Women's Health: Focus on Mental Health

Mental health is an integral component of overall health and wellness for women. Women are more likely to experience depression and anxiety, than men.  This disparity is even greater for women of lower socio-economic status and women of color.  The greatest challenge for many is seeking effective and affordable treatment.  Women suffering from mental illness may be uninsured or avoid seeking treatment because of stigma.  They may also be hesitant for fear of missing work or home and family responsibilities.

Lifetime recently produced a film “Call Me Crazy” featuring five interwoven stories about women and their families struggling and coping with mental illness.  The five compelling stories include portrayals of a female veteran returning home from war with Post-Traumatic Stress Disorder, having been raped by her commanding officer; a law student diagnosed with schizophrenia who overcomes her challenges to eventually graduate and help others living with mental illness; a daughter trying to help her mother who suffers from bipolar disorder; and a woman whose husband has debilitating depression, leading him to contemplate suicide.  The film succeeds in demonstrating the nuanced frustrations, challenges, and triumphs experienced by women with mental illness and their loved ones; helping to erode the long-standing stigma for those suffering from mental illness. 

Overcoming stigma in our culture is just one aspect of improving women’s mental health and reducing substance abuse and related illnesses.  It is essential that our leaders in state and federal government continue to adequately fund programs for treatment and public health programs focused on prevention in our communities.

The Maine Women’s Health Report examined some of these topics in depth and issued the following findings:  

• More than 1 in 4 women in Maine have ever been diagnosed with depression. The percentage of Maine women diagnosed with depression decreased as age, education, and income increased.
• In 2009, Maine women were almost two times more likely than men to report ever having been diagnosed with anxiety disorder (21.0% vs. 11.8%).
• Hospitalizations for depression among Maine men and women decreased between 1999-2009; women were more likely than men to be hospitalized for depression during this period.
• Education and income were inversely related to unhealthy physical and mental health days per month. Women who had not graduated from high school reported more than two times the number of mentally unhealthy days and three times the number of physically unhealthy days per month compared to women with a college degree.
• Depression, anxiety and alcohol abuse also commonly co-occur.  Individuals with depression are more likely to smoke, be physically inactive, and drink heavily.

The Report also compiled statistics on substance abuse:

• Over the past ten years, rates of hospitalizations related to alcohol abuse peaked for Maine men and women (in 2004) but then decreased significantly. The rate of hospitalizations for alcohol have been consistently lower among women compared to men over time, but the size the gap between males and females has diminished in recent years.
• The number of female clients served by Maine’s substance abuse treatment facilities increased 50% between 2000 and 2010.
• The number of pregnant clients seeking substance abuse treatment in Maine increased from 111 in 2001 to 251 in 2010, a 125% increase. The increase could reflect an increased number of women abusing drugs, or increased awareness in women and providers of the harmful effects of drugs in utero.

A major provision in the 2010 Affordable Care Act (ACA) is increased mental health parity for all Americans.  Starting in January 2014, all new plans will be required to cover mental health services (including substance abuse treatment) at the same level as they cover other health services (as part of the newly required Essential Health Benefits package).  Maine has enjoyed this protection for many years but now all plans sold in the U.S. will have to comply.  Other key ACA victories for women with mental illness and substance abuse diagnoses beginning in 2014 are the expansion of Medicaid in many states to cover more low-income people and new options for subsidized coverage, meaning increased access to necessary care for many.

The federal Office of Women’s Health (OWH) offers a comprehensive website outlining key topics related to mental health, including fact sheets on individual illnesses; news updates; links to resources to address mental illness including special populations like women veterans; tips to improve mental health; and hotline numbers for individuals in crisis or who are seeking mental health treatment. OWH has also created helpful guides for both consumers and providers that are accessible on their site.

