Wisconsin’s Victory on Medicaid Family Planning Waiver Brings Celebration and Caution


Wisconsin family planning advocates, providers, and citizens of reproductive age received another gift to be thankful for during the holiday season. Wisconsin became the first state in the nation to win approval of a Medicaid (MA) State Plan Amendment (SPA) — making our very successful MA Family Planning Waiver a permanent part of our MA plan.  Helping women and men protect their sexual health and future fertility; helping them take charge of timing their childbearing; helping them get testing and treatment for STDs; helping them complete their education and/or get the job training they need; these are perfect gifts in these tough economic times.

At the beginning of the year, Speaker-to-be John Boehner denounced inclusion of the plan in the American Recovery and Reinvestment Act to make it easier for states to expand their MA family planning programs saying it would not stimulate the economy. Speaker Nancy Pelosi seemed unprepared to make the economic argument for family planning services and President Obama pulled the language with a promise to bring it back later.

President Obama kept his promise. The Patient Protection and Affordable Care Act included language empowering states and the District of Columbia to have much easier access to federally-funded family planning services. In April, the Wisconsin Family Planning and Reproductive Health Association began working diligently with the Wisconsin Department of Health Services and the state MA program to enable and encourage an early application for an effective program.  Using blogs, letters-to-the-editor, web video interviews, and even a professional lobbyist, we tried to inform legislators and advocates from Wisconsin as well as from other states and the District of Columbia about the opportunity. We hoped to establish a context where legislative leaders and state employees would feel they had a solid basis to proceed with an MA State Plan Amendment in Family Planning.

Faced with an end-of-year expiration of our existing Family Planning Waiver and armed with convincing evidence of cost-efficiency, our pro-family planning administration in Wisconsin submitted a request to make our family planning program larger and permanent.  Wisconsin submitted a request before the Centers for Medicaid and Medicare Services even established the criteria. In an April 2010 RHRealitycheck.org blog, advocates set out our “recipe” for success:

  • Presumptive eligibility for immediate contraceptives and STD services.
  • Full eligibility must be processed quickly.
  • Income eligibility must be broad.
  • Covered comprehensive services must include most contraceptive methods and Emergency Contraception.
  • Eligibility for students and minors must be based on their own income.

On December 22nd Wisconsin’s application was approved.  Although there were a few points of negotiation and compromise on structural points, all of the ingredients in our “recipe” were included.  California and South Carolina have also applied for SPAs and are in the queue for approval.

The celebration is justified and the victory is truly monumental.  However, there is no time to be self-satisfied. In Wisconsin, a new anti-choice administration and an anti-choice legislature is almost certain to test the federal maintenance of effort requirements for the family planning program.  Although the program has established its cost-efficiency, ideologues are likely to try to use the budget pressures of a tough state economy as cover for efforts to dismantle the program.  Because they have repeated it so often, the opposition believes that access to family planning and sexual health care undermines parental authority and encourages promiscuity.

Although the political battles are formidable, I don’t think the ideologues at the gates are the greatest challenge ahead to family planning and reproductive health access.  I think our greatest challenge is our own vision for change in the new environment of primary preventive health care.  How will we make the transition to electronic health records? How will we collaborate with other primary care providers? Will we see ourselves or be seen as competitors and be marginalized by our unwillingness or inability to be a part of the emerging systems?  Even though Medicaid patients have a choice of provider for reproductive health care, how will we be their provider of choice? Are we ready to negotiate contracts with Health Maintenance Organizations (including state Medicaid plans) and to participate in the new Health Exchanges? 

These challenges cannot be trusted to fortune. While the opponents of sexual health care must be vigorously resisted, we must simultaneously articulate and achieve a new complementary role for family planning programs and clinics in the reformed health care world.  If we fail, the fault will not be our opponents or in our stars, it will be our own.

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  • arekushieru

    Glad to see that Wisconsin is the first to approve of this since it was the second state my ancestors from England moved to when they immigrated.

    However, I do have to say that I disagree with your conclusion.  Those who oppose abortion have long raised barriers to access to abortion under the guise of something else, as you, yourself, have noted, and ‘telemedicine’ would be no different.

  • nycprochoicemd

    I’m perplexed by this statement:

    I think our greatest challenge is our own vision for change in the new environment of primary preventive health care.  How will we make the transition to electronic health records? How will we collaborate with other primary care providers? Will we see ourselves or be seen as competitors and be marginalized by our unwillingness or inability to be a part of the emerging systems?  Even though Medicaid patients have a choice of provider for reproductive health care, how will we be their provider of choice?

