Connecting to Healthcare
The Planned Parenthood facility in Anchorage.
Three of the greatest barriers of entry for women to access healthcare in Alaska are education, time, and financial restraints—whether perceived or actual.
Money, time, and limited services increase women’s health risk
“First of all, it’s making the time, making it a priority,” says Julie Taylor, CEO of Alaska Regional Hospital. “Second is what is their out of pocket expense going to be? Is their insurance plan going to cover it with very little co-pay or deductible or do they have to pay a $5,000 deductible before they go in and get those things done?”
Medicare | Medicaid
Nonetheless, with Medicare and Medicaid there shouldn’t be as many issues with uninsured or underinsured women accessing certain preventive healthcare services, such as mammograms or cervical cancer screenings, Taylor explains.
“But there are not that many clinics that take Medicare and Medicaid,” she says, noting that Alaska Regional Hospital accepts both programs.
The reason many private practices will only take a limited number of Medicare and Medicaid patients is directly linked to economics.
“I think we need more primary care for those with Medicaid and Medicare. I think there’s plenty for the commercially insured, but it’s because reimbursement isn’t fantastic with Medicare and Medicaid,” Taylor says. “There are providers who limit their practice on how many [Medicare and Medicaid patients] they can afford to take. And, I understand it. The economics are not good, especially in Alaska, where it does cost more to run a business.”
CHCs | Title X
As a result, many practices need to have a balanced mix of payers to keep their doors open. However, individuals—male or female, of any age, and at all income levels—can access low-cost primary care and preventive health services through more than 160 federally-funded Community Health Centers (CHCs) located throughout Alaska, says Kelly Keeter, the Adult Health Services Unit/Family Planning Program Manager for the Alaska Division of Public Health. Included at some of these locations are comprehensive health and family planning services for women.
“CHCs offer services on a sliding discount schedule based on income and family size and accept Medicaid, Medicare, and most private insurance, so ability or inability to pay for services is not a barrier to care,” says Keeter.
“Although less numerous in Alaska than CHCs, Title X-funded Family Planning Centers offer comprehensive, high-quality, low-cost family planning and related preventive health services to females and males of all income levels and ages.”
Title X funding guarantees the right to family planning services regardless of a patient’s ability to pay. The Municipality of Anchorage Health Department’s Reproductive Health Clinic and the Kachemak Bay Family Planning Clinic in Homer are funded through the State of Alaska’s Title X grant program, and Planned Parenthood of the Great Northwest and Hawaiian Islands operates Title X funded family planning centers in Fairbanks, Anchorage, Soldotna, and Juneau. Individuals of all ages and income levels can get care at reduced rates or free, in some cases, depending on income and family size.
Planned Parenthood’s Fairbanks facility.
“There are providers who limit their practice on how many [Medicare and Medicaid patients] they can afford to take. And, I understand it. The economics are not good, especially in Alaska, where it does cost more to run a business.”
Along with CHCs and Title X centers, Alaska Native-operated health organizations across the state use Community Health Aides to provide preventive, primary, and urgent care services through Village Health Centers throughout most Alaska communities, Keeter says, before noting that her concern is about other hurdles to accessing healthcare.
Keeter points out that, although there are many avenues for women to seek healthcare services statewide, a lack of awareness about these services, compounded by a lack of understanding about the importance of preventive health services (such as routine breast and cervical cancer screenings), can present barriers to access for many women. Other, but just as important, concerns include providing proper education regarding topics such as the prevention of unintended pregnancies and how to minimize exposure to a wide range of health risks, such as unhealthy or abusive relationships and substance abuse.
“Other barriers to accessing care include perceived or actual lack of confidential services [like family planning and STD/HIV screening and treatment], perceived or actual financial cost of services, language, and/or transportation barriers,” Keeter says. “Finally, lack of availability of—and access to—the most effective forms of birth control, as well as non-directive, client-centered counseling and education aboutall methods of unintended pregnancy prevention, are large barriers for women of reproductive age in Alaska. Although all Title X-funded agencies in Alaska provide these services and methods, this comprehensive approach to women’s health and family planning varies greatly across other providers in Alaska, leaving many women at a disadvantage for preventing unintended pregnancy and/or achieving adequate birth spacing.”
One program that helps low-income, uninsured, or underinsured Alaskans is Ladies First, formerly the Alaska Breast and Cervical Health Check Program, established in 1995 and funded by the CDC.
“We have been around for about twenty-five years and in that time have provided over 148,000 health screening services to over 62,000 Alaskans,” says Anne Remick, Ladies First program director for the Alaska Division of Public Health. “More than 585 cases of breast cancer, 62 cases of cervical cancer, and 4,316 precancerous cervical conditions have been diagnosed through this program.”
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The Alaska Regional Image alliance ribbon-cutting ceremony in October.
Alaska Lags Behind… Again
Even with available preventative healthcare services, the CDC’s Behavioral Risk Factor Surveillance System 2016 data reveals that Alaskans are below the national average for patients getting mammograms and Pap tests.
A total of 67.9 percent of Alaskan women ages 50 to 74 surveyed had a mammogram within the past two years, while the national average is 77 percent. On the other hand, Pap tests are only slightly below the national average of 80 percent: of Alaskan women ages 21 to 65, 78.9 percent had a Pap test in the past three years.
