Purpose
This article identifies the ways in which Medicaid eligibility expansions for family planning services and the Title X network of family planning clinics provide opportunities to introduce preconception care. The introduction of family planning eligibility expansions brought in populations heretofore ineligible for Medicaid. Family planning clinics serve a large number of low-income and young women and would play an important part in introducing preconception care. However, very real barriers to preconception service provision need to be addressed before this goal can be fully realized.
Background
When established in 1965, Medicaid, by and large, covered low-income women and their children receiving welfare. A succession of Medicaid eligibility expansions for pregnancy-related care broke the link with welfare. More recently, expansions implemented in 20 states have created an eligibility pathway to Medicaid coverage for women before pregnancy. Today, whether as part of a Medicaid family planning program or independently, many women receive family planning services through the nation's system of publicly funded clinics. As the nation's only dedicated source of funding for family planning services, Title X supports a nationwide network of family planning clinics on which young women rely for affordable and confidential reproductive care.
Discussion
Working preconception care into the existing family planning and pregnancy care programs would create a single, continuous reproductive health care platform. Family planning clinics could introduce preconception health measures to the young women who rely on them for their reproductive health care. Important barriers to rolling out preconception care still exist, however. For family planning providers to integrate the services into their current practices, a definition of the package of services that is realistic to provide in a family planning setting must be crafted. In addition, securing a stable funding stream is a necessary prerequisite to any large-scale integration of preconception care into family planning settings. Finally, attention needs to be given to ways to talk to predominantly young clientele about preparing for a pregnancy at the moment when they are coming in for services precisely to avoid becoming pregnant.
Conclusion
Despite the challenges laid out, integrating preconception care into family planning services is achievable. Combining preconception care with family planning and pregnancy care initiatives would be a significant step in moving the country closer to the goal of providing the comprehensive reproductive health care women need.
Introduction
Eligibility expansions for family planning services and supplies that have been implemented under Medicaid by 20 states have created an eligibility pathway to coverage under the program for women before childbirth. This innovation makes the provision of preconception care under this massive health program—one on which nearly 4 in 20 low-income women of reproductive age rely for their care (
Gold et al., 2007
)—a possibility in a meaningful way for the first time. These programs also place family planning clinics, critical providers of sexual and reproductive health services, to center stage in the move to provide preconception care to young and low-income women. At the same time, however, these efforts raise important issues related to the package of services, the need for a stable funding stream to support the care, and protocols for providing it in a family planning setting.Gold, R.B., Richards, C., Ranji, U., & Salganicoff, A. (2007). Issue brief: Medicaid's role in family planning. Menlo Park, CA: Kaiser Family Foundation. Available: http://www.kff.org/womenshealth/upload/7064_03.pdf. Accessed June 2, 2008.
An Eligibility Pathway to Coverage Under Medicaid
When Medicaid was first established, women covered under the program generally were single mothers in families eligible for welfare. Because of Medicaid's link to welfare, a program that generally only covered families, low-income women without children would not normally be covered. In 1984, only 14% of women with an income <150% of poverty who did not have a child were covered under the program (
The Alan Guttmacher Institute, 1987a
).In the 1980s, Congress broke the welfare–Medicaid link for low-income pregnant women by first allowing—and later requiring—states to extend eligibility for Medicaid-covered prenatal, delivery, and postpartum care (specifically including postpartum family planning services) for up to 60 days postpartum. Congress required states to cover women with incomes ≤133% of the federal poverty level—far above most states’ regular Medicaid eligibility ceilings. At their option, states could expand eligibility for pregnancy-related services to women with incomes ≤185% of poverty or beyond (
Gold et al., 1993
).This expansion was critical to bringing women onto the program for a package of pregnancy-related services. The proportion of births paid for by Medicaid rose from 17% of all births in 1985 (
The Alan Guttmacher Institute, 1987b
) to >40% today (Kaiser Family Foundation, 2002
). However, it did little to extend coverage to women before a first pregnancy, a necessary prerequisite to providing preconception care.Kaiser Family Foundation. (2002). Births financed by Medicaid as a percent of total births, 2002. Available: http://www.statehealthfacts.org/comparemaptable.jsp?ind=223&cat=4. Accessed June 2, 2008.
The first steps in that direction came in the early 1990s, when states began seeking approval from the Centers for Medicare and Medicaid Services, the federal agency that administers the Medicaid program, for research and demonstration waivers to expand eligibility under the program for family planning services and supplies. These waiver programs take 3 approaches (Table 1). The first built directly on the expansions for pregnancy-related care, which allow states to provide Medicaid-funded family planning, as part of postpartum care, for 60 days after a woman gives birth. Four states currently have federal approval to continue coverage for family planning services, generally for 2 years postpartum. The second route, utilized by Delaware and Florida, is a variation on this approach. These states continue Medicaid family planning coverage for individuals who leave the Medicaid program for any reason.
