Access to Care
Financial barriers are one of the biggest obstacles to receiving health services. The hostile political environment in Ohio has exacerbated economic hurdles to accessing reproductive health care, with anti-choice lawmakers recently enacting policies such as defunding Planned Parenthood, which provides more affordable care to thousands of Ohioans. Health insurance is an important factor in reproductive choice because it enables access to contraceptive options, OB/Gyn services, prenatal care, general health assistance, and future health security for a potential child. In 2014, 63% of Ohio women ages 19 to 64 had some type of health insurance through their employment; 5% were insured in a non-group plan; 19% were insured through Medicaid; 4% were insured through other public programs; and 9% were uninsured (Kaiser Family Foundation, 2014). From 2011 to 2012, 16% of Ohio women ages 18-64 were uninsured, demonstrating a clear increase in coverage in subsequent years (Kaiser Family Foundation, 2013).
The transgender community is often neglected in statics and data on reproductive choice and health access in Ohio. Health policies are often so cisgender-oriented that sometimes they fall short of even being able to locate and describe the disparities in health care access between cisgender and transgender individuals. For example, many health care providers assign care coverage based on gender identification, meaning that trans-men who still have female reproductive organs are not covered for gynecological and obstetric service, such as pap smears (ACLU Ohio, 2009). Additionally, some trans-men can biologically give birth but are often overlooked with regards to their specific reproductive health service needs.
The accessibility of sex reassignment surgery and hormone treatment directly impacts transgender individuals’ ability to control their bodies and change their physical appearance to match their gender identity, meaning that these issues are paramount to evaluating the state of choice in Ohio. Currently, only five states have extended Medicaid coverage to transition-related health services, and Ohio is not one (Levasseur, 2014). In 2014, the U.S. Department of Health and Human Services Departmental Appeals Board reversed Medicare’s earlier exclusion of sex reassignment surgery, noting that the old policy was based on outdated science and did not reflect current understanding or standards of care (NCTE). Moreover, while transgender people may face initial denial of coverage for hormone therapy or reassignment surgery based on gender markers in their Social Security record, there are mechanisms to address inappropriate denials that include the use of a special billing code, the amendment of the markers in the Social Security record, and appealing the decision (NCTE). Private insurance policies vary; however coverage is often denied because many providers classify these surgeries as “cosmetic,” “experimental” or not medically necessary (ACLU Ohio, 2009). Many transgender people also experience difficulty obtaining insurance coverage for hormone treatments and other prescription drugs to facilitate their transition (ACLU Ohio, 2009). These policies place an economic burden on the transgender community to finance expensive health services, removing their control over their bodies and in many cases their reproductive lives.
Cancer screening rates do not provide a complete picture of women’s access to reproductive health care, although they are useful for evaluating access to basic services. In 2014, a total of 81.5% of Ohio adult women received cervical screening that met cancer-screening guidelines (OCISS, 2015). The Ohio Cancer Incidence Surveillance System 2014 regional data on cervical cancer screening indicates that women living in Appalachian counties have the least access to services with only 76.7% receiving screening followed by 80% in rural areas, 81.8% in suburban regions and 83.3% in metropolitan areas (OCISS, 2015). In 2014, a total of 75.8% of Ohio adult women obtained breast screening that met cancer-screening guidelines (OCISS, 2015). Similar to cervical screening, the 2014 data demonstrates that rural women have the least access with only 72.2% followed by 72.5% in suburban areas, 76.7% in rural regions and 77% in metropolitan areas (OCISS, 2015). These numbers demonstrate that even though a majority of Ohio women obtain recommended screening, a moderate portion do not.
In June of 2006, the FDA approved the Gardasil vaccine for the prevention of HPV-related cancers including cervical cancer, which is the most prevalent HPV-related cancer. As of 2014, it was estimated that only 30-39.7% of girls age 13 to 17 had completed the three-dose HPV vaccine series (Kaiser Family Foundation, 2015). The national average for vaccine series completion for the same demographic is roughly 40%, putting Ohio somewhat behind national access (CDC, 2015). There is not Ohio-specific data on males completing the HPV vaccine series. Much of the targeting for the vaccine and HPV screening has been focused on women and girls, although men and boys can carry and transmit the virus. They can also contract various forms of HPV-related cancer, such as anal, penile and oropharyngeal (throat and mouth). Nationally only about 22% of males age 13-17 have completed the HPV three-dose vaccine series (CDC, 2015). To discern the complete picture on access to the vaccine, Ohio needs to start tracking and reporting the number of males who have been vaccinated.
