House Speaker Paul Ryan has stated that the House bill to repeal the Affordable Care Act (ACA), like its 2016 Congressional predecessor vetoed by President Obama, will include a provision that excludes certain providers that furnish abortions (other than those permitted under the Hyde Amendment) from the Medicaid program. Not only would such providers be excluded for family planning services; their exclusion would extend to the full range of Medicaid-covered services furnished in primary and preventive settings, such as breast and cervical cancer screening, mammograms, diagnosis and treatment of sexually transmitted diseases, and care management.
Although it is not named explicitly, Planned Parenthood is the focus of the measure. Over the past several years, 12 states have attempted to remove Planned Parenthood from participation in publicly funded health programs in order to starve the organization. Because federal courts have turned back state-level Medicaid defunding efforts on Medicaid statutory grounds, and because the Centers for Medicare and Medicaid Services also has declared such state efforts contrary to the federal law itself, Congress is now poised to make exclusion the law of the land.
How Would States Fill The Void?
Despite the health benefits and cost savings that flow from family planning, there can be little doubt that withdrawal of federal funding from excluded providers will adversely affect access to care. Through Medicaid, the federal government pays for family planning services at an enhanced 90 percent rate, far more generous than the regular federal Medicaid funding rate for covered services to traditional beneficiary populations. Facing a considerable budget hole, states would inevitably eliminate excluded providers from their Medicaid programs, a decision that in turn would carry grave access implications for beneficiaries.
Responding to this likely outcome, advocates of the Planned Parenthood Medicaid exclusion frequently point to community health centers as a readily available alternative; indeed, House Speaker Paul Ryan recently did so himself in a town hall session with constituents. But to assume that health centers are in a position to fill the void left by barring a health care provider of Planned Parenthood’s importance to Medicaid beneficiaries—even providers as attuned to the needs of their communities and accessible as community health centers—is simply wrong.
No matter what the specific circumstances around any particular community’s loss of a Planned Parenthood clinic may be, health centers will rally to expand care. This comes at a time when the overall demand on their vital but limited resources has never been greater. Indeed, the current health center grant funding faces a 70 percent reduction beginning October 1, 2017, if the special health center grant fund, first authorized under the ACA and later extended under MACRA, is not continued.
Even were grant funding to remain at current levels, the task health centers would face in hundreds of communities is enormous: in 332 of the 491 counties in which Planned Parenthood affiliates operated across the U.S. in 2010, Planned Parenthood cared for at least half of all women who depend on publicly funded family planning services from a health care safety-net provider. Closing Planned Parenthood clinics in these communities leaves health centers in a position of having to make up for the loss of health care among half or more of all women in these communities who depend on safety-net providers.
The Challenge of Ramping Up Health Centers’ Role in Family Planning
According to federal data in 2015 almost 1,400 community health centers operating in nearly 10,000 locations furnished comprehensive primary health care to 24.3 million patients, including 6.4 million women of reproductive health age. Between 2013 and 2015 alone, as the insurance reforms of the Affordable Care Act kicked in, the number of patients served by health centers grew by over 2.5 million or more than 10 percent. Nearly half this growth can be attributed to women of reproductive health age.
The hallmark of health centers is that they are designed to replicate family practices. All health centers provide family planning services, and all health centers provide related services such as cervical cancer screening and treatment for sexually transmitted diseases (STDs). But all health centers also care for virtually every type of patient, from newborn infants to the frail elderly. When a woman becomes a patient of a health center for her family planning needs, she also becomes a patient for her diabetes treatment, her dental care, and her allergies. Her spouse and children also become patients for all of their needs as well. In other words, a health center, unlike Planned Parenthood, does not specialize in any one type of care; its specialty is precisely its commitment to primary care generally. For this reason, health centers typically develop collaborative and reciprocal referral arrangements with other community safety-net providers, including for more advanced contraceptive services than a health center might offer through its own program.
Because health centers must think about the full spectrum of primary health care for all patients, the absence of a specialized safety-net provider such as Planned Parenthood would be deeply problematic. When health centers attempt to respond to a surge in demand, they must think about not just the specialized services lost, but all of the health needs of the patients who find their way to a health center, not to mention those of their families. Furthermore, because health centers must make all services available to the residents of their service areas, they must ensure that at every site they operate, patients have access not just to a particular type of care (either onsite or by referral back to one of the health center’s other sites) but to all health center services. As a result, the anticipated cost per patient served is far higher than family planning and related services alone; in 2016 dollars, each patient served by a health center cost more than $800.00 according to federal data. Some of these costs may be covered by insurance, but all health center services must be available regardless of their patients’ insurance status.
