Editor’s Note: In a new blog post for The Commonwealth Fund, summarized below, Manatt Health examines the limitations some states have imposed on Medicaid-financed family planning services. The article also describes some potential actions the Biden Administration can take to restore Medicaid enrollees’ access to these essential services. Click here to read the full blog post.
Family planning services are critical to ensuring gender and racial equity and reproductive justice, and include but are not limited to contraception, pregnancy testing and fertility services. For many low-income women, particularly those living in states that have not expanded Medicaid, family planning coverage provides access to important preventive health services, such as cervical cancer screening and HPV vaccinations.
Despite the importance of these services, actions in recent years at the federal level and in some states have undercut access to family planning services, particularly for low-income women whose services are largely funded through Medicaid and the federal “Title X” grant program for family planning providers. The Biden Administration has proposed to unwind the Trump Administration’s so-called 2019 “gag rule” in the Title X program, which sharply reduced women’s access to family planning services by cutting off grant funding for any providers that offered referrals for abortion services, or that maintained any physical or financial integration with providers doing so. It remains to be seen, however, how the Administration will address similar restrictions that some states have imposed in their Medicaid programs.
State Actions That Restrict Access to Medicaid-Financed Family Planning Services
Medicaid is the largest source of public funding for family planning services. While Medicaid has long been barred by the Hyde Amendment from covering abortions except in very limited circumstances, long-standing federal law requires states to cover family planning services in their basic Medicaid programs and allows states to provide Medicaid-financed “family planning-only” coverage for low-income individuals who do not qualify for full Medicaid. In addition, the so-called “free choice of provider” guarantees Medicaid enrollees the right to seek family planning services from any willing and qualified provider.1
Some states have excluded providers that offer abortion services from participating in Medicaid. These providers are sometimes the largest—or only—local provider of comprehensive family planning services. States have pursued three primary strategies to exclude providers:
- Some states have categorically barred providers from offering Medicaid services if they also provide abortions to the general public. Courts have consistently blocked these efforts where enacted, but officials in other states continue to push these policies.
- Some states have specifically targeted individual Planned Parenthood clinics for termination from the Medicaid program. In 2016 guidance, the Obama Administration explained that it would violate the free-choice provision for a state to terminate a family planning provider “for cause” without sufficient evidence that it failed to meet the standards of the program. The Trump Administration rescinded that guidance, and certain states have forged ahead with termination efforts.
- In connection with optional Medicaid coverage authorized by Section 1115 demonstrations, four states have requested federal permission to prohibit participation by any providers that offer abortions. In January 2020, the Trump Administration approved Texas’s family planning waiver, and similar waiver requests are pending from Idaho, South Carolina and Tennessee.
Potential Federal Actions to Restore Medicaid Enrollees’ Access to Family Planning Services
The Biden Administration has the ability to reverse these access restrictions, by, for example, disapproving pending Section 1115 demonstration requests, revoking the approved Texas demonstration, reissuing guidance outlining federal free-choice requirements and initiating compliance actions in states that restrict access to family planning providers in ways not permitted by federal law.
The recently proposed reversal of the Title X gag rule may provide a signal as to the Biden Administration’s appetite for undoing family planning restrictions imposed by the prior administration. Advocates for sexual and reproductive health care are closely watching for these and other potential changes.
1 Section 1902(a)(23) of the Social Security Act generally allows Medicaid enrollees to obtain medical services from any provider that is “qualified to perform the service or services required” and that “undertakes to provide” such services. States that opt for a managed care delivery system are permitted to restrict enrollees to providers that participate in the managed care plan’s network. But even then, federal law preserves enrollees’ right to free choice of family planning providers, including those that do not participate in the plan’s network.