The Affordable Care Act brought sweeping changes to the Medicaid program that have had profound implications for family planning coverage, services, and providers. In particular, in the 17 states with family planning programs that have expanded Medicaid, many women have moved from limited benefit family planning programs into full-scope Medicaid or Marketplace insurance and now have comprehensive coverage, although it is less focused on family planning services. In light of the coverage trends and other ACA-related changes, this paper describes the impact on women and their partners, as well as family planning providers, of the shifting landscape for family planning. It is based largely on interviews with state officials, providers and consumer advocates in Alabama, California, Connecticut, Illinois, Missouri and Virginia – a cross-section of states in terms of geography, Medicaid expansion status, and implementation of a Medicaid family planning program. State interviews were supplemented by interviews with national experts, policymakers and family planning provider organizations. This study was conducted in Summer 2016 before the Presidential election.
Nationwide, states that had Medicaid family planning programs prior to passage of the ACA have generally elected to maintain them, reflecting a belief that they still have an important role to play for low-income women. Maintaining a family planning program in a non-expansion state—where the program serves women who often otherwise do not qualify for Medicaid or may find Marketplace coverage unaffordable—is a relatively easy decision. In states with Medicaid expansion, however, the role of family planning programs is a more complex decision. In California, which has retained its family planning program, interviewees explained that the program serves a unique role in helping women secure high-quality, confidential family planning services. On the other hand, Illinois terminated its program one year after Medicaid expansion on the grounds that women would be able to secure family planning services through comprehensive Medicaid or a Marketplace plan. A number of interviewees supported the decision, but others expressed concern that it has resulted in diluted access to family planning services.
The ACA’s reforms to eligibility and enrollment procedures have changed how many women learn about and enroll in Medicaid, creating new opportunities and challenges. For example, the requirement that Medicaid and Marketplaces use a “single, streamlined application” helps applicants avoid submitting duplicative applications with multiple entities and facilitates enrollment into comprehensive coverage. However, the “single, streamlined application” is also much longer and more complicated than many states’ pre-ACA family planning applications, potentially discouraging people from applying for family planning coverage. Additionally, interviewees noted that HealthCare.gov is not yet able to assess eligibility for Medicaid family planning programs, creating a missed opportunity to connect women to family planning coverage. In particular, in non-expansion states such as Alabama that rely on HealthCare.gov to conduct final determinations of Medicaid eligibility, women who fall into the coverage gap are turned away by HealthCare.gov without any coverage even though they could be enrolled in a family planning program.
Despite strong federal protections, interviewees in some states raised concerns about affordability challenges in Marketplace plans for low income women in need of family planning services. Interviewees in several states expressed concerns about cost barriers for low-income enrollees in Marketplace plans. In particular, interviewees reported that low-income women cannot always afford Marketplace plans even with premium tax credits and suggested that for these women in particular it is important to retain Medicaid family planning programs.
Stakeholders across the board reported that full-scope Medicaid and family planning programs generally cover the full range of family planning benefits that women are likely to require. Additionally, interviewees in all states indicated that very minor differences exist between the benefits offered in family planning programs and full-scope Medicaid, despite the fact that states have fairly wide discretion within federal guidelines to develop their family planning benefit packages. On the other hand, states vary in their coverage of “family planning-related” services, which include, for example, treatment of a sexually transmitted disease or infection identified during a family planning visit. In many respects, states have not yet fully caught up with the evolving definition of what constitutes comprehensive family planning services, which, as described in a 2014 report released by the Centers for Disease Control and Prevention and the Office of Population Affairs, increasingly includes providing preconception health services to improve infant and maternal health outcomes, offering a full range of contraceptive methods and providing sexually transmitted disease screening and treatment services to prevent infertility and improve health.
Interviewees suggested that women had access to family planning services from a range of providers that participate in family planning programs, but also raised concerns about access to services in the context of Medicaid managed care. Most interviewees reported that beneficiaries are able to obtain services due to the well-established infrastructure of states’ family planning programs as well as the mission-oriented nature of many of the programs’ providers. In Medicaid expansion states, enrollees have been transitioning from limited benefit programs to full-scope Medicaid and, in most instances, enrolling in Medicaid managed care organizations (MCOs). In California, where three-quarters of Medicaid enrollees are in MCOs, interviewees expressed concern that women are being assigned to primary care providers they do not know or who are difficult to get to and that MCOs are imposing step therapy and other forms of utilization review inconsistent with state and federal policy. Interviewees across states also noted that Medicaid’s “freedom of choice” provision, which provides coverage for out-of-network family planning providers, is not well understood by enrollees, providers or MCOs.
