Moving Forward: Family Planning in the Era of Health Reform
Modern contraception has given women and couples the means to control whether and when to have children. Moreover, it has had important public health consequences for women and families, and has advanced women’s self-sufficiency and their educational, social and economic opportunities and outcomes. Nonetheless, many women and couples find it difficult to avoid pregnancies they do not want, and to successfully time and space wanted pregnancies.
■ About half of U.S. pregnancies—more than three million each year—are unintended. By age 45, more than half of all U.S. women will have had an unintended pregnancy.
■ Barriers to access are particularly salient for those disadvantaged by their age or income. More than 19 million U.S. women need publicly supported contraceptive services. Of those in need, 5.8 million—or 30%—are uninsured.
■ The unintended pregnancy rate for poor women is more than five times that for higher income women.
Publicly Funded Family Planning Today
Government programs—notably, the Title X national family planning program and the joint federal-state Medicaid insurance program—have worked together for decades to improve access to contraceptive and related care. Typically, Medicaid pays for core clinical care, while Title X and other grant programs buttress the system of family planning centers and fill gaps in services and coverage.
■ Title X supports a diverse, nationwide network of health centers that provide family planning services. Health centers can use Title X’s flexible funding to bolster infrastructure, serve clients who are uninsured or unable to use their coverage because of concerns about confidentiality and meet their clients’ particular needs.
■ The Title X program sets standards for the provision of publicly supported family planning services across the United States, ensuring that care is voluntary, confidential, affordable and effective. Title X–supported health centers generally provide higher quality contraceptive care than other providers, including methods provided on site, protocols to help women avoid gaps in use and in-depth counseling tailored to clients’ needs.
■ Over the past two decades, Medicaid has become the dominant source of public family planning spending. Medicaid’s increased role has been buoyed by expansions of Medicaid coverage specifically for family planning in many states since the mid-1990s.
The Impact of the U.S. Family Planning Effort
Research demonstrates the impact of the publicly funded family planning effort for women, families and society by expanding contraceptive use, preventing unintended pregnancies, and improving maternal and child health.
■ In 2010, 8.9 million clients received publicly funded contraceptive services—47% of women in need of publicly supported care. Family planning centers provided services to 6.7 million contraceptive clients; Title X– supported centers served seven in 10 of those clients.
■ Health centers are many women’s entry point into the health care system, and the package of sexual and reproductive health services provided is at least as comprehensive as during an annual exam by a private doctor. Thus, it is no surprise that six in 10 women who obtain care at a center consider it their usual source of medical care, and for four in 10, that center is their only source of care.
■ By providing millions of women with access to contraceptive services they want and need, publicly funded family planning in 2010 helped women to avoid 2.2 million unintended pregnancies. Without these services, the rates of unintended pregnancy, unplanned birth and abortion would be 66% higher than they currently are.
■ Every public dollar invested in helping women avoid pregnancies they did not want to have saves $5.68 in Medicaid expenditures that otherwise would have gone to pregnancy-related care; in 2010, that amounted to a net government savings of $10.5 billion.
Expanding Coverage in the Era of Health Reform
Expansions in public and private health insurance under the Affordable Care Act (ACA) mean that more women and men are gaining coverage for family planning and related reproductive health services. To thrive under health reform and best serve their clients, publicly supported health centers will need to become very good at working with and securing contracts from the health plans that dominate the public and private insurance markets.
■ The ACA expands Medicaid for women and men with family incomes below 138% of poverty, but the U.S. Supreme Court ruled that states cannot be compelled to opt into that expansion. States refusing to expand Medicaid are leaving millions of low-income residents in a "donut hole" with no access to affordable coverage.
■ For higher-income individuals, the ACA is expanding access to private insurance through new marketplaces and subsidies to make coverage affordable. The ACA requires all new private health plans to cover the full range of contraceptive methods, services and counseling without any out-of-pocket costs for the patient.
■ Medicaid family planning expansions continue to have a role to play and were made easier for states to initiate under the ACA. They can provide limited but vital coverage in states not yet participating in the full-benefit Medicaid expansion, and in all states, they can provide coverage for women experiencing lapses in full-benefit coverage, enrollment difficulties and concerns about confidentiality.
■ Despite the ACA’s coverage expansions, Title X and other flexible grant funding will be needed to provide services to those falling through the cracks of health reform; to pay for services not covered under Medicaid or private insurance, such as intensive counseling and outreach; and to support and improve health centers’ infrastructure.
Accessing Care in the Era of Health Reform
Availability of public or private coverage would mean little to the U.S. family planning effort without capacity in the health care system to meet the need for care.
■ The ACA relies on federally qualified health centers (FQHCs) to help address provider shortages. FQHCs have long been required to make contraceptive services available, either directly or by referral, and have become increasingly important as family planning providers, though that care varies considerably in scope and quality.
■ Reproductive health–focused providers serve about 70% of all contraceptive clients of health centers, and they have distinct advantages in the attention, skills and experience they can provide to clients.
■ Because they are the entry point to the health care system for many of their clients, reproductive health–focused providers will continue to play important roles in connecting clients to other types of care and to health insurance coverage for which they may be eligible.
The U.S. family planning effort has helped tens of millions of disadvantaged women and men to plan their families and protect their health. For this effort to meet the challenges of today’s evolving health care system, evertightening government budgets, and political attacks on funding sources and providers, stakeholders must find ways to secure the effort’s funding and its provider network.
■ To maximize the potential of Medicaid for the family planning effort, governors and legislators in all states should extend Medicaid coverage to their residents. Moreover, policymakers should ensure that all Medicaid recipients have coverage for the full range of family planning and related services, that Medicaid reimbursement rates are sufficient to cover providers’ costs and sustain the provider network, and that states can initiate and continue Medicaid family planning expansions with a minimum of red tape.
■ Congress should ensure that Title X providers have the funding necessary to maintain and expand the scope and quality of their care. Similarly, state policymakers should fund their own family planning grant programs based on the needs of their communities and avoid policies that disadvantage or disqualify reproductive health–focused providers from government funding.
■ Congress should eliminate eligibility restrictions on public and private insurance coverage for all lawfully present immigrants. The Obama administration should enable young adults recognized as lawfully present under the Deferred Action for Childhood Arrivals program to purchase coverage through the health insurance marketplaces and to receive subsidies to make this coverage affordable.
■ Title X program guidelines should serve as the basis for standards of family planning services provided by FQHCs. Reproductive health–focused providers should be prioritized for federal and state funding to help clients navigate the enrollment process and designated essential community providers for health plan networks. Providers themselves should explore opportunities to collaborate with other safety-net providers and to become part of health care models promoting coordinated patient care.