However, in Alaska cervical cancer rates have fluctuated, whereas there has been a steady decline across the United States, says Dr. Tanya Pasternack of Planned Parenthood of the Great Northwest and the Hawaiian Islands, which includes Alaska.
Though many programs, including Ladies First, cover transportation costs, Alaska’s rural nature and geographical barriers do limit access, says Pasternack.
“We also hear from patients who are trying to access care that the modes of transportation aren’t always reliable: the state is facing some significant budget shortfalls and that will change ferry service or other transportation services, making it difficult for people to get the services they need,” Pasternack says.
“Cervical cancer is preventable with the HPV vaccine and screening test [Pap smears and HPV testing]; we should be able to eliminate mortality from cervical cancer with access to these preventative services. However, we are seeing more patients in rural areas and through Indian Health Services [IHS] with advanced cases.”
And though there are programs out there to cover underinsured and uninsured Alaskan women, Pasternack sees cost as the biggest barrier to women accessing healthcare services in Alaska and throughout the nation, despite the Medicaid Expansion in the state.
“We were proud to see Medicaid Expansion in Alaska, which has covered more than 40,000 Alaskans. A lot of our state’s healthcare is provided through this, and because the clinics/hospitals are federally funded, their providers cannot perform abortions at their facilities. This limits access as most rural towns only have an IHS health clinic,” Pasternack says.
“For many people, Planned Parenthood is their only source of healthcare. Fifty-six percent of Planned Parenthood health centers are in health professional shortage areas, rural, or medically underserved areas. Planned Parenthood health centers provide primary and preventive healthcare to many who otherwise would have nowhere to turn for family planning care.”
In her work the Denali OB-GYN Clinic Pasternack provides care to female patients ranging from adolescents to post-menopausal women for surgical procedures, well-woman care, and preventative care. Some of the treatments provided are for endometriosis, urinary incontinence, heavy bleeding, or infertility.
“What is unique about Alaska gynecologic care is that there aren’t a lot of subspecialists. For example, someone struggling with infertility would have a harder time finding a specialist, so general practice physicians with a wider scope are critical in the state,” Pasternack says.
“Cervical cancer is preventable with the HPV vaccine and screening test [Pap smears and HPV testing]; we should be able to eliminate mortality from cervical cancer with access to these preventative services. However, we are seeing more patients in rural areas and through Indian Health Services with advanced cases.”
See the Need, Make the Time
For women who do understand the importance of preventative healthcare services and have affordable access to such services, it can still be hard to make the time, Taylor says.
In October, Alaska Regional Hospital had a ribbon-cutting ceremony for the Alaska Regional Imaging Alliance, which offers 3D mammography and a wide range of women’s imaging services.
“You can get everything done at once, from your mammograms to your bone density to follow-up care. Everything is right there,” Taylor says. “And that’s what we need. We’re busy. We’re either carting kids around or leading busy lives and getting home in the evening and still having a home to take care of. If you can’t find a way to squeeze that in and make it convenient, we’re going to be the last ones to take care of ourselves.”
Taylor points out that preventative care is essential to lowering the overall burden of health costs on an individual, as well as on Alaska’s healthcare network.
“For example, breast cancer, if you catch it early, it’s probably one of the more treatable diagnoses that is out there. But if you don’t, and you end up in chemo and radiation and a mastectomy situation, the cost of that care is just tremendous,” Taylor says. “They are doing more and more with telemedicine. So, I think that does help with some of your screening activities. I know that there is also a mobile mammogram unit that goes around.”
One mobile mammogram unit is operated by the Breast Cancer Detection Center of Alaska out of Fairbanks. Another is operated by Providence Imaging Center. Screening, which takes about fifteen minutes, is applicable to women age forty years or older without specific breast concerns, though patients must schedule their exams ahead of time.
“The harder thing is to get people to admit they should be tested. It isn’t a lack of access, it’s a lack of understanding of how important it is to get it done,” Taylor says.
For example, it’s difficult to persuade people they need to be tested for sexually transmitted diseases and infections.
“Alaska is facing a public health crisis with STI infections, and the high rate of Chlamydia [highest in the nation] compared to the rest of the country is troublesome. We are working to lower this rate,” Pasternack says. “Sex education is now the most scrutinized subject in the state, and the lack of consistent sex-ed for Alaska youth is detrimental.”
Access to contraceptives and screening for STIs is particularly important for college-age women, notes Dr. Georgia DeKeyser, director of the University of Alaska Anchorage (UAA) Student Health and Counseling Center.
“It is of the utmost importance that college-age women have access to and receive healthcare in an accessible, affordable, convenient, and confidential setting. For UAA students, the Student Health and Counseling Center offers all these options,” DeKeyser says.
Though such services are available to about 8,000 UAA students, the various barriers to accessing women’s healthcare, from education to cost, leave many Alaskan women without essential services. However, even with Alaska’s rural nature and the high cost of operating a medical facility in the Last Frontier, many programs, both state and federally funded, continue to reach out to those in need to shore up the difference.
Women searching for services in their communities can use the Alaska 211 directory.
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