have shown that health care providers make more accurate diagnoses when they know their patients and can put the symptoms in the context of your life. A well-woman visit is a precious opportunity to build this trusted relationship.

As an emergency physician, I am excited about the new provisions taking effect Aug. 1, which include annual well-women visits for those who want them. I would much rather women regularly visit their health care providers than come to the E.R. later suffering from preventable problems. So please take this opportunity and make an appointment with your provider. The importance of investing in your health is too crucial to ignore.

Plus: Want to learn more about the Affordable Care Act? These resources from Countdown to Coverage provide detailed information about coverage for women, including specific information for LGBT people, women of color, young women, older women, moms and families, and more. 

===
Leana S. Wen, M.D., is an emergency physician at Brigham & Women’s Hospital and Massachusetts General Hospital and a clinical fellow at Harvard Medical School. She is the author of a forthcoming book on patient advocacy, “When Doctors Don’t Listen: How to Avoid Misdiagnoses and Unnecessary Tests.” For more information, visit her blog When Doctors Don’t Listen or her website. You can also follow her on Twitter @DrLeanaWen.

Last Thursday, the Supreme Court ruled to largely uphold the Patient Protection and Affordable Care Act, or health care reform. The Act should help women access a number of preventive services and help them access healthcare more easily.

The National Latina Institute for Reproductive Health issued a press release, Supreme Court decision means health care access for Latinas, calling the decision “a significant victory for Latinas, who are more likely than other groups to face structural barriers that prevent them from accessing health care and preventive services.” They also note, however, that works remains to be done and many immigrants still lack access to essential care.

Physicians for Reproductive Choice and Health’s board chair Douglas Laube released a statement for the organization, writing:

Thanks to today’s ruling, we can move closer to the day when our patients won’t go without basic medical care because they can’t pay for it. The Affordable Care Act has already begun to change health insurance in the United States for the better, doing away with pre-existing conditions, gender-rating (making insurance more expensive for women than men), and other practices that have hurt women’s health.

The Planned Parenthood Federation of America calls the decision a victory, and lists several benefits for women:

• More than 45 million women have already received coverage for preventive health screenings at no cost since August 2010 thanks to the Affordable Care Act – including mammograms and Pap tests – and millions more will be able to get free screenings in the coming years.
• 3.1 million young adults have already been able to stay on their parents’ insurance because of the Affordable Care Act. In the next year, millions more who would have otherwise lost coverage will continue to be insured under their parents’ plan.
• Women are guaranteed direct access to ob/gyn providers without a referral, as a result of the Affordable Care Act.
• Starting in August, birth control will be treated like any other preventive prescription under the Affordable Care Act, and will be available without co-pays or deductibles.

The National Women’s Health Network called the decision “historic and thrilling,” and is currently running a “Countdown to Coverage” campaign to highlight ways the Act will benefit women’s health.

At RH Reality Check, Jodi Jacobson writes of some women’s group’s reactions to the Supreme Court Decision. Amanda Marcotte, also at RH Reality Check, has some questions for opponents of the Affordable Care Act. Also there, an author from MADRE writes about the international and human rights context for the decision.

Raising Women’s Voices has a ton of coverage and links, including information on what women can expect out of health care reform.

President Obama on Monday said he was “confident” the Supreme Court will uphold the Affordable Care Act, adding that overturning it would be an “unprecedented, extraordinary step.”

I think it’s important — because I watched some of the commentary last week — to remind people that this is not an abstract argument. People’s lives are affected by the lack of availability of healthcare, the inaffordability of healthcare, their inability to get healthcare because of preexisting conditions.

The law that’s already in place has already given 2.5 million young people healthcare that wouldn’t otherwise have it. There are tens of thousands of adults with preexisting conditions who have healthcare right now because of this law. Parents don’t have to worry about their children not being able to get healthcare because they can’t be prevented from getting healthcare as a consequence of a preexisting condition. That is part of this law.

And, as of 2014, adults would also be protected. Women could no longer be denied coverage based on pre-existing conditions such as pregnancy or domestic violence. The law would also eliminate gender rating, in which women end up paying more than men for insurance coverage.

And there’s more, via Raising Women’s Voices: A top 10 list of benefits for women under health care reform; specifics on how the law is already helping young women; and more details on how it supports women of color.

Back to Obama’s remarks:

Millions of seniors are paying less for prescription drugs because of this law. Americans all across the country have greater rights and protections with respect to the insurance companies, and are getting preventive care because of this law.

