By all measures, Louisiana can be a hostile place for women, whether they are stay-at-home or working mothers, whether they live in poverty or are just trying to get equal pay in their careers, or whether they are average citizens or elected officials.
But there is good news, health experts say, in the form of newly expanded health care.
More than 250,000 Louisianans signed up for Medicaid after eligibility expanded June 1 under an executive order from Gov. John Bel Edwards. Called Healthy Louisiana, the expansion is a step state officials say will "dramatically" improve the lives of hundreds of thousands of women and their families.
Medicaid now covers adults with incomes up to 138 percent of the federal poverty level, according to the Henry K. Kaiser Family Foundation. That means individuals making less than $16,394 a year are eligible, as are families of four earning less than $33,500.
Among the newly qualified is New Orleans singer Lisa Lynn Kotnik.
Regular gigs around town don't necessarily mean a steady income for Kotnik. Like many musicians, she often had to go without health insurance, she recently told NPR. She noted that she has had at least five surgeries for a series of health complications that include ovarian cysts and a brain aneurysm. She had to pay for the procedures out of pocket because she couldn't afford health insurance. "It was unaffordable," she told NPR. "Completely unaffordable."
Dr. Rebekah Gee, secretary of the Louisiana Department of Health and Hospitals (DHH), says the expanded care couldn't come soon enough for women like Kotnik. Gee points to America's Health Ranking, an initiative of the United Health Organization, which in 2015 ranked Louisiana last among the 50 states for residents' overall health. The Institute for Women's Policy Research this year gave Louisiana a grade of "F" for women's health and well-being.
"Some women, we really gave them a death sentence, frankly," Gee said. "We created a sentence of poor health for women."
About 24 percent of Louisiana women 18 and older reported fair or poor health, according to a 2014 report from the Behavioral Risk Factor Surveillance System, an indicator used by DHH to learn about at-risk residents. In Louisiana, 27.4 percent of women are overweight and 35 percent are obese. More than 40 percent of all women have been diagnosed with hypertension and 41 percent have high cholesterol, the organization found.
Louisiana also is first in the nation for rates of gonorrhea and congenital syphilis, and second in the nation in HIV and AIDS case rates, according to the Louisiana STD/HIV Annual Report from 2014.
Many of the conditions that affect women's health are preventable, Gee told Gambit. Until recently, however, a large percentage of women weren't getting regular health care or any help from the state, unless they were pregnant. She said until Medicaid was expanded, 19 percent of non-elderly women were uninsured — the nation's ninth-worst rate. In addition, a study cited by Talk Poverty, a project of the Center for American Progress, found that 20 percent of all adult women below age 65 live below the federal poverty level. Those two figures give Louisiana women and girls very poor prospects for leading healthy lives.
On average, about 70 percent of Louisiana women ages 18-44 have had a routine medical checkup in the past year, the DHH behavioral risk factor report found. But a closer look shows a large racial gap in access to health care.
According to that same risk factor report, only about 38 percent of black women received a recommended yearly checkup between 2011 and 2014. Twenty-two percent of women who do not see a doctor said it was because of the cost. Not having regular care makes a big difference in a woman's health, according to the New Orleans Health Department, which found African-Americans in the city are three times more likely than whites to die of diabetes and twice as likely to die of kidney disease or HIV.
In New Orleans, there is a 25-year difference in life expectancy between those living in the 70112 ZIP code, which encompasses the Tulane-Gravier, Iberville and Treme neighborhoods, and the 70124 ZIP code, which includes Lakeview and West End.
Gee said improving women's health is important not only for adults, but also is a major factor in the health of Louisiana's children. She notes that poor preconception health, inadequate birth spacing and lack of inter-conception care, particularly for women who have had prior birthing complications, are linked to low birth weight.
In Louisiana, 11 percent of all babies had low birth weight in 2014 and 12 percent of women had a pre-term birth, Gee said. The state ranked seventh-worst in infant mortality and maternal mortality, and fifth-worst in the number of women per obstetrician/gynecologist, according to recent statistics from the Center for American Progress.
"That struggle is resulting in a difficult start for many children," Gee said.
Nor is Louisiana a good state for women's mental health. The Behavioral Risk Factor Surveillance System found 39 percent of women in Louisiana reported having poor mental health. Gee offered a ray of hope: In states that recently expanded Medicaid, studies showed those numbers vastly improved. Depression rates, for example, went down by up to 30 percent, she said.
Gee said her office has worked over the past few years to expand access to preventive health services and tried to improve some of the poor health statistics in the Pelican State. Last year, the U.S. Department of Health and Human Services Office of Minority Health awarded Louisiana a five-year grant to help prevent obesity in minority communities and increase access to physical activities and healthy food.
Before Medicaid expansion, DHH expanded coverage for reproductive health services through a program called Take Charge, which covered preventive visits and treatment for sexually transmitted infections.
As of July, Louisiana became the 31st state in the nation (and the first in the Deep South) to expand Medicaid coverage under the Affordable Care Act. Louisiana also is the first state to mine data from SNAP, the federal food stamp eligibility program, to qualify people for Medicaid — a measure Gee attributed to the early success of enrolling more than 200,000 citizens.
According to state data, as many as 450,000 people may be eligible for the expansion. If 375,000 enroll, the state could save more than $180 million in general funds in 2017.
Ruth Kennedy, the Medicaid expansion project director, said in mid-July that 100,000 eligible adults still need to be enrolled to meet that goal. "While these numbers reflect a remarkable achievement that we are very proud of, our work is far from finished," Kennedy said.
Gee said dramatically increasing the number of women covered under Medicaid or other insurance will ensure that future generations of Louisianans will be significantly healthier, because they will have the tools needed for healthy living from the time they are born to when they become parents.
"It's a quilt that's connected," Gee said. "Every piece has to be strong for women's health to be optimal."