Table 1State Medicaid Family Planning Eligibility Expansions
| State | Losing Coverage Postpartum | Losing Coverage for Any Reason | Based Solely on Income |
|---|---|---|---|
| Alabama | 133% | ||
| Arizona | 2 years | ||
| Arkansas | 200% | ||
| California | 200% | ||
| Delaware | 2 years | ||
| Florida | 2 years | ||
| Illinois | ∗ | 200% | |
| Iowa | ∗ | 200% | |
| Louisiana | 200% | ||
| Maryland | 5 years | ||
| Michigan | 185% | ||
| Minnesota | 200% | ||
| Mississippi | 185% | ||
| Missouri | 1 year | ||
| New Mexico | 185% | ||
| New York | ∗ | 200% | |
| North Carolina | 185% | ||
| Oklahoma | 185% | ||
| Oregon | 185% | ||
| Pennsylvania | 185% | ||
| Rhode Island | 2 years | ||
| South Carolina | 185% | ||
| Texas | 185% | ||
| Virginia | ∗ | 133% | |
| Washington | 200% | ||
| Wisconsin | 200% | ||
| Total | 4 | 2 | 20 |
∗State also extends Medicaid eligibility for family planning services to these individuals.
From the Guttmacher Institute. (2008). State Medicaid Family Planning Eligibility Expansions, State Policies in Brief. Available: http://www.guttmacher.org/statecenter/spibs/spib_SMFPE.pdf. Accessed September 20, 2008.
The third and boldest approach taken by states is to extend Medicaid family planning coverage based on income rather than on previous participation in the program. Twenty states have instituted these broad-based expansions, with most extending coverage to individuals with an income at or near 200% of the poverty level. In nearly all these states, the income ceiling used to determine eligibility for family planning is the same ceiling used to determine eligibility for Medicaid-covered pregnancy-related care in the state (
Kaiser Family Foundation, 2008
). By extending coverage to residents with no previous association with the program at all, these efforts have extended Medicaid coverage to large numbers of women before they become pregnant.Kaiser Family Foundation. (2008). Income eligibility levels for pregnant women under Medicaid, 2008. Available: http://www.statehealthfacts.org/comparetable.jsp?ind=206&cat=4. Accessed June 2, 2008.
Significantly, these programs are not a permanent part of the states’ efforts. Obtaining a waiver is a difficult and cumbersome process that can take a state upwards of 2 years. And even then, as research and demonstration waivers, they are approved by Centers for Medicare and Medicaid Services for an initial 5-year period and then renewed only in 3-year increments. Nonetheless, 60% of women of reproductive age live in 1 of the 20 states that have extended Medicaid coverage, at least for family planning, to women before pregnancy (
The Alan Guttmacher Institute, 2008
). By forging an eligibility pathway for these women, these efforts essentially make coverage of preconception care under Medicaid possible in a meaningful way for the first time.Title X: A Platform for Care
Although the state Medicaid expansions have the potential to give at least some women a pathway to coverage, that eligibility would be little more than a hollow promise without a network of providers able to deliver the care and services women need. For a significant proportion of young women seeking sexual and reproductive health services, family planning clinics serve as that critical network of providers. Of the teenagers who received a sexual or reproductive health care service in 2002, 41% did so at a family planning clinic, as did 28% of women in their early 20s and 21% of women in their late 20s (unpublished data, The Guttmacher Institute, April 18, 2008). In 2001, 7,600 publicly funded family planning clinics provided contraceptive services to 6.7 million women in the United States. Family planning clinics are located in 85% of counties nationwide (
Frost et al., 2004
).In many ways, Title X, the sole federal program devoted to the provision of family planning services to young and low-income women, undergirds this entire system. The program, which is administered by the US Department of Health and Human Services, awards grants to public and nonprofit private agencies who may be state or local health departments as well as nongovernmental organizations, such as community health centers, Planned Parenthood affiliates, or regional family planning councils. Each state has ≥1 grantee. Grantees can either provide services directly or do so through intermediate, delegate agencies. Of 87 current grantees, 48 are state or local are health departments; in 33 states and territories, the only Title X grantee in the jurisdiction is a health department (
Office of Population Affairs, 2008
).Office of Population Affairs. (2008). Title X-funded family planning grantees, delegates, and clinics. Available: http://www.hhs.gov/opa/familyplanning/grantees/services/index.html. Accessed June 2, 2008.
