The Affordable Care Act (ACA) represents a watershed for women's health policy in the United States. Among its many advances, the ACA establishes coverage of women's preventive health services without cost-sharing as a near-universal standard for public and private health insurance. All contraceptive methods approved by the U.S. Food and Drug Administration are part of this coverage standard, which is also integrated into Medicaid (
HRSA, 2011
; 42 U.S.C. §300gg-13; 42 CFR §147.130; 42 U.S.C. §1396). But the struggle continues in the ongoing effort to turn promise into reality, and unfortunately, poor women have been a main casualty during 5 long years of crushing implementation battles.U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA). (2011). Women's preventive services guidelines. Available: www.hrsa.gov/womensguidelines/. Accessed August 31, 2015.
The most prominent battle, perhaps, has focused on the ACA's Medicaid expansion. The poorest residents of 20 states, including close to 1.9 million women of childbearing age, remain without the law's promised reforms, because their state refuses to participate in Medicaid, an option made possible by the United States Supreme Court's decision in 2012 in National Federation of Independent Businesses v. Sebelius (
Salganicoff et al., 2015
). 1
The 1.9 million estimate reflects 22 non-Medicaid expansion states. Adoption of the expansion by Montana and Alaska means that the 1.9 million figure has decreased slightly, although given the sparseness of the population in these two states, we assume the figure remains close to the 1.9 million mark.
1The 1.9 million estimate reflects 22 non-Medicaid expansion states. Adoption of the expansion by Montana and Alaska means that the 1.9 million figure has decreased slightly, although given the sparseness of the population in these two states, we assume the figure remains close to the 1.9 million mark.
Although Alaska and Montana have recently moved to expand Medicaid, bringing total participation to 30 states and the District of Columbia, the states that continue to hold out probably will not elect to participate any time soon.The struggle extends beyond Medicaid. Had the United States Supreme Court not turned back a lethal challenge to the ACA's insurance expansions in
King v. Burwell, 2015
, millions more Americans would have lost access to affordable insurance both now and in the future. A new judicial threat on the horizon is House of Representatives v. Burwell. Although still in its earliest stages, House of Representatives v. Burwell could do enormous damage to people insured through the health insurance Marketplace by depriving eligible silver-level plan members of access to cost-sharing assistance they need to be able to afford non-preventive, covered services.The fight also continues over implementation of contraceptive benefits. Despite being exempt from the contraceptive coverage requirement where their own health plans are concerned, dozens of employers—religious and otherwise—continue (to date, unsuccessfully) to try to prevent the government from ensuring that their employees and families actually have access to services to which they are legally entitled (
Sobel and Salganicoff, 2015
).Sobel, L., & Salganicoff, A. (2015). Round two on the legal challenges to contraceptive coverage: Are nonprofits “substantially burdened” by the “accommodation”? Available: http://kff.org/womens-health-policy/issue-brief/round-2-on-the-legal-challenges-to-contraceptive-coverage-are-nonprofits-substantially-burdened-by-the-accommodation. Accessed August 31, 2015.
Yet despite these bumps in the road, the nation seems to be on a path to universal coverage, with its strong protections for women's health.
However, for poor women who live in medically underserved communities, achieving health equity does not entail insurance reform alone. Complementary interventions are needed to ensure the physical accessibility of care itself in the case of the more than 60 million Americans who live in medically underserved communities, characterized by poverty, increased health risks, and a shortage of primary health care. Where women's health is concerned, the marriage of health insurance coverage with access-creating programs rests on two iconic federal health care safety net programs: Community health centers and Title X–funded family planning centers.
