Proposed bill would ease states’ waiver requirements for expansion of Medicaid f
Proposed bill would ease states’ waiver requirements for expansion of Medicaid family planning services
States with family planning waivers report healthy enrollments, good clinical outcomes
States would not need a waiver to expand Medicaid family planning services to women with incomes of up to 185% of the poverty level under a bill recently introduced into Congress.
The Family Planning State Flexibility Act of 1999 by Sen. John Chafee (R-RI) and Sen. Dianne Feinstein (D-CA) is spurred, in part, by good news from states that have implemented waivers to expand the length and income eligibility of their Medicaid family planning services. Healthy enrollment figures and improved outcomes are raising the question of whether the burden of the section 1115 waiver process can be justified instead of a simple programmatic option open to states.
"Increasingly, the waiver process is being seen as part of the problem, rather than part of the solution," says Rachel Benson Gold in the April 1999 issue of The Guttmacher Report on Public Policy.
Existing waivers take two general forms. The first extends family planning coverage for women receiving Medicaid maternity benefits; the second makes family planning available to women who would not otherwise be eligible for Medicaid at all.
"The challenge is to find the women," says Ms. Gold. She notes, however, that the states are armed with skills and expertise learned during a similar expansion of maternity coverage in the 1980s.
States in the mid-1980s were required to expand Medicaid maternity care to women with incomes of up to 133% of the federal poverty level and could, at their discretion, extend the income cap up to 185% of poverty.
"That was something states worked very hard on throughout the 1980s, and I think those lessons can be brought to bear in this situation as well," she says.
South Carolina in 1993 was one of the first states to take advantage of its ability to expand Medicaid family planning. Services under a waiver provision are available postpartum for 22 months, as opposed to the six-month period under conventional Medicaid. Two years ago, South Carolina expanded coverage to all women with incomes of up to 185% of poverty, regardless of whether the women had any previous Medicaid coverage.
Delivering the goods
Part of the incentive to expand Medicaid coverage undoubtedly is the generous 90/10 federal match for family planning services. State officials are quick to point out where the investment in expanded coverage has reaped financial and programmatic results.
Before Rhode Island expanded its family planning program in 1993, 20% of women with a Medicaid-funded delivery had become pregnant again within nine months. Some 42% delivered again during the 18-month interbirth window recommended to protect the health of the mother and child. Two years of expanded family planning coverage under RIte Care reduced the proportion of Medicaid deliveries within the 18-month interval to 31%, roughly comparable to the experience of women with private health coverage.
While Rhode Island officials report Medicaid cost savings associated with the longer interbirth interval, the administrator of the RIte Care program says such savings were not the goal of the initiative.
"Other states do Medicaid managed care to cut costs, and that clearly was not our goal. Our goal is to increase quality and to increase access to care," says RIte Care administrator Tricia Leddy.
Ms. Leddy credits a "totally restructured" delivery system with the success of the program. In order to get access to the state’s Medicaid business, about 80,000 people accounting for 9% of Rhode Island’s population, plans had to make available to Medicaid enrollees any provider serving commercial members. "Contract mainstreaming" expanded the Medicaid provider panel to include virtually all of the state’s 950 licensed physicians, up from 350 just five years before.
"We realized that just making family planning services more accessible and available to the population we were going to cover—pregnant women and existing eligibles—would not be enough," says Ms. Leddy.
The state had to implement a "not insignificant" increase in provider payments in order to make the requirement feasible, Ms. Leddy says, but the emphasis on primary and preventive care improved clinical outcomes. For example, annual emergency visits dropped from 750 to about 400-450 per thousand among the former Aid to Families with Dependent Children population.
Unlike the rest of the country, California in 1996 responded to welfare reform with a state-only family planning program for low-income women and men. As in Rhode Island, implementation focused on expanding the provider network.
The program, dubbed Family Planning, Access, Care and Treat ment (PACT), offers family planning services to California residents at or below 200% of poverty with no other source of coverage. State officials in April applied for a waiver from the Health Care Financing Admi nistra tion that would draw down the 90% federal match for Medicaid family planning services, but they plan no other major changes to the program.
"Now, we really want to show what it can do," says Jan Treat, RN, chief of the clinical services section for California’s family planning program.
As of April 1999, Family PACT had enrolled 2,400 providers and 1.4 million clients. The provider network, previously restricted to government or community-based clinics, grew from a modest 115 contractors. State officials credit the impressive client base with simple enrollment procedures that take just a few minutes, rely on patient-self report, and can be completed in a physician’s office. Eligi bility is certified annually.
Ms. Gold calls California’s initiatives "dramatic," and notes that the state has built on existing skills and that its successes can be replicated elsewhere.
"What we’re seeing from California is that this is doable," she says.
California officials say the program helped to lower the state’s teen-age birthrate by 8% between 1996 and 1997, to 56.7 per thousand. The drop is consistent with state and national trends, but program officials note that the 96-97 drop was three times the size of the national decline in teen-age births and was seen across all major ethnic groups. The governor has budgeted $135.9 million for the program in 1999-2000.
Contact Ms. Treat at (916) 657-0764 and Ms. Gold at (202) 296-4012. "State Efforts to Expand Medicaid-Funded Family Planning Show Promise" is found on the Internet at http://www.agi-usa.org/pubs/journals/gr020208.html.
States with Medicaid Waivers Extending Family Planning Coverage |
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| To women who lose Medicaid coverage | To women solely on the basis of income | |
| ... at the end of the postpartum period | ...for any reason | |
| Alabama (2 years)*
Arizona (2 years) Florida (22 months) Illinois (10 months) New York (22 months) Rhode Island (2 years) South Carolina (22 months) |
Delaware (2 years) | Arkansas (133%)
New Mexico (185%) Oregon (185%) South Carolina (185%) |
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*Mobile County only Source: Alan Guttmacher Institute, New York City. |
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