Women aren't "small men": women's health issues are different than men's and need to be addressed specifically.

The goal is to die young, but at a very old age--active and enjoying life up to the very end," says Dr. Wanda Jones, director of the federal Office on Women's Health, who touts the triumphs of public health and modern medicine in helping people live longer and healthier.

Her message applies equally to women and men. But for women to live longer, healthier lives they must pay attention to what scientists have been discovering the last two dozen years when they started researching women's health.

Predominately, men have been medical research subjects and it was believed that except for reproductive organs, women were biologically the same. Doctors looked at women as "small men." By the 1980s, according to the Society for Women's Health Research, it was clear that the exclusion of women from clinical research trials compromised the health care they received.

Compared to men, women have different reactions and side effects to certain drugs. Women come out of anesthesia earlier. Women have different symptoms before a heart attack. Women are 2.7 times more likely to acquire an autoimmune disease, such as sclerosis, lupus or rheumatoid arthritis. Adolescent and young adult women are more apt to have eating disorders that lead to death. Women who smoke are far more likely to develop lung cancer at a younger age. Women experience depression at nearly twice the rate as men.

"Women's health issues are different than men's, and if we care about overall health we have to look at gender-specific issues," says Indiana Senator Gary Dillon, a physician and chair of NCSL's Standing Committee on Health.

In the early 1900s, women in the United States were most likely to die from infectious disease and complications of pregnancy and childbirth. Once women started to live longer, researchers found they have their own versions of chronic conditions such as heart disease, cancer and stroke, which now account for 63 percent of American women's deaths.

Heart disease is the biggest killer, responsible for more deaths in women than all forms of cancer combined. The condition kills 50,000 more women than men every year. It continues to be the most significant health concern for women in the United States today with nearly 489,000 deaths per year. Cancer is the second major threat to women, with lung cancer being the most common cause of cancer death.

"When a woman's health is bad, it affects the whole family," says Oregon Representative Carolyn Tomei. "We have to spend a lot of time with our male counterparts explaining why these women's health issues are important, not only to them, but to their entire family. Women tend to be the ones who decide when to seek medical advice for other family members." Tomei is the chair of the Human Services and Women's Wellness committee and has made women's health one of her top priorities in the legislature.

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A NEW DIRECTION

Lawmakers, doctors and scientists are starting to pay more attention to women's health, but progress has been slow. Women and minorities are still not included in research studies in large enough numbers to allow for accurate analysis by sex and ethnicity. Advocates for women's health want to improve access for women to services such as cancer screenings, reproductive health care, prenatal care, mental health care, smoking cessation classes, and appropriate treatment for their health problems.

"Women's health is often a bellwether for what's happening with overall health in a state," says Michelle Berlin with the Oregon Health & Science University and co-author of the third "Making the Grade on Women's Health: A National and State-by-State Report Card."

Based on the criteria outlined in the U.S. Department of Health and Human Services' Healthy People 2010 agenda, Berlin's report gives the nation an overall grade of "unsatisfactory." The two goals met by the nation--the percentage of women age 40 and older getting regular mammograms and the number of dental visits--represent progress, but many of the measures fall far short of the goals. In the state-by-state book, no state has a "satisfactory" grade for women's health, but Minnesota, Massachusetts, Vermont, Connecticut, New Hampshire, Hawaii, Colorado and Utah came close with "satisfactory minus." Six states--Texas, Oklahoma, West Virginia, Arkansas, Louisiana and Mississippi--received an overall failing grade because their performance was weak on a substantial number of the nation's goals.

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In addition to grading each state according to the federal health objectives, the report evaluates whether states have adopted 67 selected health policy recommendations. The only standard met by all the states--up from 40 states in 2001--was Medicaid coverage for breast and cervical cancer. California, New York and Rhode Island met a majority of the policy recommendations (more than 35), while Idaho, Mississippi and South Dakota met the fewest. Preventing tobacco sales to minors was the most consistently improved policy with 18 states now meeting the policy goal, compared to only five in 2001.

The report also found that a woman's health depends greatly on where she lives. For example, nearly 18 percent of women ages 18 to 64 nationwide are uninsured, but in top-ranked Minnesota, only 8 percent of women are uninsured. In Texas, 28 percent of women are without health insurance. In Hawaii, 85 per 100,000 women die of heart disease, but in the District of Columbia, 211 per 100,000 women do. In New Hampshire, only 8 percent of pregnant women do not receive prenatal care in the first trimester, but in New Mexico, 31 percent of women lack such care.

