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Women’s health issues across the lifespan
Article Women’s Health Issues Across the Lifespan Roberta Wyn, PhD Beatriz Solis, MPH UCLA Center for Health Policy Research Los Angeles, California
Abstract This study examines differences and similarities in women’s health status, health care needs, and access to care across age groups. Data are from the Commonwealth Fund 1998 Survey of Women’s Health. Several age-group specific issues stand out, such as more limited access to health insurance and a usual source of care among younger women, the emergence of chronic health care problems among women in the 45– 64 age group, and the presence of multiple health problems among elderly women. The analyses reveal several themes that cut across age groups, such as the relationship between poverty and health status, the importance of health insurance, and the generally limited receipt of physician information about health-related behaviors.
INTRODUCTION
A
ll women share the same need for affordable, accessible, and quality care. In this article, we examine the health concerns and patterns of use specific to women in different age cohorts. Their health care needs and access to health services are affected by the multiple circumstances of their lives, such as income, living situation, education, employment opportunities, and health status. This knowledge will enable us to better structure policies that address the special circumstances and problems women face at various stages of their lives, as well as issues that are universal among women. Although there is no set standard on how to distinguish or create age cohorts among women, there are both social and medical markers that change as women age, such as child and family responsibilities, work commitments, economic security, and health status. Each age cohort of women has experienced a set of historical events and trends, including socialization and educational influences during the group’s lifetime, although events occur throughout the lifespan that can differ from “normative expectations,” such as early or late parenthood.1 Over the past two decades, there has been a profusion of research focusing on different aspects of women’s health; few studies compare across age cohorts, but rather address all women or selected age groups. Valuable research has been conducted that has shed light on disparities in health status by income and race/ethnic background,2,3 in access to health insurance coverage and health care among women of color,3,4 and for women with low incomes.5,6 Other studies have highlighted the importance of insurance in use
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of health care.7–9 Similarly, the importance of a regular doctor in improving access has been identified.10,11 The purpose of this analysis is to examine these diverse aspects as they differ for women across age groups—young adults (aged 18 –29-years-old), adult women (30 – 44 years), mid-life women (45– 64 years), and elderly women (65 years and older). The article begins with a summary of sociodemographic differences across the age groups and then discusses for each cohort their health status, health behaviors, access to health care, and specific age-related issues.
METHODS This paper employs data from the Commonwealth Fund 1998 Survey of Women’s Health analyzed by age groups. Analysis with the Statistical Analysis System (SAS) provides descriptive statistics across age groups. Differences between groups were measured using SUDAAN software to adjust for sample design. The approach to examining health status includes analysis of: selfreported fair or poor health status, a disability or chronic disease that limited activities, physician diagnosis of a health condition in the past five years, and the number of a specific set of chronic conditions a woman has, and whether the woman experiences a high level of depressive symptoms or has a health condition requiring ongoing medical treatment. The appraisal of health-related behaviors includes whether women currently smoked or had strenuously exercised in the past week, whether they have received physician counseling on a variety of risk behaviors, and whether they were familiar with osteoporosis. Access to health insurance and care usage are examined across age groups; however, because women 65 years and over differ in their health insurance coverage from non-elderly women, other discrete categories were created for this age group (Medicare only, Medicare and Medicaid, Medicare and private coverage, other coverage, and uninsured).
FINDINGS Sociodemographic Profile across the Life Span The characteristics of women in the four age groups differ on several social and economic factors, which can affect access to health insurance and health care (Table 1). Younger and elderly women are the most economically disadvantaged, with higher proportions in families with incomes below the federal poverty level. Young and elderly women are also less represented at higher income levels; just 14% of women aged 18 –29 and 7% age 65 or older have family incomes over $50,000, in contrast to approximately one-third of women in the 30 – 44 and 45– 64 age groups. Although educational attainment is similar across nonelderly age groups, elderly women’s educational background is very different. Nearly four of ten (38%) women 65 and older have not completed high school, compared to less than one of five women in each of the other age groups. A woman’s living situation and family structure also differs by age group. Young women are less likely to be married than other nonelderly women, and one-quarter are single parents. Elderly women are the most likely to be in a household with no spouse or children. Childrearing responsibilities are highest for adult women (ages 30 – 44); nearly three-quarters have children under 18 in the household. Adult women (ages 30 – 44) also have the highest labor force participation, with rates declining dramatically for women over age 65.
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Table 1. DEMOGRAPHIC PROFILE OF WOMEN ACROSS THE LIFE SPAN, AGED 18 AND OVER, UNITED STATES, 1998 All Women (%)
Aged 18–29 (%)
Aged 30–44 (%)
Aged 45–64 (%)
Aged 65⫹ (%)
19 21 60 23 17
27 25 48 14 26
15 18 66 32 19
14 15 71 29 16
21 32 47 7 7
19 60 21
16 68 16
12 61 26
17 59 24
38 52 10
14 35 25 26
24 41 11 24
22 15 10 52
6 36 43 14
⬍1 61 39 ⬍1
43 15 ⬍1 41
43 25 ⬍1 32
57 17 ⬍1 25
51 12 2 35
5 6 ⬍1 88
Family income related to poverty Below poverty 100–200% of poverty 200%⫹ of poverty Family income over $50,000 Receives public benefits (food stamps, cash assistance) among those with family incomes ⬍$35,000 Education Less than high school education High school/some college Completed college Family structure Single parent Single, no children Married, no children Married, children Employment Full-time full-year Part time Self-employed Not working
Source: Analysis of Commonwealth Fund 1998 Survey of Women’s Health.
Young Women (Aged 18 –29 Years) Health Status The vast majority of young women report that they are in good health; overall only 12% report their health as fair or poor and just 7% have limitations in activities (Table 2). The exception among young women is those who are poor (family incomes below 100% of poverty); 24% report being in fair or poor health, compared to 5% of those with family incomes over 200% of poverty. Overall, this is a healthy group, with 84% reporting no chronic health conditions or few disabilities, but an important need for health care services for reproductive health care needs, preventive care, and services to reduce stress and anxiety. Among health conditions diagnosed by a physician within the past five years, depression or anxiety is the top ranked, with 14% reporting this. Next are hypertension and obesity (8% and 6%, respectively); remaining conditions had even lower percentages reported. Nearly one-half of young women (48%) scored high on a measure of the occurrence of depressive symptoms within the past week (this is a measure of mood rather than an actual diagnosis of depression). Health Behaviors and Physician Information The health care setting provides an important opportunity to promote healthy behaviors among women. Despite the importance of modifying risk behaviors, such as smoking and lack of exercise, physician-patient discussion of these issues is inconsistent (Table 3). For the vast majority of women, this is not part of a physician visit, although the need is there. Nearly three of ten young 150
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Table 2. HEALTH STATUS OF WOMEN BY AGE GROUP, WOMEN AGED 18 AND OVER, UNITED STATES, 1998
Self reported fair or poor health Family incomes below poverty Family incomes above 200% of poverty Has disability/chronic disease (that limits full participation in activities) Physician diagnosis in past five years of: Hypertension Heart disease/Heart attack Diabetes Cancer Arthritis Osteoporosis Obesity Depression/Anxiety High level of depressive symptoms Number of chronic conditions* No conditions 1 condition 2 conditions 3 or more conditions Health condition requiring ongoing medical treatment
All women (%)
Aged 18–29 (%)
Aged 30–44 (%)
Aged 45–64 (%)
Aged 65⫹ (%)
17 33 9 17
12 24 5 7
13 29 7 11
22 49 12 22
26 39 14 31
23 7 7 3 24 6 12 17 39
8 3 4 2 3 ⬍1 6 14 48
11 2 3 2 11 1 11 17 42
32 7 10 4 35 8 20 20 34
51 21 13 6 58 19 11 17 33
57 24 12 7 33
84 14 2 ⬍1 15
75 21 3 ⬍1 22
41 33 17 9 46
19 27 28 25 54
*Includes hypertension, heart disease/heart attack, diabetes, cancer, arthritis, and osteoporosis. Source: Analysis of Commonwealth Fund 1998 Survey of Women’s Health.