So, that’s just the part that’s already been implemented. That doesn’t speak to the 30 million people who stand to gain coverage once it’s fully implemented in 2014.

And I think it’s important, I think the American people understand and I think the justices should understand that in the absence of an individual mandate, you cannot have a mechanism to ensure that people with preexisting conditions can actually get healthcare.

We have to wait until sometime in June to find out if Obama is right, but there’s been no shortage of guess work underway to determine 1.) whether the Supreme Court will uphold the individual mandate requiring almost every American to buy health insurance; and 2.) what will become if health care reform if it does not.

Writing in The New Yorker, Jeffrey Toobin notes that the “heavy burden” of justification for the mandate — which Justice Anthony M. Kennedy asked Donald Verrilli, the solicitor general, to address — should instead be placed on the law’s challengers.

“The involvement of the federal government in the health-care market is not unprecedented; it dates back nearly fifty years, to the passage of Medicare and Medicaid,” writes Toobin. “The forty million uninsured Americans whose chances for coverage are riding on the outcome of the case are already entered ‘into commerce,’ because others are likely to pay their health-care costs.”

“Acts of Congress, like the health-care law, are presumed to be constitutional,” he later adds, “and it is—or should be—a grave and unusual step for unelected, unaccountable, life-tenured judges to overrule the work of the democratically elected branches of government.” Toobin then demonstrates how the justices’ questions reflected a troublesome meddling in policies set by Congress.

The Individual Mandate – A Not-So-Brief History
The individual mandate, as explained in this NPR story, has Republican roots dating back to 1989. Rachel Maddow discussed the party-line history during a recent segment, summed up as: “When Republicans proposed it — great idea, a conservative solution. When a Democrat has the idea, it’s socialism, tyranny and unconstitutional.”

Though Republicans circa 2012 would like Americans to believe the individual mandate is indeed “unprecedented,” Linda Greenhouse, who covered the Supreme Court for The New York Times for 30 years and who now writes a column on legal issues, applies the description to the politics of this debate:

What’s unprecedented is the singular determination of the Republicans both on Capitol Hill and in the statehouses to deprive President Obama of his major domestic achievement. Republican officeholders in all 26 states joined together in the case now known as United States Department of Health and Human Services v. State of Florida. In 22 of those states, the officeholder was the attorney general. In four states with Democratic attorneys general (Nevada, Wyoming, Iowa and Mississippi), Republican governors filed in their own names. If any of them noted any irony in the fact that not so long ago, the individual mandate was an idea cooked up by conservative policy wonks to counter more fundamental reform sought by the Clinton administration, they offer no sign.

The countless unprecedented things that Congress has done over the centuries were not, for that reason, unconstitutional. Social Security, Medicare, the Employee Retirement Income Security Act (Erisa), and the Emergency Medical Treatment and Labor Act, the 1986 law passed to prevent hospitals from refusing to care for uninsured patients in acute distress, all come to mind. (From the perspective of today’s toxic politics, it’s a miracle that any of these laws actually got passed, but that’s a separate issue.) So there must be some problem with the Affordable Care Act other than “never before.”

There are other federal mandates involving health care already on the books, including the Medicare payroll tax on workers and employers, and the 1996 Newborns’ and Mothers’ Health Protection Act, which requires plans offering maternity coverage to pay for at least a 48-hour hospital stay (96 hours following a c-section).

Isn’t It Ironic (Don’t You Think)
Some Republicans who can’t help but fly into an apoplectic rage upon hearing the term “mandate” in the context of health care reform remain surprisingly calm when mandating medical procedures for women.

Yes, I’m referring to government-mandated ultrasounds. Currently, seven states — most recently Virginia — mandate that an abortion provider perform an ultrasound on a woman seeking to have an abortion. These states, along with more than a dozen others, also require the provider to ask the woman if she’d like to view the image.

The Guttmacher Institute notes: “Since routine ultrasound is not considered medically necessary as a component of first-trimester abortion, the requirements appear to be a veiled attempt to personify the fetus and dissuade a woman from obtaining an abortion. Moreover, an ultrasound can add significantly to the cost of the procedure.”

Once again, Maddow breaks down the Republican hypocrisy:

The Road Ahead
The question of whether other parts of the Affordable Care Act can proceed without the individual mandate will continue to be debated until June. If the mandate alone is struck, insurance premiums would likely increase because insurance companies won’t have the built-in benefit of a broader insurance pool.

