New Pregnancy Assistance Fund Under Health Care Reform: An Analysis

Heather D. Boonstra, Guttmacher Institute
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In September, the Office of Adolescent Health within the Department of Health and Human Services (DHHS) announced the first round of grants to 17 states and tribes under a new Pregnancy Assistance Fund.The 10-year, $250 million competitive grant program is designed to help pregnant and parenting teens and women complete their education and gain access to health care, child care, family housing and other critical support. States may apply to use this money to create a network of support services for pregnant and parenting teens and college students.They may also direct grant money toward assistance for pregnant women who have experienced intimate partner violence, and for outreach and education campaigns to promote these resources.

The program emerged during final negotiations over the health care reform legislation enacted in March 2010. As partisans argued over provisions to prohibit insurance coverage of abortion when government funds are involved (see article, page 2), Sen. Bob Casey (D-PA) and the U.S. Conference of Catholic Bishops pressed for the fund's inclusion as part of the final legislation, characterizing it as a way to make it easier for vulnerable women to decide to carry their pregnancies to term. "For far too long, our focus on reducing the number of abortions has emphasized federal funding prohibitions," said Casey in a December 18, 2009, statement during Senate consideration of the health care reform bill. "But we must do more if we truly want to reduce the number of abortions in this country. The time has come for us to provide support and assistance to the most vulnerable of pregnant women. In the long run, supporting and empowering pregnant women is the best way to reduce the number of abortions." Although advocates on both sides of the abortion debate have since questioned whether it would in fact have any significant impact in reducing the U.S. abortion rate, the fund, combined with other pregnancy-related provisions in health care reform, could have an important beneficial impact in the lives of individual pregnant and parenting teens and women over the next decade.

The Pregnancy Assistance Fund

The Patient Protection and Affordable Care Act authorizes the Secretary of DHHS—in collaboration with the Secretary of Education, as appropriate—to establish a Pregnancy Assistance Fund and appropriates $25 million annually for FY 2010–2019 for the purpose of awarding competitive grants to states and Indian tribes for four specified sets of activities. First, states may apply to use this money to fund institutions of higher education to provide or facilitate access to a range of services—such as health care, family housing, child care and baby food—to students who are parents or who are pregnant and plan on parenting or placing the child for adoption. The institutions may also use the funds to provide referrals on request for prenatal care and delivery, infant and foster care, and adoption services. They are required to match every four dollars of federal money with one dollar of their own. Second, states may fund the same range of activities for teenagers by supporting high schools and community centers. No matching dollars are required for activities in these venues.

Third, the money may be used by states to combat violence against pregnant women, by making funding available to their attorneys general to assist in providing intervention and social services to women who are victims of intimate partner violence, sexual assault or stalking around the time of their pregnancy. Moreover, funds may be used to provide technical assistance and training on violence against pregnant women to government agencies and the courts; legal, health care and social service professionals; and nonprofit organizations, including faith-based organizations. Finally, states may use funds to increase public awareness and knowledge of the services available to pregnant and parenting teens and women under this program or similar resources already available in the community.

The guidelines make clear that the purpose of these funds is to assist pregnant teens and women who have already made the decision to carry their pregnancy to term.

Implementation Begins

In July, the Office of Adolescent Health issued guidelines in the form of a funding announcement on the Pregnancy Assistance Fund. States could propose to use grant funds to carry out any or all activities in the four areas listed in the statue. Interestingly, almost all of the grants awarded in September will be used at least in part to fund services for pregnant and parenting teens. By contrast, only a handful of projects include intimate partner violence services, and only a couple focus on supporting pregnant and parenting students at institutions of higher education.

Beyond laying out the four basic options allowed by law, the guidelines include several important requirements and recommendations that may have a significant impact on how effective the programs are on the ground. For example, the guidelines encourage states to focus on those with greatest need and prioritize underserved populations and geographic areas. They suggest creative ways of linking pregnant and parenting teens and women with support services, such as "linking with home visiting programs as a potential resource; educating eligible persons about and assisting them to enroll in Medicaid or [the Children's Health Insurance Program]; providing information about and referrals to health and social service providers in the community; or utilizing free mobile information services such as Text4baby, a service designed to promote maternal and child health."

The guidelines also require states to undertake evidence-based approaches and to describe in their applications how their approach will improve outcomes for pregnant teens and women and their children. Measures of program outcomes may include graduation rates, school retention and dropout rates, access to prenatal care, parenting skills, infant mortality rates, subsequent pregnancy rates and other maternal and child health outcomes. In addition, all activities under the grant must comply with Title IX of the Education Amendments of 1972. This means, for example, that schools may not exclude students from classes or extracurricular activities just because they are pregnant or parenting, and must excuse absences for medical reasons and allow students to make up missed work. Any alternative education programs for pregnant and parenting students must be voluntary.