women smoke, and nearly one-quarter do not engage in sustained exercise (Table 3). Sixty percent of women did not receive information about smoking, diet and weight issues, and exercise during a visit in the past year. Two-thirds of women did not receive information about use of drugs and alcohol, sexually-transmitted diseases, and the importance of calcium. Access to Health Insurance Coverage and Health Care Women aged 18 –29 are the least likely of nonelderly women to have job-based health insurance (either their own job or a spouse’s), with just slightly over one-half (52%) insured through this source (Table 4). These lower rates of job-based coverage likely reflect a combination of factors. Young women are less likely to be employed full time (43%) than other nonelderly, affecting their access to this source of coverage. They are also less likely to be married than other nonelderly women; this translates to fewer options for job-based coverage through a spouse’s employment. And their low household incomes—34% have household incomes less than $16,000 —make private purchase of health insurance financially difficult. The mechanisms for obtaining coverage in this country, which are tied to employment opportunities, marital status, and income, place young women at increased risk of lacking coverage. Medicaid, in part, compensates for the lower employment-based coverage rates of young women, with 14% covered through this public benefit, nearly twice the rate seen for other nonelderly women. Even with the assistance of Medicaid, however, many young women remain uninsured. Young women have the highest uninsured rate of the age cohorts studied,
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Table 3. HEALTH BEHAVIORS AND PHYSICIAN COUNSELING BY AGE GROUP, WOMEN AGED 18 AND OVER, UNITED STATES, 1998
Health behaviors Currently smokes cigarettes No strenuous exercise past week Received physician counseling Smoking Diet and weight Exercise Use of alcohol/drugs Sexually transmitted diseases Importance of calcium Lack of knowledge of health risk Not very familiar or not familiar at all with osteoporosis
All Women (%)
Aged 18–29 (%)
Aged 30–44 (%)
Aged 45–64 (%)
Aged 65⫹ (%)
23 30
28 23
25 25
23 34
12 42
30 46 49 23 16 41
40 39 40 32 33 33
31 43 44 24 16 32
27 51 58 21 9 53
19 51 56 13 6 47
22
33
21
15
20
*Asked of women 40 years of age and older; therefore, data reported only for the two age cohorts in which all women were asked. Source: Analysis of Commonwealth Fund 1998 Survey of Women’s Health.
with one-quarter (25%) lacking coverage, a rate twice as high as women aged 45– 64 (12%) and one and one-half times as high as women aged 30 – 44 (18%) (Table 4). Even when they obtain insurance, they are more likely than other nonelderly women to have gaps in coverage within a year. While Medicaid provides an important safety net for poor women, it certainly does not reach all poor women. One of three poor women are uninsured, compared to 15% of women with family incomes over 200% of poverty. Although women in this age group have favorable health status, there are still important health needs, such as preventive and reproductive care and treatment for acute conditions. Having a regular place to obtain care is important for receipt of all types of health care needs, yet young women are the least likely to have this connection (Table 4). Nearly one-third (30%) do not have a usual place where they receive care, with uninsured women the least likely (43% vs. 26% of those with coverage). This group does report problems with accessing care. Nearly one of four (23%) had problems with one or more of the following: not receiving needed medical care, not filling a prescription because of costs, or not seeing a specialist they thought was needed. Again, lack of insurance compromises women’s access to health care; the uninsured are twice as likely to report a problem with access than those with coverage (38% vs. 18%). The access problems of uninsured young women are also seen for doctor visits, with 15% of the uninsured without a doctor visit in the past year, compared to 5% of insured women.
Adult Women (Aged 30 – 44 Years) Health Status Perceived health status among adult women (aged 30 – 44) is similar to young women; only 13% report fair or poor health and 11% report a disability or other condition that causes limitations in activity (Table 2). Adult women who are poor report much worse health; 29% are in fair or poor health, four times the rate for women with family incomes over 200% of poverty (7%). The most frequent physician-diagnosed health issue for adult women is depression or anxiety, with 17% reporting a physician diagnosis of either of 152
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Table 4. HEALTH INSURANCE COVERAGE AND ACCESS AND USE OF CARE, WOMEN AGED 18 AND OVER, UNITED STATES, 1998
Health insurance* (aged 18–64) Medicare Medicaid Employment-based coverage Other/Private Uninsured Family incomes below poverty Family incomes above 200% of poverty Health insurance (ages 65 and over) Medicare only Medicare and Medicaid Medicare and private Other coverage, not Medicare Uninsured Gaps in health insurance coverage Continuously insured Insured with gap Uninsured Usual source Has no usual source of care Insured Uninsured Access difficulties Problem obtaining needed care*** Insured Uninsured Physician Visit No physician visit past year Insured Uninsured
All Women (%)
Aged 18–29 (%)
Aged 30–44 (%)
Aged 45–64 (%)
Aged 65⫹ (%)
18 8 53 7 15 29 7
1 14 52 8 25 32 15
⬍1 7 68 6 18 43 7
2 8 69 9 12 33 6
— — — — —
— — — — —
— — — — —
— — — — —
15 16 62 5 1
78 7 15
63 12 25
73 9 18
83 4 12
98 1 ⬍1
19 16 39
30 26 43
20 16 40
14 11 31
12 NA NA
22 18 46
23 18 38
27 23 44
21 15 62
13 NA NA
8 6 20
7 5 15
10 6 27
7 6 15
7 NA NA
NA ⫽ Sample size too small to report estimates. *Mutually exclusive health insurance categories, with coverage category reported in a hierarchical manner. **Composite health insurance variable that shows multiple coverage sources of the elderly. ***Answered yes to one or more of the following: did not get needed care, could not see a specialist when thought it was needed, or did not get prescription filled due to costs. Source: Analysis of Commonwealth Fund 1998 Survey of Women’s Health.
these conditions within the past five years. When depressive symptoms in the past week are measured (rather than an actual reported physician diagnosis of anxiety or depression), 42% of adult women score high on depressive symptomatology. Other conditions diagnosed within a five-year period in approximately one of ten adult women are hypertension, arthritis, and obesity. Although adult women do not have the level of health problems seen in older women, and only a small proportion report that their health is fair or poor, it is nonetheless a group of women with definite health care needs and concerns. A moderate segment of this age cohort (24%) report the onset of at least one of the chronic conditions measured—indicating evidence of the emergence of chronic conditions that affect an increasingly higher proportion of women as they age. Moreover, approximately one of five report that they have a health condition requiring ongoing medical treatment.
