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Projecting the Unmet Need and Costs for Contraception Services After the Affordable Care Act Euna M. August, PhD, MPH, Erika Steinmetz, MBA, Lorrie Gavin, PhD, Maria I. Rivera, MPH, Karen Pazol, PhD, MPH, Susan Moskosky, MS, RNC, Tasmeen Weik, DrPH, and Leighton Ku, PhD, MPH Objectives. We estimated the number of women of reproductive age in need who would gain coverage for contraceptive services after implementation of the Affordable Care Act, the extent to which there would remain a need for publicly funded programs that provide contraceptive services, and how that need would vary on the basis of state Medicaid expansion decisions. Methods. We used nationally representative American Community Survey data (2009), to estimate the insurance status for women in Massachusetts and derived the numbers of adult women at or below 250% of the federal poverty level and adolescents in need of confidential services. We extrapolated findings to simulate the impact of the Affordable Care Act nationally and by state, adjusting for current Medicaid expansion and state Medicaid Family Planning Expansion Programs. Results. The number of low-income women at risk for unintended pregnancy is expected to decrease from 5.2 million in 2009 to 2.5 million in 2016, based on states’ current Medicaid expansion plans. Conclusions. The Affordable Care Act increases women’s insurance coverage and improves access to contraceptive services. However, for women who remain uninsured, publicly funded family planning programs may still be needed. (Am J Public Health. 2016;106: 334–341. doi:10.2105/AJPH.2015.302928) See also Galea and Vaughan, p. 201.
T
he Patient Protection and Affordable Care Act (ACA) affects the availability of contraceptive and other preventive services for American women.1 Preliminary evidence shows that insurance coverage expanded considerably since 2014, when the main ACA expansions began.2,3 In addition, most insurers are now required to cover certain preventive services, including Food and Drug Administration–approved contraception, HIV and sexually transmitted infection (STI) services, breast and cervical cancer screening, and well-woman visits, with no cost sharing. These changes have raised questions about the need for publicly funded safety net programs4; we explored this question with regard to Title X, the federal family planning grant program. The Title X program (of the Public Health Service Act) provides grants for family planning and related preventive health services, including
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contraception, breast and cervical cancer screening, and HIV and STI services.5 Title X is designed to prioritize the needs of low-income individuals living at or below 250% of the federal poverty level (FPL), including those who are uninsured or underinsured or who seek confidential services, including adolescents.5 It also funds personnel training, community education, and research and evaluation to enhance the quality of family planning services.5 Title X has established a clinical network of approximately
95 grantees that deliver services through more than 4000 service sites nationwide, caring for 5 million clients annually.6 Agencies can use Title X grants flexibly to support infrastructure, such as salaries and supplies, as well as services for uninsured individuals. The ACA, as modified by a 2012 Supreme Court decision, gives states the option to expand Medicaid coverage to nonelderly adults with incomes below 138% FPL.7 As of March 2015, 28 states and the District of Columbia have expanded Medicaid, though states may elect to expand or to terminate an expansion at a later time.8 Some states that are not expanding have adult income criteria as low as 23% FPL (in Alabama), and many do not cover childless adults.9 Although Title X is a critical source of public funding for family planning, Medicaid has become an increasingly important source of revenue for Title X service sites, accounting for 40% of total revenue in 2013.10 Title X complements Medicaid, covering costs Medicaid does not cover, such as serving low-income women ineligible for Medicaid, filling gaps between Medicaid reimbursement and actual costs of services, and funding infrastructure (e.g., provider training and community outreach). Another important option to expand family planning coverage exists under Medicaid. States may expand eligibility for family planning services through temporary federal waivers or permanent state plan amendments (SPAs).11,12 Both family planning waivers and
ABOUT THE AUTHORS Euna M. August, Maria I. Rivera, and Karen Pazol are with Centers for Disease Control and Prevention, Division of Reproductive Health, Atlanta, GA. Erika Steinmetz and Leighton Ku are with George Washington University, Center for Health Policy Research, Washington, DC. Susan Moskosky, Lorrie Gavin, and Tasmeen Weik are with Office of Population Affairs, Washington, DC. Correspondence should be sent to Euna M. August, PhD, MPH, Prevention Communication Branch, Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, 1600 Clifton Rd, MS E-49, Atlanta, GA 30333 (e-mail: eaugust@cdc. gov). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted September 28, 2015. doi: 10.2105/AJPH.2015.302928
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SPAs include coverage of contraceptive services.11 As of 2014, 30 states extended Medicaid eligibility for family planning services to those who would otherwise be ineligible; 19 states operate under a family planning waiver, whereas 11 states have an SPA for family planning services.13 Under these waivers and SPAs, family planning eligibility typically ranges from 185% to 250% FPL, well above the ACA levels of 138% FPL. Insurance coverage can increase access to and use of contraceptive services.14,15 Analyses of the 2006–2010 National Survey of Family Growth found that women with any period without insurance coverage in a year were less likely to have used a family planning service.16 As more women gain insurance coverage for family planning services, it is important to know the potential implications for Title X clients. After Massachusetts’ 2006 insurance expansions, the state’s extensive network of family planning clinics still found that a large fraction of Title X clients were uninsured.17,18 Other analyses have found that, after health care reform, the use of safety-net facilities (e.g., community health centers) surged; patients continued to use these facilities even after they gained insurance, and newly insured patients flocked to them, partially because of difficulties accessing care in regular physicians’ offices.17,19 We sought to determine the extent to which ACA could reduce the number of women of reproductive age who are in need of health care coverage, access to confidential contraceptive services, or both, and affect the need for Title X to address the unmet family planning needs. We focused on women of reproductive age in need, which consisted of the primary target population of Title X, adult women with incomes at or below 250% FPL and female adolescents in need of confidential care.5 We restricted the target population to women who are “in need” of contraceptive services (i.e., at risk for an unintended pregnancy), defined as those who had ever had sexual intercourse and who were not pregnant, sterile, or seeking pregnancy. We projected the number of low-income women who would need contraceptive services after implementation of health insurance expansions, examined how that need would vary on the basis of state decisions whether to expand Medicaid, and estimated the level of funding
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that would be needed for Title X to deliver that level of direct services.
METHODS We used data on insurance coverage following Massachusetts’ state health care reform law in 2006 to project the effect of the ACA on women’s health insurance coverage and on access to contraceptive services among low-income women in all 50 states and Washington, DC, in 2016. As states may opt not to expand Medicaid coverage through the ACA without penalty,20 we estimated the potential impact in each state with and without Medicaid expansion, with consideration of expansions specific to family planning. An appendix (available as a supplement to the online version of this article at http://www.ajph.org) provides more detailed information about our estimation methods. We based the projection model on a previously published simulation of the effect of the ACA on women’s access to breast and cervical cancer screening.4 As elements of the ACA are similar to those of health care reform in Massachusetts, we assumed that the effect of the ACA on health insurance coverage would be comparable to outcomes experienced in Massachusetts.21 We used data from the Census Bureau’s American Community Survey (ACS),22 to estimate a multivariate logit model of insurance coverage for all adult residents in Massachusetts in 2009 and then used the coefficients of this model to estimate insurance status in each of the remaining states, all based on the characteristics of low-income women, aged 18 to 44 years, in each state. The model included gender, age, race/ethnicity, marital status, parity, employment status, industry of employment, household income, citizenship status, disability, and education. We adjusted these estimates for population growth and aging from 2009 to 2016 by using Census Bureau projections of expected changes in the size and age distribution of women.23 Because the basic model assumed that all states expanded Medicaid, we modified the estimates to reflect insurance coverage without Medicaid expansion, resulting in with-and-without expansion scenarios for every state, as some of the states now opting out may expand later and some states now expanding might revert back.