There is a need for more consistent, reliable and comprehensive data on the Medicaid program’s role in family planning. Limited data has made it difficult for states to draw conclusions on a range of important issues, including service utilization by type, wait times, geographic proximity of providers to enrollees, appropriateness of care, ability to see the provider of an individual’s choosing, and the frequency with which people take advantage of the “freedom of choice” provision. There are notable exceptions however. California’s previous evaluation efforts through the University of California at San Francisco and Alabama’s annual waiver analysis reports have documented the role of the family planning programs in providing contraceptives and other services to low-income women and men. However, the lack of recent, uniform data makes it difficult to comprehensively assess how the ACA-related changes have affected access to and use of family planning services.
Family planning providers continue to face an uncertain future. Many family planning providers have long been accustomed to working in an environment dominated by fee-for-service Medicaid payments, Title X grant funding and self-pay patients, but the ACA has markedly increased the need to contract with Medicaid MCOs and Marketplace plans. Many family planning providers are seeking to re-position themselves as providers of a broader array of services, building stronger partnership and referral relationships with other providers, and increasing their capacity to contract directly with Medicaid MCOs and Marketplace plans. Others, however, are not interested in or able to adopt these types of changes, including those who work in rural markets that do not support service expansion or in urban markets where other primary care providers already provide a full array of services. These family planning providers tend to be more focused on maintaining core family planning services and increasing reimbursement and awareness of those services. Regardless of their approach to adapting to these circumstances, family planning providers see themselves as the frontline providers of care for many low income women and are increasingly making the case to payers and policymakers who want to prevent unintended pregnancies about the value they can offer, highlighting their deep experience and training to provide family planning services, including those that pose stumbling blocks for other primary care providers (e.g., contraceptive counseling, LARC insertion), the ability to offer same-day access to family planning services, and a unique understanding of what differentiates family planning services from other medical services.
Moreover, family planning providers sit at the center of state and federal political controversies around abortion services and face significant uncertainty about funding and sustainability. While federal law guarantees that Medicaid beneficiaries can see any qualified family provider they choose, there have been efforts at the state and federal levels to eliminate some providers from the program. This will be particularly important to monitor in the months ahead, as President Trump has voiced his intention to bar federal funds to Planned Parenthood, a major provider of family planning services for Medicaid beneficiaries.
Across interviewee states, family planning issues and providers are not at the table for broad Medicaid delivery system reform efforts. Most of the states interviewed for this analysis were engaged in or exploring Medicaid delivery system reform, but none had significant initiatives that include family planning issues and providers. As with most delivery system reform efforts, they were heavily focused on the most expensive enrollees and services, not the often younger and relatively healthy Medicaid beneficiaries who use family planning services. For many interviewees, the exclusion of family planning issues from delivery system reform is a missed opportunity given that family planning can be a major gateway into the healthcare system for low income and racially and ethnically diverse women of reproductive age. Family planning providers also note that they can help Medicaid programs avoid the delivery costs associated with unintended pregnancies. Finally, interviewees highlighted that the lack of family planning specific quality measures has been a hurdle for inclusion in delivery reform efforts, as current efforts strive to provide incentives to meet target quality measures.
Long-acting reversible contraception (LARC) continues to garner significant attention from states. Many of the states in this analysis are actively reviewing their Medicaid LARC policies to reduce access barriers, recognizing LARC’s high effectiveness rates and potential to reduce unintended pregnancies; however, states are also seeking to ensure women are presented with a range of contraceptive options and not unduly pressured to select a LARC. Interviewees highlighted existing barriers to accessing LARC, including: a shortage of providers trained to insert LARC methods; the high upfront cost of LARC devices for providers; and low Medicaid reimbursement rates for these procedures. A number of states are working to address these issues. For example, Illinois raised Medicaid reimbursement rates for insertions and removals of LARC devices in October 2014, and in July 2015, began allowing hospitals to receive a separate payment for LARC devices, making it more financially attractive for providers to insert LARC after delivery.
This study reviews the important role that Medicaid continues to play in delivery of family planning services to low-income women and how it has evolved since the passage of the ACA. Shifts in the coverage landscape, federal efforts to reduce spending on discretionary programs such as Title X, the focus on broad delivery system reform, and clinical and political trends have created an uncertain future for many family planning providers. States, enrollees, and providers have been adapting to these changes and continue to do so to ensure family planning services remain accessible to low-income women and men.
The Trump Administration has signaled its willingness to put more decisions about the program’s benefits, eligibility, and distribution of funds in the hands of state policymakers. As we see in this study, several states have used the 1115 waiver process to extend Medicaid coverage for family planning services to groups that have historically been ineligible for full scope Medicaid coverage. Alternatively, state and federal policymakers could structure an 1115 waiver to scale back the range of participating providers, covered services, or eligibility criteria.
This study shows that when states have choices in crafting family planning benefits under Medicaid, the results can vary widely. Moving forward, it will be important to continue to monitor the impact of Medicaid policy changes at the state and federal levels to assess the impact of policy decisions on access to family planning services for low-income women and men.