Because the vaccine is relatively new and must be given before exposure, HPV is still the most prevalent sexually transmitted infection in the U.S. (CDC, 2014). The CDC reports on Ohio-specific rates of cancers related to HPV. In 2010, which is the most recent data, the cervical cancer related to HPV rate was an estimated 6.66-7.87 cases per 100,000 females (CDC, 2014). The vaginal cancer related to HPV rate was an estimated 0.29-0.39 (CDC, 2014). The vulvar cancer rate related to HPV was estimated at 1.9-2.2 (CDC, 2014). The anal cancer rate associated with HPV for females was estimated at 1.61-1.81, while for males it was an estimated 0.95-1.12 (CDC, 2014). The oropharyngeal (throat and mouth) cancer associated with HPV for males was 6.09-7.03 while for females it was much lower at a rate of 1.37-1.59 (CDC, 2014). The penile cancer associated with HPV was an estimated rate of 0.71-0.85 (CDC, 2014). These rates indicate that cervical cancer in females and oropharyngeal cancer in males are the most prevalent HPV related cancers.
From 2008-2012 in Ohio, the annual average incident rate for cervical cancer was 7.5 cases per 100,000 women, representing an annual average of 460 cases state-wide (ODH, 2015). During that same time period, the average mortality rate for cervical cancer was 2.6 (ODH, 2015). From 2006-2010, the annual average rate of new cases of cervical cancer for white women was 7.6, while for Black women it was an average of 8.8 (OCISS, 2014). According to the Ohio Cancer Incidence Surveillance System, “Hispanic women have more than twice the risk of developing cervical cancer compared to non-Hispanic white women, and African American women have 1.5 times the risk of non-Hispanic white women” (OCISS, 2014). From 2006-2010, 52% of cervical cancer was detected in late stages of development (OCISS, 2014). Cervical cancer, when diagnosed in its early stages, is one of the most treatable cancers, but the later it is diagnosed, the lower the survival rate (OCISS, 2014).
The Ohio Department of Health’s cancer profile for 2015 tracks the incidence and mortality of breast cancer across Ohio. Between 2008 and 2012, the breast cancer incidence rate was an estimated average of 120.9 cases per 100,000 females (ODH, 2015). The breast cancer incidence rate decreased from 2000 to 2012. For the 2000 to 2004 period, the estimated breast cancer incidence rate was 123.7 (OCISS, 2007). The national incidence rate from 2008 to 2012 was an estimated 124.8, meaning that Ohio was slightly lower than the national incidence for those years (ODH, 2015). Ohio’s average mortality rate for breast cancer from 2008 to 2012 was 23.6, representing around 1,775 deaths (ODH, 2015). However the national mortality rate for breast cancer for the same time period was 21.9, slightly lower than the Ohio rate (ODH, 2015). There was a decrease in the breast cancer mortality rate between 2000 and 2012 in Ohio. From 2000 to 2004, the estimated annual breast cancer mortality rate was 27.9, while from 2006 to 2010 that rate dropped to 24.7 (OCISS, 2007 and OCISS, 2015).
Incidence rates for both ovarian and uterine cancer are much lower than breast cancer. Between 2008 and 2010, Ohio’s average annual ovarian cancer incidence rate was 11.9 cases per 100,000 females, while nationally it was 12.1 (ODH, 2015). In the same time period, the state’s ovarian cancer annual mortality rate averaged 7.9, representing 597 deaths per year (ODH, 2015). Although breast cancer has a much higher incidence rate than ovarian cancer, the mortality rate for breast cancer is much lower. In 2012 in Ohio there were 2,030 new invasive cases of uterine cancer, signifying a rate of 26.9 per 100,000 females (ODH: Office of Health Improvement and Wellness, 2015). The mortality rate in Ohio for uterine cancer in 2012 was 4.9 (ODH: Office of Health Improvement and Wellness, 2015).
Sexually Transmitted Infection Rates
Sexually Transmitted Infections (STI) rates are a critical component of the state of choice. STIs impact fertility and cause a myriad of other physical health issues. These infections can also change people’s relationships to their partners and their future sexuality because of entrenched societal associations of STIs with promiscuity, shame, and guilt. Tracking STIs is thus necessary for creating a holistic picture of reproductive choice in Ohio. It should be noted that the data presented here does not depict all cases of STIs, but instead is representative of all known cases reported to the Ohio Department of Health.
In 2014, 54,301 cases of chlamydia were reported to the Ohio Department of Health (United States Census, 2014, ODH, 2015). The rate of chlamydia cases, defined as the number of cases per 100,000 people, has increased from 443.7 in 2010 to the 469.3 in 2014. Women in Ohio are substantially more likely than men to contract chlamydia, with the number of cases in women being almost double the number in men (ODH, 2015). Since 2010, the Black population in Ohio has had the highest number of cases of chlamydia, followed by the white population (ODH, 2015). The higher number of cases for the Black population is more statistically significant because they comprise a smaller percentage of the population than white people. The rate of cases amongst the Black population was 1,283.6 in 2014, while for whites it was 175.5 (ODH, 2015). In Ohio younger age groups seem to have highest rates of chlamydia, with the highest numbers in the 20 to 24 range followed by the 15 to 19 age range (ODH, 2015).