“Republicans would blame Obama for making health insurance more expensive. Democrats would blame insurers for the higher premiums. In other words: Déjà vu and total gridlock,” writes Jennifer Haberkorn of Politico. Her story explains what’s likely to happen if the Supreme Court strikes just the mandate, or the mandate and insurance reforms, along with the political fall-out if most of the law falls or is upheld.

Josh Gerstein, also of Politico, looks at the effects beyond health care reform: “If the justices knock out key parts of the law or bring down the whole thing, the reverberations could be felt across the legal landscape for generations to come, radically reining in the scope of federal power, according to supporters of the law and others who closely track the high court. And if the justices decide the individual mandate is a constitutional overreach, these observers say, federal labor and environmental laws could be the next on the firing line.”

If you think that seems too dire a prediction, consider Dahlia Lithwick’s reaction to comments made by the court’s conservative justice’s last week: “[A]s the justices pondered whether the individual mandate—that part of the Affordable Care Act that requires most Americans to purchase health insurance or pay a penalty—is constitutional, we got a window into the freedom some of the justices long for. And it is a dark, dark place.”

Those who would welcome the disintegration of health care reform include The Cato Institute’s Michael Cannon. He told NPR that if the entire law were to go away, “we would have just dodged this whole nasty debate over religious freedom and abortion.”

Meaning: There would be no increased access to preventive health care such as contraception, breastfeeding support, and screening for breast and cervical cancers and HIV. But hey, women’s health is so darn offensive when you get down to it, better to just cast it off. Thanks, but we’ve been there.

On the other hand, maybe a defeat at the hands of the Supreme Court will open new doors, for everyone.

* * * * * * * * *

Additional Resources
- The National Women’s Law Center posted a short video explaining the legal challenges, why it thinks the law is constitutional, and what women could lose if the law is struck down.
- Jessica Gonzales-Rojas of the National Latina Institute for Reproductive Health explains more here.
- Kaiser Health News coverage of the two-year anniversary of health care reform, from all angles. Plus, a timeline of major implementation milestones and the legal questions involved in the Supreme Court’s review.
- Audio excerpts of arguments challenging the constitutionality of the 2010 health care law are posted on the NYT website, along with reporters’ analysis.

Every year in the United States alone, more than 12,000 women are diagnosed and more than 4,000 women die of cervical cancer, a preventable disease that disproportionately affects women of color.

January is Cervical Cancer Awareness Month, and the National Latina Institute for Reproductive Health (NLIRH) is launching “¡Acábalo Ya! Working Together to End Cervical Cancer.” The campaign is aimed at educating Latinas about this disease and how to protect their health; raising the profile of cervical cancer prevention as a national reproductive justice and women’s health priority; and advocating for greater access to the tools and care needed to prevent, detect, and eventually end cervical cancer.

The NLIRH is hosting a blog carnival this week on the topic: What will it take to end cervical cancer? Read more on Why Cervical Cancer is a LGBT Issue by Verónica Bayetti-Flores, NLIRH policy research specialist; Cervical Cancer Awareness Month: Trans Men and Genderqueer/Gender Nonconforming People by the National Center for Transgender Equality; Screen More Women for Cervical Cancer – Not the Same Women More Often! by Kate Ryan, program coordinator, National Women’s Health Network; and Thank YOU Affordable Care Act for Helping Cervixes Stay Healthy by Keely Monroe, program coordinator, National Women’s Health Network.

The following text on disparities in access to Pap tests and HPV vaccines has been adapted from the 2011 edition of “Our Bodies, Ourselves.”

* * * * * * *

Most women who die of cervical cancer never had regular Pap tests, had false-negative results, or did not receive proper follow-up.

In the United States, socioeconomic and racial disparities are evident in statistics for cervical cancer. Vietnamese immigrants are five times more likely to be diagnosed with cervical cancer than white women. African-American and Native-American women are twice as likely to die of the disease as are white women. In one study, Hispanic women had about twice the cervical cancer incidence of non-Hispanic women in border counties near Mexico, and Hispanic women are 1.5 times more likely to die from cervical cancer as compared to non-Hispanic white women.

Disparities are due, at least in part, to women of color having less access to Pap screening and regular health care. It is quite possible that those women with the highest rates of cervical cancer will also have less access not only to Pap screening but also to the HPV vaccine. Until our health care system addresses such disparities in access, girls and women likely to benefit the most from this vaccine may well not be able to choose it.

