U.S. Women’s Health: Not So Great

In another international comparison, the health status of American women lags behind that of women in other developed countries.

Jan Greene
Contributing Editor

The U.S. health care system places some unique burdens on women, who use more health care services than men and manage most of the bills for their families, researchers at the Commonwealth Fund found when they crunched some numbers about women’s health for 11 industrialized countries.

The largely gloomy report found that U.S. women experience more chronic illness, are less satisfied with their care, and have more trouble affording it—skipping needed care because of cost—than women in comparable nations. The United States ranks low in women’s health despite the ACA, which required many health plans to cover a number of women’s preventive care services with no copay. And yet, stubborn financial issues remain, making care anything but affordable.

High chronic disease burden among U.S. women

Percentage of women ages 18–64 who had two or more chronic conditions

Having a chronic disease was defined as ever being told by a doctor as having two or more of the following: joint pain or arthritis; asthma or chronic lung disease; diabetes; heart disease, including heart attack; or high blood pressure.

*Statistically significant difference compared with the United States (P<.05).

“The reason for the divergence in U.S. rates from other countries does stem directly from the lack of universal coverage in the U.S.,” explains Sara Collins, vice president at the Commonwealth Fund. “Even though women have made great gains since the ACA passed, women in other countries with full coverage tend to have lower out-of-pocket payments and deductibles.”

The data came from a 2016 Commonwealth Fund survey of women in Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States.

Many of the findings in the report seem to feed on one other. For instance, U.S. women have comparatively higher rates of obesity and diabetes, along with more cesarean sections, leading to greater maternal mortality. The United States led the pack on that unsettling statistic, with 14 deaths per 100,000 live births. New Zealand was next with 11 per 100,000. Sweden had the best maternal mortality rates of the group, at four per 100,000.

Rates of cesarean sections highest in Australia, Switzerland, and the U.S.

Cesarean sections—inpatient procedures per 1,000 live births

*2015 data.
**2014 data.
Data source: Organisation for Economic Co-operation and Development, Health Statistics, 2018

Maternal mortality rate is highest in the U.S.

Maternal mortality ratio (maternal deaths/100,000 live births) among women ages 15–49

Data reflect UNICEF estimates because of missing internationally comparable data for the U.S. National statistics are available for most countries from the Organisation for Economic Co-operation and Development.

Efforts for mothers

There are efforts within the United States to do something about maternal mortality. President Trump signed legislation in December 2018 authorizing funding for each state to set up a panel that will collect and study data on deaths of expectant and new mothers. While many states already have such panels, this will be the first time they get federal funding to do their work.

The review committees do vital work in trying to gain a better understanding of the causes of maternal mortality, particularly the reasons that black women die three or four times more often than white women after giving birth. For instance, they have identified cardiac issues as a major cause of maternal mortality, reports ProPublica, the investigative news organization whose coverage of the issue helped raise its national profile.

The chronic disease burden U.S. women face is notably greater than in the comparison countries, the Commonwealth Fund report found, with 20% of American women aged 18 to 64 reporting that they had two or more chronic conditions (a diagnosis of joint pain or arthritis, asthma or chronic lung disease, diabetes, heart disease, or high blood pressure). Canada was the next highest at 16%. Germany was lowest at 7%.

While the Commonwealth Fund report did not address opioid use, new CDC data are not bearers of good tidings about the health of American women. The CDC data show that the drug overdose death rate among women aged 30 to 64 grew more than 260% from 1999 to 2017. The greatest increase was, not surprisingly, deaths involving synthetic opioids.

A couple of bright spots

The report does have some bright spots. Women in the United States (and Sweden) appear to get screened for breast cancer more often than women in other countries. Ninety percent of Swedish women aged 50 to 69 were screened for breast cancer, as were 80% of American women; in Switzerland, France, and Germany, about half of the women in that age group were screened for breast cancer. American women also have among the lowest rates of breast cancer-related deaths than women elsewhere. In the United States, 23 of every 100,000 women died from breast cancer. Rates in the countries studied ranged from 19 per 100,000 in Norway to 31 per 100,000 in the Netherlands.

American women also had quicker access to specialists than women in the other countries in the Commonwealth Fund report; 26% said they had to wait four or more weeks to see a specialist. At the other end of the spectrum, 61% of Canadian women reported the same.

Fewer women in the U.S. wait to see specialists

Percentage of women ages 18–64 who reported having to wait more than four weeks to see a specialist

Excludes women who did not need to see a specialist in the past two years.