We adapted the model to generate estimates of differences in insurance status depending on whether the income limit for family planning services in Medicaid in each state is based on (1) the ACA Medicaid expansion criterion of 138% FPL, (2) the income criterion used in a state’s Medicaid family planning waiver or SPA (which is generally higher than 138% FPL), as of July 2013,24 or (3) the state’s previous (year 2013) Medicaid eligibility criterion (nonexpanding states typically do not cover women without dependent children, regardless of income).9 We drew data about income criteria from the Kaiser Commission on Medicaid and the Uninsured9 and the Guttmacher Institute.24 For scenarios without a Medicaid expansion, we assumed that uninsured women with incomes above the relevant Medicaid criterion but below 100% FPL would remain uninsured. In those cases, we assumed a portion of the uninsured women with incomes between 100% and 138% FPL would gain coverage under the health insurance marketplaces. (See the appendix.) Because we included the Medicaid family planning waivers or SPAs, we estimated women’s insurance coverage for family planning services; those insured through the family planning waivers or SPAs are only covered for family planning, not for comprehensive medical care. We based projected insurance coverage of female adolescents aged 15 to 17 years on a simulation model created by the Urban Institute, which projected that the proportion of uninsured adolescents after health care reform nationwide would be 7.1%.25 Given the sensitive nature of reproductive health services, many adolescents may turn to family planning clinics for confidential care, regardless of whether they are insured.26–29 We reduced the estimated proportion of insured adolescents by 37% to account for those adolescent females who would not use reproductive health services because of concerns about confidentiality on the basis of results of an earlier study.29 We further refined our estimates to reflect the women who are “in need” of contraceptive services (i.e., at risk for an unintended pregnancy), based on the proportion of women in the 2006–2010 National Survey of Family Growth who had ever had sexual intercourse and who were not pregnant, sterile, or seeking pregnancy.30 We calculated
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these estimates separately for adolescents (aged 15–17 years) and adults (aged 18–44 years). We calculated costs required to provide family planning services to women in need of contraceptive services by insurance status for each state by using the national average revenue per Title X user reported in the Family Planning Annual Report, an administrative report filed by all Title X grantees.31 Previous research has used revenue per user to estimate costs of care for these services.32 Because the most recent Family Planning Annual Report data are for 2012, we projected the costs to 2016 levels, based on the Personal Consumption Expenditures Price Index for health care.10,33,34
RESULTS Table 1 illustrates our findings from a national perspective; the appendix provides estimates for all 50 states and Washington, DC. Nationally, we estimate that there will be
31.1 million low-income women of reproductive age (15–44 years) in 2016. This is a projected increase of more than 800 000 from 2009 to 2016 (Table 1). The implementation of ACA results in a projected drop in the number of low-income women of reproductive age without insurance coverage for family planning from more than 9.3 million in 2009 to between 4.0 million and 4.8 million by 2016, depending on state policies about full Medicaid eligibility expansions. Given current state Medicaid expansion decisions and family planning waivers or SPAs, we estimate that 4.7 million lowincome women of reproductive age will lack family planning coverage. After adjustment for those in need of family planning services, the number of low-income women of reproductive age at risk for unintended pregnancy will fall from 5.2 million in 2009 to between 2.2 million and 2.6 million in 2016, with an estimate of 2.5 million with current state Medicaid expansion plans.
TABLE 1—Projected Impact of the Patient Protection and Affordable Care Act and Medicaid Expansion on Insurance Coverage and Costs Among Low-Income Women (£ 250% Federal Poverty Level) of Reproductive Age (15–44 Years) in the United States: 2009 vs 2016 Medicaid Expansion, as of 2016 Low-Income Women of Reproductive Age
a
Noneb
Partialc
Fulld
31.1
32.0
32.0
32.0
9.3
4.8
4.7
4.0
2009
Total, no. Uninsured,e no. e,f
Uninsured in need of family planning services,
no.
Public cost to provide family planning services for uninsured,g $
5.2 1226
2.6 763
2.6 737
2.2 628
Note. Values are in millions. a Based on data collected through the 2009 American Community Survey Public Use Microdata Sample22 and projections provided through the US Census Bureau, US Interim Projections by Age, Sex, Race, and Hispanic Origin.23 b No Medicaid expansion: based on projections of states not expanding Medicaid, as of May 2014 (Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision).35 c Partial Medicaid expansion: based on projections of Medicaid expansion, as of May 2014 (Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision).35 d Full Medicaid expansion: refers to expansion of the full Medicaid program, in accordance with the Patient Protection and Affordable Care Act of 2010.1 e For states with family planning waivers or SPAs, projections of uninsured women in 2016 considers the impact of expanded coverage through these programs. f Estimates of women in need of family planning services based on data collected through the National Survey of Family Growth, 2006–2010.16 “Women in need of family planning services” defined as women who are not pregnant, not seeking pregnancy, not sterile, and have had sexual activity. Need among insured adolescents aged 15–17 years further adjusted by the proportion of female adolescents who may stop using reproductive health care services because of confidentiality concerns. g Estimates of 2009 costs based on the national average revenue per user estimate collected through the Family Planning Annual Report,31 estimated at a national average of $237 per user in 2009. Estimates of 2016 costs based on the national average revenue per user estimate collected through the Family Planning Annual Report, estimated at a national average of $265 per user in 2012 and adjusted for the average national growth of personal consumption expenditures pertaining to medical products, for an estimate of $289 per user in 2016.
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On the basis of states’ policies about whether to expand Medicaid35 and whether they have Medicaid family planning waivers or SPAs13 (as of May 2014), we compared the relative number of low-income women of reproductive age in the 27 states, including Washington, DC, planning to expand Medicaid and the 24 that are not (Table 2). States expanding Medicaid will collectively have approximately 1.1 million uninsured, low-income women of reproductive age who require family planning services (6.6% of all low-income women of reproductive age in those states), compared with 1.5 million uninsured women in nonexpanding states (9.4%). If all low-income women of reproductive age who require family planning services receive Title X services, the national level of Title X funding required would range from $628 million to $763 million in 2016 (Table 1). Based on Medicaid expansion plans (as of May 2014), approximately $737 million would be needed to provide family planning services to all uninsured low-income women of reproductive age in the United States. Those states that do not expand their state Medicaid programs will have a relatively greater need for publicly funded family planning programs than those that do expand. State policies will determine the magnitude of need for programs to address the family planning needs of women who lack insurance coverage. Four scenarios are possible (Table 3), all of which assume that the other ACA expansion policies, such as health insurance marketplaces, remain in effect in all states. The first 2 scenarios represent states that do not have a preexisting family Medicaid planning expansion program, whereas the last 2 represent states that do have an expansion program. In the first scenario, states neither expand their general Medicaid program nor have a family planning waiver or SPA. For example, Tennessee has a Medicaid income criterion of 122% FPL, no family planning waiver or SPA, and does not currently plan to expand Medicaid. We estimated that there would be 63 000 low-income women of reproductive age in Tennessee in need of contraceptive services without coverage in 2016. This is about 30% higher than if the state expanded Medicaid eligibility to 138% FPL (43 000 women). Thus, the need for
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TABLE 2—Projected Impact of the Patient Protection and Affordable Care Act and Medicaid Expansion on Insurance Coverage and Costs Among Low-Income Women (£ 250% Federal Poverty Level) of Reproductive Age (15–44 Years) Within Nonexpansion vs Expansion States: United States, 2009 vs 2016 Medicaid Expansion, as of 2016 Low-Income Women of Reproductive Age
2009a
Noneb
Fullc 16.5
Expansion states Total, no.
16.1
NA
Uninsured,d no.
4.3
NA
2.0
Uninsured in need of family planning services,d,e no.
2.4
NA
1.1
Public cost to provide family planning services for uninsured,f $
568
NA
317
Nonexpansion states Total, no. Uninsured,d no.
15.1 5.0
Uninsured in need of family planning services,d,e no.