To ensure more equal access to any adolescent vaccine, adequate infrastructure and resources must be made available. Some recommend implementation of school-based adolescent immunization programs similar to those formerly in place for delivery of hepatitis B vaccines. The United Kingdom and Australia have volunteer, nationally supported school-based campaigns that have resulted in high HPV vaccine coverage for about 70 percent of girls.

Currently, school-based health programs and routine preventive care visits for adolescents are limited in the United States, making it highly difficult to provide good access to HPV vaccines, especially the type of access needed to ensure all three required vaccine doses are administered. Available data suggest HPV vaccine coverage in the United States is low (less than 50 percent), and the proportion of girls receiving all three doses of the HPV vaccine is even lower (less than 25 percent).

Pap Tests Essential for Prevention and Treatment

HPV vaccines do not protect against all types of HPV associated with cervical cancer, and it is currently unclear how long they remain effective or whether booster shots will be needed to maintain protection throughout adulthood. Thus, regular Pap tests among sexually active women remain essential for cervical cancer prevention. Resources should not be diverted away from Pap screening programs to pay for the unusually expensive cervical cancer vaccine. Because Merck marketed Gardasil with a campaign that unnecessarily frightened girls, young women, and parents, many people now have a distorted view of this disease, the vaccine, and the continued importance of Pap screening.

There is no question that HPV vaccines represent an important scientific advance in the field of vaccine research, but exaggerating their potential benefit in places such as North America will not serve us well. In countries where there is little or no access to Pap screening, current HPV vaccines might have much more potential for saving lives if their costs were reduced considerably and if adequate infrastructure to prove them responsibly were securely in place.

The District of Columbia and dozens of states — many of which have been lobbied by vaccine makers to expand vaccination requirements — have introduced legislation to require, fund, or educate the public about the HPV vaccine. However, since 30 percent of infections are now caused by virus types for which the HPV vaccines do not provide protection, universal access to Pap tests remains critically important. Unfortunately, many girls in underserved communities (where HPV infection rates are often high) have less access to both the Pap test and the HPV vaccine.

For example, as of September 2009, when the CDC released its first state-level statistics for Gardasil, only 15.8 percent of girls in the relatively poor state of Mississippi had received the vaccine, compared with 54.7 percent of girls in the relatively wealthy state of Rhode Island. Partly because of greater access to Pap testing, the cervical cancer mortality rate in Rhode Island was already 50 percent lower than in Mississippi — which means the girls in Rhode Island are at much lower risk of contracting HPV to start with.

To reduce disparities for Latinas and other under-served women, we will need to make systemic changes in our health care system to increase access to screening and vaccinations for those who need it most.

The July/August issue of the Journal of Obstetric, Gynecologic, & Neonatal Nursing includes a series of articles on the health care needs of women in prison, including the need to address inequalities, provide thorough care for complex health conditions, and to attend to the end-of-life needs of female prisoners.

In End-of-Life Care and Barriers for Female Inmates, the authors explore a little-discussed topic. For background, they explain that “end-of-life” in prisons does not typically occur they way we might think, and so health care, and especially end-of-life care, for incarcerated women is much more complex than we might be aware:

Stereotypical images in the popular media promote a perception that prison death is due to suicide or homicide by fellow inmates. In reality, execution, homicide, and suicide combined account for less than one fourth of all prison deaths. The vast majority of deaths in U.S. prisons are a result of natural causes, and the leading causes are chronic, debilitating diseases, with heart disease, cancer, and liver disease the top three for women, followed by AIDS, suicide, septicemia, respiratory diseases, cerebrovascular diseases, influenza/pneumonia, and digestive diseases.

The authors explore the current problems with end-of-life care, such as inmates being removed to infirmaries that create social isolation and lack visiting hours, adequate facilities, or comfort care. They put it bluntly: “Within the current, prevalent public climate of ‘let ‘em rot,’ incarcerated women with EOL (end-of-life) needs are highly vulnerable.”

The authors then come to the following conclusion in response, one that we can certainly get behind: “The time has come to set aside the question ‘why provide humane care to dying female inmates?’ and to provide better EOL to all people.”

Another piece in the series advocates for prison health care providers to consider how past traumas might inform a female inmate’s health needs, encouraging providers to develop greater understanding of trauma in order to provide better care.