In 2014 there were 16,041 cases of gonorrhea reported to the Ohio Department of Health (ODH, 2015). The rate of gonorrhea decreased in Ohio between 2013 and 2014 from 144 to 138.6 cases per 100,000 people (ODH, 2015). The incidence of gonorrhea is consistently higher in women than men, although there is not as great of a difference between the sexes as seen with chlamydia (ODH, 2015). Black people had the highest number of cases from 2010 to 2014, followed by white populations (ODH, 2015). The rate of gonorrhea decreased amongst Blacks from 666.1 in 2010 to 534.6 in 2014, while the rate increased in the white population from 29.2 in 2010, to 38.7 in 2014 (ODH, 2015). Although whites have the second highest number of cases of gonorrhea in Ohio, Hispanic populations have a much higher rate at 57.5 in 2014 (ODH, 2015). Younger age groups in Ohio have higher rates and number of cases of gonorrhea than older groups, with the 20-24 group having the highest figures, followed by those aged 15-19 (ODH, 2015).
There were 1,220 syphilis cases reported to the Ohio Department of Health in 2014, putting the rate at 10.5 cases per 100,000 people (ODH, 2015). Men were far more likely to report incidents of syphilis, with the number of cases for men being two or three times higher than for women. In 2014 the rate of syphilis was 16.9 for men and 4.5 for women in Ohio (ODH, 2015). Black people consistently had the highest number of cases and rates of syphilis, with a rate of 44.5 in 2014 (ODH, 2015). The Hispanic population has higher rates of syphilis than white people, though there are more cases reported amongst white people. In 2014 the rate of cases was 12.3 for Hispanic people, an increase from 7.9 in 2010 (ODH, 2015). For white people, the rate was 4.7 in 2014 (ODH, 2015). Ohioans in their twenties have the highest rates of syphilis with the 20-24 group reporting the highest numbers followed by the 25-29 aged range (ODH, 2015).
In 2014 there were 950 newly diagnosed cases of HIV infection in Ohio, representing a rate of 8.2 per 100,000 people (Ohio Department of Health HIV/AIDS Surveillance Program, 2014). These cases of HIV infection include “persons newly diagnosed with HIV (not AIDS), persons previously diagnosed with HIV who are now newly diagnosed with AIDS, and persons concurrently diagnosed with HIV and AIDS at initial diagnosis” (ODH HIV/AIDS Surveillance Program, 2014). In 2014 there were 709 newly diagnosed cases of HIV (not AIDS), 179 newly diagnosed cases of HIV & later AIDS, and 62 newly diagnosed cases of AIDS in Ohio (ODH HIV/AIDS Surveillance Program, 2014). Since 2010 there has been a decrease in the number of cases of AIDS and HIV & later AIDS (ODH HIV/AIDS Surveillance Program, 2014). Sexual contact is not the only means of transmission of HIV. Injection drug use is also a significant cause of new infections of the virus. In Ohio, 73% of diagnosed HIV cases in men and 65% of cases in women were transmitted through sexual contact (ODH HIV/AIDS Surveillance Program, 2014).
Gender and race are significant factors in HIV infection rates in Ohio. Black men have the highest rate of newly diagnosed HIV infection at 60.5 per 100,000, accounting for 43% of cases in Ohio in 2014 (ODH HIV/AIDS Surveillance Program, 2014). That same year, white men were the second largest demographic group, comprising 33% of cases. However, their HIV infection diagnosis rate of 6.9 was lower than Hispanic males who had a 28.5 rate (ODH HIV/AIDS Surveillance Program, 2014). Asian and Pacific Islander males made up about 1% of the HIV infection diagnoses in 2014, with a rate of 5.3 (ODH HIV/AIDS Surveillance Program, 2014).
Females have much lower rates and numbers of HIV infection diagnoses than males in their same racial or ethnic demographic. Black women have the highest rate of their gender at 10.9, and make up 9% of cases in Ohio, followed by Hispanic women with a rate of 4.6, representing 1% of cases (ODH HIV/AIDS Surveillance Program, 2014). White women make up 4% of total newly diagnosed HIV infections, with a rate of 0.9 (ODH HIV/AIDS Surveillance Program, 2014). Asian and Pacific Islanders, American Indian, and Alaska Native women have the lowest numbers, making up less than one percent of the cases, with no rate reported for 2014 (ODH HIV/AIDS Surveillance Program, 2014).
The most recent data in Ohio suggest that people in their twenties are at the highest risk of contracting HIV. In 2014, the largest groups of people newly diagnosed with HIV were those aged 20 to 24, followed by the 25 to 29 group (ODH HIV/AIDS Surveillance Program, 2014). Together, these groups comprised 42% of the newly diagnosed cases in Ohio in 2014 (ODH HIV/AIDS Surveillance Program, 2014). Individuals in the 30 to 34 and the 45 to 49 age ranges were the most likely to be diagnosed with both HIV and AIDS at the time of initial diagnosis (ODH HIV/AIDS Surveillance Program, 2014).