Finally, the guidelines make clear that the purpose of these funds, in addition to supporting parenting teens and women, is to assist pregnant teens and women who have already made the decision to carry their pregnancy to term. In fact, the legislative proposal from which the Casey provision was taken—the Pregnant Women Support Act—included a number of provisions aimed at persuading pregnant women to forgo abortion and carry their pregnancies to term. One such provision would have made funds available to direct women to crisis pregnancy centers and other organizations that provide pregnancy options counseling from an antiabortion perspective; another would have supported the purchase of ultrasound equipment; and a third would have mandated abortion counseling requirements. These provisions were dropped from the final language included in health care reform. In this regard, it is also notable that the guidelines require all materials to be "medically accurate," defined as "verified or supported by the weight of research conducted in compliance with accepted scientific methods; and published in peer-reviewed journals, where applicable or comprising information that leading professional organizations and agencies with relevant expertise in the field recognize as accurate, objective, and complete." This definition of medically accuracy is consistent across DHHS's other state grant programs, such as the Personal Responsibility Education Program and the Title V abstinence education program.

Enter Abortion Politics

In July, when the White House issued the funding announcement, it tied the program to its "common ground" initiative. Much discussed but never formally unveiled, the initiative is often spoken of as a way to lower the decibel level on abortion, by bringing together partisans on both sides of the debate to work on abortion-related issues on which they can agree. "While this is a sensitive and often divisive issue," said President Obama on the anniversary of the Roe v. Wade decision, January 22, 2009, "no matter what our views, we are united in our determination to prevent unintended pregnancies, reduce the need for abortion, and support women and families in the choices they make."

The 'common ground' initiative is often spoken of as a way to lower the decibel level on abortion, by bringing together partisans on both sides of the debate to work on issues on which they can agree.

The common ground initiative, however, may be something of a misnomer in two respects. First, by the administration's design, the initiative is not focused on abortion or aimed at directly influencing women's decision whether to have an abortion. Rather, it encompasses a wide range of existing programs and proposed initiatives "around" abortion—such as tax credits for adoption, sex education for youth and improved family leave policies—that presumably could have an indirect effect on reducing abortion. Moreover, the efforts under the initiative are not necessarily ones that partisans on both sides would be expected to work on together—or even get behind.

As a case in point, the Pregnancy Assistance Fund should be a classic example of a common ground program. Certainly, for progressive prochoice advocates, whose concerns go far beyond abortion rights, there is nothing not to like about the fund, which promises to improve pregnant women's and new parents' access to a wide range of health and social supports. But it is a different story for at least some antiabortion advocates, who want the program to be used directly to persuade women not to have an abortion, primarily by supporting antiabortion crisis pregnancy centers. "We are encouraged that the government is finally setting aside a small amount of funds in the Pregnancy Assistance Fund to support those women who make the courageous and selfless choice to give life to their babies despite life's challenges," said Melinda Delahoyde, president of Care Net, a network of crisis pregnancy centers, in an article published by the Christian News Service. "Our hope is that the White House will be true to its word and use this money to reduce abortion by giving it to those organizations that truly help women choose life." The Family Research Council's criticism of the program was more direct: "How can [President Obama] find common ground on abortion if the Fund never mentions it?" Other activists, particularly in the antiabortion blogosphere, opposed the creation of the fund as a "social spending" program. Financial rewards, they say, incentivize the nation's teens to have children.

Supporting Women and Their Children

For all practical purposes, the Pregnancy Assistance Fund is a small pot of money that—by itself—may be expected to have only a limited effect. But the Patient Protection and Affordable Care Act also includes a host of far-reaching provisions aimed at improving maternal and child health (see article, Summer 2010, page 13). In addition to expanding insurance coverage generally—which should mean that more women will be able to plan their pregnancies by using contraceptives and to obtain early and sufficient prenatal care—health care reform designates maternal and newborn care as one of only 10 types of health care services explicitly required to be covered nationwide for all enrollees in all plans included in the forthcoming health insurance exchanges. The law also includes provisions related to pregnancy and parenting that go beyond the realm of insurance coverage to address broader public health and social outcomes, such as a new investment of $1.5 billion over five years in home-visiting programs. These new initiatives—combined with the existing Title V Maternal and Child Health Services Block Grant, the Title X family planning program, the Adolescent Family Life program and the new Pregnancy Assistance Fund—have given maternal and child health advocates new reason for optimism.

"When the health care reform legislation is implemented, for the first time every pregnant woman in America will know that whatever her financial circumstances, she and her child will be covered by a seamless network of health care and other support, from the time she becomes pregnant until her child reaches adulthood," said Casey in a guest editorial published in The Scranton Times Tribune. That may be a bit of an overstatement, but taken together, these various programs and initiatives have the potential to make a real difference in the lives of pregnant women and new parents who are struggling to make ends meet while also achieving their educational, vocational and other life goals.