The twenty-first century is nearly upon us - and the demographic trends are irrevocable. Women will continue to outnumber men by a margin of three to one. What changes in political, social, and economic systems will influence the experience of being old and female in America? A cursory review of the current status of policy and practice in the sociopolitical arena can provide incentive and direction for changes that will become increasingly important and critical to women's quality of life.
It has been said that being old, female, and poor is the "triple jeopardy" for women in our society. However, the consequences of age, gender, and socioeconomic status are further compounded by ethnicity. Women of color, who are the fastest growing segment of the female population, are at high risk of experiencing the final stage of life in poverty and poor health. Obsession with youth and physical beauty, coupled with the patriarchal structure of power that exists in society, ensures the continuance of inequality in all major aspects of older women's lives unless counter forces are mounted to defend and ensure the rights of women.
Equality is the dominant issue for women as the twentieth century comes to a close, and it will continue to be of major importance in the year 2000 and beyond. Equal access to and experience in the health care system depends, at least in part, on economic and social equality between men and women. In practical terms, this begins with equal pay for equal work, reimbursement for caregiving work performed in the home, and elimination of the inherent biases against women in the Social Security system. These changes could have positive consequences for older women's health.
Gender-based inequities in health care for older women result from the notso-subtle biases in Medicare reimbursement policies. Medicare, a major and often only source of health insurance for older women, discriminates against women because of its heavy emphasis on acute illness and highly technological medical care. It disproportionately provides better coverage for men, who are more likely to use acute services (which are covered by Medicare), than for women, whose medical needs are often for chronic care.
Out-of-pocket costs borne by older women far exceed those for men. Examples of health conditions that have high out-ofpocket costs are depression, arthritis, hypertension, and stroke; the first three conditions occur statistically more often in women than in men. In contrast are the low out-ofpocket costs for hip fracture, heart attacks, and lung cancer; of these conditions, only hip fracture is more prevalent in women than in men (refer to Sofaer, 1990, for an analysis of older women's vulnerability in the current health care system).
For older women, particularly those who live alone and are of color, Medicare co-payments, deductibles, and numerous uncovered services make out-ofpocket costs prohibitive. Incriminatory Medicare policies, combined with the rare likelihood of private insurance coverage, create major barriers to health care access for older women.
Treatment of women often differs from that of men for the same medical condition. The most obvious example of this is cardiovascular disease, which remains the leading cause of death for women who are 65 and older. Women receive less aggressive diagnostic work-ups, are more likely to be diagnosed with anxiety or depression (and receive antianxiety or antidepressant drugs) when presenting with cardiac symptoms, are less likely to be enrolled in cardiac rehabilitative programs, are more likely to reinfarct, and are more likely to die from heart disease than men (Young, 1993).
As the proposals for health care reform become more defined, rationing care by age will enter the public debate. While the tensions between generations with regard to rationing have already surfaced, little has been said about the gender effects of rationing. Rationing health care on the basis of age would "affect women disproportionately since more women than men occupy the ranks of older Americans" (Jecker, 1991).
Gerontological nurses need to be informed and to be articulate about the issues of health reform - including proposed payment structures - that can adversely affect the greatest percentage of older person for whom we care: older women.
- Jecker, N. Age-based rationing and women. JAMA 1991; 266(21):3012-3015.
- Sofaer, S., Abel, E. Older women's health and financial vulnerability: Implications of the Medicare benefit structure. Women and Health 1990; 16(3/4): 4767.
- Young, R., Kahana, E. Gender, recovery from late life heart attack, and medical care. Women and Health 1993; 20(1 ):1 1-31.