"The outlook for women's health is grim and nowhere near approaching the goals for 2010 the U.S. Department of Health and Human Services Healthy People initiative set for the nation," says Berlin. "Failing to meet these goals undermines not only the health and well-being of women, but the well-being of our country as well."

WHAT STATES CAN DO

The "Making the Grade" report also encourages states to adopt certain policies to achieve federal health objectives. For example, the report recommends insurance mandates to cover a variety of services, ranging from mammography to treatment for eating disorders. And it calls for pre- and post-natal care for low-income women.

Although most policymakers would agree about wanting to achieve health goals, their strategies for achieving them vary. Some of the report's recommendations go too far for many legislators, such as those concerning insurance mandates or even more controversial areas such as reproductive health issues.

Oregon's Representative Tomei supports insurance mandates to improve her state's ranking, while Kansas Senator Vicki Schmidt favors consumer education and improving access to services to achieve better results in Kansas.

Tomei supported Oregon's requirement for insurance plans to cover cervical cancer screening and mammography. She credits the Pap test for the dramatic 74 percent drop in the number of U.S. cervical cancer deaths between 1955 and 1992. She sponsored a bill to ban smoking in the workplace, including bars and taverns. "Women work in bars and taverns more often than men do," she says.

She supported an increase in cigarette taxes, with a portion earmarked to help both girls and boys avoid smoking. More than one in four high school girls are smokers, and studies have shown that women who start smoking as adolescents are more likely to be heavy adult smokers.

Senator Schmidt, vice chair of Kansas' Public Health and Welfare committee, believes state governments have an important role to play. "I keep looking at the top killers of women and I believe education is the key." She sponsored the American Heart Association's "Go Red for Women" campaign in the Kansas Senate. "Anything we can do to publicize healthy lifestyles will help," Schmidt says. As a practicing pharmacist, she hopes to make women more aware of treatable diseases and get them to seek early detection and appropriate treatment. "Treatable diseases are often ignored because women don't go in for early detection," she says. Her state created the Kansas Health Policy Authority in 2006, which will help coordinate health programs and emphasize prevention.

PREVENTION SAVES MONEY

Many chronic diseases that kill women and men can be prevented or postponed, says Dr. Jones. "Premature death and disability are actually results of the choices we make day in and out."

Medical costs for people with chronic diseases account for more than 75 percent of the nation's $1.4 trillion health care costs. In 2001, approximately $300 billion was spent to treat cardiovascular diseases. Obesity-related chronic disease accounted for an estimated $75 billion in U.S. health expenditures, according to the Centers for Disease Control and Prevention.

"If more people focused on prevention," says Senator Schmidt, "the budget savings would be tremendous. It's our job to make sure that we're out in front on those issues. We need to start with prevention."

Although some states are doing specific things to address women's health, no state has come close to meeting the Healthy People 2010 goals.

"States continue to adopt a piecemeal approach that fails to meet the health care needs of women," Dr. Berlin says. "On the policy indicators since the previous Report Card issued in 2001, states have taken two steps forward and one step back." Berlin adds that even though states have made more positive changes in their policies than harmful ones, "There is still a long way to go. Greater commitment to women's health is needed at both the state and federal levels."

States can use the Report Card to address women's health by looking at the expanded version to identify what's missing in their states and develop new initiatives and policies to address it. For example, several years ago in Kansas, state health officials found that 23 percent of Medicaid-enrolled women who had three or fewer prenatal visits gave birth to low weight babies, compared with only 7 percent of the women who had 10 or more prenatal visits. As a result, the state increased outreach to low-income pregnant women.

State efforts to promote wellness have increased dramatically in recent years, for women, men and children alike. Taking a lesson from the private sector, where workplace wellness initiatives have demonstrated cost savings and healthier workers, states have created programs to increase physical fitness and better eating habits, decrease smoking and alcohol use, and promote health screenings.

"While men and women share risks for many diseases and conditions, the differences in those risks, the differences in presentation, the differences in age or the differences in treatment do matter in terms of outcomes and should absolutely drive programming," says Dr. Jones.

Rather than alienate women from the larger health care spectrum, she urges policymakers to be aware of the differences between men and women and make sure those differences are not overlooked.

