As of mid-September 2017, healthcare legislation in Congress was in a state of chaos. Congressional attempts to repeal and replace the Affordable Care Act (ACA) had seemingly failed over the summer, but Sens. Lindsey Graham (R-SC) and Bill Cassidy (R-LA) were leading a last-ditch effort before a September 30 procedural deadline.1 Simultaneously, Sens. Lamar Alexander (R-TN) and Patty Murray (D-WA) were working on bipartisan legislation to shore up the ACA’s health insurance marketplaces.2 Sen. Bernie Sanders (I-VT) introduced his vision for a single-payer U.S. health system, with 16 original Democratic co-sponsors.3 And in the background, the Trump administration was working to sabotage the ACA through such measures as gutting funding for the “navigator” program that helps people sign up for, understand, and use their health coverage.4
Amid this chaos, state policymakers around the country are pursuing changes to Medicaid that could have implications just as serious for access to healthcare, including sexual and reproductive healthcare, as anything proposed in Washington. The Trump administration has encouraged states to apply for research and demonstration “waivers” of federal law, particularly those that “build on the human dignity that comes with training, employment and independence” and “help working age, nonpregnant, nondisabled adults prepare for private coverage.”5 Medicaid waivers are nothing new, but conservative state officials are seeking approval — and appear likely to receive it — for changes that previous administrations had consistently rejected.6
Keep an Eye on Texas
Most directly alarming for reproductive health advocates is a pending application by Texas. Several years ago, Texas chose to forgo federal funding for its family planning program to exclude Planned Parenthood and other providers with ties to abortion. Texas now is seeking to reinstate federal funding for the program (“Healthy Texas Women”) with permission to carry over several policies that would be unprecedented under Medicaid.
First, Texas is seeking to exclude health centers that either provide abortion (with nongovernmental funds) or are associated with a provider that does so — a policy that would conflict with Medicaid law guaranteeing enrollees’ ability to receive family planning services from any qualified provider. Over the course of multiple years, the Texas policy has already been demonstrated to obstruct rather than facilitate women’s access to publicly funded contraceptive care, and if the federal government were to endorse the policy, it would establish a dangerous precedent for other states to follow.7
Second, Texas is looking to carry over an existing state policy that effectively requires minors ages 15-17 to obtain consent from a parent or legal guardian to receive publicly funded family planning services. Parental consent has never been permitted for family planning services under Medicaid, with good reason: It would impose a severe barrier for teenagers, many of whom might forgo needed family planning services if they could not get them confidentially, but remain sexually active and at risk of unintended pregnancies and sexually transmitted infections.
Broader Waivers Threaten Reproductive Health
Other pending Medicaid waivers would endanger reproductive health services in a less-targeted manner, as part of broader attempts to reshape Medicaid.8 Among other things, conservative policymakers are seeking to impose work requirements for some Medicaid enrollees; to limit how long an individual can enroll in Medicaid or to temporarily lock out enrollees for failing to follow Medicaid rules; to require mandatory drug screening and testing; to reverse efforts that have streamlined Medicaid enrollment; and to ramp up premiums and cost sharing. For example, a pending waiver application from Maine includes a work requirement, monthly premiums, and lock-out periods for “able-bodied” adults on Medicaid, including those enrolled in the state’s Medicaid family planning expansion.9
Work requirements, lock-out periods, premiums, and other eligibility limitations would constitute barriers to getting and staying enrolled in Medicaid and thereby would impede access to reproductive health services, interfere with continuity of care, undermine patient-provider relationships, and jeopardize patient health. These provisions also could be coercive, such as by providing financial incentives for Medicaid enrollees to choose long-term or permanent contraceptive methods because they may have coverage only for a short time or cannot pay further premiums or copayments.
Maine’s proposed premium requirement would be especially problematic as applied to the state’s Medicaid family planning expansion. Enrollees would be charged as much as $360 a year — an amount well above the average annual cost of providing publicly supported family planning care or what an uninsured woman might pay out of pocket for many forms of contraception. This premium requirement would dissuade people from enrolling in the state’s family planning expansion, leading them to rely on limited over-the-counter options or on subsidized care from safety-net providers that have limited grant funding.
- Kliff S, Cassidy-Graham: The last GOP health plan left standing, explained. Vox, Sept. 13, 2017. Available at: . Accessed Sept. 19, 2017.
- Levey NN. Bipartisan effort to stabilize health insurance markets is coming down to the wire. Los Angeles Times, Sept. 13, 2017. Available at: . Accessed Sept. 19, 2017.
- Sanger-Katz M. How the Bernie Sanders plan would both beef up and slim down Medicare. New York Times, Sept. 13, 2017. Available at: . Accessed Sept. 19, 2017.
- Eilperin J, Goldstein A. HHS slashes funding to groups helping ACA consumers enroll by up to 92 percent. Washington Post, Sept. 14, 2017. Available at: . Accessed Sept. 19, 2017.
- U.S. Department of Health and Human Services (HHS). Secretary Price and CMS Administrator Verma take first joint action: Affirm partnership of HHS, CMS, and states to improve Medicaid program. Available at: . Accessed Sept. 19, 2017.
- Hinton E, Musumeci M, Rudowitz R, Antonisse L. Section 1115 Medicaid demonstration waivers: A look at the current landscape of approved and pending waivers. The Henry J. Kaiser Family Foundation. Available at: . Accessed Sept. 19, 2017.
- Hasstedt K, Sonfield A. At it again: Texas continues to undercut access to reproductive health care. Health Affairs Blog July 18, 2017. Available at: . Accessed Sept. 19, 2017.
- Sonfield A. Efforts to transform the nature of Medicaid pose dangers for reproductive health. Guttmacher Policy Review 2017; in press.
- Hamilton R, Department of Health and Human Services, Maine. Letter to the Office of the Secretary of the Department of Health and Human Services re: MaineCare 1115 demonstration project application. Available at: . Accessed Sept. 26, 2017.