The federal government, which spends billions of dollars each year covering unintended pregnancies, is encouraging states to adopt policies that help boost the number of Medicaid enrollees who use highly effective long-acting contraceptives.
In California, that number is lower than the national average.
Unplanned pregnancies cost the federal government $21 billion in 2010, according to the most recent data available. That was about half of the total spent on publicly funded pregnancies overall.
Long-acting reversible contraceptives, or LARCs, refer to intrauterine devices and hormonal implants that, once inserted in the uterus or implanted under the skin, provide nearly complete protection against pregnancy for three to 10 years. In contrast, birth control pills are about 90 percent effective.
Although an IUD and its insertion may cost several hundred dollars up front, they’re cost effective because they last so long.
Still, overall adoption of these methods has been slow. About 11 percent of low-income women who were on Medicaid used a LARC in 2012, similar to the percentage of women overall who used this type of contraception.
In California, even fewer women on Medicaid use long-acting contraception — just 6.8 percent in 2014, according to the state’s Department of Health Care Services.
Last year, the agency received a federal grant to collect data on contraceptive use in women and report it back to federal health officials. The DHCS is also exploring strategies used by other states, such as specialty pharmacies to deliver LARCs directly to medical providers, a department spokeswoman said.
Under Medicaid, the state/federal health program for low-income people, states must cover family planning services for men and women without charge, but states have considerable latitude in determining which services and supplies they cover.
Generally, states have covered most methods of birth control, said Adam Sonfield, a senior public policy associate at the Guttmacher Institute, a research and advocacy organization focusing on reproductive and sexual health.
Access to long-acting contraceptives in state Medicaid programs can be hampered by policies related to how LARCs are paid for and how services are provided, the CMS bulletin said. It highlighted how some states are making changes to expand LARC use.
For example, it often is more efficient for a woman who has just delivered a baby to have an IUD inserted while she’s still at the hospital rather than wait until a post-partum visit several weeks later, which she might miss. But health care providers generally receive a bundled payment for labor and delivery services under Medicaid, which doesn’t include IUD insertion. A handful of states have implemented policies that now reimburse providers separately for inserting an IUD or implants at the time of delivery.
Another potential hurdle is the high up-front cost of long-acting contraceptives. This can be addressed by increasing payment rates to doctors to help provide incentives for them to buy and stock the devices.
Some state programs require that Medicaid participants try a different contraceptive method first before moving to a LARC, a practice referred to as step therapy, or they require prior authorization from a plan for long-acting contraceptives, which can delay or prevent women from getting that method, the bulletin said.
The Center for American Progress, a left-leaning think tank, in May published a study calling for the increased use of LARCs for Medicaid enrollees both immediately after birth and following abortion.
The recently published rule for managed care organizations that run many Medicaid programs addressed this. It said states can’t preclude enrollees from having a choice of contraceptive methods or impose prior authorization or step therapy requirements, said Mara Gandal-Powers, counsel for health and reproductive rights at the National Women’s Law Center.
“The language reinforces women’s access to the birth control method of their choice,” she said.
Many state Medicaid programs already make long-acting contraceptives available, said Deidre Gifford, director of state policy and programs at the National Association of Medicaid Directors.
As for encouraging more extensive use of LARCs, she said, “It’s not the most complex or labor intensive task, but it does involve some administrative oversight and work on the part of managed care organizations to make sure they get it in place and get it right.”
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