Washington Watch: Future uncertain for state family planning waivers
By Cynthia Dailard
Senior Public Policy Associate
Alan Guttmacher Institute
Washington, DC
The Bush administration appears to be backpedaling from its decision in July 2001 to oppose expansions of state family planning programs under Medicaid. At that time, the Department of Health and Human Services (HHS) announced that it would no longer approve state applications for "1,115 waivers" to extend Medicaid coverage for family planning services to low-income individuals who would not otherwise meet a state’s Medicaid eligibility criteria.
To gain approval, the administration said, states would instead have to provide coverage of a broad package of primary care services — a requirement that many states claimed was prohibitively expensive and would stand in their way of providing family planning services to low-income women in need of care.
Since 1993, 14 states have received approval from the federal government for demonstration projects allowing them to expand Medicaid coverage of family planning services. The earliest of these waivers allowed states to provide family planning services to low-income women enrolled in Medicaid for up to five years following the birth of a child, rather than the traditional 60-day postpartum period. More recent waivers allow states to provide family planning services to any woman with an income up to 200% of the federal poverty level. States with waivers in place include Alabama, Arizona, Arkansas, California, Delaware, Florida, Maryland, Missouri, New Mexico, New York, Oregon, Rhode Island, South Carolina, and Washington.
According to data collected by the New York City-based Alan Guttmacher Institute, these family planning state expansions serve at least 1.3 million enrollees a year. Moreover, results from the earliest of these waivers show that in addition to being cost-effective, they successfully help low-income women to avoid unintended pregnancy and to properly space their births.
For example, California was able to avoid more than 100,000 unintended pregnancies between fiscal year 1998-99, resulting in a savings of more than half a billion dollars in public expenditures for medical care and social services (or $4.48 for every dollar invested). Additionally, in Rhode Island, the percent of Medicaid recipients with short interbirth intervals (who became pregnant within 18 months of having given birth) showed a significant drop.
Waivers challenged
Nonetheless, the administration in July announced that it would reject all pending applications for family planning waivers. In addition to Wisconsin’s waiver request, signed by HHS Secretary Tommy Thompson while he was governor, states with pending applications included Colorado, Georgia, Kentucky, New York, Mississippi, North Carolina, and Virginia. The administration also announced that existing waivers, which typically last five years, would not be renewed.
Reaction to this policy change was swift on Capitol Hill. Within only a few days, Sen. Lincoln Chafee (R-RI), Rep. Nita Lowey (D-NY) and 23 of their colleagues introduced "The State Family Planning Empowerment Act" that would allow states to implement family planning expansions without applying to the federal government for a waiver.
Given the powerful results beginning to emerge from these programs, Chafee and Lowey argued that these expansions should no longer be considered demonstration projects that require federal approval, but instead should be an option readily available to all states. In September, a bipartisan group of senators wrote to Sens. Tom Harkin (D-IA) and Arlen Specter (R-PA), the chairman and ranking member of a Senate appropriations subcommittee, urging them to include language in pending legislation to fund HHS to facilitate states’ ability to expand Medicaid coverage for family planning.
In response to this pressure, the administration appears to be easing its stance. While administration officials initially indicated that programs would have to include coverage of primary care services, it is now informing states that the primary care requirement can be met by including referrals for primary care. States will need to make formal arrangements with community health centers to provide primary care services and will need to submit a letter of support from community health centers with their waiver application. Additionally, enrollees in the family planning program must be given information on how to access primary care services from community health centers.
A number of states have responded favorably to this requirement, now that they will not have to bear the cost of providing primary care services. At least some states have begun the process of revising their waiver applications to accommodate this new referral requirement. However, as of mid-October, the Bush administration had not yet approved a single waiver application, leaving at least some family planning advocates skeptical about the future of these important initiatives.
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