In Maine, there are many organizations dedicated to caring for people with mental illness.  NAMI Maine provides support, education, and advocacy on behalf of people with mental illness and their families.  NAMI Maine offers a hotline for non-crisis inquiries.  The Disability Rights Center also offers a comprehensive resources site with links to many Maine programs and services for people with mental illness.

-Andrea Irwin, Co-Chair, Maine Women's Health Campaign 

Guest post: Connecting Violence Against Women and Health

We’ve all been witness to the increasing violence against women—put on very public display with media coverage of high profile sexual assault cases.The trauma this inflicts on women is profound. Consider the recent suicide of a Nova Scotia teenager who was gang-raped and then endured years of bullying before ending her life in early April.

Similar stories come from Maine, too. I have spent time working with victims of sexual assault in Maine, and I have heard many stories about the violence that women of all ages endure. The most recent Women’s Health Profile puts those stories into perspective:

“Violence against women includes intimate partner violence, domestic violence and sexual assault. These kinds of violence are defined by a pattern of coercive behaviors which may include social isolation, deprivation, intimidation, psychological abuse, childhood physical or sexual abuse, sexual assault, or repeated battering. Intimate partner violence (IPV), domestic violence (DV) and sexual assault (SA) are most often perpetrated by someone who is or was involved in a familial or intimate relationship with the victim. Women and girls of all ages are vulnerable to this kind of violence.”(page 104).

The National Survey of Violence Against women found that 17.6% of women were ever the victims of a rape or attempted rape. In Maine, that number is considerably higher: 28.5% of female respondents to a Maine survey reported that they had been the victim of rape or attempted rape.

There is a huge body of evidence showing the impact that trauma has on health outcomes. For example, Maine has been engaged over the last few years with national trauma expert Vincent Felitti on the "adverse childhood experiences" or ACES, scoring, which is a strong predictor for future health outcomes. Among the traumatic events that impact health outcomes, violence plays a big role. According to the federal CDC, an ACE score “assesses the total amount of stress during childhood and has demonstrated that as the number of ACE increase, the risk for the following health problems increases in a strong and graded fashion.”

 

The increased risk includes:

· Alcoholism and alcohol abuse

· Chronic obstructive pulmonary disease (COPD)

· Depression

· Fetal death

· Health-related quality of life

· Illicit drug use

· Ischemic heart disease (IHD)

· Liver disease

· Risk for intimate partner violence

· Multiple sexual partners

· (for a full list, see the federal CDC website)

The Maine Women's Health Profile underscores the impact of violence on Maine women:

“Data on adverse childhood experiences among adults in Maine were collected for the first time by Maine’s 2010 BRFSS survey. The survey included 11 items that assessed experiences with verbal, physical and sexual abuse and witnessing domestic violence, as well as items that assessed household functioning, such as contact with an incarcerated, mentally ill, or substance abusing household member or parental divorce or separation. Based on these questions, over 60% of women reported experiencing at least one adverse childhood experience. Women were almost two times as likely as men to report experiencing at least five ACEs during childhood; one in every ten Maine adult women reported experiencing five or more ACEs." (page 108)

An international agency called One concludes that there are concrete ways—both locally and internationally—to address violence against women. For a list of these strategies, click here. Locally, you can think about what your community—especially schools—are doing to promote a culture of safety for women and girls. For resources, check out the Maine Coalition Against Sexual Assault website here.

-Darcy Shargo, Co-Chair, Maine Women's Health Campaign

Darcy is the Chief Operating Officer of the Maine Primary Care Association.

Reproductive Health and the Affordable Care Act (ACA)

Reproductive health care is basic health care for women. Yet many women lack access to the care they need to stay healthy and to make healthy decisions for themselves and their families. The good news is that the federal health reform law, the Affordable Care Act (ACA), includes provisions that improve access to health insurance coverage for maternity care and family planning services, making it easier for states to expand Medicaid coverage of family planning, and more.