With roots in the Great Society's war on poverty, community health centers have long represented a general public policy response to the lack of access to primary health care (
Shin et al., 2015, July
). The grants available to establish and operate community health centers enable the anchoring of comprehensive, affordable primary health care in medically underserved urban and rural communities. Family planning is a required service of all health centers, which in 2014 served about 6 million women of childbearing age (>1 in 4 low-income women nationally; Rosenbaum, 2015
).Title X of the Public Health Service Act traces its origins to the massive national awakening, at roughly the same time period that the community health centers program was born, regarding the importance of women's health and family planning as distinct population health concerns (
Gold, 2001
). Title X grants support the development and operation of clinics that ensure access to family planning and other preventive reproductive health services. Title X grantees encompass a wide range of entities, including state health agencies, freestanding family planning clinics such as those operated by Planned Parenthood, and community health centers that participate in both programs to augment their family planning programs.In some communities, Title X clinics and community health centers work alongside one another and in tandem. In far more, however, a general shortage of primary health care in poorer communities means that one program may be present while the other is not. Furthermore, although it is true that family planning is a required health center service, the community health center mission spans the full age cycle. Community health centers must respond to community need, whether for contraception or home health services for their frail elderly patients. Our research has shown that while community health centers do indeed provide family planning services, the scope of those services may be limited and variable, depending on the particular grantee (
Wood et al., 2013
). Furthermore, despite community health centers' rapid growth over the past 20 years, for every patient served another three people continue to need access to affordable care and remain in communities without a community health center (Wood, S., Goldberg, D., Beeson, T., Bruen, B., Johnson, K., Mead, H., … Rosenbaum, S. (2013). Health Centers and family planning: Results of a nationwide study. Available: www.rchnfoundation.org/wp-content/uploads/2013/04/Health_Centers_and_Family_Planning-final-1.pdf. Accessed August 31, 2015.
Rosenbaum, 2015
).Title X–funded clinics fulfill a critical need by providing affordable, preventive women's health services where they would not otherwise exist. In 2010, 72% of U.S. counties, representing 94% of women in need of subsidized care, had at least one Title X–funded clinic; together these clinics served more than 4 million women in 2013 (
Frost and Gold, 2015
). Four out of every 10 women served report that reproductive health-focused clinics focused represent their only source of care (2015). In 2013, Title X–funded clinics helped to avert 1 million unplanned pregnancies, one of the greatest threats to the health of women, infants, children, and families (2015). Yet with 20.1 million women in need of publicly funded family planning services, funding for Title X funding continues to sink relative to need, and the program has been threatened with outright extinction next year, with zero funding recommended by House Appropriations Committee and a significant cut by Senate appropriators for fiscal 2016.And Title X depends on Planned Parenthood. The Guttmacher Institute reports that in two-thirds of the 491 counties in which they are located, Planned Parenthood-affiliated centers provide care for at least one-half of all women who depend on the health care safety net for publicly funded contraceptive services; in one-fifth of the counties in which they are located, Planned Parenthood-operated clinics are the sole source of safety net family planning care (
Frost and Hasstedt, 2015
). In short, Planned Parenthood turns out to be crucial to the success of Title X.Now, this enduring but fragile system of clinical anchors for underserved populations is under existential threat. Lawmakers opposed to Planned Parenthood are vowing to shut down the government this fall unless Planned Parenthood is completely barred from federal programs such as Title X and Medicaid. Planned Parenthood opponents dismiss any talk of catastrophic health results for women and loss of access to family planning and other preventive services, arguing that community health centers can pick up the slack, using funds that previously went to Planned Parenthood. (These opponents, of course, seem to overlook the fact that the House of Representatives is proposing a complete elimination of the Title X program).
Anyone with any basic knowledge of the U.S. health care system knows how dangerously foolish such claims are. Even were Title X funding to continue at current levels, and even were all health centers to apply for Title X funding (only about 25% currently participate in the Title X program), they could no more offset the impact of eliminating Planned Parenthood from Title X than they could compensate the loss of other major safety net providers for any population health need, young or old (
Wood et al., 2013
).Wood, S., Goldberg, D., Beeson, T., Bruen, B., Johnson, K., Mead, H., … Rosenbaum, S. (2013). Health Centers and family planning: Results of a nationwide study. Available: www.rchnfoundation.org/wp-content/uploads/2013/04/Health_Centers_and_Family_Planning-final-1.pdf. Accessed August 31, 2015.
