Editor’s Note: The Affordable Care Act (ACA) brought sweeping changes to the Medicaid program that have had profound implications for family planning coverage, services and providers. In particular, in the 17 states with family planning programs that have expanded Medicaid, many women have moved from limited benefit family planning programs into full-scope Medicaid or Marketplace insurance and now have comprehensive coverage, although it is less focused on family planning services.

In light of the coverage trends and other ACA-related changes, Manatt Health prepared a new white paper for the Kaiser Family Foundation that describes the impact on women and their partners, as well as on family planning providers, of the shifting landscape for family planning. Based on case studies in six states and interviews with national experts, providers, advocates and government officials, the paper describes major trends in how women secure Medicaid family planning coverage and services, the implications of ACA-related changes for family planning providers, and the role of family planning more broadly in Medicaid delivery system reform initiatives. Key findings from our study—conducted in the summer of 2016 before the Presidential election—are summarized below. Click here to download the free full-length white paper.

The passage of the ACA in 2010 enabled many low and modest-income women, who were previously either uninsured or only eligible for stand alone, limited Medicaid benefit family planning programs, to obtain full-scope insurance through Medicaid or the Marketplaces for the first time. These changes altered the role of family planning programs within many states and created a more complex environment for family planning providers. Manatt Health’s new study addresses the changing environment in which family planning services are being provided, including routes to coverage, eligibility and enrollment, benefits, access, the impact of changes on providers, and delivery system reform. The study was conducted before the November 2016 election changed the outlook for the ACA and Medicaid. With Medicaid reform under debate at the federal and state levels, it is important to understand the role of family planning programs and how they could be affected by Medicaid re-structuring.

Key Findings

Nationwide, states that had Medicaid family planning programs prior to the passage of the ACA have generally elected to maintain them, reflecting a belief that they still have an important role to play for low-income women. Maintaining a family planning program in a non-expansion state—where the program serves women who often otherwise do not qualify for Medicaid or may find Marketplace coverage unaffordable—is a relatively easy decision. In states with Medicaid expansion, however, it is more complex. California retained its family planning services, with interviewees explaining that the program serves a unique role in helping women secure high-quality, confidential family planning services. In contrast, Illinois terminated its program one year after expansion on the grounds that women would be able to secure family planning services through a comprehensive Medicaid or Marketplace plan. A number of interviewees supported the decision, but others expressed concern that it has diluted access to family planning services.

The ACA’s reforms to eligibility and enrollment procedures have changed how women learn about and enroll in Medicaid, creating new opportunities and challenges. For example, the requirement that Medicaid and Marketplaces use a “single, streamlined application” helps applicants avoid submitting duplicative applications with multiple entities and facilitates enrollment in comprehensive coverage. However, the “single, streamlined application” is also much longer and more complicated than many states’ pre-ACA family planning applications, potentially discouraging some people from applying for family planning services. Additionally, interviewees noted that HealthCare.gov is not yet able to assess eligibility for Medicaid family planning programs, creating a missed opportunity to connect women to family planning coverage.

Despite federal protections, interviewees in some states raised concerns about affordability challenges in Marketplace plans for low-income women in need of family planning services. Interviewees in several states expressed concerns about cost barriers for low-income enrollees in Marketplace plans. In particular, interviewees reported that low-income women cannot always afford Marketplace plans, even with premium tax credits and that for these women in particular, it is important to retain Medicaid family planning programs.

Stakeholders across the board reported that full-scope Medicaid and family planning programs generally cover the full range of family planning benefits that women are likely to require. Additionally, interviewees in all states indicated that very minor differences exist between the benefits offered in family planning programs and full-scope Medicaid, despite the fact that states have fairly wide discretion within federal guidelines to develop their family planning benefit packages. On the other hand, states vary in their coverage of “family planning-related” services, such as treatment of sexually transmitted diseases identified during family planning visits.

Interviewees suggested that women had access to family planning services from a range of providers that participate in family planning programs but also raised concerns about access to services in the context of Medicaid managed care. Most interviewees reported that beneficiaries are able to obtain services due to the well-established infrastructure of states’ family planning programs, as well as the mission-oriented nature of many of the programs’ providers. In Medicaid expansion states, enrollees have been transitioning from limited benefit programs to full-scope Medicaid and, in most instances, enrolling in Medicaid managed care organizations (MCOs).