2.8
Public cost to provide family planning services for uninsured,f $
658
15.5 2.6
NA NA
1.5
NA
420
NA
Note. NA = not applicable. Values are in millions. “Expansion states” includes 27 states (including Washington, DC) that have already or are expected to expand Medicaid as of May 2014. “Nonexpansion states” includes 24 states that are not expected to expand Medicaid as of May 2014. Projections of Medicaid expansion based on updates from the Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision.35 a Based on data collected through the 2009 American Community Survey Public Use Microdata Sample22 and projections provided through the US Census Bureau, US Interim Projections by Age, Sex, Race, and Hispanic Origin.23 b No Medicaid expansion: based on projections of states not expanding Medicaid, as of May 2014 (Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision).35 c Full Medicaid expansion: refers to expansion of the full Medicaid program, in accordance with the Patient Protection and Affordable Care Act of 2010.1 d For states with family planning waivers or SPAs, projections of uninsured women in 2016 considers the impact of expanded coverage through these programs. e Estimates of women in need of family planning services based on data collected through the National Survey of Family Growth, 2006–2010.16 “Women in need of family planning services” defined as women who are not pregnant, not seeking pregnancy, not sterile, and have had sexual activity. Need among insured adolescents aged 15–17 years further adjusted by the proportion of female adolescents who may stop using reproductive health care services because of confidentiality concerns. f Estimates of 2009 costs based on the national average revenue per user estimate collected through the Family Planning Annual Report,31 estimated at a national average of $237 per user in 2009. Estimates of 2016 costs based on the national average revenue per user estimate collected through the Family Planning Annual Report, estimated at a national average of $265 per user in 2012 and adjusted for the average national growth of personal consumption expenditures pertaining to medical products, for an estimate of $289 per user in 2016.
publicly funded family planning services will be 30% higher because more women would be uninsured and lack coverage for family planning services. However, the number of uninsured women would still be lower than the 2009 level of 105 000 uninsured women. In the second scenario, among states without a family planning waiver or SPA that expand the full Medicaid program, the number of low-income women of reproductive age would be reduced. For example, Colorado’s Medicaid expansion would result in about 10 000 fewer lowincome women of reproductive age who
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require family planning; 39 000 lowincome women of reproductive age would be without coverage, compared with 50 000 without a Medicaid expansion. The expansion of the full Medicaid program could reduce the need for publicly funded family planning services by approximately 20%. In the third scenario, states that have a preexisting family planning waiver or SPA but are not expanding the full Medicaid program, no further change in the number of low-income women of reproductive age is expected, as these individuals are already
eligible under the Medicaid waivers or SPAs. For example, Georgia is not planning to expand Medicaid at this time, but already has a family planning waiver or SPA that expands coverage to 200% FPL, compared with its regular Medicaid income criterion of 48% FPL for women with dependent children and no coverage for childless women. In this case, the family planning waiver or SPA income limit of 200% FPL would leave 82 000 women with incomes between 200% and 250% FPL who are at risk for unintended pregnancy and without coverage in 2016. In the fourth scenario, states have a preexisting family planning waiver or SPA and are expanding the full Medicaid program. One such state, California, would experience no changes in the number of lowincome women of reproductive age who are uninsured because other previously uninsured individuals are already covered under the state family planning SPA (at or below 200% FPL).
DISCUSSION Our findings show that the ACA should increase health insurance coverage and, thereby, expand access to essential preventive family planning services among low-income women of reproductive age. This analysis suggests that ACA will not eliminate the need for categorical publicly financed family planning programs to address the reproductive health needs of lowincome, uninsured women. Of the 310 million people in the United States, 62 million are women of reproductive age, 15 to 44 years.36 Our study found that approximately half (32 million) of these women will be in need (i.e., women aged 18–44 years who are at or below 250% FPL or female adolescents aged 15–17 years who need confidential services). Based on states’ Medicaid expansion plans (as of May 2014), more than 2.5 million low-income women of reproductive age without insurance will be at risk for unintended pregnancy and may need family planning services. The estimated cost of providing direct services to these women is $737 million in 2016. In fiscal year 2014, Title X is funded at $286 million, less than half that level.5,37 Multiple streams of funding have historically supported the Title X network. In addition to
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funding from the Title X program (21% or $267.1 million) and Medicaid (40% or $498.7 million), Title X centers reported substantial funding from state and local governments (16% or $204.5 million) in 2012.10 Many states also support family planning services through grant programs and provided 10% of Title X centers’ revenue in 2013.38 Thus, to sustain the critical services provided by Title X centers and provide a continuum of care for uninsured women, our results suggest that there will remain a need for publicly funded programs for family planning services, including both Title X and state-funded grants.
This analysis also documents the important role of the Medicaid family planning waivers or SPAs and how they can mitigate the impact on family planning in states that decide not to expand the Medicaid program. Our findings underscore the important partnership between Medicaid and Title X in creating a safety net for low-income women. As of May 2014, 24 states elected not to expand Medicaid.35 Of these states, only 6—Indiana, North Carolina, Oklahoma, South Carolina, Virginia, and Wisconsin—have Medicaid family planning SPAs, and 7 have Medicaid family planning waivers (Alabama, Georgia, Louisiana, Mississippi, Missouri, Montana,
and Pennsylvania).13 Title X service sites could be particularly vital to filling gaps in Medicaid coverage in the remaining states (Alaska, Florida, Idaho, Kansas, Maine, Nebraska, South Dakota, Tennessee, Texas, Utah, and Wyoming). The cost of direct services is only part of Title X’s mandate. Title X also plays a central role in maintaining the operational infrastructure for family planning services, including the availability of a cadre of trained providers, the presence of service sites in underserved areas, and onsite provision of contraceptive supplies. Many Title X sites also provide a broader range of
TABLE 3—Projected Impact of the Patient Protection and Affordable Care Act and Medicaid Expansion on Insurance Coverage and Costs Among Low-Income Women (£ 250% Federal Poverty Level) of Reproductive Age (15–44 Years) for 4 Selected States: United States, 2009 vs 2016
Family Planning Expansion Programa
Scenarios, Low-Income Women of Reproductive Age
Medicaid Expansion
Medicaid Expansion, as of 2016 2009b
Nonec
Partiald
Fulle
Tennessee No
No
Traditional Medicaid eligibilityf: with children, 122% FPL; without children, NE Total, no.
703
721
721
721
Uninsured,g no. Uninsured in need of family planning
186 105
113 63
113 63
80 43
24 778
17 896
17 896
12 431
Total, no.
470
483
483
483
Uninsured,g no. Uninsured in need of family planning
150 83
90 50
72 39
72 39
19 735
14 289
11 289
11 289
1 119
1 149
1 149
1 149
410
150
150
150
229
82
82
82
54 228
23 348
23 348
23 348
services,g,h no. Public cost to provide family planning services for uninsured,i $ Colorado No
Yes
Traditional Medicaid eligibilityf: with children, 106% FPL; without children, NE
services,g,h no. Public cost to provide family planning services for uninsured,i $ Georgia Yes
No
Total, no. Traditional Medicaid eligibilityf: with children, 48% FPL; without children, NE Uninsured,g no. Family planning expansion at 200% FPLa Uninsured in need of family planning services,g,h no. Public cost to provide family planning services for uninsured,i $
Continued
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TABLE 3—Continued California Yes
Yes
Total, no. Traditional Medicaid eligibilityf: with children, 106% FPL;
3 868
3 975
3 975
3 975
1 284
526
526
526
Uninsured in need of family planning services,g,h no.
711
286
286
286
Public cost to provide family planning
168 451
81 711
81 711
81 711
without children, NE Uninsured,g no. Family planning expansion at 200% FPLa
services for uninsured,i $ Note. FPL = federal poverty level; NE = not eligible. Values are in thousands. The selected states represent 4 possible scenarios affecting insurance coverage and family planning services a Family Planning Expansion Program consists of either a waiver to the state Medicaid program or a permanent state plan amendment that expands eligibility for family planning services. States considered to have a preexisting waiver if it was income-based (excluded those that were linked to pregnancy or for a limited time period). Based on status reported by the Guttmacher Institute.13 b Based on data collected through the 2009 American Community Survey Public Use Microdata Sample22 and projections provided through the US Census Bureau, “US Interim Projections by Age, Sex, Race, and Hispanic Origin.”23 c No Medicaid expansion: based on projections of states not expanding Medicaid, as of May 2014 (Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision.)35 d Partial Medicaid expansion: based on projections of Medicaid expansion, as of May 2014 (Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision.35 e Full Medicaid expansion: refers to expansion of the full Medicaid program, in accordance with the Patient Protection and Affordable Care Act of 2010.1 f For states with family planning waivers or SPAs, projections of uninsured women in 2016 consider the impact of expanded coverage through these programs. g Estimates of women in need of family planning services based on data collected through the National Survey of Family Growth, 2006–2010.16 “Women in need of family planning services” defined as women who are not pregnant, not seeking pregnancy, not sterile, and have had sexual activity. Need among insured adolescents aged 15–17 years further adjusted by the proportion of female adolescents who may stop using reproductive health care services because of confidentiality concerns. h Estimates of 2009 costs based on the national average revenue per user estimate collected through the Family Planning Annual Report,31 estimated at a national average of $237 per user in 2009. Estimates of 2016 costs based on the national average revenue per user estimate collected through the Family Planning Annual Report, estimated at a national average of $265 per user in 2012 and adjusted for the average national growth of personal consumption expenditures pertaining to medical products, for an estimate of $289 per user in 2016. i Based on Medicaid eligibility reported by the Kaiser Family Foundation (Heberlein et al.9).
preventive services; 28% of Title X centers report providing primary care services, and 13% have contracted relationships to provide primary care.39 Six of 10 women cite publicly funded family planning as their primary source of medical care,40 indicating that Title X clinics may fill an important need for both insured and uninsured women.