Community health centers have been credited with enormous patient and population health gains over the decades of their existence. But they are not magicians. In hundreds of communities served by a Planned Parenthood clinic, there simply may be no health center with the capacity to assume responsibility for care. With the surge of patients as a result of the ACA's insurance expansions, community health centers in many locales already are stretched to the limit. Simply hiring and training the staff needed to respond to the additional flood of women in search of accessible care were Planned Parenthood clinics to close would take an extended amount of time. Yet were Planned Parenthood to be barred from further participation in Title X or Medicaid, clinic closures would start overnight.
We already have seen what such a damaging policy can do. In 2013, Texas eliminated Planned Parenthood as a participating family planning provider. The experience of state residents and community health centers showed that health centers could not compensate for the loss. Texas experienced a 9% decrease in family planning program enrollees, a 26% decrease in Medicaid claims, and a 54% decline in contraceptive claims.
This is a time when the nation should be building access points in its most underserved communities, not eliminating them. If Title X funding is permitted to erode further or disappear altogether, or if Planned Parenthood is barred from Title X and Medicaid, the results for millions of women will be catastrophic. As storied as the community health center program has been in its ability to reach medically underserved communities with comprehensive primary care, to expect health centers to save women of childbearing age and their families from this catastrophic failure of public policy is to demand the impossible. It simply eliminates a crucial source of health care for the women who need it the most.
References
Frost, J., & Gold, R. B. (2015, August). Publicly funded family planning services: Need and impact. Guttmacher Institute presentation at Title X Grantee Meeting, Washington, DC.
- Quantifying Planned Parenthood's critical role in meeting the need for publicly supported contraceptive care.Health Affairs Blog. 2015; (Available:) (Accessed August 31, 2015)
- Title X: Three decades of accomplishment.Guttmacher Report on Public Policy. 2001; 4 (Available:) (Accessed August 31, 2015)
King v. Burwell, 576 U.S. ___ (2015).
- Planned Parenthood, Community Health Centers, and women's health: Getting the facts right.Health Affairs Blog. 2015; (Available:) (Accessed August 31, 2015)
- Medicaid at 50: Marking a milestone for women's health.Women's Health Issues. 2015; 25: 198-201
- Community Health Centers and Medicaid at 50: An enduring relationship essential for health system transformation.Health Affairs. 2015; 34: 1096-1104
Sobel, L., & Salganicoff, A. (2015). Round two on the legal challenges to contraceptive coverage: Are nonprofits “substantially burdened” by the “accommodation”? Available: http://kff.org/womens-health-policy/issue-brief/round-2-on-the-legal-challenges-to-contraceptive-coverage-are-nonprofits-substantially-burdened-by-the-accommodation. Accessed August 31, 2015.
U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA). (2011). Women's preventive services guidelines. Available: www.hrsa.gov/womensguidelines/. Accessed August 31, 2015.
Wood, S., Goldberg, D., Beeson, T., Bruen, B., Johnson, K., Mead, H., … Rosenbaum, S. (2013). Health Centers and family planning: Results of a nationwide study. Available: www.rchnfoundation.org/wp-content/uploads/2013/04/Health_Centers_and_Family_Planning-final-1.pdf. Accessed August 31, 2015.
Biography
Sara Rosenbaum, JD, is the Harold and Jane Hirsh Professor of Health Law and Policy and Founding Chair, Department of Health Policy and Management, Milken Institute School of Public Health at George Washington University.
Biography
Susan F. Wood, PhD, is Associate Professor of Health Policy and Management and Environmental and Occupational Health and Director of the Jacobs Institute of Women's Health, Milken Institute School of Public Health, George Washington University.
Article info
Publication history
Published online: October 20, 2015
Accepted:
September 15,
2015
Received:
September 15,
2015
Identification
Copyright
© 2015 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.