Health centers have become the go-to source of health care for the full complement of primary health care needs, including early childhood development, long-term support services, oral and mental health, and treatment for opioid use disorder. This reliance is well-founded; health centers are effective and efficient at what they do. But although health centers are nimble, they also operate under strict federal requirements. Regulatory considerations applicable to meeting expanded need are considerable. Health center service areas (which may be very large or highly concentrated depending on community configuration and population density) must be explicitly designated as part of their federal funding, and changes to the service area must be explicitly sanctioned by the federal government in advance. Health centers have more latitude to build capacity within an existing service area, but if a health center wants to add services, staff, or a new site, it has to have the resources and staffing to do this.
Two Possible Health Center Expansion Scenarios in Response to Defunding Planned Parenthood
Were President Trump to sign legislation immediately cutting of federal Medicaid funds for Planned Parenthood, two possible scenarios might emerge. In the first, a Planned Parenthood clinic that is forced to dramatically scale back its services or close may be located in a community health center’s established service area, thereby necessitating a further increase in health center capacity. In the second, the Planned Parenthood clinic may be wholly or partially outside the health center’s service area. Regardless of whether the first or second scenario applies in any particular instance, the idea that the health center would be able to swiftly close the treatment gap simply does not hold water.
The following is a rough description of what a health center would need to do to fill the void left by the loss of Planned Parenthood
Scenario 1: Planned Parenthood closes In a health center’s established service area
In this scenario, for a health center to respond, it would need to ensure that it has the capacity to do so. This means sufficient staffing to meet anticipated need, not just for family planning services but for primary care generally. Therefore, the health center would need to focus on not only filling the immediate gap resulting from the loss of Planned Parenthood but also its ability to meet the comprehensive range of primary health care, medical, and dental needs experienced by patients and their families. In other words, the expansion must meet full health center standards.
This is a tall order; a recent report from the National Association of Community Health Centers documents that every health center in the country is currently searching for one or more clinical staff, and that health centers now face a staffing gap equal to about 2 million additional patients served. Furthermore, were a health center to try to expand capacity by adding new sites or services, it would need sufficient working capital to be able to expand without pulling resources from its other services and patients. Adding capacity within the scope of a current grant does not mean more grant funding; many treatments may remain uncovered, and even for insured services, up-front resources are needed to get the service capacity built in advance. To the extent that new family planning patients translate into a much broader array of new service needs, many of these additional services—whether for family planning patients or their families—also would have to be accounted for.
Scenario 2: Planned Parenthood closes outside a health center’s established service area
In order to move into a new service area, a health center would need to show the Health Resources and Service Administration that it can do so without new federal funding, either at the time of expansion or thereafter (there has been no indication that the exclusion of Planned Parenthood will be accompanied by additional grant funding to support either expanded capacity or service areas; current funding is entirely accounted for by current services). Furthermore, a new service area proposal would need to be bid competitively only after full notice of a funding opportunity, and with competition open not only to existing health centers but to new entities that might want to become health centers.
This process could take a year or longer. In estimating the cost of an expanded service area, a health center would have to think about acquiring one or more sites, staffing and equipping the sites, and costs associated with coming into compliance with all applicable federal, state, and local requirements. It would also have to certify the site as part of the health center for insurance payment services, and ensure that services not available at the new site are offered through the health center at its other sites are available to all new patients. A considerable amount of start-up capital would be required — but again, even the grant funding health centers currently receive is under serious jeopardy. And the current health center staffing shortage would grow worse.
Thanks to Texas, the nation has experienced a dry run of sorts for the impact on medically underserved communities of excluding Planned Parenthood. Following that state’s decision to bar Planned Parenthood from its family planning program, the state turned to its community health centers to step into the breach, and they attempted to do so. Nonetheless, Medicaid family planning claims dropped by over 35 percent, and claims for the most effective form of long-acting contraception dropped significantly. In the wake of the exclusion, Medicaid births also rose.
These outcomes suggest that reducing access to family planning services carries adverse consequences for patients and public health, since unplanned pregnancy represents a basic health and social threat to babies, their mothers, and their families. Implicitly, at least, this study also suggests that despite the fact that they are the largest and most important part of the nation’s primary health care safety net, health centers cannot carry out this responsibility alone.