Limitations This study necessarily has limitations. We used a simulation model that projects insurance coverage in all states in 2016 based on data from Massachusetts in 2009. Similar to other simulation models, we assumed that future behaviors and outcomes may be predicted by trends observed in the past and that the distribution of residents’ characteristics in 2016 is akin to that in 2009. We adjusted results to account for ways in which Massachusetts differs from other states but
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might not have adequately controlled for variances in reform implementation across states. We used nationally representative data to estimate the potential universe of women who are in need of family planning services. As a consequence, these estimates were based on the responses at the point in time when the survey was administered and do not reflect possible changes over time and are not state-specific. We estimated the need for services for women but did not include the needs of men, who constitute about 8% of Title X clients.10 In our model, we adjusted for the proportion of female adolescents aged 15 to 17 years who may not access family planning services because of confidentiality concerns. However, because of the lack of reliable estimates, we were unable to adjust for confidentiality concerns among young adult women, aged 18 to 26 years, who may remain under parental coverage, as allowable under the ACA. This may have resulted in an
underestimate of the number of low-income women of reproductive age. In addition, we did not address changes in demand for contraception among low-income, uninsured women. It is plausible that demand for family planning services could rise over time because of increased awareness of available services. Cost estimates in this analysis used national data from the Title X administrative reports and may not fully account for state variation in family planning costs. We did not account for recent Supreme Court cases. The Supreme Court decision on Burwell v Hobby Lobby41 allows closely held for-profit companies to claim a religious exemption to the ACA mandate for contraceptive coverage, and a similar accommodation was offered to religious nonprofits. Although the final impact is not yet known, the number of women employed in such organizations is relatively small, so the expected impact ought not to be large. Overall, both not-for-profit organizations and
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for-profit organizations with religious affiliations may choose not to provide a full array of contraceptive options. We focused on changes in insurance coverage and did not directly measure changes in access to family planning services. Furthermore, we acknowledge that a range of barriers that were not addressed in this study may prohibit access to contraceptive services among low-income women of reproductive age, including, but not limited to, inability to prioritize reproductive health because of competing financial and personal needs, institutional barriers to women such as stigmatization and discrimination, and difficulty accessing health facilities because of transportation, hours, and service availability.42,43 However, previous evidence indicates that coverage is related to use of services16 and that coverage expansions can increase use of contraception and reduce unintended pregnancies.14,15 We also did not consider the quality and scope of contraceptive services offered through the available coverage. Although this model, like all models, has limitations, these estimates could provide insights about future policy impacts and health needs.
Conclusions The ACA expands health insurance coverage and enhances the affordability of preventive services, including family planning for the nation’s women, which may result in fewer unintended pregnancies and greater screening for other health needs. The need for programs such as Title X and similar state programs will likely remain. After Massachusetts’ health care reform to increase insurance coverage in 2006, the demand for publicly funded family planning services decreased by 10%.17 States that do not expand Medicaid will likely have larger gaps in coverage for women’s reproductive health needs than states that do. For millions of women, the publicly funded family planning programs, including the federal Title X program and related state-funded programs, could fill a critically important role in meeting their family planning needs. CONTRIBUTORS All authors participated meaningfully in the conceptualization and design of the research, writing, and approval of the article. E. M. August conceptualized and designed
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the study, conducted the statistical analysis, and drafted the article. E. Steinmetz conducted statistical analysis, provided technical support, and aided in the revision of the article. L. Gavin and L. Ku supported the conceptualization of the study, aided in interpretation of study findings, and provided critical revision to the article. M. I. Rivera and K. Pazol conducted statistical analysis and provided critical revision to the article. S. Moskosky aided in interpretation and study supervision and provided critical revision to the article. T. Weik aided in interpretation and provided critical revision to the article.
ACKNOWLEDGMENTS We thank and acknowledge Marion Carter, David Goodman, and Shanna Cox for their assistance and support in the formative development and conceptualization of this study.
HUMAN PARTICIPANT PROTECTION Institutional review board approval was not required because no human participants were involved in this study.
REFERENCES 1. Patient Protection and Affordable Care Act of 2010. Available at: http://www.gpo.gov/fdsys/pkg/PLAW111publ148/pdf/PLAW-111publ148.pdf. Accessed December 7, 2015. 2. Sommers BD, Musco T, Finegold K, Gunja MZ, Burke A, McDowell AM. Health reform and changes in health insurance coverage in 2014. N Engl J Med. 2014;371(9): 867–874. 3. Martinez ME, Cohen RA. Health insurance coverage: early release of estimates from the National Health Interview Survey, January–June 2014. Hyattsville, MD: National Center for Health Statistics; 2014. 4. Levy AR, Bruen BK, Ku L. Health care reform and women’s insurance coverage for breast and cervical cancer screening. Prev Chronic Dis. 2012;9:E159. 5. Office of Population Affairs. Title X Family Planning. Washington, DC: US Department of Health and Human Services; 2013. 6. Frost JJ, Zolna MR, Frohwirth L. Contraceptive needs and services, 2010. New York, NY: Guttmacher Institute; 2013. 7. Rosenbaum S, Westmoreland TM. The Supreme Court’s surprising decision on the Medicaid expansion: how will the federal government and states proceed? Health Aff (Millwood). 2012;31(8):1663–1672. 8. Status of state action on the Medicaid expansion decision, 2015. Washington, DC: Kaiser Family Foundation; 2015. 9. Heberlein M, Brooks T, Alker J, Artiga S, Stephens J. Getting into gear for 2014: findings from a 50-state survey of eligibility, enrollment, renewal, and cost-sharing policies in Medicaid and CHIP, 2012–2013. Washington, DC: Kaiser Commission on Medicaid and the Uninsured; 2013.
planning services: summary of state survey findings. Menlo Park, CA: Kaiser Family Foundation; 2009. 13. State policies in brief: Medicaid family planning eligibility expansions (as of May 1, 2014). Washington, DC: Guttmacher Institute; 2014. 14. Foster DG, Klaisle CM, Blum M, Bradsberry ME, Brindis CD, Stewart FH. Expanded state-funded family planning services: estimating pregnancies averted by the Family PACT Program in California, 1997–1998. Am J Public Health. 2004;94(8):1341–1346. 15. Sonfield A, Gold RB, Frost JJ, Darroch JE. US insurance coverage of contraceptives and the impact of contraceptive coverage mandates, 2002. Perspect Sex Reprod Health. 2004;36(2):72–79. 16. Martinez G, Chandra A, Febo-Vazquez I, Mosher W. Use of family planning and related medical services among women aged 15–44 in the United States: National Survey of Family Growth, 2006–2010. Hyattsville, MD: National Center for Health Statistics; 2013. 17. Carter M, Desilets K, Gavin L, Moskosky S, Clark J. Trends in uninsured clients visiting health centers funded by the Title X family planning program—Massachusetts, 2005–2012. MMWR Morb Mortal Wkly Rep. 2014;63(3): 59–62. 18. Gold RB. Family planning centers meet health care reform: lessons from Massachusetts. Guttmacher Policy Review. 2009;12(3):2–10. 19. Ku L, Jones E, Shin P, Byrne FR, Long SK. Safetynet providers after health care reform: lessons from Massachusetts. Arch Intern Med. 2011;171(15): 1379–1384. 20. National Federation of Independent Business v Sebelius, Secretary of Health and Human Services, 567 US 11–393 (2012). Available at: http://www.supremecourt.gov/ opinions/11pdf/11-393c3a2.pdf. Accessed December 7, 2015. 21. Gruber J. Massachusetts points the way to successful health care reform. J Policy Anal Manage. 2011;30(1): 184–192. 22. US Census Bureau. American Community Survey. n.d. 23. US interim projections by age, sex, race, and Hispanic origin. Washington, DC: US Census Bureau; 2004. Available at: http://www.census. gov/ipc/www/usinterimproj. Accessed February 13, 2013. 24. State policies in brief: Medicaid family planning eligibility expansions (as of July 1, 2013). Washington, DC: Guttmacher Institute; 2013. 25. Kenney GM, Buettgens M, Guyer J, Heberlein M. Improving coverage for children under health reform will require maintaining current eligibility standards for Medicaid and CHIP. Health Aff (Millwood). 2011;30(12): 2371–2381.