The nearly 4,500 providers that receive some Title X funding serve approximately 5 million clients each year (
Fowler et al., 2008
). In addition to funding the provision of direct medical services, Title X supports the clinic infrastructure, contributes to the extensive counseling needed by some clients and provides so-called enabling services such as the as outreach, education, and training.Almost 60% of women served at clinics receiving Title X funds are <25 years old (
Fowler et al., 2008
). Basic hallmarks of the Title X effort make clinics funded under the program accessible to young women (The Guttmacher Institute, 2000
). Title X-funded clinics offer a broad range of US Food and Drug Administration-approved contraceptive methods. All clients, including teenagers, receiving care in a clinic funded through the program are entitled to confidential services. As a way to ensure confidentiality, teens are charged based on their own incomes, not their family's income.Clients may not be denied care because of an inability to pay. Services are provided free of charge to poor clients. Other clients are assessed a fee based on their ability to pay, with clients with an income >250% of the federal poverty level ($17,600 for a family of 3 in 2008) required to pay the full fee (
US Department of Health and Human Services, 2008
).US Department of Health and Human Services. (2008). Poverty guidelines. Federal Register [serial online], 73(15). Available: http://aspe.hhs.gov/poverty/08poverty.shtml. Accessed January 23, 2008.
Opportunities and Issues
Together, the Medicaid eligibility expansions and the family planning clinic network pose a rare opportunity to develop the same sort of synergy between Title X-funded providers and Medicaid as is emerging to expand access to family planning services (
Gold, 2007
). The Medicaid expansions offer the eligibility pathway and the family planning clinic network provides a constellation of providers with a proven ability to deliver sexual and reproductive health services to women before pregnancy. Nonetheless, critical challenges remain, including developing a precise definition of the package of care that can be provided in a family planning clinic, securing an adequate funding stream, and developing ways to provide the service as part of a family planning visit.Defining the service set
The first step in establishing a health care home for preconception care is defining the package of services to be offered. Some large, influential associations such as the American Academy of Nurse Practitioners, have not adopted specific guidelines for preconception care, whereas others have identified only general guidance. However, some organizations offer detailed guidelines that often include services usually associated with primary health care. The most detailed plans, such as those adopted by the American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention, stress the inclusion of nutritional supplementation, vaccinations, management of chronic health conditions, patient history reviews, genetic screening, identification and treatment of physical and mental health risk behaviors, and family planning counseling (
Centers for Disease Control and Prevention, 2006
, Centers for Disease Control and Prevention. (2006). At a glance: Preconception health and care, 2006. Available: http://www.cdc.gov/ncbddd/preconception/documents/At-a-glance-4-11-06.pdf, Accessed June 2, 2008.
Freda et al., 2006
).Providing such a wide array of services is likely not a realistic expectation for most family planning clinics. Although family planning clinics typically offer a wide range of contraceptive services and counseling, they offer fewer noncontraceptive services, such as primary health and gynecologic care. In 1999, only half of all family planning agencies and 38% of Title X funded agencies provided primary health care services to their clients (
Finer et al., 2002
).With family planning clinics unlikely to reconfigure their efforts to provide the full range of primary care, it is necessary to narrow the package of services considerably to a subset of particular relevance and importance to the clinics’ client base. Toward this end, officials in Illinois identified common risk factors associated with poor pregnancy outcomes in their state. Officials used this information to craft a smoking cessation program and a perinatal depression initiative to address 2 risk factors strongly associated with poor pregnancy outcomes (
Saunders, 2007
).Even this narrower package of care will nonetheless likely include services that are new and largely unfamiliar to clinics, creating a critical need for extensive training for both the clinical and administrative staff to avoid the oft-noted historic reticence of providers to discuss preconception care because of their own lack of knowledge (
Curtis et al., 2006
). Providers will likely need to attain a rudimentary knowledge of chronic disease case management, mental health care, and nutritional counseling, among other issues. Moreover, clinics would need to develop and maintain extensive referral networks for services, such as smoking cessation programs, weight management classes, and treatment of chronic conditions that remain outside their ability to provide.Securing adequate funding
Successful integration of preconception care into family planning clinics will depend, in no small measure, on the availability of a secure funding stream. Medicaid would be an ideal centerpiece of this effort. As a first step, each state Medicaid program would need, either individually or as a result of action on the federal level, to ensure that the full range of preconception services is covered for its enrollees.