August 1, 2012, marked the start of the women’s health preventive benefits coverage, expanding access to routine preventive health care services, including contraceptive coverage and counseling, well-woman visits, STD testing, and domestic violence counseling, at no additional cost to women with private insurance. As of August 1, 2012, all new health plans began to cover a range of women’s preventive services without cost sharing. These services have been identified by the Institute of Medicine and endorsed by the Health Resources and Services Administration, or HRSA. They include:

(1) Breastfeeding support, supplies, and counseling;
(2) Screening and counseling for interpersonal and domestic violence;
(3) Screening for gestational diabetes;
(4) DNA testing for high-risk strains of HPV;
(5) Counseling regarding sexually transmitted infections, including HIV;
(6) Screening for HIV;
(7) Contraceptive methods and counseling; and
(8) Well woman visits.

The importance of these benefits is underscored by local data that demonstrates a need for increased access to reproductive health services. According to Maine’s 2011 Women’s Health Report:

[A] woman’s reproductive health status is associated with the long-term social, economic, physical and mental well-being of herself and her children. Improving maternal and newborn health reduces unintended pregnancies and abortion rates, saves women’s lives, decreases infant mortality rates, improves child health outcomes and women’s status in society, as well as reduces and protects against sexually transmitted infections (STI’s). (page 38).

Key reproductive health data from the Report includes:

• Of the reported sexually transmitted diseases, chlamydia is the most frequently reported in Maine and the number of reported cases has increased in recent years.
• Maine women who gave birth in 2009, 88% initiated prenatal care in the first trimester of their pregnancy and more than 85% received adequate prenatal care.
• In 2009 more than 1 in 3 (39%) new Maine mothers reported that the birth of their most recent child was unintended.
• Rates of Cesarean delivery have increased by more than 40% over the past decade in Maine and the U.S. Nearly seven in ten Maine births in 2009 were delivered vaginally and approximately 30% by Cesarean section (C-section).
• About three out of every four (75.2%) children born in Maine in 2007 were ever breastfed. About half (48.2%) of children born in Maine in 2007 were breastfed for at least 6 months and 18.2% were exclusively breastfed for 6 months.
• More than 1 in every 10 (11.3%) new mothers in Maine reported symptoms of depression after the birth of their most recent child.

Our hope is that increased awareness of the reproductive health challenges women face and better access to preventive care will help Maine improve upon these statistics and ensure that all women benefit from better health.

-Darcy Shargo and Andrea Irwin

Co-Chairs, Maine Women's Health Campaign

Happy National Women's Health Week!

May 12-18 is National Women's Health Week!  On Sunday we celebrated our mothers and all they do to make our lives better.  Women are typically the key decision makers for their families' health care and are more likely to be caregivers to their children, spouses, or elderly relatives.  But in the midst of all that caregiving, it is important for all women to get the medical care we need. Today, celebrate National Women’s Checkup Day by calling your health care provider for a regular checkup.  I've scheduled my annual physical for later this month and I'm already preparing a list of questions to ask my doctor.  One of the (many) reasons I prioritize these annual visits is to maintain and build a relationship with her so that when I get sick or have an immediate need, I know we're already on the same page and have a connection. 

If you don't have a primary care provider, today's the perfect opportunity to find one!  If you have insurance, you may need to find an "in-network" provider and can usually do so on the insurer's website.  If you don't have insurance and are worried about cost, you might want to contact your local community health center.  Federally qualified health centers across Maine are committed to providing high quality health care to people of all income levels, regardless of insurance status or ability to pay.

And if you live in the Farmington area, you're in luck because our friends at the Family Planning Association of Maine are hosting their own event to honor National Women's Health Week.  On May 14 and May 17, they are hosting Well-Women Exam and Spa Day where women in the community will be able to schedule a visit that includes pap tests, clinical breast exams, blood pressure and bone density screenings, and enjoy the benefits of Reiki, acupuncture, massage therapy and more.  Click here for more information!