Finally, Barbara Guthrie writes a compelling piece, Toward a Gender-Responsive Restorative Correctional Health Care Model, which argues for institutions to completely rework their model of providing health care to female inmates. She calls for the explicit addressing of women’s specific health care needs and disparities, development of health action plans, free access to children and.or their caregivers, inclusion of educational and vocational training, and identification of health resources (such as community clinics) for women to access after release.

Guthrie writes about the need to address health and other inequities women experience prior to becoming incarcerated, and the ways in which confinement can make these inequalities worse. She writes:

At the time of confinement, female inmates are sicker than their male counterparts and are in dire need of health care….Specifically, female inmates, irrespective of their ethnicity or race, are more likely than their male counterparts to enter the correctional system with very serious and long-standing comorbidities as well as preexisting infectious diseases (HIV/AIDS, STIs, TB), chronic illness (diabetes, hypertension, cardiac disease, asthma), cancer (cervical and breast), substance use and abuse, and mental health issues/disorders (bipolar, depression, abuse, posttraumatic stress disorder…

Female inmates also report long-standing reproductive issues, such as intermittent bleeding and pelvic pain/discomfort that require screening and/or follow-up tests (Pap smears and or breast exams) or treatment during and after their confinement. Unfortunately, most correctional health care systems are unable to address the existing physical, mental, and social needs of female inmates, which exacerbates their already poor health.

Related to Guthrie’s work, this piece on gender-responsive strategies in jails may be of interest and covers some of the same principles.

As previously reported, women with health insurance will soon have access to a host of preventive health care services, including contraception, without having to pay out-of-pocket costs such as co-payments, co-insurance and deductibles.

Not surprisingly, the news rankled some conservatives who refuse to acknowledge the long-term economic or health benefits.

Take, for instance, Sandy Rios, a FOX News contributor and vice president of the Family-PAC Federal, a conservative political action committee, who likened women’s health needs to beauty services: ”We’re $14 trillion in debt and now we’re going to cover birth control, breast pumps, counseling for abuse? Are we going to do pedicures and manicures as well?”

Once again, we turn to Stephen Colbert to explain the outrage. And he does so beautifully, noting, for instance, that “a woman’s health decisions are a private matter between her priest and her husband,” and insurance companies should be in the business of covering only “necessary medical expenses — like boner pills.”

Plus, learn what happens when U.S. women get their hands on birth control pills …

Today, the U.S. Department of Health and Human Services announced that it is adopting the Institute of Medicine’s recommendations for preventive care services for women. This will ensure that women have access to the following services under health insurance plans without having to pay a co-payment, co-insurance or deductible:

• well-woman visits
• screening for gestational diabetes
• HPV testing
• STI counseling
• HIV screening and counseling
• contraception methods and counseling
• breastfeeding support, supplies, and counseling
• screening and counseling for domestic and interpersonal violence

Coverage for these services is expected to begin Aug. 1, 2012.

There is one caveat for some women regarding access to contraception without a co-pay — a provision that “Group health plans sponsored by certain religious employers, and group health insurance coverage in connection with such plans, are exempt from the requirement to cover contraceptive services.”

An announcement at the HealthCare.gov site indicates that public comment is welcome on this provision. Although I haven’t yet been able to locate it on Regulations.gov, instructions for comment and more detail about the exemption is provided in this document.

Last week, we highlighted the Institute of Medicine’s recommendation that birth control be covered without co-pays as a preventive service under health care reform.

Several other aspects of women’s health were also covered by the Institute’s recommendations, including “screening and counseling for interpersonal and domestic violence.” While the birth control prevention got a lot of attention online, we’ve seen less discussion of this and other recommendations, so thought we’d highlight it.

An email we received from Futures Without Violence called it a “historic victory,” and explained, “This is not a requirement for screening for domestic violence. It does however, break down significant barriers to integrating comprehensive responses to domestic violence and we believe it will create new opportunities to train providers how to identify and help patients in abusive relationships.”

Seen any good discussion of this violence screening/counseling recommendation? Let us know in the comments.

As a reminder, you can view the Institute’s press release, recommendations, report brief, and full report, “Clinical Preventive Services for Women: Closing the Gap,” online. The Department of Health and Human Services will still need to adopt this list of recommendations for the care to be covered under the Affordable Care Act.

Somewhat relatedly, the Department of Health and Human Services (which will decide whether to accept the Institute’s recommendations), is holding an “Apps Against Abuse” challenge, inviting people to develop applications that “provide young adults with tools to help prevent sexual assault and dating violence.” More information on entering the challenge is available here.

