States extend Medicaid for birth control, cutting costs — and future enrollment

Mar 22 2018

The Lone Star State eliminated its Medicaid-funded family planning program five years ago when state officials said they wanted to specifically exclude Planned Parenthood because the group provides abortions. Dozens of women's health clinics closed as Texas established a wholly state-funded program that officials say today serves 220,000 women.

Medicaid's family planning program is optional for states and used by half of them to provide contraception services for low-income women who earn too much to qualify for traditional Medicaid.

Texas, Iowa and Missouri gave up that federal money to avoid supporting groups that offer abortion. Planned Parenthood says it does not use any government money for abortions.

Texas is the first state to appeal to a more conservative White House to restore the funds. The federal government has historically declined to provide Medicaid dollars to states that don't allow patients to choose between "any willing provider." Texas is asking for a change in that position.

As part of its “Medicaid Nation” series, Kaiser Health News is examining the far-reaching impact of Medicaid — which has expanded its services in the past decade — and how millions of American households routinely access health care through its programs.

The provision that covers only family planning is a tiny part of Medicaid, which now serves about 74 million Americans. But it is seen by advocates as a vital way to avoid unwanted pregnancies and for states to save money by reducing Medicaid-covered births and coverage for infants and children.

Nationally, about 2.8 million people were enrolled in the coverage last year, according to a Kaiser Health News survey of state Medicaid officials. California alone had 1.8 million people in the program.

"This is expanding Medicaid to cut Medicaid," said Elizabeth Momany, associate research scientist at the University of Iowa. "If you avert one childbirth, you save quite a bit," she said, noting that children on full Medicaid remain in the program for at least five years after birth, on average.

Medicaid began in 1965 as a way to provide for poor children, their mothers and people with disabilities. Maternal benefits are a key part of traditional Medicaid. It pays for half of all U.S. births and covers 45 percent of children under the age of 6.

The federal government encourages the benefit limited to family planning— which does not include physician visits or hospital care — by covering 90 percent of the cost. In contrast, Medicaid covers births and related costs at 50 to 74 percent, with states picking up the rest of the tab.

The cost savings help explain why the family planning program is popular among states. Even some of those most opposed to the expansion of Medicaid under the Affordable Care Act — including the entire Southeast — largely take part in the Medicaid family planning program. North Carolina, South Carolina, Alabama and Florida rank in the top five by enrollment, behind California, the Kaiser survey found.

“For two decades, states across the country, red, blue and purple, have expanded Medicaid eligibility for family planning services because doing so helps people to avoid unintended pregnancies and to plan and space wanted pregnancies," said Adam Sonfield, senior policy manager at the Guttmacher Institute, a reproductive health research organization that supports abortion rights. "In the process, that has also been proven to save the state and federal governments many millions of dollars.”

While eligibility and benefits vary by state, the family planning programs generally provide free coverage for a wide array of contraceptives, including birth control pills and long-acting implants. Some also provide checkups, assistance in kicking tobacco, cancer screenings and testing for sexually transmitted infections.

In family planning programs around the country, services are generally provided by Planned Parenthood clinics, county health departments, federally funded community health centers and private physician offices. Critics say prohibiting Planned Parenthood from family planning programs would hurt patients' access to services.

Eligibility in some states starts as early as age 12, while others automatically enroll women in the programs after their maternity benefit expires, typically 60 days after giving birth.

In California and some other states, both men and women are eligible, but women make up the vast majority of the enrollees.

North Carolina Medicaid officials estimate the program saves the state about $15 million a year, according to spokesman Cobey Culton.

Alabama has also seen savings. Kari White, a health policy professor at the University of Alabama at Birmingham, said the program covers about 120,000 women in the state with income levels below 141 percent of the federal poverty level, or about $17,000 for an individual.

An evaluation she conducted for the state last year found the birth rate for women enrolled in the program was one-third of what would have been estimated without the coverage.

"It helps to save Medicaid dollars overall to have these programs," White said.

Even the Trump administration, which is seeking to reduce the number of adults on Medicaid rolls, signaled its support of the family planning program in late December when it approved a 10-year extension of Mississippi's program.

California's program — called Family Pact (Planning, Access, Care and Treatment) — covers people with incomes up to 200 percent of the federal poverty level (about $24,000) who don't have other sources of family planning coverage.

"It provides a very essential public health benefit to all Californians who otherwise wouldn't get these services," said Claire Brindis, director of the Philip R. Lee Institute for Health Policy Studies at the University of California-San Francisco, who evaluated California's program.

A big reason California's enrollment is so much higher than other states, in addition to its much larger population, is that undocumented immigrants can also receive the services, although their care is paid for only with state funds.

Marta Mateo of Los Angeles is using the family planning program for a tubal ligation to prevent another pregnancy.

"I'm ready to have my tubes tied," she said in the lobby at Eisner Pediatric & Family Medical Center as the youngest of her four children slept in her arms. "I don't want any more babies."

Mateo said she's grateful for the coverage because her factory job doesn't offer it, and she can't afford to buy it on her own.

"I just don't have the money for that," she said. "This is a good opportunity for us to get care."

Nationwide, the number of women covered by the Medicaid family planning program dropped from 3.8 million in 2013 to last year's 2.8 million, as many people gained other coverage through the Affordable Care Act, according to the KHN survey and interviews with state officials. The enrollment decline was also due to several states discontinuing the program.

Three states that expanded Medicaid under the ACA dropped the program — Michigan, Illinois and Ohio. But the Medicaid expansion covers women up to 138 percent of the federal poverty level, which is an annual income of about $16,700 for an individual, while the family planning programs had an average eligibility level of 185 percent of federal poverty level, or $22,400.

KHN's coverage of women's health care issues is supported in part by The David and Lucile Packard Foundation.