In California, where three-quarters of Medicaid enrollees are in MCOs, interviewees expressed concern that women are being assigned to providers they do not know or are difficult to get to and that MCOs are imposing forms of utilization review that are inconsistent with federal and state guidelines. Interviewees across states noted that Medicaid’s “freedom of choice” provision, which provides coverage for out-of-network family planning providers, is not well understood by enrollees, providers or MCOs.

There is a need for consistent, reliable and comprehensive data on the Medicaid program’s role in family planning. Limited data has made it difficult for states to draw conclusions on a range of important issues, including service utilization by type, wait times, geographic proximity of providers to enrollees, appropriateness of care, ability to see the provider of an individual’s choosing, and the frequency with which people use the “freedom of choice” provision. There are some notable exceptions, such as California’s evaluation efforts through the University of San Francisco and Alabama’s annual waiver analysis reports, which have documented the role of family planning programs in providing contraceptive and other services to low-income women and men.

Family planning providers continue to face an uncertain future. Many family planning providers have long been accustomed to working in an environment dominated by fee-for-service Medicaid payments, Title X grant funding and self-pay patients, but the ACA has markedly increased the need to contract with Medicaid MCOs and Marketplace plans. Many family planning providers are seeking to re-position themselves as providers of a broader range of services, building stronger partnership and referral relationships with other providers and increasing their capacity to contract directly with Medicaid MCOs and Marketplace plans. Others have no interest or are unable to adopt these types of services—such as those in rural markets that do not support service expansion—and tend to be more focused on maintaining core family planning services and increasing reimbursement and awareness of those services.

Regardless of their approach, family planning providers see themselves as the frontline providers of care for low-income women and are increasingly making their case to payers and policymakers who want to prevent unwanted pregnancies of the value they offer. Moreover, family planning providers sit at the center of state and federal political controversies around abortion services and face significant uncertainty about funding and sustainability. This will be particularly important to monitor in the months ahead, as President Trump has voiced his intention to bar federal funds to Planned Parenthood, a major provider of family planning services for Medicaid beneficiaries.

Across interviewee states, family planning issues and providers are not at the table for broad Medicaid delivery system reform efforts. Most of the states interviewed are engaged in or exploring Medicaid delivery system reform but none have significant initiatives that include family planning issues and providers. Rather, they are focused on the most expensive enrollees and services instead of the younger and healthier Medicaid beneficiaries who use family planning services. Many interviewees see the exclusion of family planning services from delivery reform as a missed opportunity given that family planning may be a major gateway into the healthcare system for low-income and racially and ethnically diverse women of reproductive age. Family planning providers also note that they can help the Medicaid program avoid the delivery costs associated with unintended pregnancies. Finally, interviewees highlighted that the lack of family planning quality measures has been a hurdle to inclusion in delivery reform efforts, which strive to provide incentives to meet target quality measures.

Long-acting reversible contraception (LARC) continues to garner significant attention from states. Many states in this analysis are actively reviewing their Medicaid LARC policies to reduce access barriers. However, states also are seeking to ensure women are presented with a range of contraception options and not unduly pressured to select a LARC. A number of states are working to address the barriers to accessing LARC, including the shortage of providers trained to insert LARC methods, the high upfront costs of LARC devices, and the low Medicaid reimbursement rates for these procedures. For example, Illinois raised Medicaid reimbursement rates for insertions and removals of LARC devices in October 2014, and in July 2015, began allowing hospitals to receive a separate payment for LARC devices, making it more financially attractive for providers to insert LARC after delivery.

Conclusion

Medicaid continues to play an important role in the delivery of family planning services to low-income women. Shifts in the coverage landscape, federal efforts to reduce spending on discretionary programs, the focus on broad delivery system reform, and clinical and political trends have created an uncertain future for many family planning providers. States, enrollees and providers have been adapting to these changes to ensure family planning services remain accessible to low-income women and men.

The Trump Administration has signaled its willingness to put more decisions about benefits, eligibility and funds in the hands of state policymakers. Several states in this study have used 1115 waivers to extend Medicaid coverage of family planning services to groups that have historically been ineligible for full-scope Medicaid coverage. Alternatively, state and federal policymakers could structure an 1115 waiver to scale back the range of participating providers, covered services, or eligibility criteria.

Our study shows that when states have choices in crafting family planning benefits under Medicaid, the results can vary widely. Moving forward, it will be important to monitor the impact of Medicaid policy changes at the state and federal levels to assess the effects of policy decisions on access to family planning services for low-income women and men.