We received the following letter from Physicians for a National Health Program yesterday regarding political negotiations that range from raising the eligibility age for Medicare and increasing costs for participants to dismantling the program altogether. It’s an important issue and we hope you’ll take the time to learn more :

With the 46th anniversary of Medicare only a few weeks away (July 30), the program is in serious danger. … You may have seen the Washington Post story last week that said, “President Obama is pressing congressional leaders to consider a far-reaching debt-reduction plan that would force Democrats to accept major changes to Social Security and Medicare in exchange for Republican support for fresh tax revenue,” and as that part of his pitch he’s proposing “significant reductions in Medicare spending.”

Yesterday’s New York Times reports that the president has “agreed to consider a change in Medicare, which would have pushed up the eligibility requirement for recipients from the age of 65 to 67.” Others, such as Sen. Joseph Lieberman, I-Conn., have made similar proposals and are also pushing for increased cost-sharing by Medicare beneficiaries, e.g. much higher deductibles for doctors’ visits.

Such measures would unquestionably reduce access to health care by our nation’s elderly and severely disabled, worsen their health outcomes and increase financial hardship.

Still worse, others such as Rep. Paul Ryan, R-Wis., would dismantle the Medicare program altogether, replacing it with vouchers to buy private insurance.

As you know, PNHP has joined with others in calling for the protection of the Medicare and Medicaid programs, even as we have pointed out their limitations and advocated for a single-payer national health insurance program, an improved Medicare for all, as the best way to assure truly universal coverage and control costs.

We urge you to speak out on this issue and to submit a letter to the editor or an opinion piece to your local newspaper along these lines. You can find tips on how to do so here. Already a number of PNHP activists had their comments published, as illustrated by this op-ed by Dr. Jim Recht in Massachusetts and this letter by Ann Molison in Colorado.

This Thursday night, July 14, PNHP is hosting a special conference call on the status of Medicare featuring Bruce Vladeck, Ph.D., at 9 p.m. Eastern time. Vladeck, the former top administrator of the Medicare and Medicaid programs, will be followed by several PNHP national board members who will lead a discussion on “Medicare and single payer.” Dr. Claudia Fegan, past president of PNHP, will moderate the call. RSVP today and get call-in details by clicking here!

Cordially,
Garrett Adams, M.D., M.P.H.
President

On July 21, the National Women’s Law Center is hosting a “Birth Control: We’ve Got You Covered” blog carnival to talk about the importance of access to birth control and to encourage the U.S. government to include birth control in a list of services that will be available without a co-pay.

The Affordable Care Act requires coverage – without a co-pay – for preventive services. Decisions about which services will be included are expected sometime this summer. Advocates, including the NWLC, have been working to encourage the Institute of Medicine and Department of Health and Human Services to include birth control as one of the preventive services to be covered.

If you’re unfamiliar with the “blog carnival” concept, it’s when lots of people post on the same topic or theme, and links to the posts are usually collected somewhere online – in this case by the NWLC. If you plan to participate with your own blog post on why birth control should be included as a key preventive care services for women, sign up online.

Last week, Vermont Governor Peter Shumlin signed into law a bill requiring that any health insurance and health benefit plans that provide maternity benefits (including Medicaid and public health care assistance plans) must provide coverage for midwifery services in hospitals, other health care facilities, and at home.

As I read the legislation, it includes coverage for both certified professional midwives and certified nurse-midwives.

The Governor remarked, “Access to midwifery care and home birth should not be limited only to those who can afford those services out of pocket. This law will ensure that all expectant mothers get the coverage and care they want and deserve.”

The legislation establishes a maternal mortality review board made up of an obstetrician, maternal-fetal medicine specialist, neonatologist, CNM, CPM, and other relevant specialists, along with a member of the public. This board will review maternal deaths in Vermont for factors associated with the deaths, and will make recommendations for systemic changes and legislation to address those factors.

Although it seems to have received less media attention, the law also includes a provision to allow transgender individuals to acquire new birth certificates reflecting their gender rather than the one assigned at birth. This will require a doctor’s note submitted to a court “stating that the individual has undergone surgical, hormonal, or other treatment appropriate for that individual for the purpose of gender transition.”

This reportedly makes Vermont the only state with a law that explicitly specifies that surgery is not required in order to obtain a new birth certificate. The law also provides that the original birth certificates will not be available for public inspection in order to protect individual privacy.