A new state-by-state scorecard of women’s health released this week by the Commonwealth Fund raises concerns over the care women receive and the ripple effects of the Supreme Court’s 2022 decision to overturn Roe v. Wade.

The “2024 State Scorecard on Women’s Health and Reproductive Care” is based on 32 measures of state health systems and examines how state policy actions are changing the way women can access and use health care.

“Based on the evidence and data, one thing is absolutely clear, women’s health is in a very fragile state,” said Dr. Joseph Betancourt, president of the Commonwealth Fund, during a briefing with reporters on Wednesday. “There are stark disparities in women’s access to quality health care among states across racial, ethnic, and socioeconomic lines. Those inequities are longstanding, no doubt, but recent policy choices and judicial decisions restricting access to reproductive care have and may continue to exacerbate them.”

Rates of maternal deaths were highest in the Mississippi Delta region, which includes Arkansas, Louisiana, Mississippi, and Tennessee. North Carolina’s rates for maternal deaths while pregnant and for infant mortality were both above the national average.

Eighteen percent of North Carolina women aged 18-64 reported being in fair or poor health based on the data from 2022.

More than 1 in 5 women in our state (21%) reported having 14 of more poor mental health days in the past month.

North Carolina performed best on women who were up to date on colon cancer screenings.

Such screenings are critically important as deaths from breast and cervical cancer are considered preventable and treatable for women who receive timely screening and follow-up health care.

Researchers found that Black women experienced higher breast cancer mortality than white women due to a variety of factors, including poorer quality of care after an abnormal test, or a diagnosis made at a more advanced stage.

The scorecard also found deaths among women of reproductive age are highest in southeastern states. Causes of death included pregnancy related complications and other preventable causes such as substance use, COVID-19, and treatable chronic conditions.

The uninsured rates among women in the U.S. ranged from 2.5% to over 20% with the highest uninsured rates in states that have not expanded their Medicaid programs.

North Carolina expanded its Medicaid coverage on December 1, 2023. Just last week the NC Department of Health and Human Services announced the enrollment of more than 500,000 North Carolinians in the seven months since the program was launched.

“Each of those 500,000 who now have the peace of mind to be able to face some of the greatest challenges that they ever thought they could face and know that they are not alone,” said North Carolina Department of Health and Human Services Secretary Kody Kinsley in marking the milestone.

But while North Carolina has made progress in expanding health care access, 10 states have yet to expand eligibility for Medicaid. That leaves nearly 800,000 women uninsured.

A maternity care desert made worse by Dobbs ruling

The Commonwealth Fund experts said access to care isn’t just about having coverage, it’s also about being able to get to a service provider when care is needed.

“It’s estimated that over five million women (nationwide) already live in a county that’s considered a maternity care desert, meaning there’s no hospital or birth center offering obstetric care and there are no obstetric providers,” explained David Radley, Ph.D., a senior scientist for the Commonwealth Fund.

Twenty percent of women in North Carolina age 18-44 said they did not have a person who was their personal or primary health care provider.

Abortion bans are also having an impact on the care that women receive, said Sara Collins, the Commonwealth Fund’s vice president for health care coverage and tracking health system performance.

“A clear pattern in the study is states that have had abortion restrictions prior to Dobbs rank lower and a lot of our measures, including having adequate numbers of maternal health care providers,” Collins shared. “We’re seeing post-Dobbs the effect that decision is having on states delivery systems. We’re seeing lower residency applications in states with abortion bans from new medical students.”

So, is there going to be a growing divide across the states between those that have left abortion legal and those that have enacted the tightest restrictions?

“I think that time will tell,” Collins said.

North Carolina’s legislature enacted a 12-week abortion ban in 2023 and could move toward a six-week ban in 2025.

What researchers do know now is that states in which a large share of residents are living in rural areas, there tend to be the fewest obstetric providers.

Fewer providers means that patients face barriers in receiving the full continuum of prenatal and postnatal care.

Elections will shape future health access

How women’s health fares in the future could very well depend on the outcome of the 2024 presidential election.

The Affordable Care Act (ACA) not only expanded Medicaid and provided subsidies the help lower-income families, but it also banned insurers in the individual market from charging young women higher premiums than young men. The ACA also required insurers to cover maternity care –something that was not guaranteed prior to the law.

After more than 60 failed Republican-led votes to repeal Obamacare, experts believe a scenario could emerge if the GOP takes control of Congress and the White House in 2025 that would involve passage of legislation requiring slimmed down plans and fewer guaranteed benefits. It remains unclear if insurers would be allowed to deny coverage to those with pre-existing conditions.

“While some states undoubtedly are championing women’s continued access to vital health and reproductive services, many others are failing to ensure that women can get and afford the health care they need. The failure is having a disproportionate impact on women of color and women with low incomes,” said Betancourt.

Click here to read the 2024 State Scorecard on Women’s Health and Reproductive Care for North Carolina.