The Bush administration appears to have retreated from its hard-line opposition to state proposals to extend Medicaid eligibility for family planning to individuals whose incomes are low but who nonetheless are not eligible for full Medicaid coverage. The saga began in July, when the Department of Health and Human Services (DHHS) announced that it no longer would approve requests from the states for approval of programs that would expand eligibility exclusively for family planning services and supplies. Instead, these "waiver" programs would be required to include coverage of at least some other primary care services along with family planning, which many states said would make their expansion efforts prohibitively expensive ("Administration's New Medicaid Rules Could Limit Family Planning," TGR, August 2001 ).
Since 1993, 14 states have obtained approval to extend eligibility for family planning to populations that would otherwise not be eligible; data collected by The Alan Guttmacher Institute indicate that these programs serve at least 1.3 million enrollees a year. Several additional states—significantly including Wisconsin, whose application was submitted by then-governor and current DHHS Secretary Tommy G. Thompson—have waiver requests pending.
Reaction to the policy change was immediate. Within days, Sen. Lincoln Chafee (R-RI) and Rep. Nita M. Lowey (D-NY), along with 23 of their colleagues, introduced legislation to allow states to implement family planning expansions without first having to obtain a federal waiver. Shortly thereafter, a bipartisan group of senators wrote Sens. Tom Harkin (D-IA) and Arlen Specter (R-PA), the chairman and ranking minority member, respectively, of the subcommittee that handles DHHS appropriations, urging them to include in the annual funding bill language that would facilitate states' ability to expand Medicaid coverage for family planning.
While Congress so far has taken no formal action, the administration clearly is feeling the pressure. Although officials from the DHHS Centers for Medicare and Medicaid Services (CMS) initially had indicated that waiver programs would be required to include coverage of primary care services, CMS is now informing states that the primary care requirement can be met by including referrals for primary care. Specifically, states would need to establish formal arrangements with community health centers to provide primary care services to individuals enrolled in the family planning program. In addition, any materials or counseling provided to these enrollees would have to include information on how to access primary care services from community health centers.
States appear to have responded favorably to this requirement, with many saying that the cost of adding referrals would not be prohibitive. Moreover, the new linkages appear to be a comfortable fit; community health centers are charged with providing a range of primary and preventive health care to the uninsured, the same population that would be served under the family planning waivers, and are already obligated to have referral arrangements with a range of other health and social service providers (see related story). At least some states have indicated that they already are building these arrangements into their waiver applications; to date, however, no waiver has yet been approved under the new rules.