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Health Behaviors and Physician Information As is seen for young women, smoking remains a health problem for women aged 30 – 44 (Table 3). One-quarter smoke, with the highest rates among women with family incomes below the federal poverty level (34%). Women in this group exercise at a similar level to younger women; one in four do not engage in sustained exercise. The health care setting provides a unique opportunity for physician advice or counseling about health behaviors; the majority of adult women have had some contact with a health care provider in the past year. Physicians are most likely to discuss exercise and diet or weight issues with this age group; slightly over four of ten women received this information. Approximately one-third of women report discussion of smoking and the importance of calcium. Less likely to be discussed are more socially-sensitive issues: use of alcohol and drugs (24%) and sexually-transmitted diseases (16%). Access to Health Insurance Coverage and Health Care Adult women have better access to health insurance coverage than younger women. Approximately two-thirds (68%) of adult women have coverage through their own or their spouses’ employment (Table 4). Nearly threequarters (73%) report that they were continuously insured during the past year. Although women in this age group have several opportunities for coverage, such as relatively high labor force participation rates and opportunities for coverage through a spouse, a significant portion (18%) remain uninsured, and another 9% have gaps in coverage. Although Medicaid is an important source of coverage for poor women (26%), 43% remain uninsured. Although women aged 30 – 44 are better connected to the health care system than young women, they are less likely than older women to have a regular place where they receive care (Table 4). One in five has no usual source of care, a rate that rises to 40% among uninsured adult women. Furthermore, slightly over one-quarter (27%) of adult women report a problem with accessing care (either receiving care when needed, filling a prescription, or seeing a specialist). Women without coverage during the past year were nearly twice as likely to have access problems (44%) as were insured women (23%). Although the vast majority of women in this age cohort (90%) had a doctor visit in the past year, those who are uninsured had more limited access than those with coverage (27% vs. 6%, respectively).
Mid-Life Women (Aged 45– 64 Years) Health Status Nearly one-quarter of women in this age cohort (22%) report being in fair or poor health, rates nearly double those of women in the younger age cohorts and similar to women over age 65 (Table 2). Limitations in activity also begin to increase in this age group: 22% report a disability or health condition that limits participating fully in work, household tasks, or other activities. Particularly affected by health problems are poor women: nearly one-half (49%) are in fair or poor health, compared to 12% of women with family incomes over 200% of poverty. The presence of chronic conditions starts to manifest itself for women in this age group. Six of ten mid-life women report a physician diagnosis in the past five years of one or more of the survey-asked chronic conditions, and approximately one-quarter report two or more conditions. Rates of hypertension and arthritis, conditions with a high prevalence among women over 65, 154
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start to surface among these women. Thirty-two percent report they were diagnosed with high blood pressure and 35% with arthritis within the past five years. Another health concern for women in this age group is obesity, with 20% diagnosed with obesity, again within the past five years. Women who have a diagnosis of obesity have higher rates of several of the other chronic health conditions measured as well. For example, among women who are obese, one-half also have been diagnosed with arthritis and high blood pressure (data not shown). Depression or anxiety has affected a considerable portion (20%) of women in this age group within the past five years. One-third (34%) of mid-life women score high on a depression scale measured over the past week. Women with multiple health conditions score higher on the scale (data not shown). The health conditions affecting women in this age group—arthritis, high blood pressure, obesity, depression or anxiety—require ongoing health care contact and effective maintenance to prevent future problems and limit the scope of current ones. Nearly one-half of mid-life women have health conditions requiring ongoing medical treatment, unlike younger age groups, where only one-fifth or fewer women require ongoing medical treatment. Health Behaviors and Physician Information There are several areas where mid-life women could benefit from physician counseling on health behaviors (Table 3), especially in light of increasing health problems in this age cohort. Nearly one-fourth of women aged 45– 64 smoke. Many women in this age group would have reached young adulthood—when smoking habits often form— before warnings about the negative effects of smoking were part of national campaigns. As women get older, they are less likely to engage in sustained exercise; one-third (34%) report that they do not exercise. Physicians are more likely to discuss exercise and diet and weight issues with their mid-life female patients than smoking. Approximately one-half of women received information about the importance of calcium. Women in this age group need more information from their health care providers about osteoporosis. Fifteen percent have little or no familiarity with osteoporosis, and four of ten report they are only somewhat familiar with this health condition. Access to Health Insurance Coverage and Health Care Nearly seven of ten mid-life women have coverage through their own or their spouses’ employment, a rate similar to women in the 30 – 44 age cohort (Table 4). Public programs and insurance (Medicaid and Medicare) play a relatively small, but still important, role in providing coverage (10%). Mid-life women are more likely than younger groups to have continuous health insurance coverage, with 83% continuously insured during the past year. Twelve percent of women aged 45– 64 are uninsured, one of the lower rates, yet among poor mid-life women, one-third are uninsured. The majority of women in this cohort have a usual place where they seek health care. For uninsured mid-life women, however, the connection to the health care system is less established; nearly one-third do not have a regular source of care. One of five women aged 45– 64 report problems obtaining needed care—paying for prescription medications, obtaining care when needed, or access to a specialist—which is problematic, given the high proportion who report at least one of the chronic physical conditions measured. Among uninsured mid-life women, 62% report a problem with accessing care, compared to 15% of those with coverage.
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Older Women (Aged 65 and Older) Health Status Even though older women have more health conditions than mid-life women, a similar proportion report that their health is fair or poor (26% of elderly vs. 22% of mid-life women) (Table 2). Elderly women have more health conditions that limit activity. Nearly one-third (31%) of women over age 65 have a disability or health condition that limits full participation in daily activities, a rate higher than any other age group. Both fair or poor health and limitations in activity are highest among poor, elderly women. Nearly four of ten (39%) older women living in poverty are in fair or poor health and nearly equal proportion has a disability that limits activity (41%). In contrast, among older women with family incomes over 200% of poverty, 14% report fair or poor health and 27% have a limiting disability. Although a similar proportion of elderly women and women aged 45– 64 report being in fair or poor health, the presence of selected physiciandiagnosed chronic conditions is considerably higher in elderly women. Onehalf or more of elderly women report a diagnosis of hypertension or arthritis within the past five years, and about one in five report a diagnosis of heart disease or osteoporosis (19%). Less common, but certainly reported at a higher prevalence than for other age groups, are diabetes (13%) and cancer (6%). Depression or anxiety is also a concern for elderly women, and one that is often under-recognized. Seventeen percent of elderly women report a physician diagnosis of depression or anxiety within the past five years. Furthermore, one-third score high on self-reported depressive symptoms. The physical health of older women is complicated by multiple chronic conditions; over one-half report two or more, and one-quarter three or more, of the chronic conditions assessed. Furthermore, those women who have multiple conditions are more likely to score high on a depression scale. Although the prevalence of any chronic condition and of multiple conditions is highest for women 65 and over, 19% have none of the six chronic health conditions assessed in the survey and a substantial majority (69%) do not have a condition or disability that limits full participation in daily activities. Health Behaviors and Physician Information Smoking rates are lowest among elderly women (12% smoke), about one-half the rate of non-elderly women. Elderly women are the least likely to exercise; about four of ten elderly women do not engage in sustained exercise. Slightly over one-half of women in this age group received information about diet and exercise from their physicians, a similar rate as mid-life women. Approximately one-half received information about the importance of calcium intake. Women in this age group need more information about osteoporosis: 20% have little familiarity with this condition. Access to Health Insurance Coverage and Health Care The connection women have to the health care system becomes increasingly important as women age. Over one-half (54%) of older women said their health status requires ongoing medical care (Table 2). In contrast to women under age 65, less than 1% of elderly women are uninsured because of entitlement to Medicare (Table 4). Although Medicare ensures coverage for most elderly, there are gaps in coverage benefits and many elderly have additional coverage. Sixty-two percent have private supplemental coverage in addition to Medicare, and 16% of low-income elderly receive Medicaid in addition to Medicare (Table 4). 156
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Elderly women have some of the most established connections to the health care system. Approximately nine of ten have a usual source of care. Even with health insurance and established connections, 13% of elderly women report problems with obtaining needed care, paying for a prescription, or seeing a specialist. This problem is exacerbated for women with multiple health problems. For women with three or more of the chronic conditions measured, nearly one-quarter (22%) report an access problem (data not shown). Although the majority of older women are insured, differences in access exist by the combination of coverage women have. Whereas only 10% of women with Medicare and private supplemental coverage report a problem with access, 21% of women with Medicare and Medicaid, and 16% of women with only Medicare report an access problem (data not shown).
