North Carolina

Family planning services are vital: Women who are not using contraceptives, or who are using them inconsistently, represent one-third of all women at risk of unintended pregnancy but account for 95% all unintended pregnancies.(1) Unintended pregnancy and inadequate pregnancy spacing, in turn, have been linked with numerous negative maternal and child health outcomes. In addition, women’s ability to rely on contraception enables them to invest in higher education and to be full participants in the nation’s workforce.(2)

Publicly funded family planning services in the United States helped serve more than nine million female contraceptive clients in 2006.(1) They helped women and couples avoid 1.94 million unintended pregnancies, which would have resulted in 860,000 unplanned births and 810,000 abortions. Without these services, unintended pregnancy and abortion in the United States would be nearly two-thirds higher. And by helping women avoid unintended pregnancies, the services provided by publicly supported family planning centers saved taxpayers $5.1 billion in 2008, amounting to nearly $4 saved for every $1 spent providing contraceptive care.(3)

Medicaid is central to the U.S. family planning effort. In 2010, 15% of women of reproductive age (15–44) relied on Medicaid, as did 38% of poor women in that age-group.(4) Federal law since the early 1970s has required that family planning services and supplies be covered for all program enrollees and that those services be exempt from any type of patient cost-sharing, such as copayments. The federal government reimburses the states for 90% of Medicaid family planning expenditures, a considerably higher rate than for most other services (50–75%, depending on the state). In addition, more than half of states have expanded Medicaid eligibility specifically for family planning services to women and men who do not qualify for the broader Medicaid program.(5) Altogether, although family planning constitutes only about one-half of 1% of all Medicaid expenditures, it is the financial cornerstone of the publicly funded family planning effort: Medicaid spent nearly $1.8 billion on family planning services in FY 2010, amounting to 75% of all public family planning spending.(6)

• In 2008, 524,000 women in North Carolina were in need of publicly supported contraceptive services and supplies.(3) (These are women who are sexually active; are aged 13–44; are able to become pregnant but are not pregnant, postpartum nor trying to become pregnant; and either have a family income below 250% of the federal poverty level or are younger than age 20.)

• In 2006, 106,000 North Carolina residents had an unintended pregnancy, for a rate of 58 per 1,000 women aged 15–44.(7) Births resulting from these unintended pregnancies cost the state and federal governments $580 million that year.(8)

• In 2007, 30,220 North Carolina residents obtained abortions, for a rate of 16.1 per 1,000 women aged 15–44, compared with 19.4 per 1,000 nationally.(9)

• In 2005, there were 21,720 pregnancies among North Carolina teens aged 15–19, for a rate of 76 pregnancies per 1,000 teen women, compared with 70 per 1,000 nationally.(10)

• In 2009, there were 14,093 births among North Carolina teens aged 15–19, for a rate of 44.9 births per 1,000 teen women, compared with 39 per 1,000 nationally.(11,12)

• In 2008, contraceptive services provided at publicly funded centers in North Carolina helped women avoid 34,000 unintended pregnancies, which would have resulted in 15,100 births and 14,200 abortions.(3)

• In the absence of these services, the number of unintended pregnancies in North Carolina would be 34% higher, and the number of abortions would be 47% higher.(13)

• In 2006, contraceptive services provided at publicly funded centers in North Carolina helped 8,508 women younger than age 20 avoid an unintended pregnancy.(14)

• In the absence of these services, the number of teen pregnancies in North Carolina would be 39% higher.(13)

• By helping women avoid unintended pregnancies and the births that would follow, the services provided at publicly supported centers in North Carolina saved $133 million in public funds in 2008.(3)

• In 2009–2010, 271,900 women of reproductive age were enrolled in Medicaid, accounting for 14% of women in that age-group.(4)

• Medicaid provides critical support to the network of 181 family planning centers that serve 163,700 women in North Carolina.(3,15)

• The federal government and North Carolina together spent $32.5 million on family planning services for women enrolled in the state’s Medicaid program in FY 2010. That amounts to 41% of all public funding for family planning in North Carolina.(6)

• Medicaid’s role is slated to expand in the near future, as a result of the federal health reform legislation enacted in 2010. After expansion, 59% of currently uninsured women aged 18–64, amounting to roughly 387,000 women, are projected to be eligible for Medicaid in 2014, when all states will be required to cover individuals up to 133% of poverty.(16)

Since the mid-1990s, 24 states have initiated broad income-based expansion programs providing family planning services under Medicaid to women (and, in some states, men) with incomes well above the cut-off for Medicaid eligibility overall and regardless of whether they meet other requirements for Medicaid coverage, such as being a low-income parent.(5) States have usually sought to match the eligibility level they have set for pregnant women under Medicaid, typically 185% or 200% of the federal poverty level. Five additional states have implemented more limited expansions for individuals losing full-benefit Medicaid coverage (most often after giving birth).