10. Family Planning Annual Report: 2012 National Summary. Research Triangle Park, NC: RTI International; 2013.
26. Jones RK, Boonstra H. Confidential reproductive health services for minors: the potential impact of mandated parental involvement for contraception. Perspect Sex Reprod Health. 2004;36(5):182–191.
11. Sonfield A, Frost JJ, Gold RB. Estimating the impact of expanding Medicaid eligibility for family planning services: 2011 update. New York, NY: Guttmacher Institute; 2011.
27. Reddy DM, Fleming R, Swain C. Effect of mandatory parental notification on adolescent girls’ use of sexual health care services. JAMA. 2002;288(6): 710–714.
12. Ranji U, Salganicoff A, Stewart AM, Cox M, Doamekpor L. State Medicaid coverage of family
28. Lehrer JA, Pantell R, Tebb K, Shafer MA. Forgone health care among US adolescents: associations between
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risk characteristics and confidentiality concern. J Adolesc Health. 2007;40(3):218–226. 29. Franzini L, Marks E, Cromwell PF, et al. Projected economic costs due to health consequences of teenagers’ loss of confidentiality in obtaining reproductive health care services in Texas. Arch Pediatr Adolesc Med. 2004;158 (12):1140–1146. 30. Groves RM, Mosher WD, Lepkowski JM, Kirgis NG. Planning and development of the continuous National Survey of Family Growth. Vital Health Stat 1. 2009;(48): 1–64. 31. Fowler CI, Gable J, Wang J, Lloyd SW. Family Planning Annual Report: 2009 National Summary. Research Triangle Park, NC: RTI International; 2010. 32. Frost JJ, Finer LB, Tapales A. The impact of publicly funded family planning clinic services on unintended pregnancies and government cost savings. J Health Care Poor Underserved. 2008;19(3):778–796. 33. National Health Expenditure Accounts: methodology paper, 2010. Baltimore, MD: Centers for Medicare and Medicaid Services; n.d. 34. Grosse S. How to adjust medical costs for inflation. Method Moments: A Periodic Newsletter on Analytical Methods. 2013;1(1):3. 35. Kaiser Family Foundation. Status of state action on the Medicaid expansion decision, 2014. Available at: http://kff.org/health-reform/state-indicator/stateactivity-around-expanding-medicaid-under-theaffordable-care-act. Accessed May 30, 2014. 36. Age and sex composition in the United States: 2011. Washington, DC: US Census Bureau; 2012. 37. Fiscal year 2015: budget in brief. Washington, DC: US Department of Health and Human Services; 2014. 38. Sonfield A, Gold RB. Public funding for family planning, sterilization and abortion services, FY 1980–2010. New York, NY: Guttmacher Institute; 2012. 39. Moskosky S, Weik T. The Affordable Care Act and the future of Title X [Webinar]. Washington, DC: Family Planning National Training Centers; 2013. 40. Frost JJ. US women’s use of sexual and reproductive health services: trends, sources of care and factors associated with use, 1995–2010. New York, NY: Guttmacher Institute; 2013. 41. Burwell, Secretary of Health and Human Services v Hobby Lobby Stores Inc, US 13–354(2014). Available at: http:// www.supremecourt.gov/opinions/13pdf/13-354_olp1. pdf. Accessed December 7, 2015. 42. Casey F, Gomez-Lobo V. Disparities in contraceptive access and provision. Semin Reprod Med. 2013;31(5): 347–359. 43. Kennedy S, Grewal M, Roberts EM, Steinauer J, Dehlendorf C. A qualitative study of pregnancy intention and the use of contraception among homeless women with children. J Health Care Poor Underserved. 2014;25(2): 757–770.
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Projecting the Unmet Need and Costs for Contraception Services After the Affordable Care Act Euna M. August, PhD, MPH, Erika Steinmetz, MBA, Lorrie Gavin, PhD, Maria I. Rivera, MPH, Karen Pazol, PhD, MPH, Susan Moskosky, MS, RNC, Tasmeen Weik, DrPH, and Leighton Ku, PhD, MPH Objectives. We estimated the number of women of reproductive age in need who would gain coverage for contraceptive services after implementation of the Affordable Care Act, the extent to which there would remain a need for publicly funded programs that provide contraceptive services, and how that need would vary on the basis of state Medicaid expansion decisions. Methods. We used nationally representative American Community Survey data (2009), to estimate the insurance status for women in Massachusetts and derived the numbers of adult women at or below 250% of the federal poverty level and adolescents in need of confidential services. We extrapolated findings to simulate the impact of the Affordable Care Act nationally and by state, adjusting for current Medicaid expansion and state Medicaid Family Planning Expansion Programs. Results. The number of low-income women at risk for unintended pregnancy is expected to decrease from 5.2 million in 2009 to 2.5 million in 2016, based on states’ current Medicaid expansion plans. Conclusions. The Affordable Care Act increases women’s insurance coverage and improves access to contraceptive services. However, for women who remain uninsured, publicly funded family planning programs may still be needed. (Am J Public Health. 2016;106: 334–341. doi:10.2105/AJPH.2015.302928) See also Galea and Vaughan, p. 201.
T
he Patient Protection and Affordable Care Act (ACA) affects the availability of contraceptive and other preventive services for American women.1 Preliminary evidence shows that insurance coverage expanded considerably since 2014, when the main ACA expansions began.2,3 In addition, most insurers are now required to cover certain preventive services, including Food and Drug Administration–approved contraception, HIV and sexually transmitted infection (STI) services, breast and cervical cancer screening, and well-woman visits, with no cost sharing. These changes have raised questions about the need for publicly funded safety net programs4; we explored this question with regard to Title X, the federal family planning grant program. The Title X program (of the Public Health Service Act) provides grants for family planning and related preventive health services, including
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contraception, breast and cervical cancer screening, and HIV and STI services.5 Title X is designed to prioritize the needs of low-income individuals living at or below 250% of the federal poverty level (FPL), including those who are uninsured or underinsured or who seek confidential services, including adolescents.5 It also funds personnel training, community education, and research and evaluation to enhance the quality of family planning services.5 Title X has established a clinical network of approximately
95 grantees that deliver services through more than 4000 service sites nationwide, caring for 5 million clients annually.6 Agencies can use Title X grants flexibly to support infrastructure, such as salaries and supplies, as well as services for uninsured individuals. The ACA, as modified by a 2012 Supreme Court decision, gives states the option to expand Medicaid coverage to nonelderly adults with incomes below 138% FPL.7 As of March 2015, 28 states and the District of Columbia have expanded Medicaid, though states may elect to expand or to terminate an expansion at a later time.8 Some states that are not expanding have adult income criteria as low as 23% FPL (in Alabama), and many do not cover childless adults.9 Although Title X is a critical source of public funding for family planning, Medicaid has become an increasingly important source of revenue for Title X service sites, accounting for 40% of total revenue in 2013.10 Title X complements Medicaid, covering costs Medicaid does not cover, such as serving low-income women ineligible for Medicaid, filling gaps between Medicaid reimbursement and actual costs of services, and funding infrastructure (e.g., provider training and community outreach). Another important option to expand family planning coverage exists under Medicaid. States may expand eligibility for family planning services through temporary federal waivers or permanent state plan amendments (SPAs).11,12 Both family planning waivers and
ABOUT THE AUTHORS Euna M. August, Maria I. Rivera, and Karen Pazol are with Centers for Disease Control and Prevention, Division of Reproductive Health, Atlanta, GA. Erika Steinmetz and Leighton Ku are with George Washington University, Center for Health Policy Research, Washington, DC. Susan Moskosky, Lorrie Gavin, and Tasmeen Weik are with Office of Population Affairs, Washington, DC. Correspondence should be sent to Euna M. August, PhD, MPH, Prevention Communication Branch, Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, 1600 Clifton Rd, MS E-49, Atlanta, GA 30333 (e-mail: eaugust@cdc. gov). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted September 28, 2015. doi: 10.2105/AJPH.2015.302928
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SPAs include coverage of contraceptive services.11 As of 2014, 30 states extended Medicaid eligibility for family planning services to those who would otherwise be ineligible; 19 states operate under a family planning waiver, whereas 11 states have an SPA for family planning services.13 Under these waivers and SPAs, family planning eligibility typically ranges from 185% to 250% FPL, well above the ACA levels of 138% FPL. Insurance coverage can increase access to and use of contraceptive services.14,15 Analyses of the 2006–2010 National Survey of Family Growth found that women with any period without insurance coverage in a year were less likely to have used a family planning service.16 As more women gain insurance coverage for family planning services, it is important to know the potential implications for Title X clients. After Massachusetts’ 2006 insurance expansions, the state’s extensive network of family planning clinics still found that a large fraction of Title X clients were uninsured.17,18 Other analyses have found that, after health care reform, the use of safety-net facilities (e.g., community health centers) surged; patients continued to use these facilities even after they gained insurance, and newly insured patients flocked to them, partially because of difficulties accessing care in regular physicians’ offices.17,19 We sought to determine the extent to which ACA could reduce the number of women of reproductive age who are in need of health care coverage, access to confidential contraceptive services, or both, and affect the need for Title X to address the unmet family planning needs. We focused on women of reproductive age in need, which consisted of the primary target population of Title X, adult women with incomes at or below 250% FPL and female adolescents in need of confidential care.5 We restricted the target population to women who are “in need” of contraceptive services (i.e., at risk for an unintended pregnancy), defined as those who had ever had sexual intercourse and who were not pregnant, sterile, or seeking pregnancy. We projected the number of low-income women who would need contraceptive services after implementation of health insurance expansions, examined how that need would vary on the basis of state decisions whether to expand Medicaid, and estimated the level of funding
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that would be needed for Title X to deliver that level of direct services.
