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Arkansas’ Medicaid family planning program looks good in a new study that compares the programs in 26 states, but there is still a need to enroll more women in the program.

“Arkansas was one of the first states to seek and receive federal approval for their program. They’ve been leaders,” said Rachel Benson Gold, director of policy analysis of the Guttmacher Institute in Washington, D.C., and one of the study’s authors.
“I see Arkansas as doing well, but with room for improvement,” said Bradley Planey, associate branch chief, family health branch, Arkansas Department of Health in Little Rock. “Arkansas was one of the first states to have a family planning Medicaid Waiver. Five years ago we extended coverage for women with incomes up to 133 percent of the federal poverty level to women with incomes up to 200 percent of the FPL. Arkansas ranks 12th in service availability and 25th in public funding for family planning services. Still, it is estimated only half of the women who are in need of publicly supported contraceptive services are accessing services in Arkansas.”

Planey said that according to 2007 figures, there were 742,965 unduplicated Medicaid recipients, which was 26 percent of the state’s population.

“The Family Planning or Women’s Health Medicaid Waiver is a much smaller population and is a specific program for funding family planning services to women of reproductive age,” Planey said. “There are approximately 60,000 women enrolled at this time.”

The study, “State Government Innovation in the Design and Implementation of Medicaid Family Planning Expansions,” was designed to compile good ideas from the 26 participating state programs and to help other states that may be implementing their own family planning expansions in the future.

The states were not ranked or graded on their family planning programs.

That was by design, Gold said. “We wanted to focus on some of the innovative practices some of the states are doing.”
The survey concludes that state officials have demonstrated enormous creativity and entrepreneurship in developing their Medicaid family planning programs. The innovations identified are relevant to the broader health care reform debate, since any efforts to expand health care coverage for lower-income women are likely to build extensively on the framework provided by Medicaid and the State Children’s Health Insurance Program, or SCHIP, the authors say.

“Although numerous studies have documented the positive impact of family planning expansions in providing essential care to low-income Americans, no previous studies looked in detail at how these expansions have been implemented nationwide,” said Adam Sonfield, the report’s lead author, in a statement. “State and federal policymakers have made numerous decisions, large and small, that have shaped the various expansions.” 

When Medicaid was started in 1965, the low-income families eligible for the program were mainly headed by single mothers who received welfare assistance. In the 1980s, Congress began allowing and then requiring states to extend eligibility for Medicaid-covered prenatal, delivery and postpartum care (including postpartum family planning services) to all women with incomes of up to 133 percent of the federal poverty level, which is well above most state eligibility ceilings. At their option, states could offer family planning services to women with incomes of up to 185 percent of the poverty level. In the 1990s, Congress enacted SCHIP as a companion to existing Medicaid coverage for low-income children. Some states began expansions of their family planning program, arguing that it is cheaper to provide birth control supplies to prevent unwanted pregnancies than to give prenatal, delivery and postpartum care. To implement these “expansion” programs, the states must receive waivers from the Centers for Medicare and Medicaid Services, the federal agency that oversees the Medicaid program. So far, 26 states have done so.

The waiver programs are limited to family planning services and to an initial five-year period, although they may apply for three-year extensions from the CMS. Arkansas’ initial five-year period expires in 2009. 

The Women’s Health Waiver, as the Arkansas program is called, serves a critical need to help prevent unplanned pregnancies, Planey said.

“In Arkansas 22.7 percent of the women 15-44 years of age lived at or below 100 percent of the federal poverty level in 2006 (128,729 women) and 49.6 percent (281,136 women) lived at or below 200 percent of the FPL,” Planey said. In addition, 26.6 percent (150,781 women) ages 15-44 had no health insurance coverage in 2006.

“The Women’s Health Waiver makes a strong contribution in helping women avoid unintended pregnancy, particularly low-income women, who are less likely to afford contraception,” Planey said. “In avoiding unintended pregnancies we are also increasing the age of the waiver participants when they have their first birth and increasing the length of the interval between births. This all contributes to healthier babies and decreases the chances for infant mortality. This can contribute to the economic well being of the family and saves Medicaid money by averting unintended births.”

He added that in 2005, the Women’s Health Waiver saved an estimated $135,650,018 by averting 5,117 births which would have cost Arkansas Medicaid an average of $29,046 each, as estimated by the Women’s Health Waiver Evaluation Team.    
Among the key findings in the study:

• States have pioneered new techniques to make it easier for clients to apply for the program – and in some cases even enroll – during a family planning visit.
• In steps to streamline the enrollment process, states have automatically enrolled potential clients, such as postpartum women who are leaving Medicaid, and used databases to verify citizenship status and income.
• To reach out to clients, states have used tailored, community-based tactics, established informative program Web sites and contacted individuals receiving other forms of public assistance.
• To recruit a large network of providers, states have worked with professional organizations and associations, used targeted ads, e-mails and mailings, and developed Web sites for interactive orientation and training.
• To ensure adequate provider reimbursement, states have strived for regularly scheduled rate increases and targeted funding for client counseling and application assistance.
• To guarantee client confidentiality, states have enrolled teens based on their own (rather than their parents’) income and enrolled clients unable to use private insurance for fear of abuse.

“Many of the issues that policymakers have grappled with in the context of these expansions – reaching out to new populations, streamlining enrollment and working effectively with a state’s provider network – are universal,” Sonfield said.
“Therefore, the report should not only be of great interest to state officials, policymakers, advocates and others who are directly involved in family planning expansions, but can also serve future program design for Medicaid and health care reform more broadly.”



August 2008

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