DISCUSSION This study documents both the specific health care needs of women as they move through the life span as well as universal issues that cut across age groups. We will capture both in this discussion and highlight programs and policies important for all women, as well as those specific to a particular age group. Several issues regarding women’s health status and access to care stand out. This study found a persistent health status gap by income within each age group. Women with family incomes below poverty have reported worse health status than higher income women, confirming findings from other studies.2,5 Particular consideration of poor and limited income women is required in formulating new health policy. Poor and uninsured women experience some of the worst access problems in the health care system, although they often have the most need because of their generally poorer health status. Another area of concern seen across all age groups was the high level of depressive symptoms reported, with a one-third or higher portion of women reporting this in each age cohort. This confirms the need for adequate access to mental health-related services and programs to handle stress. These findings reinforce the need for adequate coverage of mental health services and parity with physical health care as well as a better understanding of the multiple factors that lead to these high ratings. Also, among mid-life and elderly women, there was a pattern of higher rates of depressive symptoms among women with multiple health conditions, a reminder that health care professionals need to be aware of the emotional toll of multiple health problems. The analysis revealed a distinct pattern of increasing chronic conditions that begin among mid-life women (aged 45– 64) and persist into the elderly age cohort. Six of ten women aged 45– 64 years report one or more of the chronic health conditions measured in the survey— hypertension, diabetes, arthritis, cancer, heart disease, or osteoporosis— conditions that require ongoing health care contact and effective maintenance to prevent future problems and limit the scope of current ones. Mid-life is an important time for increased and concentrated education efforts on the part of both health professionals and women themselves to minimize the onset of chronic conditions. This study also reinforced the need for management and coordination of health care for elderly women. Over one-half of women over age 65 report two or more of the chronic conditions measured in the survey and one-half require ongoing medical care. Multiple health conditions often means several prescriptions and instructions, which can be overwhelming for people of any age, but particularly so for those managing multiple health issues. Data in the study confirm the persistence of smoking among nonelderly women (one of four smoke). Its link to many health problems, including lung
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cancer, make it one of the most preventable causes of morbidity and mortality. Physician information and discussion about smoking, as well as other modifiable health behaviors, such as diet and exercise typically reaches fewer than one-half of women. More focus needs to be placed on the importance of these issues in women’s lives, as well as information about osteoporosis and ways to prevent it. A policy priority for all nonelderly women is expanding options for coverage in both the private and public sectors, but it is particularly salient for young women. They are the least likely to have job-based coverage, and have the least stable coverage. Young women are often in a transitional period: completing their education, starting families, or entering the labor force. Changes in welfare law that include time limits on benefits and welfare diversion programs may further depress access to coverage through Medicaid.12 One-half of women with children in the 18 –29 age group are single parents, shouldering the responsibility of health care alone, not only for themselves, but for their children. In all nonelderly age groups, efforts need to focus on the high uninsured rates among poor women. Poor women who are not eligible for Medicaid have few options for affordable health insurance and often rely on safety net providers whose financial viability is increasingly at risk.13 The importance of health insurance coverage for all women is reiterated in the findings, confirming several other studies. Women who are insured have better access to care, across all nonelderly age groups.9 Elderly women have unique health care needs and concerns. They have greater health needs than women in the other age cohorts, but lower incomes than most other women. Approximately one-half have incomes below 200% of poverty. It is elderly women with the lowest incomes who have poorer health status. Without Medicare, health care expenses for this age group would be unmanageable. Even with Medicare, and often an additional source of coverage, cost-sharing obligations remain daunting. An elderly individual spends about 20% of income on health care out-of-pocket costs, and for the poor elderly, the figure rises to 34% of income.14 Although Medicare has virtually eliminated uninsurance, elderly women do report problems with access to care— obtaining medical care, getting a prescription, or seeing a specialist— particularly those with multiple health problems and those with very low incomes. This study found that women in the younger age groups generally had worse problems with access to care than those in older age groups. In addition to the structural and financial barriers that women face, many also experience competing demands on their time that can interfere with their own need for health care.8 For example, among women aged 30 – 44 in the study, 74% have a child under 18 in the household, three-quarters are employed, nearly six of ten work full time, and one of four is a single parent. In summary, the system of health care works unevenly for women. Facilitating access to the health care system is only part of the process of improving the health of women. The process and quality of care that a woman receives once in the health care system, and any barriers to that treatment, are important areas for continued research.
REFERENCES 1. Wheaton B, Gotlib IH. Trajectories and turning points over the life course: concepts and themes. In: Gotlib IH, Wheaton B, editors. Stress and Adversity Over the Life Course: Trajectories and Turning Points. New York: Cambridge University Press; 1997.
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2. Schoen C, Duchon L, Simantov E. The Link Between Health and Economic Security for Working-Age Women. Issue brief. New York: The Commonwealth Fund, May 1999. 3. National Institute of Health, Office of Research on Women’s Health. Women of color health data book. Washington, DC: Department of Health and Human Services (NIH Publication No. 98-4247); 1998. 4. Ramirez de Arellano A. Latino women: health status and access to health care. In: Falik M, Scott Collins K, editors. Women’s Health: The Commonwealth Fund Survey. Baltimore: The Johns Hopkins University Press, 1996. pp. 123– 44. 5. Lyons B, Salganicoff A, Rowland D. Poverty, access to health care, and Medicaid’s critical role for women. In: Falik M, Scott Collins K, editors. Women’s Health: The Commonwealth Fund Survey. Baltimore: The Johns Hopkins University Press, 1996. pp. 273–95. 6. The Commonwealth Fund. Health Insurance Coverage and Access to Care for Working-Age Women. New York: The Commonwealth Fund, May 1999. 7. Lenhard-Reisinger A. Health insurance and women’s access to health care. In: Falik M, Scott Collins K, editors. Women’s Health: The Commonwealth Fund Survey. Baltimore: The Johns Hopkins University Press, 1996. pp. 324 – 44. 8. Wyn R, Brown ER, Yu H. Women’s use of preventive health services. In: Falik M, Scott Collins K, editors. Women’s Health: The Commonwealth Fund Survey. Baltimore: The Johns Hopkins University Press, 1996. pp. 49 –75. 9. Hoffman C. Uninsured in America: A Chart Book. Washington DC: The Henry J. Kaiser Family Foundation, 1998. 10. Lambrew JM, DeFriese GH, Carey T, Ricketts TC, Biddle AK. The effects of having a regular doctor on access to primary care. Med Care 1996;34:138 –151. 11. Brown ER, Wyn R, Cumberland WG, Yu H, Gelberg L, Ng L. Women’s healthrelated behaviors and use of preventive services. Report to the Commonwealth Fund, Commission on Women’s Health; 1995. 12. Garret B, Holahan, J. Welfare leavers, Medicaid Coverage, and Private Health Insurance. Washington, DC: Urban Institute; 2000. 13. Institute of Medicine, Committee on the changing market, managed care, and the future viability of safety net providers. America’s Health Care Safety Net. Washington, DC: National Academy Press, 2000. 14. Rowland D. The challenge of meeting the diverse needs of Medicare’s beneficiaries. Hearing on Medicare Reform, The Committee on Finance, US Senate; 1999.