METHODS We used data on insurance coverage following Massachusetts’ state health care reform law in 2006 to project the effect of the ACA on women’s health insurance coverage and on access to contraceptive services among low-income women in all 50 states and Washington, DC, in 2016. As states may opt not to expand Medicaid coverage through the ACA without penalty,20 we estimated the potential impact in each state with and without Medicaid expansion, with consideration of expansions specific to family planning. An appendix (available as a supplement to the online version of this article at http://www.ajph.org) provides more detailed information about our estimation methods. We based the projection model on a previously published simulation of the effect of the ACA on women’s access to breast and cervical cancer screening.4 As elements of the ACA are similar to those of health care reform in Massachusetts, we assumed that the effect of the ACA on health insurance coverage would be comparable to outcomes experienced in Massachusetts.21 We used data from the Census Bureau’s American Community Survey (ACS),22 to estimate a multivariate logit model of insurance coverage for all adult residents in Massachusetts in 2009 and then used the coefficients of this model to estimate insurance status in each of the remaining states, all based on the characteristics of low-income women, aged 18 to 44 years, in each state. The model included gender, age, race/ethnicity, marital status, parity, employment status, industry of employment, household income, citizenship status, disability, and education. We adjusted these estimates for population growth and aging from 2009 to 2016 by using Census Bureau projections of expected changes in the size and age distribution of women.23 Because the basic model assumed that all states expanded Medicaid, we modified the estimates to reflect insurance coverage without Medicaid expansion, resulting in with-and-without expansion scenarios for every state, as some of the states now opting out may expand later and some states now expanding might revert back.
We adapted the model to generate estimates of differences in insurance status depending on whether the income limit for family planning services in Medicaid in each state is based on (1) the ACA Medicaid expansion criterion of 138% FPL, (2) the income criterion used in a state’s Medicaid family planning waiver or SPA (which is generally higher than 138% FPL), as of July 2013,24 or (3) the state’s previous (year 2013) Medicaid eligibility criterion (nonexpanding states typically do not cover women without dependent children, regardless of income).9 We drew data about income criteria from the Kaiser Commission on Medicaid and the Uninsured9 and the Guttmacher Institute.24 For scenarios without a Medicaid expansion, we assumed that uninsured women with incomes above the relevant Medicaid criterion but below 100% FPL would remain uninsured. In those cases, we assumed a portion of the uninsured women with incomes between 100% and 138% FPL would gain coverage under the health insurance marketplaces. (See the appendix.) Because we included the Medicaid family planning waivers or SPAs, we estimated women’s insurance coverage for family planning services; those insured through the family planning waivers or SPAs are only covered for family planning, not for comprehensive medical care. We based projected insurance coverage of female adolescents aged 15 to 17 years on a simulation model created by the Urban Institute, which projected that the proportion of uninsured adolescents after health care reform nationwide would be 7.1%.25 Given the sensitive nature of reproductive health services, many adolescents may turn to family planning clinics for confidential care, regardless of whether they are insured.26–29 We reduced the estimated proportion of insured adolescents by 37% to account for those adolescent females who would not use reproductive health services because of concerns about confidentiality on the basis of results of an earlier study.29 We further refined our estimates to reflect the women who are “in need” of contraceptive services (i.e., at risk for an unintended pregnancy), based on the proportion of women in the 2006–2010 National Survey of Family Growth who had ever had sexual intercourse and who were not pregnant, sterile, or seeking pregnancy.30 We calculated
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these estimates separately for adolescents (aged 15–17 years) and adults (aged 18–44 years). We calculated costs required to provide family planning services to women in need of contraceptive services by insurance status for each state by using the national average revenue per Title X user reported in the Family Planning Annual Report, an administrative report filed by all Title X grantees.31 Previous research has used revenue per user to estimate costs of care for these services.32 Because the most recent Family Planning Annual Report data are for 2012, we projected the costs to 2016 levels, based on the Personal Consumption Expenditures Price Index for health care.10,33,34
RESULTS Table 1 illustrates our findings from a national perspective; the appendix provides estimates for all 50 states and Washington, DC. Nationally, we estimate that there will be
31.1 million low-income women of reproductive age (15–44 years) in 2016. This is a projected increase of more than 800 000 from 2009 to 2016 (Table 1). The implementation of ACA results in a projected drop in the number of low-income women of reproductive age without insurance coverage for family planning from more than 9.3 million in 2009 to between 4.0 million and 4.8 million by 2016, depending on state policies about full Medicaid eligibility expansions. Given current state Medicaid expansion decisions and family planning waivers or SPAs, we estimate that 4.7 million lowincome women of reproductive age will lack family planning coverage. After adjustment for those in need of family planning services, the number of low-income women of reproductive age at risk for unintended pregnancy will fall from 5.2 million in 2009 to between 2.2 million and 2.6 million in 2016, with an estimate of 2.5 million with current state Medicaid expansion plans.
TABLE 1—Projected Impact of the Patient Protection and Affordable Care Act and Medicaid Expansion on Insurance Coverage and Costs Among Low-Income Women (£ 250% Federal Poverty Level) of Reproductive Age (15–44 Years) in the United States: 2009 vs 2016 Medicaid Expansion, as of 2016 Low-Income Women of Reproductive Age
a
Noneb
Partialc
Fulld
31.1
32.0
32.0
32.0
9.3
4.8
4.7
4.0
2009
Total, no. Uninsured,e no. e,f
Uninsured in need of family planning services,
no.
Public cost to provide family planning services for uninsured,g $
5.2 1226
2.6 763
2.6 737
2.2 628
Note. Values are in millions. a Based on data collected through the 2009 American Community Survey Public Use Microdata Sample22 and projections provided through the US Census Bureau, US Interim Projections by Age, Sex, Race, and Hispanic Origin.23 b No Medicaid expansion: based on projections of states not expanding Medicaid, as of May 2014 (Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision).35 c Partial Medicaid expansion: based on projections of Medicaid expansion, as of May 2014 (Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision).35 d Full Medicaid expansion: refers to expansion of the full Medicaid program, in accordance with the Patient Protection and Affordable Care Act of 2010.1 e For states with family planning waivers or SPAs, projections of uninsured women in 2016 considers the impact of expanded coverage through these programs. f Estimates of women in need of family planning services based on data collected through the National Survey of Family Growth, 2006–2010.16 “Women in need of family planning services” defined as women who are not pregnant, not seeking pregnancy, not sterile, and have had sexual activity. Need among insured adolescents aged 15–17 years further adjusted by the proportion of female adolescents who may stop using reproductive health care services because of confidentiality concerns. g Estimates of 2009 costs based on the national average revenue per user estimate collected through the Family Planning Annual Report,31 estimated at a national average of $237 per user in 2009. Estimates of 2016 costs based on the national average revenue per user estimate collected through the Family Planning Annual Report, estimated at a national average of $265 per user in 2012 and adjusted for the average national growth of personal consumption expenditures pertaining to medical products, for an estimate of $289 per user in 2016.