-Andrea Irwin, Co-Chair, Maine Women's Health Campaign

GOAL: Enroll Almost 800 Medically Uninsured People A Day in Maine

More Than Enough Work for Agents, Brokers, and Navigators

By Joseph Ditré, Esq., Executive Director

Hard to imagine, but it’s true. If Maine wanted to enroll all of its 144,959 medically uninsured people according to the most recent estimates during the 6 month open enrollment period that begins on October 1, 2013 and continues through March 31, 2014 – that’s a total of 182 days – it would require us to enroll 797 people a day. Think of that! We have to enroll almost 800 people each day during the open enrollment period into some form of affordable health coverage in the new Health Insurance Marketplace (Exchange) to reach universal health coverage in Maine. Obviously some may enroll as families, but the total number of people to be enrolled each day during open enrollment comes out to almost 800. By any standard, that is a huge task – and one that requires all of us to work together to accomplish.

I wasn’t thinking about the magnitude of the task until I was at a recent meeting of the National Association of Insurance Commissioners in Houston, TX.  Colorado Insurance Commissioner Jim Riesberg said if you take all of CO’s uninsured and divide that number by 365 days a year, it would require CO to enroll about 800 people a day to enroll them all in a one year period. But since enrollment is open only for six months, CO’s number doubles to 1,600 for enrollment. Commissioner Riesberg was onto something! By reducing the magnitude of the task into understandable numbers it quickly became clear to me that agents, brokers, health care providers, consumer advocates, Navigators, and others have a monumental task ahead. So, let’s get to it!

How Agents, Brokers, and Navigators Can Work Together

Federal law prevents Navigators from enrolling people into coverage. Only licensed agents and brokers, or the people working in the Exchange, can enroll people into a qualified health plan. Navigators cannot sell, negotiate, or solicit insurance policies. Put differently, Navigators are not in the business of insurance.

Wisely, federal lawmakers wanted people who are uninsured and coming into private insurance coverage on their own to obtain fair, accurate, and impartial information from local community sources that are not financially motivated. Unlike agents and brokers, who are paid commissions by insurance companies to sell their products, Navigators are not. Navigators will be funded by federal grants under strict federal criteria that prevent them from receiving commissions or working for insurance companies. Federal law requires Navigators to participate in federal training programs, to provide “fair, accurate, and impartial” information about qualified health plans, to obtain state certification or licenses not preempted by federal law, and most importantly – it prevents them from enrolling people into a qualified health plan. Again, only licensed agents or brokers, or the federally facilitated exchange, can enroll people into coverage.

In short, agents and brokers need Navigators, and Navigators need agents and brokers to complete the full task of educating and enrolling medical uninsured people into coverage. When uninsured people choose a plan, they can either go to the Exchange website or call the toll-free Call Center, or they can call a local agent to enroll in that plan.

Needless to say, there is a tremendous amount of work to be done – there are almost 800 uninsured Mainers to enroll each day during the open enrollment period! Only by working together can it get done. Let’s keep in mind that children and adults who desperately need medical care are counting on us.  Who wants to help? To learn more about Navigators click here.

CAHC advocates to reduce barriers in current Maine law in order to have Navigators help more Mainers understand their public and private coverage options.  CAHC testified on April 11, 2013 on a set of bills in the Maine Legislature that addressed these issues.  To read that testimony, click here.

3 Crucial Messages About Health Reform

Given yesterday's release of the navigator funding announcement, the timing couldn't be better for advocates and others working with consumers to get up to speed on what 2014 holds for Maine's health care system. Our friends at the Maine Health Access Foundation (MEHAF) recently published a guest blog post by our Associate Director, Mia Poliquin Pross, on the 3 things we need to be telling people now: 

Since shortly after passage of the Affordable Care Act (ACA) in 2010, Consumers for Affordable Health Care (CAHC) has participated in a collaborative effort with 10 other organizations supported by MeHAF to get the word out on what the ACA will mean for Maine people. As part of this effort, CAHC conducts workshops across Maine where we often ask people: How many of you have heard that you must have health insurance in 2014? Almost all raise their hands. We then follow it up with this question: How many of you know that there will be subsidies that will help you pay for health insurance?