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Abstract This study examines differences and similarities in women’s health status, health care needs, and access to care across age groups. Data are from the Commonwealth Fund 1998 Survey of Women’s Health. Several age-group specific issues stand out, such as more limited access to health insurance and a usual source of care among younger women, the emergence of chronic health care problems among women in the 45– 64 age group, and the presence of multiple health problems among elderly women. The analyses reveal several themes that cut across age groups, such as the relationship between poverty and health status, the importance of health insurance, and the generally limited receipt of physician information about health-related behaviors.
INTRODUCTION
A
ll women share the same need for affordable, accessible, and quality care. In this article, we examine the health concerns and patterns of use specific to women in different age cohorts. Their health care needs and access to health services are affected by the multiple circumstances of their lives, such as income, living situation, education, employment opportunities, and health status. This knowledge will enable us to better structure policies that address the special circumstances and problems women face at various stages of their lives, as well as issues that are universal among women. Although there is no set standard on how to distinguish or create age cohorts among women, there are both social and medical markers that change as women age, such as child and family responsibilities, work commitments, economic security, and health status. Each age cohort of women has experienced a set of historical events and trends, including socialization and educational influences during the group’s lifetime, although events occur throughout the lifespan that can differ from “normative expectations,” such as early or late parenthood.1 Over the past two decades, there has been a profusion of research focusing on different aspects of women’s health; few studies compare across age cohorts, but rather address all women or selected age groups. Valuable research has been conducted that has shed light on disparities in health status by income and race/ethnic background,2,3 in access to health insurance coverage and health care among women of color,3,4 and for women with low incomes.5,6 Other studies have highlighted the importance of insurance in use
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© 2001 by the Jacobs Institute of Women’s Health Published by Elsevier Science Inc. 1049-3867/01/$20.00 PII S1049-3867(01)00081-0
of health care.7–9 Similarly, the importance of a regular doctor in improving access has been identified.10,11 The purpose of this analysis is to examine these diverse aspects as they differ for women across age groups—young adults (aged 18 –29-years-old), adult women (30 – 44 years), mid-life women (45– 64 years), and elderly women (65 years and older). The article begins with a summary of sociodemographic differences across the age groups and then discusses for each cohort their health status, health behaviors, access to health care, and specific age-related issues.
METHODS This paper employs data from the Commonwealth Fund 1998 Survey of Women’s Health analyzed by age groups. Analysis with the Statistical Analysis System (SAS) provides descriptive statistics across age groups. Differences between groups were measured using SUDAAN software to adjust for sample design. The approach to examining health status includes analysis of: selfreported fair or poor health status, a disability or chronic disease that limited activities, physician diagnosis of a health condition in the past five years, and the number of a specific set of chronic conditions a woman has, and whether the woman experiences a high level of depressive symptoms or has a health condition requiring ongoing medical treatment. The appraisal of health-related behaviors includes whether women currently smoked or had strenuously exercised in the past week, whether they have received physician counseling on a variety of risk behaviors, and whether they were familiar with osteoporosis. Access to health insurance and care usage are examined across age groups; however, because women 65 years and over differ in their health insurance coverage from non-elderly women, other discrete categories were created for this age group (Medicare only, Medicare and Medicaid, Medicare and private coverage, other coverage, and uninsured).
FINDINGS Sociodemographic Profile across the Life Span The characteristics of women in the four age groups differ on several social and economic factors, which can affect access to health insurance and health care (Table 1). Younger and elderly women are the most economically disadvantaged, with higher proportions in families with incomes below the federal poverty level. Young and elderly women are also less represented at higher income levels; just 14% of women aged 18 –29 and 7% age 65 or older have family incomes over $50,000, in contrast to approximately one-third of women in the 30 – 44 and 45– 64 age groups. Although educational attainment is similar across nonelderly age groups, elderly women’s educational background is very different. Nearly four of ten (38%) women 65 and older have not completed high school, compared to less than one of five women in each of the other age groups. A woman’s living situation and family structure also differs by age group. Young women are less likely to be married than other nonelderly women, and one-quarter are single parents. Elderly women are the most likely to be in a household with no spouse or children. Childrearing responsibilities are highest for adult women (ages 30 – 44); nearly three-quarters have children under 18 in the household. Adult women (ages 30 – 44) also have the highest labor force participation, with rates declining dramatically for women over age 65.
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Table 1. DEMOGRAPHIC PROFILE OF WOMEN ACROSS THE LIFE SPAN, AGED 18 AND OVER, UNITED STATES, 1998 All Women (%)
Aged 18–29 (%)
Aged 30–44 (%)
Aged 45–64 (%)
Aged 65⫹ (%)
19 21 60 23 17
27 25 48 14 26
15 18 66 32 19
14 15 71 29 16
21 32 47 7 7
19 60 21
16 68 16
12 61 26
17 59 24
38 52 10
14 35 25 26
24 41 11 24
22 15 10 52
6 36 43 14
⬍1 61 39 ⬍1
43 15 ⬍1 41
43 25 ⬍1 32
57 17 ⬍1 25
51 12 2 35
5 6 ⬍1 88
Family income related to poverty Below poverty 100–200% of poverty 200%⫹ of poverty Family income over $50,000 Receives public benefits (food stamps, cash assistance) among those with family incomes ⬍$35,000 Education Less than high school education High school/some college Completed college Family structure Single parent Single, no children Married, no children Married, children Employment Full-time full-year Part time Self-employed Not working
Source: Analysis of Commonwealth Fund 1998 Survey of Women’s Health.
Young Women (Aged 18 –29 Years) Health Status The vast majority of young women report that they are in good health; overall only 12% report their health as fair or poor and just 7% have limitations in activities (Table 2). The exception among young women is those who are poor (family incomes below 100% of poverty); 24% report being in fair or poor health, compared to 5% of those with family incomes over 200% of poverty. Overall, this is a healthy group, with 84% reporting no chronic health conditions or few disabilities, but an important need for health care services for reproductive health care needs, preventive care, and services to reduce stress and anxiety. Among health conditions diagnosed by a physician within the past five years, depression or anxiety is the top ranked, with 14% reporting this. Next are hypertension and obesity (8% and 6%, respectively); remaining conditions had even lower percentages reported. Nearly one-half of young women (48%) scored high on a measure of the occurrence of depressive symptoms within the past week (this is a measure of mood rather than an actual diagnosis of depression). Health Behaviors and Physician Information The health care setting provides an important opportunity to promote healthy behaviors among women. Despite the importance of modifying risk behaviors, such as smoking and lack of exercise, physician-patient discussion of these issues is inconsistent (Table 3). For the vast majority of women, this is not part of a physician visit, although the need is there. Nearly three of ten young 150
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Table 2. HEALTH STATUS OF WOMEN BY AGE GROUP, WOMEN AGED 18 AND OVER, UNITED STATES, 1998
Self reported fair or poor health Family incomes below poverty Family incomes above 200% of poverty Has disability/chronic disease (that limits full participation in activities) Physician diagnosis in past five years of: Hypertension Heart disease/Heart attack Diabetes Cancer Arthritis Osteoporosis Obesity Depression/Anxiety High level of depressive symptoms Number of chronic conditions* No conditions 1 condition 2 conditions 3 or more conditions Health condition requiring ongoing medical treatment
All women (%)
Aged 18–29 (%)
Aged 30–44 (%)
Aged 45–64 (%)
Aged 65⫹ (%)
17 33 9 17
12 24 5 7
13 29 7 11
22 49 12 22
26 39 14 31
23 7 7 3 24 6 12 17 39
8 3 4 2 3 ⬍1 6 14 48
11 2 3 2 11 1 11 17 42
32 7 10 4 35 8 20 20 34
51 21 13 6 58 19 11 17 33
57 24 12 7 33
84 14 2 ⬍1 15
75 21 3 ⬍1 22
41 33 17 9 46
19 27 28 25 54
*Includes hypertension, heart disease/heart attack, diabetes, cancer, arthritis, and osteoporosis. Source: Analysis of Commonwealth Fund 1998 Survey of Women’s Health.