Initially, states seeking to initiate this type of expansion were required to receive federal approval under a long and complicated process known as a “waiver.” Because evaluations over nearly two decades showed these temporary demonstration programs have clear health benefits and generate significant government cost-savings, Congress included a groundbreaking provision in the Patient Protection and Affordable Care Act of 2010 designed to facilitate states’ adoption of an expansion program.(17) Under that new authority, known as a State Plan Amendment, a state may set the eligibility level for family planning up to the highest level for pregnant women in place under Medicaid or the Children’s Health Insurance Program; the state may not exclude individuals based on age or gender. The provision also greatly simplifies the process for a state seeking to implement an expansion program and allows the program to be permanent (rather than having to be renewed periodically, as is the case for waivers).

States’ long experience in implementing these programs has made it clear that, to maximize its impact, a program must make serious efforts to ensure that potential clients learn about the program.(17) To reach out to new clients, state agencies have established program Web sites and telephone hotlines, linked up with other health and social services programs, and used tailored messages and tactics to reach young adults, Latinas and other groups in need.

States have also taken a number of steps to streamline enrollment.(17) For example, they have used tactics such as simplifying application forms, offering online applications, using databases to verify citizenship status and income, automatically enrolling certain groups of potential clients, and facilitating applications and enrollment at the point of service.

Collectively, the income-based Medicaid expansion programs spent $626 million on family planning services in FY 2010.(6) The limited expansion programs spent $3.7 million that year. Together, spending under the expansions constitutes 36% of total Medicaid family planning expenditures in the United States. These programs serve about 2.7 million clients over the course of a year.(17)

According to state and federal evaluations and independent studies, the programs have expanded the network of family planning providers and increased their capacity to meet the need for services.(17) The services provided have helped reduce levels of unprotected sex, increase use of more-effective contraceptive methods and improve continuity of contraceptive use. They have also expanded access to related preventive care, such as screening for STIs and cervical cancer. Improved contraceptive use has translated into measurable declines in unintended and teen pregnancy, and improvements in women’s ability to space their pregnancies. In the process, the expansions have substantially reduced federal and state Medicaid expenditures on unplanned pregnancy.

• North Carolina currently has a Medicaid family planning waiver program that serves individuals with income up to 185% of the federal poverty level.(5) The expansion excludes individuals younger than 19 and includes men.

• In 2010, the most recent program year for which data are available, this expansion program served 29,900 individuals.(17)

• In FY 2010, the federal government and North Carolina together spent $7.9 million on family planning client services under the state’s Medicaid family planning expansion. That amounts to 24% of the state’s total Medicaid family planning expenditures.(6)

• The Medicaid family planning expansion program in North Carolina makes use of the following techniques for streamlining enrollment:(17)

	The program uses simplified application forms—typically one or two pages—that can be filled out quickly and require less information than standard Medicaid applications.
	The program allows applicants to start or complete the process remotely, by mail, fax or telephone or on the Internet, and without requiring an in-person interview.
	The state uses simultaneous application or screening for the family planning expansion and for other public programs, such as other types of health care coverage.
	The state uses state, federal or private databases to verify applicants’ information related to citizenship.
	The state uses state, federal or private databases to verify applicants’ information related to income.
	The state helps clients meet citizenship documentation requirements by obtaining birth certificates for applicants born out of state.
	The program has eliminated the application process entirely for certain groups of individuals losing full Medicaid coverage, by automatically enrolling them in the family planning expansion program.
	The program allows family planning providers to verify at the point of service documents for applications submitted by mail, phone or the Internet.
	The program allows clients to complete and submit an application at the point of service.
	The program reimburses family planning providers for assisting clients in the application process.

• Evaluations of the Medicaid family planning expansion in North Carolina have shown that the program has had an impact:(17)

• According to 2011 projections from the Guttmacher Institute, if North Carolina switched to implementing its expansion program as a State Plan Amendment and maximized its eligibility criteria, the benefits could be considerable.(18) In addition to what its current expansion program achieves today, the state could:

• provide family planning services to 7,100 individuals;
• help women and couples avoid 1,010 unintended pregnancies per year, which would otherwise result in 340 abortions and 530 births; and
• achieve net savings of $5.0 million annually, including $2.3 million in state dollars.