*Statistically significant difference compared with the United States (P<.05).

Affordability, though, is where the United States really stands out—and not in a good way.

Out-of-pocket costs for women in the United States were many times higher than those in most other countries studied. About a quarter of women aged 18 to 64 said they spent $2,000 or more on health care in the past year for themselves and their families; the proportion of women in most of the countries in the report with health care costs that high was less than 10%. Switzerland, which had the highest rate at 28%, was an interesting outlier. It also has a private health insurance system, although its insurers are not for profit and are tightly regulated.

Women in Switzerland and the U.S. report very high out-of-pocket costs

Percentage of women ages 18–64 with out-of-pocket costs of $2,000 or more

Percentage of respondents who reported that their annual (past year) family out-of-pocket spending for medical treatments or services, that were not covered by public or private insurance, was $2,000 or more. Does not include adults who reported “don’t know”/refused to respond.

*Statistically significant difference compared with the United States (P<.05).

Nearly half of American women (44%) said they had at least one medical bill problem on which they had to spend time disputing or difficulty paying. France was next highest at 36%, while very few women (just 2%) in the United Kingdom reported having such issues, likely because of the country’s National Health Service, which puts the provision and financing of health care in the hands of the public sector.

Nearly half of U.S. women report medical bill problems

Percentage of women ages 18–64 with at least one medical bill problem

Medical bill problems include any of the following in the past year: 1) serious problems paying or were unable to pay medical bills; 2) spent a lot of time on paperwork or disputes related to medical bills; or 3) insurance denied payment or paid less than expected.

*Statistically significant difference compared with the United States (P<.05).

Paying more for care and having trouble with bills leads to a choice to forgo medical care, the data suggest; 38% of U.S. women said they skipped needed medical care because of the cost. That compares with just 5% of women in the U.K. and 7% in Germany.

More than a third of women in the U.S. skip care because of cost vs. 5% in the U.K.

Percentage of women ages 18–64 with at least one cost-related access problem

Cost-related access problems include any of the following in the past year: 1) having a medical problem but did not visit a doctor; 2) skipped a medical test, treatment, or follow-up recommended by a doctor; 3) did not fill or collect a prescription for medicine, or skipped doses of medicine, because of the cost in the past 12 months.

*Statistically significant difference compared with the United States (P<.05).

Despite (or maybe because of) out-of-pocket spending, U.S. women don’t seem to think they’re getting a lot of value from the system, with just 24% rating quality of care as very good or excellent, the lowest proportion among the 11 countries. On the other end of the satisfaction spectrum were women in the U.K., 62% of whom rated their care as very good or excellent.

One-quarter of women in the U.S. rate their quality of care as excellent or very good

Percentage of women ages 18–64 who rated their quality of medical care as excellent or very good

Other answer categories were “good,” “fair,” and “poor.” Excludes women who did not receive care in the past year and women who did not have a regular doctor or place of care.

* Statistically signicant difference compared with the United States (P<.05).

Financial stress and the chronic illness burden may be reasons why American women had the greatest percentage of those reporting emotional distress, described as anxiety or sadness that was difficult to cope with alone. The numbers: 34% of U.S. women reported emotional distress, and in Canada, 33% of women did—compared with 11% in France and 7% in Germany.

While the United States ranks relatively well on providing access to preventive care, in part because of the ACA, the Trump administration’s efforts to roll back some provisions of the law put women’s health at risk, Collins says. These changes include allowing individuals to purchase short-term and non–ACA-compliant plans that don’t provide as much coverage and that may make ACA-compliant plans more expensive by shrinking their risk pool.

“Women have made gains under the ACA through coverage expansions and expanded benefit packages,” Collins says. “But these findings really do indicate that more needs to be done to improve those gains and move American women closer to other industrialized countries.”

Data in all charts are from the Commonwealth Fund International Health Policy Survey of Adults in 11 Countries conducted between March and June 2016. Countries studied: AUS=Australia, CAN=Canada, FRA=France, GER=Germany, NETH=Netherlands, NOR=Norway, NZ=New Zealand, SWE=Sweden, SWIZ=Switzerland, UK=United Kingdom, US=United States.

Source for all charts: Gunja MZ et al., What Is the Status of Women’s Health and Health Care in the U.S. Compared to Ten Other Countries?” Commonwealth Fund, December 2018

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