Washington Watch

Medicaid expansions for family planning progress

By Adam Sonfield
Senior Public Policy Associate
Guttmacher Institute
Washington, DC

In October 2011, Ohio became the seventh state to use new authority under the Affordable Care Act (ACA) to extend coverage for family planning services to women and men with incomes well above the state's standard Medicaid income eligibility ceilings.1 This move is notable because Ohio's "state plan amendment," slated to become operational as early as January 2012, will be the first entirely new expansion; the other six states had previously expanded their family planning coverage via a more burdensome and time-limited "waiver" process.

Ohio's move is also notable because it was made under the state's fiscally and socially conservative Republican governor, John Kasich.

In total, 24 states, which are home to 71% of women of reproductive age, have received approval from the Centers for Medicare and Medicaid Services (CMS), through a state plan amendment or a waiver, for a broad-based family planning eligibility expansion based solely on income, generally up to 185% or 200% of the federal poverty level.1,2 (Five additional states have limited programs offering family planning coverage to individuals whose general Medicaid coverage is ending.)

Over the past two decades, these programs, which collectively serve about 2.7 million clients annually, have yielded substantial benefits for women, families, and society, as documented in a new Guttmacher Institute report that draws upon national-level analyses and evaluation reports from almost every state with an income-based expansion.3

The services accessed under these expansions have helped to increase and improve the use of contraceptives, including the use of highly effective methods such as the Pill, injectables, intrauterine devices, and sterilization. Better contraceptive use, in turn, is reflected in measurable declines in unplanned pregnancy and teen pregnancy and improvements in pregnancy spacing. Reductions in unplanned pregnancy have resulted in substantial savings for the federal and state governments, with California alone estimating that its family planning expansion saved upward of $4 billion in a single year. And beyond this, the programs also have improved access to related preventive services, including Pap tests and sexually transmitted infection screening and treatment.

Outlining what works

The same Guttmacher report, drawing on evaluations and a survey of state officials, documents the strategies taken by states to reach out to potential clients and streamline the enrollment process. States have developed Web sites and telephone hotlines to help people learn about the family planning expansions and find local providers. Many states also have worked with family planning providers to conduct community outreach, coordinate outreach across public programs, and tailor messages and activities for young adults, Latinas, and other high-priority populations.

Almost all states, meanwhile, have simplified the application and renewal process by using a bare-bones application form and relying on public and private databases to verify information such as citizenship status and income. They have worked to enhance accessibility by allowing applications online, by phone, or by mail, without an in-person interview, with several states working toward real-time eligibility determination. States also have improved accessibility by facilitating applications at the point of service. California and Iowa pioneered an approach that allows clients to leave the provider's office officially enrolled in the program.

Most of the states also have worked to coordinate the application process for their family planning expansion with other public programs, such as the broader Medicaid program and food subsidies. At least eight of the states have automated the process of shifting some enrollees between their family planning expansion and broader Medicaid, most commonly for women otherwise losing Medicaid coverage after giving birth.

These same types of enrollment and outreach strategies will be central to efforts to expand Medicaid and private insurance coverage more broadly under the ACA, under the plans laid out by the law itself and a regulations being finalized by the Department of Health and Human Services.4-7

For that reason, state family planning officials and family planning providers should be key partners as states develop and implement these efforts. They should draw on experiences with their own expansion programs and those run by other states and provide valuable on-the-ground support.8 Moreover, it is in the best interest of the national family planning effort to help ensure the success of the ACA. Family planning providers today rely on scarce grant funding, such as Title X, to subsidize care for uninsured clients. Converting uninsured clients to insured ones can secure additional revenue to meet ever-escalating demands and costs.


  1. Guttmacher Institute, Medicaid family planning eligibility expansions. State Policies in Brief 2011. Accessed at http://www.guttmacher.org/statecenter/spibs/spib_SMFPE.pdf.
  2. Special tabulations of data from the Guttmacher Institute and the 2010 and 2011 U.S. Census Bureau Current Population Surveys.
  3. Sonfield A, Gold RB. Medicaid Family Planning Expansions: Lessons Learned and Implications for the Future. New York: Guttmacher Institute, 2011 (forthcoming).
  4. Public Law 111-148, March 23, 2010.
  5. 76 Fed Reg 41866–41927 (July 15, 2011). Accessed at http://www.gpo.gov/fdsys/pkg/FR-2011-07-15/pdf/2011-17610.pdf.
  6. 76 Fed Reg 51148–51199 (Aug. 17, 2011). Accessed at http://www.gpo.gov/fdsys/pkg/FR-2011-08-17/pdf/2011-20756.pdf.
  7. 76 Fed Reg 51202– 51237 (Aug. 17, 2011). Accessed at http://www.gpo.gov/fdsys/pkg/FR-2011-08-17/pdf/2011-20776.pdf.
  8. Sonfield A. Implementing the Affordable Care Act: enrollment strategies and the U.S. family planning effort. Guttmacher Policy Review 2011; 14(4):20-25.