Pennsylvania Gov. Tom Corbett recently unveiled Healthy PA, his proposed alternative to Medicaid expansion. Within hours, health policy experts were panning the plan, calling it “unnecessarily punitive toward potential enrollees” and “laden with red tape.”
Experts say one of the big problems that hasn’t been discussed yet is that it reduces access to affordable birth control for low-income women in Pennsylvania.
“[Corbett] is for no apparent reason, certainly not financial, changing family planning in Pennsylvania,” said Janet Weiner, associate director for health policy at the University of Pennsylvania’s Leonard Davis Institute. “And that’s a problem.”
The Affordable Care Act has been called “the greatest advance for women’s health in a generation” for pro-actively addressing women’s health issues, including providing access to birth control without co-pay. The mandate reflects a goal set in the U.S. Department of Health and Human Services’ Healthy People 2020 report to prioritize family planning in order to reduce “the negative health and economic consequences” that come with unplanned pregnancies.
But as currently proposed, Healthy PA undermines that intention.
Using Arkansas’ plan as a blueprint, Corbett presents Healthy PA as a free-market alternative to traditional Medicaid expansion option as offered in the Affordable Care Act (ACA). Under the ACA, states are encouraged to expand access to Medicaid coverage, with the federal government picking up the tab for the first three years, then paying no less than 90 percent on a permanent basis.
Instead of pursuing the ready-made expansion, though, Corbett submitted a 97-page waiver requesting the federal government let Pennsylvania use those funds to help low-income residents purchase privatized Medicaid insurance through state exchanges—which, in Pennsylvania, is run by the federal government.
The proposal includes a searching-for-work requirement. In order to receive coverage, un- and underemployed enrollees will have to prove they are searching for full-time work to receive benefits. Every expert RH Reality Check spoke with speculated this provision would not be approved. Many critics cite the fact that a similar requirement was rejected in Utah.
In any case, it is a solution in search of a problem.
“Seventy-five percent of individuals that qualify under the Medicaid expansion have at least one full-time worker in their household,” Antoinette Kraus, director of the Pennsylvania Health Access Network, told RH Reality Check.
With record-low approval ratings a year away from his re-election campaign, it seems Corbett is just playing to his conservative base. But playing politics will just slow down the overall approval process.
“Our neighboring states, starting January 1, will be able to get coverage. This waiver process is probably going to take the better part of the year. So now we’re still going to have a half a million people without health insurance coverage,” Kraus said.
The proposed private option would also require, for the first time, that Medicaid recipients earning more than 50 percent of the federal poverty line pay monthly premiums (with exceptions for pregnant women, people with disabilities, the elderly, and residents of institutions).
However, the federal government rejected a similar proposal in Iowa. According to the New York Times, “Federal officials said Iowa could charge only those with incomes above 100 percent of poverty.”
Under the new plan, premiums will be required to be paid a month in advance, with the state sending monthly invoices to recipients. Reduced premiums incentivize enrollees to meet certain healthy-behavior objectives. But enrollees are also punished if they don’t pay on time. From the waiver:
If the eligible adult or household fails to pay their premium for the three subsequent months, the adult’s or household’s eligibility will be terminated.
The first time an enrollee misses three consecutive payments, they—and possibly their household—will lose their heath insurance for the next three months. Time frames for punitive denial of health care extend from there.
By wielding a lack of health care as punishment for non-compliance—for being too poor to pay the premiums—Healthy PA institutionalizes discontinuity of care for the working poor.
The results of haphazard access to preventative health care are predictable: a diabetic could go into shock, a mentally ill person’s condition may get worse, and a woman of reproductive age may become pregnant with an unplanned pregnancy.
Less than a year ago, the state conducted an analysis of its own data and concluded that providing poor women with more access to contraception improved health outcomes and was cost-effective for taxpayers.
Despite these findings, Healthy PA, as proposed, reduces low-income women’s access to contraception.
Pennsylvania Touts Success of Birth Control Program It’s Now Cutting
Currently, the state offers a plan called SelectPlan for Women. SelectPlan enables women who earn up to 185 percent of the federal poverty line to access free contraception and related reproductive health services such as pap smears, sexually transmitted disease screenings, and associated lab tests—even emergency contraception.