    Are you talking about your family planning clinics?  This victory is a victory for all women and all providers, not simply family planning providers.  I actually would argue that you should educate primary care clinics about this benefit for their patients so they can take advantage of it.  Although stand-alone family planning clinics have a role, as more and more women attain full health coverage the task in the future is to transition away from independent, narrow spectrum family planning clinics and to begin to incorporate them into broader primary care systems.  Although family planning, STI, and cervical cancer screenings are the primary health care needs of many young women, we do them a disservice when we segregate these services from other health services.  I would argue that women with Medicaid would ideally *not* use your clinics, as they are eligible for more holistic care elsewhere, and that family planning clinics were always meant as a safety net for women without access to broad spectrum care.

     

    I think family planning clinics are amazing, and they fill an important role, but moving forward, as you suggest, their role will need to change.  This will be a benefit for women, as long as they continue to have access to the same kind of excellent reproductive health care offered in the standalone clinics.

  • crowepps

    As I understand it, clinics which focus on family planning hire people who understand their job includes and who are willing to provide the various aspects of family planning.  This may not continue to be true if the women change their provider to a broad spectrum general clinic where doctors, nurses and other staff are entitled to restrict the information available to the patient only to that which the providers feel to be “moral”.

     

    I would agree with you that reproductive health care should be integrated into more general services IF there were some law that guaranteed “the same kind of excellent reproductive health care” generally, but the present state of the law segregates this one aspect of health care and makes this aspect of health care UNIQUELY optional, stripping patients of their right to request care and vesting in providers the right to withhold any information the providers don’t agree with, so that the providers are the ones who determine whether their patients are entitled to have sex, get permission to avoid pregnancy or can have the facts and details necessary to make decisions in cases of pregnancy complications.

     

    So long as providing family planning is considered optional for providers, and pregnant women can be considered non-persons enslaved by their fetus, it seems to me that rather than eliminating family planning clinics, it might be wiser to actually expand their role to cover other health areas and refer to specialists as necessary.

  • nycprochoicemd

    That’s a good point, crowepps.  Dedicated family planning clinics have been necessary partly because primary care providers have been unwilling or unable to provide the services.  I agree that family planning providers should start to build their practices to provide full spectrum primary care services, or should merge with primary care systems to ensure that women get holistic care.  As a family doctor, it pains me when women use family planning clinics as their primary care providers, because they’re missing out on a different model of comprehensive care where their entire family could be taken care of by the same doctor or by the same team.  But, as you point out, we’re far from that being the norm, and physicians are protected by conscience clauses when they refuse to provide family planning services.

  • crowepps

    The “different model of comprehensive care” is going to have find a way to publicly identify itself as nonjudgmental and patient centered before women will trust it.  Women have a history of patronizing doctors teaming with paternalistic husbands to decide what women were allowed to know.  Women were treated like children, and decisions were made on their behalf by people who did not really represent their best interests.  Most of us are not eager to return there.

     

    Doctors and medical staff have every right to sustain and act upon their own ethical and moral positions, but any assumption that their position entitles them to interfer with or dictate the  patient’s choices disqualifies them from providing “comprehensive care”.

  • lon-newman

    The discussion about the role of family planning clinics and programs, in the context of the larger primary preventive care system is very important and the comments here are very helpful and thoughtful.  I would like to add my thoughts briefly and do a longer blog on a vision for integrated sexual health care from a patient-centered community-based starting point at a later time.

    Family planning programs do several things in addition to providing clinic services and a strictly clinical “you come to us for services and we coordinate your care for you” model misses several very important aspects of the best outcomes for sexual health.

    Quickly and on a “bullet point” basis:

    * FP programs advocate (for example for this expansion of services under MA – for expedited partner treatment – for EC access in emergency rooms – for the right of patients to have their prescriptions filled) . . . what “pays the bills” is the clinical care and supplies – but it is mission that drives the victories

    * FP programs are community public health providers (educating communities and making reproductive health acceptable with a guarantee of access to comprehensive care

    * FP programs are focused on sexual health.  For example, every patient at our clinics is offered EC in advance and condoms with a reminder at every visit . . . not every primary care provider is equally committed to preventing unintended pregnancies and STDs

    * FP programs provide an option for people who, for many reasons, wish to seek a reproductive health specialist with a certainty of guaranteed confidential quality care – within Medicaid, patients have a right to a choice of provider for reproductive health care and there are very important reasons to empower patients in that way.

    * “Care coordination” should not require the patient to give up her right to choose her sexual health care provider —  it is, I think, an obligation of health care providers to (such as through meaningful use requirements for electronic health records) enable the patient to get the reproductive health care she wants or needs in a quality setting that is acceptable to her

    I agree that we do a disservice segregating family planning services from the primary care system, but integration should not mean absorption and neglect. With emerging standards of care and new systems for patient health records, the possibilities for patient-driven decision-making and collaboration between providers is wider not narrower.  

    I also agree that Wisconsin’s expansion of eligibility to family planning services is a victory for all men and women and all health care providers and for public health. 

  • lon-newman

    well, OK, I guess I don’t mind blaming our opponents — but the main thing is to take charge of our own destiny proactively to guarantee access to sexual health care in a rapidly changing primary health care system.