But, to fully realize the program's promise as a funding source, each state program would need to replicate and build on what some state programs have done for family planning: to base eligibility solely on income and to establish a single comprehensive eligibility pathway for family planning, preconception care as well as prenatal, delivery, and postpartum care. Such a comprehensive eligibility category and package of services is a critical first step in ensuring low-income women the reproductive health care they need.
Nonetheless, recent changes to Medicaid preclude coverage under the program for many most in need, including recent and undocumented immigrants (
Sonfield, 2007
). These policy changes are already putting an increasing burden on family planning clinics funded through the Title X program that are prohibited from denying care because of an inability to pay. Increasingly, clinics are forced to turn to capped sources of revenue such as Title X or state funds to pay for what seems to be a growing number of clients ineligible for Medicaid because of these restrictions.But even for those clients who would qualify for reimbursement, Medicaid does not fully reimburse providers for the cost of care. A small-scale study of Title X grantees in 2004 found that Medicaid reimbursed family planning providers, on average, for 54% of the cost of an initial visit (
Sonfield, Gold, Frost, & Alrich 2006
). Of the 19 respondents, 7 indicated that the amount they received as reimbursement from Medicaid covered <40% of the cost of providing the care.Moreover, although some states adjust their Medicaid reimbursement levels for family planning periodically, some do so only intermittently. In fact, roughly half of the states with income-based family planning waivers adjust their Medicaid rates on an ad hoc basis, depending on state finances and politics, a practice that can result in years-long stretches where rates are left untouched, not even adjusted to keep up with inflation (
Sonfield, Alrich, & Gold, 2008
). As a result, family planning clinics often look to programs such as Title X to fill this gap as well.Already struggling to fill these gaps to provide access to family planning services to women in need, Title X would be hard pressed to cover the costs of providing preconception care for women either ineligible for Medicaid or whose care is not fully reimbursed under the program. Although the cost of providing reproductive health care rose dramatically over the past 25 years, Title X funding has stagnated. For Title X clinics, the cost per user of providing contraceptive services rose >50% between 1995 and 2001 alone, but funding has not kept pace (
Gold, 2002
). When taking inflation into account, Title X funding for fiscal year 2007 was 63% lower than it was in fiscal year 1980 (unpublished data, The Guttmacher Institute, February 5, 2008). Although Congress took the extraordinary step of increasing appropriations under the program by nearly $20 million for 2008, increases of such magnitude would need to continue annually for decades to fully fund the effort. An expansion to include preconception care would require additional, and significant, funding increases.Providing the service in a family planning setting
Pregnancies occurring among young women often pose the highest risk of complications (
Fraser et al., 1995
). That fact makes the delivery of preconception care in family planning settings at once critical and extremely difficult. To realize clinics’ potential, significant effort needs to be invested in developing ways to talk to a predominantly young clientele about why and how to prepare for a pregnancy in the future when they are coming in for services precisely to avoid becoming pregnant. Developing methodologies to deliver this set of services to this population, at this specific moment and in this setting, is critical to realizing the enormous opportunities that exist.Despite these myriad challenges, there are reasons to be optimistic. The Medicaid eligibility expansions for family planning developed an eligibility pathway to coverage for a large number of women before their first childbirth. The nationwide network of family planning clinics has proven its ability to reach out to these women and to provide them with a critical set of reproductive health services.
Nonetheless, fully integrating preconception care into this provider network raises important questions. Health care providers have yet to settle on a universal framework for preconception care or identify a funding stream capable of covering the potentially considerable costs. And finding ways to talk to clients about preparing for a pregnancy at some point when they are seeking, first and foremost, to prevent a pregnancy in their lives at the moment, is a critical but undeniably difficult task. In short, although these new opportunities to reach young, childless women with preconception care raise important logistical questions, they clearly signal that health care providers are moving in the right direction.
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Biography
Rachel Benson Gold is Director of Policy Analysis with the Guttmacher Institute. She serves on the Board of Directors of the National Family Planning and Reproductive Health Association and is a Lecturer in Health Policy at the George Washington University School of Public Health and Health Services. Ms. Gold earned a Master of Public Affairs from the Woodrow Wilson School of Public and International Affairs of Princeton University and a Bachelor of Arts from Wesleyan University.
Casey Alrich was Senior Public Policy Assistant with the Guttmacher Institute from 2004 to 2008. He received a Masters of Public Health from the George Washington University and a Bachelor of Arts from Carlton College.
Article info
Publication history
Accepted:
August 18,
2008
Received in revised form:
August 18,
2008
Received:
April 28,
2008
Footnotes
The authors have no direct financial interests that might pose a conflict of interest in connection with the submitted manuscript.
Identification
Copyright
© 2008 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.