women smoke, and nearly one-quarter do not engage in sustained exercise (Table 3). Sixty percent of women did not receive information about smoking, diet and weight issues, and exercise during a visit in the past year. Two-thirds of women did not receive information about use of drugs and alcohol, sexually-transmitted diseases, and the importance of calcium. Access to Health Insurance Coverage and Health Care Women aged 18 –29 are the least likely of nonelderly women to have job-based health insurance (either their own job or a spouse’s), with just slightly over one-half (52%) insured through this source (Table 4). These lower rates of job-based coverage likely reflect a combination of factors. Young women are less likely to be employed full time (43%) than other nonelderly, affecting their access to this source of coverage. They are also less likely to be married than other nonelderly women; this translates to fewer options for job-based coverage through a spouse’s employment. And their low household incomes—34% have household incomes less than $16,000 —make private purchase of health insurance financially difficult. The mechanisms for obtaining coverage in this country, which are tied to employment opportunities, marital status, and income, place young women at increased risk of lacking coverage. Medicaid, in part, compensates for the lower employment-based coverage rates of young women, with 14% covered through this public benefit, nearly twice the rate seen for other nonelderly women. Even with the assistance of Medicaid, however, many young women remain uninsured. Young women have the highest uninsured rate of the age cohorts studied,
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Table 3. HEALTH BEHAVIORS AND PHYSICIAN COUNSELING BY AGE GROUP, WOMEN AGED 18 AND OVER, UNITED STATES, 1998
Health behaviors Currently smokes cigarettes No strenuous exercise past week Received physician counseling Smoking Diet and weight Exercise Use of alcohol/drugs Sexually transmitted diseases Importance of calcium Lack of knowledge of health risk Not very familiar or not familiar at all with osteoporosis
All Women (%)
Aged 18–29 (%)
Aged 30–44 (%)
Aged 45–64 (%)
Aged 65⫹ (%)
23 30
28 23
25 25
23 34
12 42
30 46 49 23 16 41
40 39 40 32 33 33
31 43 44 24 16 32
27 51 58 21 9 53
19 51 56 13 6 47
22
33
21
15
20
*Asked of women 40 years of age and older; therefore, data reported only for the two age cohorts in which all women were asked. Source: Analysis of Commonwealth Fund 1998 Survey of Women’s Health.
with one-quarter (25%) lacking coverage, a rate twice as high as women aged 45– 64 (12%) and one and one-half times as high as women aged 30 – 44 (18%) (Table 4). Even when they obtain insurance, they are more likely than other nonelderly women to have gaps in coverage within a year. While Medicaid provides an important safety net for poor women, it certainly does not reach all poor women. One of three poor women are uninsured, compared to 15% of women with family incomes over 200% of poverty. Although women in this age group have favorable health status, there are still important health needs, such as preventive and reproductive care and treatment for acute conditions. Having a regular place to obtain care is important for receipt of all types of health care needs, yet young women are the least likely to have this connection (Table 4). Nearly one-third (30%) do not have a usual place where they receive care, with uninsured women the least likely (43% vs. 26% of those with coverage). This group does report problems with accessing care. Nearly one of four (23%) had problems with one or more of the following: not receiving needed medical care, not filling a prescription because of costs, or not seeing a specialist they thought was needed. Again, lack of insurance compromises women’s access to health care; the uninsured are twice as likely to report a problem with access than those with coverage (38% vs. 18%). The access problems of uninsured young women are also seen for doctor visits, with 15% of the uninsured without a doctor visit in the past year, compared to 5% of insured women.
Adult Women (Aged 30 – 44 Years) Health Status Perceived health status among adult women (aged 30 – 44) is similar to young women; only 13% report fair or poor health and 11% report a disability or other condition that causes limitations in activity (Table 2). Adult women who are poor report much worse health; 29% are in fair or poor health, four times the rate for women with family incomes over 200% of poverty (7%). The most frequent physician-diagnosed health issue for adult women is depression or anxiety, with 17% reporting a physician diagnosis of either of 152
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Table 4. HEALTH INSURANCE COVERAGE AND ACCESS AND USE OF CARE, WOMEN AGED 18 AND OVER, UNITED STATES, 1998
Health insurance* (aged 18–64) Medicare Medicaid Employment-based coverage Other/Private Uninsured Family incomes below poverty Family incomes above 200% of poverty Health insurance (ages 65 and over) Medicare only Medicare and Medicaid Medicare and private Other coverage, not Medicare Uninsured Gaps in health insurance coverage Continuously insured Insured with gap Uninsured Usual source Has no usual source of care Insured Uninsured Access difficulties Problem obtaining needed care*** Insured Uninsured Physician Visit No physician visit past year Insured Uninsured
All Women (%)
Aged 18–29 (%)
Aged 30–44 (%)
Aged 45–64 (%)
Aged 65⫹ (%)
18 8 53 7 15 29 7
1 14 52 8 25 32 15
⬍1 7 68 6 18 43 7
2 8 69 9 12 33 6
— — — — —
— — — — —
— — — — —
— — — — —
15 16 62 5 1
78 7 15
63 12 25
73 9 18
83 4 12
98 1 ⬍1
19 16 39
30 26 43
20 16 40
14 11 31
12 NA NA
22 18 46
23 18 38
27 23 44
21 15 62
13 NA NA
8 6 20
7 5 15
10 6 27
7 6 15
7 NA NA
NA ⫽ Sample size too small to report estimates. *Mutually exclusive health insurance categories, with coverage category reported in a hierarchical manner. **Composite health insurance variable that shows multiple coverage sources of the elderly. ***Answered yes to one or more of the following: did not get needed care, could not see a specialist when thought it was needed, or did not get prescription filled due to costs. Source: Analysis of Commonwealth Fund 1998 Survey of Women’s Health.
these conditions within the past five years. When depressive symptoms in the past week are measured (rather than an actual reported physician diagnosis of anxiety or depression), 42% of adult women score high on depressive symptomatology. Other conditions diagnosed within a five-year period in approximately one of ten adult women are hypertension, arthritis, and obesity. Although adult women do not have the level of health problems seen in older women, and only a small proportion report that their health is fair or poor, it is nonetheless a group of women with definite health care needs and concerns. A moderate segment of this age cohort (24%) report the onset of at least one of the chronic conditions measured—indicating evidence of the emergence of chronic conditions that affect an increasingly higher proportion of women as they age. Moreover, approximately one of five report that they have a health condition requiring ongoing medical treatment.
