States eye benefits as family planning expands
By Adam Sonfield
Senior Public Policy Associate
Guttmacher Institute
Washington, DC
Among the seemingly countless provisions in the March 2010 health reform law is one that greatly simplifies the process by which a state may extend Medicaid eligibility for family planning services and supplies to individuals ineligible for comprehensive health coverage under the program.1 These expansions have the potential to greatly expand the capacity of family planning clinics and private providers to help thousands of women and couples avoid unplanned pregnancies, births, and abortions, and in the process improve public health and save millions in public dollars.2
Before the new law, states had been able to initiate a Medicaid family planning expansion only as a temporary demonstration program, under the complicated, time-consuming process of seeking a "waiver" from Medicaid law and regulations. Despite the red tape, a geographically and politically diverse group of 22 states have taken this approach since the mid-1990s. Those states have extended eligibility to women, and sometimes men, typically up to the same income eligibility level used in the state for coverage of pregnancy-related care. In most states, that level is at or near 200% of the federal poverty level.3 (Six additional states have more limited expansions in place, typically for postpartum women. See list below.)
State Family Planning Expansion Overview |
|
States with Family Planning State Plan Amendments |
|
| South Carolina | Wisconsin |
States with Income-Based Family Planning Waivers |
|
Alabama |
Arkansas |
States with Limited Family Planning Waivers |
|
Arizona |
Delaware |
Source: Guttmacher Institute, State Medicaid family planning eligibility expansions, State Policies in Brief (as of January 14, 2011), 2011. Accessed at http://www.guttmacher.org/statecenter/spibs/spib_SMFPE.pdf |
|
Under their new authority, states may set up a family planning expansion under a streamlined process, known as a state plan amendment (SPA). The programs must cover all of the family planning services and supplies available under the state's full-benefit Medicaid program. Those usually include the complete range of contraceptive methods and associated examinations and lab tests. States pay for only 10% of the costs of these services, with the federal government reimbursing them for the other 90%. States must also cover transportation costs and at least some of a broader set of related services, such as treatment for sexually transmitted infections or the human papillomavirus vaccine, provided as part of or follow-up to a family planning visit. The costs for those services are split more evenly between the state and federal governments.
The law allows states to cover a broader population than currently covered under any existing waiver program. It also requires states' expansions to cover adolescents and men, two groups excluded under some current waivers. A SPA is a permanent change to a state's Medicaid program. By contrast, a waiver must be renewed every several years and requires ongoing evaluation.
Programs make impact
A large body of evidence from program evaluations and independent studies indicates that the existing programs have had a significant impact.
Waiver programs have been found to expand women's access to contraceptive services and improve their contraceptive use. In turn, those changes have helped thousands of women and couples avoid unplanned pregnancies and the births and abortions that follow. In doing so, the programs have helped women extend their interpregnancy intervals, a key factor in maternal and child health. The cost of providing Medicaid-covered, pregnancy-related care greatly outstrips the cost of providing contraceptive services. Thus, these programs also have generated tens of millions of dollars in state and federal savings annually in states as diverse as Alabama, Arkansas, California, Oregon, and South Carolina.2,4
A new Guttmacher Institute analysis, drawing on the experience of existing waiver programs, projects that most states could see this type of impact if they took up the new family planning SPA authority. Twenty-eight states don't have an income-based family planning expansion. Nineteen of them could each serve at least 10,000 individuals, enable women to prevent at least 1,500 unintended pregnancies, and save at least $2.3 million in state funds in a single year, beyond what their Medicaid program is already accomplishing. Nine of the 19 could each serve at least 50,000 individuals, avert at least 7,500 unintended pregnancies, and save at least $17.4 million. Even states that already have a waiver program could benefit from switching to a SPA, because they could cover additional women and men. Among the 22 states with waivers, 11 of them could each serve at least 10,000 new participants, avert at least 1,300 unintended pregnancies, and save at least $1.7 million in state funds annually, beyond what their expansions achieve today.2
The ultimate impact of any new expansion would depend greatly on state-level decisions and factors, including the range of services covered, the quality of care provided, and the capacity of the state's provider network and Medicaid systems. Nevertheless, the potential benefits of expansion are clear enough that they might override the numerous fiscal and political pressures that state legislators and officials are facing. Already as of mid-January 2011, two states Wisconsin and South Carolina had received federal approval to shift from a waiver to a SPA and expand the scope of their programs.3 To date, none of the states without waiver programs have received approval for a family planning SPA, but it was only in July 2010 that the Centers for Medicare and Medicaid Services issued formal guidance to states on the implementation of the new provision.5
References
- Patient Protection and Affordable Care Act, P.L. 111–148, Sec. 2303, March 23, 2010.
- Sonfield A, Frost JJ, Gold RB, Estimating the Impact of Expanding Medicaid Eligibility for Family Planning Services: 2011 Update. New York: Guttmacher Institute, 2011.
- Guttmacher Institute, State Medicaid family planning eligibility expansions, State Policies in Brief (as of January 14, 2011), 2011. Accessed at http://www.guttmacher.org/statecenter/spibs/spib_SMFPE.pdf.
- Edwards J, Bronstein J, Adams K. Evaluation of Medicaid Family Planning Demonstrations. Alexandria, VA: CNA Corp., 2003.
- Centers for Medicare and Medicaid Services. Family planning services option and new benefit rules for benchmark plans. State Medicaid Director Letter, July 2, 2010, SMDL No. 10-013, ACA No. 4. Accessed at http://www.cms.gov/smdl/downloads/SMD10013.pdf.
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