by Liz Carey, The Daily Yonder
August 14, 2024

New research has found that rural women are seeing more negative health outcomes as a result of state policy choices that limit their access to health and reproductive care. The study found that differences in Medicaid coverage – whether it is in the 10 states that have yet to expand Medicaid, or the unwinding of Covid-19-based Medicaid coverage – has left millions of women either uninsured or with gaps in their health care coverage.

A report from the Commonwealth Foundation, the 2024 State Scorecard on Women’s Health and Reproductive Care, is the first comprehensive look at women’s health care in all 50 states and the District of Columbia. David Radley, senior scientist with the Commonwealth Fund, said the picture is worse for rural women. While the report looks at state-level data, past research has found that access to health care  and reproductive care in rural communities negatively affects women’s health.

“The report represents those state averages, but of course, when we do a report like this, it’s a combination of data… and it also relies heavily on information that we take in from other research that’s happened,” he said in an interview with the Daily Yonder. “We know from lots of other research, that women struggle in terms of health care access in rural parts of every state. In states that have more rural areas, we’ve seen for a long time, even in our state level reports… people’s ability to access care is almost always more limited.”

Using data from the Centers for Disease Control and Prevention (CDC), as well as other research, the foundation graded states based on health care access, affordability, quality of care and health outcomes for women. The findings revealed widening disparities in women’s health and reproductive care across the U.S.

Limited access to care can be fatal to rural women, the report found.

According to a study by the Georgetown University Center for Families and Children, almost half of children (47%) and one in five adults (18%) in rural areas and small towns rely on Medicaid, a figure the center assumes to be an undercount. States in the South and Southwest, including New Mexico, Louisiana and Kentucky, have the highest Medicaid and CHIP coverage rates for rural residents. Nationwide, seven rural counties have 50% or more adults covered by Medicaid, and six of those are in Kentucky.

The loss in coverage for rural women not only interferes with women’s ability to access care, but is increasing the risk of closure for providers who serve those low-income women, decreasing even further women’s ability to access care, the Commonwealth Foundation study found..

The lowest-ranking states overall were also in the Southeast and Southwest – Mississippi, Texas, Nevada, Oklahoma and Arkansas. Deaths from all causes among women between 15 and 44 were the highest in southeastern states, the study found, and the causes of those deaths included pregnancy, breast and cervical cancer, and other preventable causes like substance use and treatable chronic conditions. The highest maternal death rates were in Tennessee, Mississippi and Louisiana.

The report blamed inadequate access to health care services before, during and after pregnancy, combined with underlying health conditions and poor quality of care. In some cases, access to postpartum screening can make a difference, Radley said.

“We know from other research that access to health care, including mental health care and maternal health care, is limited in states that have large rural populations… some states that have large rural populations don’t do particularly well on those screenings,” he said.

However, states that do well on the screenings, he said, tend to have better maternal health outcomes. The report found that the states with the lowest rates of maternal mortality had more maternity care providers, fewer women with no prenatal care, fewer women with no postpartum checkups and fewer uninsured women between the ages of 19 to 64.

The conditions surrounding rural access to women’s healthcare and reproductive care will likely get worse, Radley said. The study only looked at data up to 2022, the year the U.S. Supreme Court overturned Roe v. Wade. The fallout from that decision, and from the unwinding of Medicaid will continue for years, he said.

Katy Backes Kozhimannil, professor at the University of Minnesota School of Public Health, said research is already showing some of those effects. A recent study found that access to maternity care in rural communities is continuing to decline. Overall, 49 percent of rural counties had hospital-based obstetrics units in 2010, and only 41 percent had them by 2022, meaning more than half (58.8%) had no hospital-based obstetrics units.

Rural hospital administrators said the closures were due to not having enough revenue to keep the units open, as well as not having enough births and specialized skills to care for obstetric patients and not having enough trained clinicians to keep the unit operating, Kozhimannil wrote in an email exchange with the Daily Yonder.

She anticipates that rural communities will continue to see obstetrics units close as the impact of the Supreme Court’s decision on abortion restrictions, the Dobbs’ case, reverberates through the country.

“The Dobbs decision has already affected access to maternity care in the US since 2022,” she wrote. “States with severe restrictions on abortion access have higher rates of maternal mortality and infant death, as well as greater racial inequities in health, and fewer maternity care clinicians. Additionally, the workforce challenges may worsen, as states with abortion restrictions struggled to fill Ob/Gyn residency slots in 2024.”

More needs to happen to ensure women have access to the care they need, she said.

“Unless there are substantial changes in financing and investments in maternity care access, these trends will continue,” she wrote. “We’ve been aware of this problem since 2018, and rural counties keep losing obstetric units. Awareness is the first step; action is the next step.”

This article first appeared on The Daily Yonder and is republished here under a Creative Commons license.