The push comes in the wake of the U.S. Supreme Court Hobby Lobby ruling that allows private employers to refuse contraceptive coverage and the Obama administration’s latest attempt to find a compromise to maintain access. The changes states are pursuing also come in response to growing evidence that making long-term birth control more available is a clear policy win.
This appears in the free Health e-newsletter. Click to subscribe.
“I think that what we saw was there was national attention focused on family planning and the availability (or lack of availability) of certain methods of birth control, and it was to us a perfect opportunity to launch our initiative so women on Medicaid know all methods of FDA birth control are available to them,” said Julie Hamos, Illinois’ Medicaid director.
Hamos is referring to forms of Long-Acting Reversible Contraception (LARC), such as intrauterine devices and implants under the skin, that last for years and don’t require any further action from women to be effective, unlike pills that have to be taken around the same time every day. LARC devices can be removed at the request of patients when they decide they want to have children.
A five-year study launched in 2007 by St. Louis’ Washington University has bolstered public health arguments in favor of LARC. More than 9,000 women ages 14 through 45 were educated on different contraception options and given a choice of method; 75 percent selected a form of LARC. Across all age categories, women who chose LARC had significantly lower pregnancy rates -- 20 times less than those using a pill, ring or patch.
Those findings and a growing awareness of the costs of unintended pregnancies first spurred a few states in recent years to evaluate Medicaid payment policies, which typically don’t pay doctors to insert LARC immediately after a woman gives birth. Studies show women who don't get LARC immediately after delivering a baby are less likely to come back for it later and far more likely to get pregnant in the next year. So more states -- including Illinois, New York and Texas most recently -- are trying to make Medicaid changes and help doctors deal with LARC's high upfront costs of $400 to $1,000.
That price is based both on the long-term nature of the contraception, its high rates of effectiveness and the determination of manufacturers that Americans can afford to pay for it. The price also reflects the high public costs of unintended pregnancy, which totaled $12.5 billion in 2008, according to the Guttmacher Institute, a research and advocacy group focused on reproductive health. About 50 percent of all pregnancies in the U.S. are unintended. The rate is even higher among teenagers, minorities and women with lower levels of education and income. Medicaid or other public health programs cover nearly two out of three unplanned pregnancies (about 1.1 million births). From a health standpoint, unplanned pregnancies are associated with delayed prenatal care, premature birth and other complications.
In Illinois, the state has historically paid for 50 percent or more of the cost of births to low-income women. That led Hamos, the Medicaid director, to pitch a plan in late August that doubles doctor reimbursements for LARC and vasectomies to encourage those procedures when patients want them. But the plan also requires doctors to talk about all family planning options, and it focuses on Medicaid reimbursement for long-term contraception within the same office visit or delivery.
Changing reimbursement policies, particularly to allow immediate post-birth insertion of LARC, requires changing the way Medicaid bundles together payments to allow doctors to charge the program separately so they’re not eating into the money they receive for delivering the baby. Only six other states -- Colorado, Georgia, Iowa, New Mexico, New York and South Carolina -- have taken that step or plan to, according to Eve Espey, a doctor who leads the LARC committee for the American Congress of Obstetricians and Gynecologists. New York was the most recent addition, announcing its move in July, and women’s health advocates say they expect others to follow.
But another key barrier, which Illinois is still trying to address, is the high cost of LARC for doctors. The state is talking with manufacturers about ways to make the implants and devices more readily available for doctors. Officials say there’s nothing concrete yet, but based on Medicaid history and what other states are doing, a deal could mean negotiating a discount or allowing doctors to avoid upfront costs by having pharmacies bill Medicaid directly upon request.
The latter is what Texas decided to do starting in August. Providers with Medicaid or the state’s women’s health program can order LARC from three pharmacies at no upfront cost instead of paying between $600 and $800 to a drug wholesaler.
There’s good reason for the state to shoulder that cost. For one, the payment rate from the federal government for Medicaid family planning services is 90 percent, as opposed to the usual average rate of about 50 percent. That applies to traditional Medicaid recipients, not expansion populations, which are covered at 100 percent for the next two and half years. Beyond that, there’s recent evidence that the cost is worth it.
A March study from the journal Reproductive Health found Medicaid spending was lower for women receiving LARC (even after accounting for the much higher cost of the method) than for pregnant women or those taking oral contraceptives. Colorado, which started a five-year initiative in 2009, saved a reported $42.5 million after its first year as teen pregnancy rates in particular started to plummet.
South Carolina -- the first state to initiate Medicaid changes in 2011 -- adopted a billing policy similar to Texas’ this March. Providers there have a 30-day window to use a LARC, which is delivered the day after it’s requested, or return it. The changes started as part of a wider birth outcomes initiative that’s spawning similar efforts in New Mexico. But South Carolina’s campaign grew out of a deep budget deficit as a way to save money, after hospital groups and doctors pitched the idea as one of many to pursue. In a state noted for its conservatism, there’s been no political opposition to encouraging the wider use of birth control, says Melanie “BZ” Giese, the director of the state’s Birth Outcomes Initiative.
“We’re very conservative, but we’re also very rural and we’re looking to improve outcomes, and if that means a teenager gets to not have a pregnancy she didn’t want or didn’t expect, we have not seen opposition to that,” she said.
Health analysts expect attention on LARC to grow and more states to act. Political opposition could very well rise, said Joan Henneberry of Health Management Associates. South Carolina played it smart by couching the effort as part of a wider initiative and focusing on the cost element, Henneberry added.
“Once they had support for this overall quality goal in improving birth outcomes and reducing teen pregnancies, how they went about that wasn’t as big of a problem,” she said.