Crickets. No hands.

Therein lies the rub, and our job as advocates during this critical year for implementation of the ACA.
I venture to guess that many people reading this blog are health advocates or are otherwise "in the know" on health reform. This year, our job as advocates is to remember that we know more than the average person, and to share what we know - as often as we possibly can. Our health care system (using that term loosely) is a complex, tangled web of laws and regulations and all sorts of variables and moving targets. Putting all the wonk-talk aside, however, from our experiences at CAHC talking to real people on our HelpLine and in communities, here are 3 basic things about the ACA that all advocates and others in the know should tell people right now.

1. "Yes, you are required to have insurance in 2014 or you may have to pay a fee at tax time, BUT most uninsured people in Maine will get help paying for that insurance."

2. "Buying health insurance will be a different experience than it is now, and you will be able to get help."

3. "Open enrollment starts October 1, 2013 and will last only until March 31, 2014. If you don't enroll during this time, you may have to wait until the next annual open enrollment period."

To read Mia's full blog post and learn more, please visit MeHAF's blog here.

Broken Promises:

Despite Promises of Lower Premiums, Maine’s New Republican-Passed Law Increased Premiums for About 90% of Maine Small Businesses

Insurance companies have now filed three full quarters of small group rate renewal data with the Maine Bureau of Insurance. The data continue to show the trend documented in our recent report -  the vast majority of small businesses are being quoted premium increases – not decreases. But who needs facts when you have spin? Rather than evaluating the results of the new Republican-passed health law called Public Law 90 by the standards that its proponents set at the time they were passing the law, they now want to judge it by much lower standards. Unfortunately, even by their lower standards the data still show that the law is hurting the vast majority of small businesses in Maine with older workers across the state.

Promises, Promises…

Here is what the Bangor Daily News reported the day Governor LePage signed Chapter 90 into law:

Calling it a top priority of his administration, Gov. Paul LePage on Tuesday signed into law a bill designed to lower health insurance costs and cover more Mainers through a series of market changes including a new high risk pool and allowing smaller companies to band together to get better rates.

Backed by dozens of Republican lawmakers who supported the bill, LePage thanked party leaders who shepherded the bill through grueling House and Senate debates, making it the biggest political trophy for the GOP so far this session.

“This legislation has been a top priority,” the governor said during the State House bill-signing.

“Most importantly, this will create choice for Mainers,” LePage said. “This will lower health care costs for Mainers. This will help Maine small businesses. This will create more jobs for Maine people. This is a step in the right direction. This legislation is going to drive health care costs down so we can be competitive with our neighbors.” BDN, May 17, 2011

Of course, promises are easier made than kept.

Promises v. Results…

Last week, Consumers for Affordable Health Care released a report called Few Winners, Many Losers: Evaluating the Impact of Maine's New Health Insurance Law To Date. The report is based on insurance company filings with the Maine Bureau of Insurance. The filings document the devastating impact of the new law called Chapter 90 on individuals and small businesses in Maine. The report also clearly stated that a relatively small percentage of small businesses were quoted rate decreases. It also provided Anthem’s analysis of the distribution of its individual policyholders who got rate increases and rate decreases by age group. The report painstakingly provided all of the insurance company filings for readers to see for themselves. It did not hide or misstate any of the facts.