DISPARITIES PERSIST

Women of color will constitute almost half of all American women by 2050. They suffer disproportionately from disease and early mortality. African-American women are three to four times more likely than white women to die of complications from pregnancy. African-American newborns are twice as likely than the population as a whole to be born small, which leads to higher infant mortality rates. Diabetes is at least two to four times higher among African-American, Hispanic, American Indian and Asian Pacific Islander women than among white women.

Breast cancer is the leading cause of cancer deaths among Hispanic women, yet only 38 percent of Hispanic women over age 40 have regular mammograms. Disparities are present in cervical cancer as well, where Hispanic females have the highest incidence rates and are the least likely to get Pap tests. About half of women diagnosed with cervical cancer have never had a Pap test.

"Legislators cannot look at the population as a whole when determining health policy, but must look at specific populations to identify needs and appropriate strategies," says Missouri Senator Rita Heard Days. Caucasian women have the highest incidence of breast cancer, but African-American women are more likely to die from the disease.

"I think that the statistics speak for themselves," she says. "Minority women are not getting the care they need. We need better outreach, education and access to services, which can be accomplished by a Medicaid expansion, through private insurance coverage and supporting community health centers."

Many of the health disparities between populations are a result of differences in obtaining access to insurance and services. Nearly 17 million American women are uninsured. Latinas have the highest rate of uninsurance of all groups of women (38 percent), three times the uninsured rate of white (13 percent) women.

Many states have tried to improve access and expand insurance coverage for the uninsured population. Other states are helping to reduce racial disparities by addressing language and cultural barriers and supporting community health centers. Kansas is considering legislation to create a guaranteed loan program to build or expand community health clinics.

"The statistics are appalling. We need to do much more," says Representative Carolyn Tomei. "Oregon has health clinics for people without health insurance, but there aren't enough clinics. And there just isn't enough money. We hope to find more money for that."

Jody Ruskamp-Hatz is NCSL's expert on women's health issues. For more information visit NCSL's website at: www. ncsl.org/programs/health/womenmain.htm

                                            ESTIMATED WOMEN'S DEATHS
TOP THREATS TO WOMEN'S HEALTH                        IN 2005

1. Heart Disease                                           489,000
2. Cancer                                     (for lung, breast and
                                               colorectal) 141,000
3. Stroke                                                  163,000
4. Chronic obstructive pulmonary disease                    64,000
5. Alzheimer's disease                                      42,000
6. Diabetes                                                 38,000
7. Accidents                                                37,000
8. Pneumonia and influenza                                  36,000

STATE-BY-STATE
REPORT CARD 2004

"Making The Grade on Women's
Health" graded the states against benchmarks
drawn primarily from the health
objectives set for the nation by the U.S.
Department of Health and Human Services'
Healthy People 2010 agenda. No
state met all 100 benchmarks. Those
meeting between 70 and 99 were ranked
"satisfactory minus;" between 50 and 69,
"unsatisfactory;" below 50, "failing."

Rank                            Grade

  1     Minnesota                S-
  2     Massachusetts            S-
  3     Vermont                  S-
  4     Connecticut              S-
  5     New Hampshire            S-
  6     Hawaii                   S-
  7     Colorado                 S-
  8     Utah                     S-
  9     Maine                     U
 10     Washington                U
 11     Rhode Island              U
 12     Arizona                   U
 13     Iowa                      U
 14     North Dakota              U
 15     Maryland                  U
 16     Oregon                    U
 17     Montana                   U
 18     New Jersey                U
 19     Nebraska                  U
 20     California                U
 21     Florida                   U
 22     Kansas                    U
 23     Wisconsin                 U
 24     Delaware                  U
 25     Alaska                    U
 26     Virginia                  U
 27     South Dakota              U
 28     Wyoming                   U
 29     New York                  U
 30     Idaho                     U
 31     Pennsylvania              U
 32     Michigan                  U
 33     Nevada                    U
 34     Georgia                   U
 35     Missouri                  U
 36     Ohio                      U
 37     New Mexico                U
 38     North Carolina            U
 39     Illinois                  U
 40     South Carolina            U
 41     Indiana                   U
 42     Tennessee                 U
 43     Kentucky                  U
 44     District of Columbia      U
 45     Alabama                   U
 46     Texas                     F
 47     Oklahoma                  F
 48     West Virginia             F
 49     Arkansas                  F
 50     Louisiana                 F
 51     Mississippi               F