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On the basis of states’ policies about whether to expand Medicaid35 and whether they have Medicaid family planning waivers or SPAs13 (as of May 2014), we compared the relative number of low-income women of reproductive age in the 27 states, including Washington, DC, planning to expand Medicaid and the 24 that are not (Table 2). States expanding Medicaid will collectively have approximately 1.1 million uninsured, low-income women of reproductive age who require family planning services (6.6% of all low-income women of reproductive age in those states), compared with 1.5 million uninsured women in nonexpanding states (9.4%). If all low-income women of reproductive age who require family planning services receive Title X services, the national level of Title X funding required would range from $628 million to $763 million in 2016 (Table 1). Based on Medicaid expansion plans (as of May 2014), approximately $737 million would be needed to provide family planning services to all uninsured low-income women of reproductive age in the United States. Those states that do not expand their state Medicaid programs will have a relatively greater need for publicly funded family planning programs than those that do expand. State policies will determine the magnitude of need for programs to address the family planning needs of women who lack insurance coverage. Four scenarios are possible (Table 3), all of which assume that the other ACA expansion policies, such as health insurance marketplaces, remain in effect in all states. The first 2 scenarios represent states that do not have a preexisting family Medicaid planning expansion program, whereas the last 2 represent states that do have an expansion program. In the first scenario, states neither expand their general Medicaid program nor have a family planning waiver or SPA. For example, Tennessee has a Medicaid income criterion of 122% FPL, no family planning waiver or SPA, and does not currently plan to expand Medicaid. We estimated that there would be 63 000 low-income women of reproductive age in Tennessee in need of contraceptive services without coverage in 2016. This is about 30% higher than if the state expanded Medicaid eligibility to 138% FPL (43 000 women). Thus, the need for
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TABLE 2—Projected Impact of the Patient Protection and Affordable Care Act and Medicaid Expansion on Insurance Coverage and Costs Among Low-Income Women (£ 250% Federal Poverty Level) of Reproductive Age (15–44 Years) Within Nonexpansion vs Expansion States: United States, 2009 vs 2016 Medicaid Expansion, as of 2016 Low-Income Women of Reproductive Age
2009a
Noneb
Fullc 16.5
Expansion states Total, no.
16.1
NA
Uninsured,d no.
4.3
NA
2.0
Uninsured in need of family planning services,d,e no.
2.4
NA
1.1
Public cost to provide family planning services for uninsured,f $
568
NA
317
Nonexpansion states Total, no. Uninsured,d no.
15.1 5.0
Uninsured in need of family planning services,d,e no.
2.8
Public cost to provide family planning services for uninsured,f $
658
15.5 2.6
NA NA
1.5
NA
420
NA
Note. NA = not applicable. Values are in millions. “Expansion states” includes 27 states (including Washington, DC) that have already or are expected to expand Medicaid as of May 2014. “Nonexpansion states” includes 24 states that are not expected to expand Medicaid as of May 2014. Projections of Medicaid expansion based on updates from the Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision.35 a Based on data collected through the 2009 American Community Survey Public Use Microdata Sample22 and projections provided through the US Census Bureau, US Interim Projections by Age, Sex, Race, and Hispanic Origin.23 b No Medicaid expansion: based on projections of states not expanding Medicaid, as of May 2014 (Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision).35 c Full Medicaid expansion: refers to expansion of the full Medicaid program, in accordance with the Patient Protection and Affordable Care Act of 2010.1 d For states with family planning waivers or SPAs, projections of uninsured women in 2016 considers the impact of expanded coverage through these programs. e Estimates of women in need of family planning services based on data collected through the National Survey of Family Growth, 2006–2010.16 “Women in need of family planning services” defined as women who are not pregnant, not seeking pregnancy, not sterile, and have had sexual activity. Need among insured adolescents aged 15–17 years further adjusted by the proportion of female adolescents who may stop using reproductive health care services because of confidentiality concerns. f Estimates of 2009 costs based on the national average revenue per user estimate collected through the Family Planning Annual Report,31 estimated at a national average of $237 per user in 2009. Estimates of 2016 costs based on the national average revenue per user estimate collected through the Family Planning Annual Report, estimated at a national average of $265 per user in 2012 and adjusted for the average national growth of personal consumption expenditures pertaining to medical products, for an estimate of $289 per user in 2016.
publicly funded family planning services will be 30% higher because more women would be uninsured and lack coverage for family planning services. However, the number of uninsured women would still be lower than the 2009 level of 105 000 uninsured women. In the second scenario, among states without a family planning waiver or SPA that expand the full Medicaid program, the number of low-income women of reproductive age would be reduced. For example, Colorado’s Medicaid expansion would result in about 10 000 fewer lowincome women of reproductive age who
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require family planning; 39 000 lowincome women of reproductive age would be without coverage, compared with 50 000 without a Medicaid expansion. The expansion of the full Medicaid program could reduce the need for publicly funded family planning services by approximately 20%. In the third scenario, states that have a preexisting family planning waiver or SPA but are not expanding the full Medicaid program, no further change in the number of low-income women of reproductive age is expected, as these individuals are already
eligible under the Medicaid waivers or SPAs. For example, Georgia is not planning to expand Medicaid at this time, but already has a family planning waiver or SPA that expands coverage to 200% FPL, compared with its regular Medicaid income criterion of 48% FPL for women with dependent children and no coverage for childless women. In this case, the family planning waiver or SPA income limit of 200% FPL would leave 82 000 women with incomes between 200% and 250% FPL who are at risk for unintended pregnancy and without coverage in 2016. In the fourth scenario, states have a preexisting family planning waiver or SPA and are expanding the full Medicaid program. One such state, California, would experience no changes in the number of lowincome women of reproductive age who are uninsured because other previously uninsured individuals are already covered under the state family planning SPA (at or below 200% FPL).
DISCUSSION Our findings show that the ACA should increase health insurance coverage and, thereby, expand access to essential preventive family planning services among low-income women of reproductive age. This analysis suggests that ACA will not eliminate the need for categorical publicly financed family planning programs to address the reproductive health needs of lowincome, uninsured women. Of the 310 million people in the United States, 62 million are women of reproductive age, 15 to 44 years.36 Our study found that approximately half (32 million) of these women will be in need (i.e., women aged 18–44 years who are at or below 250% FPL or female adolescents aged 15–17 years who need confidential services). Based on states’ Medicaid expansion plans (as of May 2014), more than 2.5 million low-income women of reproductive age without insurance will be at risk for unintended pregnancy and may need family planning services. The estimated cost of providing direct services to these women is $737 million in 2016. In fiscal year 2014, Title X is funded at $286 million, less than half that level.5,37 Multiple streams of funding have historically supported the Title X network. In addition to
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funding from the Title X program (21% or $267.1 million) and Medicaid (40% or $498.7 million), Title X centers reported substantial funding from state and local governments (16% or $204.5 million) in 2012.10 Many states also support family planning services through grant programs and provided 10% of Title X centers’ revenue in 2013.38 Thus, to sustain the critical services provided by Title X centers and provide a continuum of care for uninsured women, our results suggest that there will remain a need for publicly funded programs for family planning services, including both Title X and state-funded grants.
This analysis also documents the important role of the Medicaid family planning waivers or SPAs and how they can mitigate the impact on family planning in states that decide not to expand the Medicaid program. Our findings underscore the important partnership between Medicaid and Title X in creating a safety net for low-income women. As of May 2014, 24 states elected not to expand Medicaid.35 Of these states, only 6—Indiana, North Carolina, Oklahoma, South Carolina, Virginia, and Wisconsin—have Medicaid family planning SPAs, and 7 have Medicaid family planning waivers (Alabama, Georgia, Louisiana, Mississippi, Missouri, Montana,
and Pennsylvania).13 Title X service sites could be particularly vital to filling gaps in Medicaid coverage in the remaining states (Alaska, Florida, Idaho, Kansas, Maine, Nebraska, South Dakota, Tennessee, Texas, Utah, and Wyoming). The cost of direct services is only part of Title X’s mandate. Title X also plays a central role in maintaining the operational infrastructure for family planning services, including the availability of a cadre of trained providers, the presence of service sites in underserved areas, and onsite provision of contraceptive supplies. Many Title X sites also provide a broader range of
TABLE 3—Projected Impact of the Patient Protection and Affordable Care Act and Medicaid Expansion on Insurance Coverage and Costs Among Low-Income Women (£ 250% Federal Poverty Level) of Reproductive Age (15–44 Years) for 4 Selected States: United States, 2009 vs 2016
Family Planning Expansion Programa
Scenarios, Low-Income Women of Reproductive Age
Medicaid Expansion
Medicaid Expansion, as of 2016 2009b
Nonec
Partiald
Fulle
Tennessee No
No
Traditional Medicaid eligibilityf: with children, 122% FPL; without children, NE Total, no.