SelectPlan began as an experiment in distributing Medicaid funds in a specific population to achieve a better overall public health result. In bureaucratic terms, that meant it was a Medicaid “demonstration” project. All demonstration plans have five years to prove their value to the Center for Medicare and Medicaid Services (CMS). Initially approved in 2007, SelectPlan was scheduled to expire in May 2012.
In a report submitted to the CMS requesting renewal of the program just last April, the Pennsylvania Department of Public Welfare outlined the program’s resounding success. The DPW concluded that providing poor and working women consistent access to birth control significantly decreased unplanned pregnancies, saving the state millions of dollars in Medicaid funds on maternity, delivery, and newborn care.
Pennsylvania’s results echoed those found by a meta-study of the 22 states that expanded eligibility for family planning services under Medicaid between 1997 and 2011 thanks to “a long-standing provision of the Medicaid statute allows states to claim federal reimbursement for 90% of the cost of these services and supplies.” In fact, it’s the clear cost-effectiveness of subsidizing family planning in almost half the states in the country that informed facilitating access to these services under ACA in the first place.
In Pennsylvania, state data shows that between 2008 and 2010, the approximately $23.7 million spent on birth control and related services for 64,885 women earning between 100 percent and 185 percent of the federal poverty line prevented 7,061 unwanted pregnancies, saving Medicaid $113.8 million in payments for maternity, delivery and newborn care. (It is unclear if the estimated number of births resulting from unplanned pregnancies factors in the percentage of women who would have chosen abortion under the circumstances.)
According to the state’s own report, increasing access to contraception for low-income women improved the health outcomes of women and babies. Contraception helps women space pregnancies, and successive closely-spaced pregnancies can lead to pre-term births—a problem that is at crisis level in Pennsylvania and especially in Philadelphia, where 40 percent of babies are born pre-term.
Now, just months after demonstrating a compelling government interest in increasing access to birth control, that state is planning to drop the program to make way for Healthy PA. SelectPlan is currently scheduled to expire in June 2014, according to a spokesperson for the Department of Public Welfare.
Healthy PA Cuts Women’s Access to Contraception
The proposed start date for Healthy PA is January 1, 2015. It’s unclear what benefits women currently enrolled in SelectPlan will receive between June 2014 and January 2015. (The DPW was unable to respond to a request for comment before publication.)
It’s also altogether unclear what will happen to the women who fall into gap—women earning between 133 percent (the cap to qualify for Healthy PA) and 185 percent (the cap to qualify for SelectPlan) who can still not afford to purchase coverage through the exchange.
According to Corbett’s proposal, women currently on the plan with earnings at or below 133 percent of the federal poverty line will be rolled into a private subsidized Healthy PA plan, which will require paying premiums and wields access to health care, including contraception, as punishment for not meeting various conditions. (It’s worth noting here that many women who take birth control pills do so for reasons other than preventing pregnancy.)
The cumulative result is less access to affordable, consistent birth control for the poor working women of Pennsylvania—which, as the federal birth control mandate demonstrates, is counter to the intention of health-care reform.
Meanwhile, Corbett has spent his administration strategically reducing poor women’s access to other free-market contraceptive services by shutting down freestanding clinics that also provided abortion services. In 2012, after the state passed new regulations requiring freestanding abortion clinics to comply with guidelines developed for ambulatory surgical centers, three freestanding clinics closed “voluntarily” and another closed because it could not afford the renovations required to comply with new regulations. There is no evidence that the new regulations improve patient safety.
State Rep. Brian Cutler (R-Lancaster), a leader in the Pennsylvania legislature’s unofficial “Pro-Life Caucus” recently announced he will be pursuing admitting privileges legislation in the wake of similar legislation passed in Texas that is likely to shut down a third of the state’s clinics.
While Pennsylvania reduces poor women’s access to contraception, unintended pregnancy rates among poor and low-income women are five times higher than for high-income women. The rates have been increasing in that group even as it declines in others, according to the Guttmacher Institute.
As per the DWP’s analysis, by reducing access to contraception, Healthy PA will likely increase the state’s expenditures on subsequent maternity, delivery, and newborn care for women who choose to carry unplanned pregnancies to term.