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Health Behaviors and Physician Information As is seen for young women, smoking remains a health problem for women aged 30 – 44 (Table 3). One-quarter smoke, with the highest rates among women with family incomes below the federal poverty level (34%). Women in this group exercise at a similar level to younger women; one in four do not engage in sustained exercise. The health care setting provides a unique opportunity for physician advice or counseling about health behaviors; the majority of adult women have had some contact with a health care provider in the past year. Physicians are most likely to discuss exercise and diet or weight issues with this age group; slightly over four of ten women received this information. Approximately one-third of women report discussion of smoking and the importance of calcium. Less likely to be discussed are more socially-sensitive issues: use of alcohol and drugs (24%) and sexually-transmitted diseases (16%). Access to Health Insurance Coverage and Health Care Adult women have better access to health insurance coverage than younger women. Approximately two-thirds (68%) of adult women have coverage through their own or their spouses’ employment (Table 4). Nearly threequarters (73%) report that they were continuously insured during the past year. Although women in this age group have several opportunities for coverage, such as relatively high labor force participation rates and opportunities for coverage through a spouse, a significant portion (18%) remain uninsured, and another 9% have gaps in coverage. Although Medicaid is an important source of coverage for poor women (26%), 43% remain uninsured. Although women aged 30 – 44 are better connected to the health care system than young women, they are less likely than older women to have a regular place where they receive care (Table 4). One in five has no usual source of care, a rate that rises to 40% among uninsured adult women. Furthermore, slightly over one-quarter (27%) of adult women report a problem with accessing care (either receiving care when needed, filling a prescription, or seeing a specialist). Women without coverage during the past year were nearly twice as likely to have access problems (44%) as were insured women (23%). Although the vast majority of women in this age cohort (90%) had a doctor visit in the past year, those who are uninsured had more limited access than those with coverage (27% vs. 6%, respectively).
Mid-Life Women (Aged 45– 64 Years) Health Status Nearly one-quarter of women in this age cohort (22%) report being in fair or poor health, rates nearly double those of women in the younger age cohorts and similar to women over age 65 (Table 2). Limitations in activity also begin to increase in this age group: 22% report a disability or health condition that limits participating fully in work, household tasks, or other activities. Particularly affected by health problems are poor women: nearly one-half (49%) are in fair or poor health, compared to 12% of women with family incomes over 200% of poverty. The presence of chronic conditions starts to manifest itself for women in this age group. Six of ten mid-life women report a physician diagnosis in the past five years of one or more of the survey-asked chronic conditions, and approximately one-quarter report two or more conditions. Rates of hypertension and arthritis, conditions with a high prevalence among women over 65, 154
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start to surface among these women. Thirty-two percent report they were diagnosed with high blood pressure and 35% with arthritis within the past five years. Another health concern for women in this age group is obesity, with 20% diagnosed with obesity, again within the past five years. Women who have a diagnosis of obesity have higher rates of several of the other chronic health conditions measured as well. For example, among women who are obese, one-half also have been diagnosed with arthritis and high blood pressure (data not shown). Depression or anxiety has affected a considerable portion (20%) of women in this age group within the past five years. One-third (34%) of mid-life women score high on a depression scale measured over the past week. Women with multiple health conditions score higher on the scale (data not shown). The health conditions affecting women in this age group—arthritis, high blood pressure, obesity, depression or anxiety—require ongoing health care contact and effective maintenance to prevent future problems and limit the scope of current ones. Nearly one-half of mid-life women have health conditions requiring ongoing medical treatment, unlike younger age groups, where only one-fifth or fewer women require ongoing medical treatment. Health Behaviors and Physician Information There are several areas where mid-life women could benefit from physician counseling on health behaviors (Table 3), especially in light of increasing health problems in this age cohort. Nearly one-fourth of women aged 45– 64 smoke. Many women in this age group would have reached young adulthood—when smoking habits often form— before warnings about the negative effects of smoking were part of national campaigns. As women get older, they are less likely to engage in sustained exercise; one-third (34%) report that they do not exercise. Physicians are more likely to discuss exercise and diet and weight issues with their mid-life female patients than smoking. Approximately one-half of women received information about the importance of calcium. Women in this age group need more information from their health care providers about osteoporosis. Fifteen percent have little or no familiarity with osteoporosis, and four of ten report they are only somewhat familiar with this health condition. Access to Health Insurance Coverage and Health Care Nearly seven of ten mid-life women have coverage through their own or their spouses’ employment, a rate similar to women in the 30 – 44 age cohort (Table 4). Public programs and insurance (Medicaid and Medicare) play a relatively small, but still important, role in providing coverage (10%). Mid-life women are more likely than younger groups to have continuous health insurance coverage, with 83% continuously insured during the past year. Twelve percent of women aged 45– 64 are uninsured, one of the lower rates, yet among poor mid-life women, one-third are uninsured. The majority of women in this cohort have a usual place where they seek health care. For uninsured mid-life women, however, the connection to the health care system is less established; nearly one-third do not have a regular source of care. One of five women aged 45– 64 report problems obtaining needed care—paying for prescription medications, obtaining care when needed, or access to a specialist—which is problematic, given the high proportion who report at least one of the chronic physical conditions measured. Among uninsured mid-life women, 62% report a problem with accessing care, compared to 15% of those with coverage.
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Older Women (Aged 65 and Older) Health Status Even though older women have more health conditions than mid-life women, a similar proportion report that their health is fair or poor (26% of elderly vs. 22% of mid-life women) (Table 2). Elderly women have more health conditions that limit activity. Nearly one-third (31%) of women over age 65 have a disability or health condition that limits full participation in daily activities, a rate higher than any other age group. Both fair or poor health and limitations in activity are highest among poor, elderly women. Nearly four of ten (39%) older women living in poverty are in fair or poor health and nearly equal proportion has a disability that limits activity (41%). In contrast, among older women with family incomes over 200% of poverty, 14% report fair or poor health and 27% have a limiting disability. Although a similar proportion of elderly women and women aged 45– 64 report being in fair or poor health, the presence of selected physiciandiagnosed chronic conditions is considerably higher in elderly women. Onehalf or more of elderly women report a diagnosis of hypertension or arthritis within the past five years, and about one in five report a diagnosis of heart disease or osteoporosis (19%). Less common, but certainly reported at a higher prevalence than for other age groups, are diabetes (13%) and cancer (6%). Depression or anxiety is also a concern for elderly women, and one that is often under-recognized. Seventeen percent of elderly women report a physician diagnosis of depression or anxiety within the past five years. Furthermore, one-third score high on self-reported depressive symptoms. The physical health of older women is complicated by multiple chronic conditions; over one-half report two or more, and one-quarter three or more, of the chronic conditions assessed. Furthermore, those women who have multiple conditions are more likely to score high on a depression scale. Although the prevalence of any chronic condition and of multiple conditions is highest for women 65 and over, 19% have none of the six chronic health conditions assessed in the survey and a substantial majority (69%) do not have a condition or disability that limits full participation in daily activities. Health Behaviors and Physician Information Smoking rates are lowest among elderly women (12% smoke), about one-half the rate of non-elderly women. Elderly women are the least likely to exercise; about four of ten elderly women do not engage in sustained exercise. Slightly over one-half of women in this age group received information about diet and exercise from their physicians, a similar rate as mid-life women. Approximately one-half received information about the importance of calcium intake. Women in this age group need more information about osteoporosis: 20% have little familiarity with this condition. Access to Health Insurance Coverage and Health Care The connection women have to the health care system becomes increasingly important as women age. Over one-half (54%) of older women said their health status requires ongoing medical care (Table 2). In contrast to women under age 65, less than 1% of elderly women are uninsured because of entitlement to Medicare (Table 4). Although Medicare ensures coverage for most elderly, there are gaps in coverage benefits and many elderly have additional coverage. Sixty-two percent have private supplemental coverage in addition to Medicare, and 16% of low-income elderly receive Medicaid in addition to Medicare (Table 4). 156
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Elderly women have some of the most established connections to the health care system. Approximately nine of ten have a usual source of care. Even with health insurance and established connections, 13% of elderly women report problems with obtaining needed care, paying for a prescription, or seeing a specialist. This problem is exacerbated for women with multiple health problems. For women with three or more of the chronic conditions measured, nearly one-quarter (22%) report an access problem (data not shown). Although the majority of older women are insured, differences in access exist by the combination of coverage women have. Whereas only 10% of women with Medicare and private supplemental coverage report a problem with access, 21% of women with Medicare and Medicaid, and 16% of women with only Medicare report an access problem (data not shown).
