States are employing a variety of strategies across coverage, payment, and quality to provide access to different types of contraception for people with Medicaid coverage.
State Medicaid strategies for contraceptive care
Coverage
Alabama’s Plan First 1115 Demonstration Waiver has a goal of reducing unintended pregnancies. Specifically, the waiver expands coverage for family planning services to women whose Medicaid eligibility for pregnancy had ended and for low-income women who would not otherwise qualify for Medicaid unless pregnant. Income-eligible men over age 21 who wish to receive a vasectomy may also be covered under the demonstration.
New York’s Medicaid program covers nonprescription Plan B emergency contraception directly from a pharmacy, without the need to visit a physician or clinic. In 2017, in alignment with U.S. Food and Drug Administration guidelines, the state eliminated age restrictions on dispensing nonprescription emergency contraception.
Payment
In 2014, Oregon created an incentive measure for voluntary Effective Contraceptive Use, defined as the proportion of women enrolled in Medicaid ages 15 to 50 not currently pregnant and using an effective contraceptive method. From 2015-2020, Coordinated Care Organizations (CCOs) that met the measure benchmarks qualified for incentive payments. To reduce the risk of coercion, the incentive was at the CCO level, not the individual clinician or clinic level. The state also provided guidance to CCOs with strategies to increase voluntary contraceptive use. An evaluation found a consistent annual increase in contraceptive use among women enrolled in Medicaid. As a result of improvement, the state stopped using this metric in 2020.
Many state Medicaid programs have “unbundled” long-acting reversible contraceptive methods (LARCs) placed immediately after labor and delivery from the global maternity fee. For example, since 2014, the Georgia Department of Community Health, which administers Medicaid, has allowed hospitals to submit separate Medicaid reimbursement for the insertion of a LARC device provided immediately postpartum in a hospital setting.
Quality
Following a policy change unbundling LARC devices and insertions in the state Medicaid program, the Tennessee Initiative for Perinatal Quality Care launched a statewide quality improvement project in 2018 to increase access to LARCs during the immediate postpartum period. The project included provider and patient education with a focus on women-centered, non-coercive, comprehensive contraceptive counseling, along with a Tennessee State LARC Champion to work with the hospital. A report found that over 2,000 women were able to receive LARC devices during the project, which was active from 2018-2019 and is now in sustainment.
What are the health and economic benefits of contraceptive care?
Health
According to a 2011 study published in the New England Journal of Medicine, nearly half (45%) of all pregnancies were unintended. For women with low income, the rate of unintended pregnancies was higher, with 60% of pregnancies unintended among women with income below the federal poverty level.
Unintended pregnancy is associated with:
- Increased risk of health challenges for women and their babies, including postpartum depression, low birth weight, and preterm birth
- Lower likelihood of receiving early prenatal care.
Postpartum contraception helps prevent short interpregnancy spacing, which is associated with preterm birth, low birth weight, and small for gestational age infants.
Economic
- Medicaid paid for 41% of all U.S. births in 2021.
- Public insurance programs, including Medicaid, the Children’s Health Insurance Program (CHIP), and the Indian Health Service (IHS) paid for over two-thirds (68%) of unintended births in 2010.
- One study estimated that government expenditures on unintended pregnancies nationwide was $21 billion in 2010.
What is contraception?
Contraception, also known as birth control, is the use of drugs, barriers, or surgery to prevent pregnancy. Some types of contraception also protect against sexually transmitted infections (STIs), and some may help control painful, heavy menstrual periods. According to the Centers for Disease Control and Prevention, a wide range of contraceptives are available.
Reversible options include:
- Intrauterine contraception, including the Levonorgestrel intrauterine system (LNG IUD) and the Copper T intrauterine device (IUD), are inserted by a doctor one time, and they last 3 to 10 years. These are also called long-acting reversible contraceptive (LARC) methods.
- Hormonal methods include the injection or “shot”, combined oral contraceptives, progestin-only pills, patch, and hormonal vaginal contraceptive ring and are prescribed by a doctor. These methods are taken by the individual every day or every month; the shot is administered by a doctor every three months. The implant is another type of hormonal contraceptive that is a single, thin rod that is inserted under the skin of the upper arm. It contains progestin that is released into the body over 3 years and is also considered a LARC method.
- Barrier methods include the diaphragm or cervical cap, sponge, male condom, female condom, and spermicides. These methods need to be used each time a person has sex.
- Emergency contraception, including the copper IUD and emergency contraceptive pills, are not regular methods of birth control but can be used after sex without birth control or if the birth control method failed. The copper T IUD can be inserted within 5 days of unprotected sex and emergency contraceptive pills can be taken up to 5 days after unprotected sex. Some emergency contraceptive pills are available over the counter.
- Fertility awareness-based methods and lactational amenorrhea are birth control methods that can also be used to prevent pregnancy.
Permanent options include:
- Tubal ligation is a procedure in which a woman can have her fallopian tubes tied or closed at the hospital or an outpatient surgical center.
- A vasectomy is a procedure that cuts the supply of sperm to a man’s semen, so his ejaculate never has any sperm in it that can fertilize an egg. This procedure is usually done in an outpatient surgical center and the man can go home the same day.
This product was made possible through generous support from Arnold Ventures.