The facts are clear and indisputable: under the Republican majority’s new law health insurance rates increased for the majority (54%) of individual policyholders with Anthem (see Table 5, p. 7) and the overwhelming majority (90%) of small businesses in every geographic area (Table 6, p. 12), with those in rural counties seeing the highest increases. Under the law’s weakened rate review standards (Section 4, p. 22), Anthem got an additional $1.8 million in profits for its individual product alone, unlike the three prior years when their profit margins were significantly reduced or denied. Proponents argue that Anthem’s individual rate increase was lower than prior years. In fact, it was - but only after factoring in $11 million in taxes paid by all 532,000 people who are privately insured in Maine! The new tax of $4 per insured person per month was authorized by the new law and can be increased by another $2 per person per month without further action of the Maine Legislature. Finally, Anthem’s new insurance products introduced after the new law significantly reduce coverage, and increase deductibles (Table 7, pp. 14-16).

These are the facts. The success of the law should be judged by the standards set by the proponents of the law as they were passing it.  The Republican majority promised that the law would lower premiums and cover more Mainers. The data show that it did not.

Those who supported the law should take ownership of the results. They should not make excuses or try and judge the law by new standards.

Promise:           The bill will not increase premiums for older policyholders. (LD 1333: Health Insurance Reform, Frequently Asked Question, Prepared by the Speaker’s Office)

Result:              Fifty-four percent of Anthem’s individual policyholders got rate increases, some as high as 18%.  For example, 91% of policyholders age 55-59, and 100% over age 60 got premiums increases

Promise:           It will lower the cost of insurance for all Maine people through increased competition. (Sen. Rodney Whittemore, Senate Chair, Insurance and Financial Services Committee, Legislative Record, S-650, 1^st Regular Session 2011)

Result:              90% of Maine small businesses and 54% of individual policyholders received premium increases. No new insurance companies have entered the market. Only one company offered a new product, which reduced coverage and increased deductibles.

Promise:           Over-regulation in the Maine market is reflected in Maine’s premiums. (Rep. Jonathan McKane, Maine House Gives Health Care Final OK, Associated Press, May 13, 2011)

Result:              Weakened rate review regulations resulted in Maine’s largest individual insurance company getting its full profit margin of $1.8 million (which added $185 to each of its 9,500 policyholders’ premiums – an amount three times higher than 2011). Anthem’s profit margin had been denied or reduced in each of the three years prior to Chapter 90 because of effective rate review regulations. By way of comparison, in 2011 the stronger rate review standard resulted in a reduced profit margin of $650,000 (or about $65 for each of its 10,000 policyholders).

Promise:           Increased competition and more affordable coverage options will enable young and healthy people to buy insurance policies and lower costs for everyone. (Rep. Wes Richardson, House Chair, Insurance and Financial Services Committee, Maine House Republican Press Release (May 5, 2011)

Result:              Premiums went up. There is no evidence that young, healthy people are buying coverage. The new product called HealthChoice Plus offered by Anthem reduced coverage (no maternity coverage), and significantly increased deductibles and cost-sharing.

Promise:           It will provide affordable insurance for the 133,000 Maine people who currently have no health insurance due to affordability. (Sen. Rodney Whittemore, Senate Chair, Insurance and Financial Services Committee, Legislative Record, S-650, 1^st Regular Session 2011)

Result:              There is no evidence that Maine’s uninsured people bought health insurance or that the vast majority of Maine’s uninsured, who have incomes under 300% of the federal poverty level (i.e., $33,510 in a household of 1 person), can now afford premium rates – whether higher or lower – after Chapter 90 without subsidies.

Proponents of the new law will continue to blame everyone but themselves for its harmful results and try to make a silk purse out of a sow’s ear by pointing to the few instances where there were rate decreases. However, the data confirm what opponents feared – young and healthy uninsured Mainers are not flocking to buy insurance and rates have not gone down for everyone. Rather as evidenced by the data, the law has resulted in higher premiums for the majority of older and rural people, higher premiums for the overwhelming majority of small businesses in every area of Maine, higher profits for insurance companies, and weakened consumer protections. Read the report and the insurance company filings for yourself!

 

 

~Joseph P. Ditré, Esq.

Executive Director