DISCUSSION This study documents both the specific health care needs of women as they move through the life span as well as universal issues that cut across age groups. We will capture both in this discussion and highlight programs and policies important for all women, as well as those specific to a particular age group. Several issues regarding women’s health status and access to care stand out. This study found a persistent health status gap by income within each age group. Women with family incomes below poverty have reported worse health status than higher income women, confirming findings from other studies.2,5 Particular consideration of poor and limited income women is required in formulating new health policy. Poor and uninsured women experience some of the worst access problems in the health care system, although they often have the most need because of their generally poorer health status. Another area of concern seen across all age groups was the high level of depressive symptoms reported, with a one-third or higher portion of women reporting this in each age cohort. This confirms the need for adequate access to mental health-related services and programs to handle stress. These findings reinforce the need for adequate coverage of mental health services and parity with physical health care as well as a better understanding of the multiple factors that lead to these high ratings. Also, among mid-life and elderly women, there was a pattern of higher rates of depressive symptoms among women with multiple health conditions, a reminder that health care professionals need to be aware of the emotional toll of multiple health problems. The analysis revealed a distinct pattern of increasing chronic conditions that begin among mid-life women (aged 45– 64) and persist into the elderly age cohort. Six of ten women aged 45– 64 years report one or more of the chronic health conditions measured in the survey— hypertension, diabetes, arthritis, cancer, heart disease, or osteoporosis— conditions that require ongoing health care contact and effective maintenance to prevent future problems and limit the scope of current ones. Mid-life is an important time for increased and concentrated education efforts on the part of both health professionals and women themselves to minimize the onset of chronic conditions. This study also reinforced the need for management and coordination of health care for elderly women. Over one-half of women over age 65 report two or more of the chronic conditions measured in the survey and one-half require ongoing medical care. Multiple health conditions often means several prescriptions and instructions, which can be overwhelming for people of any age, but particularly so for those managing multiple health issues. Data in the study confirm the persistence of smoking among nonelderly women (one of four smoke). Its link to many health problems, including lung
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cancer, make it one of the most preventable causes of morbidity and mortality. Physician information and discussion about smoking, as well as other modifiable health behaviors, such as diet and exercise typically reaches fewer than one-half of women. More focus needs to be placed on the importance of these issues in women’s lives, as well as information about osteoporosis and ways to prevent it. A policy priority for all nonelderly women is expanding options for coverage in both the private and public sectors, but it is particularly salient for young women. They are the least likely to have job-based coverage, and have the least stable coverage. Young women are often in a transitional period: completing their education, starting families, or entering the labor force. Changes in welfare law that include time limits on benefits and welfare diversion programs may further depress access to coverage through Medicaid.12 One-half of women with children in the 18 –29 age group are single parents, shouldering the responsibility of health care alone, not only for themselves, but for their children. In all nonelderly age groups, efforts need to focus on the high uninsured rates among poor women. Poor women who are not eligible for Medicaid have few options for affordable health insurance and often rely on safety net providers whose financial viability is increasingly at risk.13 The importance of health insurance coverage for all women is reiterated in the findings, confirming several other studies. Women who are insured have better access to care, across all nonelderly age groups.9 Elderly women have unique health care needs and concerns. They have greater health needs than women in the other age cohorts, but lower incomes than most other women. Approximately one-half have incomes below 200% of poverty. It is elderly women with the lowest incomes who have poorer health status. Without Medicare, health care expenses for this age group would be unmanageable. Even with Medicare, and often an additional source of coverage, cost-sharing obligations remain daunting. An elderly individual spends about 20% of income on health care out-of-pocket costs, and for the poor elderly, the figure rises to 34% of income.14 Although Medicare has virtually eliminated uninsurance, elderly women do report problems with access to care— obtaining medical care, getting a prescription, or seeing a specialist— particularly those with multiple health problems and those with very low incomes. This study found that women in the younger age groups generally had worse problems with access to care than those in older age groups. In addition to the structural and financial barriers that women face, many also experience competing demands on their time that can interfere with their own need for health care.8 For example, among women aged 30 – 44 in the study, 74% have a child under 18 in the household, three-quarters are employed, nearly six of ten work full time, and one of four is a single parent. In summary, the system of health care works unevenly for women. Facilitating access to the health care system is only part of the process of improving the health of women. The process and quality of care that a woman receives once in the health care system, and any barriers to that treatment, are important areas for continued research.
REFERENCES 1. Wheaton B, Gotlib IH. Trajectories and turning points over the life course: concepts and themes. In: Gotlib IH, Wheaton B, editors. Stress and Adversity Over the Life Course: Trajectories and Turning Points. New York: Cambridge University Press; 1997.
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2. Schoen C, Duchon L, Simantov E. The Link Between Health and Economic Security for Working-Age Women. Issue brief. New York: The Commonwealth Fund, May 1999. 3. National Institute of Health, Office of Research on Women’s Health. Women of color health data book. Washington, DC: Department of Health and Human Services (NIH Publication No. 98-4247); 1998. 4. Ramirez de Arellano A. Latino women: health status and access to health care. In: Falik M, Scott Collins K, editors. Women’s Health: The Commonwealth Fund Survey. Baltimore: The Johns Hopkins University Press, 1996. pp. 123– 44. 5. Lyons B, Salganicoff A, Rowland D. Poverty, access to health care, and Medicaid’s critical role for women. In: Falik M, Scott Collins K, editors. Women’s Health: The Commonwealth Fund Survey. Baltimore: The Johns Hopkins University Press, 1996. pp. 273–95. 6. The Commonwealth Fund. Health Insurance Coverage and Access to Care for Working-Age Women. New York: The Commonwealth Fund, May 1999. 7. Lenhard-Reisinger A. Health insurance and women’s access to health care. In: Falik M, Scott Collins K, editors. Women’s Health: The Commonwealth Fund Survey. Baltimore: The Johns Hopkins University Press, 1996. pp. 324 – 44. 8. Wyn R, Brown ER, Yu H. Women’s use of preventive health services. In: Falik M, Scott Collins K, editors. Women’s Health: The Commonwealth Fund Survey. Baltimore: The Johns Hopkins University Press, 1996. pp. 49 –75. 9. Hoffman C. Uninsured in America: A Chart Book. Washington DC: The Henry J. Kaiser Family Foundation, 1998. 10. Lambrew JM, DeFriese GH, Carey T, Ricketts TC, Biddle AK. The effects of having a regular doctor on access to primary care. Med Care 1996;34:138 –151. 11. Brown ER, Wyn R, Cumberland WG, Yu H, Gelberg L, Ng L. Women’s healthrelated behaviors and use of preventive services. Report to the Commonwealth Fund, Commission on Women’s Health; 1995. 12. Garret B, Holahan, J. Welfare leavers, Medicaid Coverage, and Private Health Insurance. Washington, DC: Urban Institute; 2000. 13. Institute of Medicine, Committee on the changing market, managed care, and the future viability of safety net providers. America’s Health Care Safety Net. Washington, DC: National Academy Press, 2000. 14. Rowland D. The challenge of meeting the diverse needs of Medicare’s beneficiaries. Hearing on Medicare Reform, The Committee on Finance, US Senate; 1999.
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