703
721
721
721
Uninsured,g no. Uninsured in need of family planning
186 105
113 63
113 63
80 43
24 778
17 896
17 896
12 431
Total, no.
470
483
483
483
Uninsured,g no. Uninsured in need of family planning
150 83
90 50
72 39
72 39
19 735
14 289
11 289
11 289
1 119
1 149
1 149
1 149
410
150
150
150
229
82
82
82
54 228
23 348
23 348
23 348
services,g,h no. Public cost to provide family planning services for uninsured,i $ Colorado No
Yes
Traditional Medicaid eligibilityf: with children, 106% FPL; without children, NE
services,g,h no. Public cost to provide family planning services for uninsured,i $ Georgia Yes
No
Total, no. Traditional Medicaid eligibilityf: with children, 48% FPL; without children, NE Uninsured,g no. Family planning expansion at 200% FPLa Uninsured in need of family planning services,g,h no. Public cost to provide family planning services for uninsured,i $
Continued
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TABLE 3—Continued California Yes
Yes
Total, no. Traditional Medicaid eligibilityf: with children, 106% FPL;
3 868
3 975
3 975
3 975
1 284
526
526
526
Uninsured in need of family planning services,g,h no.
711
286
286
286
Public cost to provide family planning
168 451
81 711
81 711
81 711
without children, NE Uninsured,g no. Family planning expansion at 200% FPLa
services for uninsured,i $ Note. FPL = federal poverty level; NE = not eligible. Values are in thousands. The selected states represent 4 possible scenarios affecting insurance coverage and family planning services a Family Planning Expansion Program consists of either a waiver to the state Medicaid program or a permanent state plan amendment that expands eligibility for family planning services. States considered to have a preexisting waiver if it was income-based (excluded those that were linked to pregnancy or for a limited time period). Based on status reported by the Guttmacher Institute.13 b Based on data collected through the 2009 American Community Survey Public Use Microdata Sample22 and projections provided through the US Census Bureau, “US Interim Projections by Age, Sex, Race, and Hispanic Origin.”23 c No Medicaid expansion: based on projections of states not expanding Medicaid, as of May 2014 (Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision.)35 d Partial Medicaid expansion: based on projections of Medicaid expansion, as of May 2014 (Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision.35 e Full Medicaid expansion: refers to expansion of the full Medicaid program, in accordance with the Patient Protection and Affordable Care Act of 2010.1 f For states with family planning waivers or SPAs, projections of uninsured women in 2016 consider the impact of expanded coverage through these programs. g Estimates of women in need of family planning services based on data collected through the National Survey of Family Growth, 2006–2010.16 “Women in need of family planning services” defined as women who are not pregnant, not seeking pregnancy, not sterile, and have had sexual activity. Need among insured adolescents aged 15–17 years further adjusted by the proportion of female adolescents who may stop using reproductive health care services because of confidentiality concerns. h Estimates of 2009 costs based on the national average revenue per user estimate collected through the Family Planning Annual Report,31 estimated at a national average of $237 per user in 2009. Estimates of 2016 costs based on the national average revenue per user estimate collected through the Family Planning Annual Report, estimated at a national average of $265 per user in 2012 and adjusted for the average national growth of personal consumption expenditures pertaining to medical products, for an estimate of $289 per user in 2016. i Based on Medicaid eligibility reported by the Kaiser Family Foundation (Heberlein et al.9).
preventive services; 28% of Title X centers report providing primary care services, and 13% have contracted relationships to provide primary care.39 Six of 10 women cite publicly funded family planning as their primary source of medical care,40 indicating that Title X clinics may fill an important need for both insured and uninsured women.
Limitations This study necessarily has limitations. We used a simulation model that projects insurance coverage in all states in 2016 based on data from Massachusetts in 2009. Similar to other simulation models, we assumed that future behaviors and outcomes may be predicted by trends observed in the past and that the distribution of residents’ characteristics in 2016 is akin to that in 2009. We adjusted results to account for ways in which Massachusetts differs from other states but
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might not have adequately controlled for variances in reform implementation across states. We used nationally representative data to estimate the potential universe of women who are in need of family planning services. As a consequence, these estimates were based on the responses at the point in time when the survey was administered and do not reflect possible changes over time and are not state-specific. We estimated the need for services for women but did not include the needs of men, who constitute about 8% of Title X clients.10 In our model, we adjusted for the proportion of female adolescents aged 15 to 17 years who may not access family planning services because of confidentiality concerns. However, because of the lack of reliable estimates, we were unable to adjust for confidentiality concerns among young adult women, aged 18 to 26 years, who may remain under parental coverage, as allowable under the ACA. This may have resulted in an
underestimate of the number of low-income women of reproductive age. In addition, we did not address changes in demand for contraception among low-income, uninsured women. It is plausible that demand for family planning services could rise over time because of increased awareness of available services. Cost estimates in this analysis used national data from the Title X administrative reports and may not fully account for state variation in family planning costs. We did not account for recent Supreme Court cases. The Supreme Court decision on Burwell v Hobby Lobby41 allows closely held for-profit companies to claim a religious exemption to the ACA mandate for contraceptive coverage, and a similar accommodation was offered to religious nonprofits. Although the final impact is not yet known, the number of women employed in such organizations is relatively small, so the expected impact ought not to be large. Overall, both not-for-profit organizations and
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for-profit organizations with religious affiliations may choose not to provide a full array of contraceptive options. We focused on changes in insurance coverage and did not directly measure changes in access to family planning services. Furthermore, we acknowledge that a range of barriers that were not addressed in this study may prohibit access to contraceptive services among low-income women of reproductive age, including, but not limited to, inability to prioritize reproductive health because of competing financial and personal needs, institutional barriers to women such as stigmatization and discrimination, and difficulty accessing health facilities because of transportation, hours, and service availability.42,43 However, previous evidence indicates that coverage is related to use of services16 and that coverage expansions can increase use of contraception and reduce unintended pregnancies.14,15 We also did not consider the quality and scope of contraceptive services offered through the available coverage. Although this model, like all models, has limitations, these estimates could provide insights about future policy impacts and health needs.
Conclusions The ACA expands health insurance coverage and enhances the affordability of preventive services, including family planning for the nation’s women, which may result in fewer unintended pregnancies and greater screening for other health needs. The need for programs such as Title X and similar state programs will likely remain. After Massachusetts’ health care reform to increase insurance coverage in 2006, the demand for publicly funded family planning services decreased by 10%.17 States that do not expand Medicaid will likely have larger gaps in coverage for women’s reproductive health needs than states that do. For millions of women, the publicly funded family planning programs, including the federal Title X program and related state-funded programs, could fill a critically important role in meeting their family planning needs. CONTRIBUTORS All authors participated meaningfully in the conceptualization and design of the research, writing, and approval of the article. E. M. August conceptualized and designed
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the study, conducted the statistical analysis, and drafted the article. E. Steinmetz conducted statistical analysis, provided technical support, and aided in the revision of the article. L. Gavin and L. Ku supported the conceptualization of the study, aided in interpretation of study findings, and provided critical revision to the article. M. I. Rivera and K. Pazol conducted statistical analysis and provided critical revision to the article. S. Moskosky aided in interpretation and study supervision and provided critical revision to the article. T. Weik aided in interpretation and provided critical revision to the article.
ACKNOWLEDGMENTS We thank and acknowledge Marion Carter, David Goodman, and Shanna Cox for their assistance and support in the formative development and conceptualization of this study.
HUMAN PARTICIPANT PROTECTION Institutional review board approval was not required because no human participants were involved in this study.
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