Executive Summary

Since taking office, the Trump Administration has implemented a range of policies to curb immigration and enhanced immigration enforcement efforts. Amid this policy and political climate, immigrant families are reporting growing fears and challenges which are affecting their and their children’s health and well-being and have implications for organizations serving immigrant families and their broader local communities. This brief presents findings from discussions with service providers across sectors (including health, legal, and education), local officials, and parents in immigrant families in the San Francisco Bay Area and San Diego about issues facing immigrant families and providers in the current environment, how the local communities have responded to growing needs, and key priorities and opportunities identified for serving immigrant communities. It is based on roundtable discussions and interviews with service providers and local officials (referred to as providers throughout this brief) and focus groups with parents in immigrant families that were conducted by the Kaiser Family Foundation in Summer 2019. It finds:

Providers and families reported that the shifting policy and political environment has substantially increased fear and uncertainty among immigrant families, leading to negative effects on families and growing pressures on local organizations and communities. They noted that families, including children, have increased mental health needs, such as anxiety and depression, and are facing growing economic pressures that are compounded by fears of accessing public programs and services. Providers expressed concerns about the long-term negative consequences of the current environment for families and the potential implications of worsened health conditions and unrealized potential among the youth for the broader community. They also pointed to growing pressures on service providers and local communities, including stress and secondary trauma among staff serving families and increased challenges providing services, particularly legal support, to families in light of ongoing and uncertain policy changes. Providers and families noted that organizations and communities have shifted some resources and efforts away from longstanding immigrant populations to address needs of new migrants, who are often in crisis and need immediate support.

Families are decreasing use of programs and services due to fears. Families and providers pointed to a range of concerns among families about using programs and services, including increased risk of deportation, potential negative impacts on ability to adjust status and/or sponsor relatives, and being required to pay back benefits. Providers indicated that the administration’s changes to public charge and housing assistance policies have amplified fears. Providers and families reported that families are disenrolling themselves and their children from Medi-Cal (the Medicaid program in California) and other programs, and declining to renew or enroll themselves or their children in programs despite being eligible.

Providers described how the San Francisco Bay Area and San Diego communities have responded to growing needs among immigrant families by strengthening cross-sector relationships and enhancing services and supports. They highlighted a range of strategies including strengthening existing or developing new cross-sector relationships, expanding capacity in other sectors to provide mental health screenings and services, increasing services and supports in schools, identifying trusted individuals and organizations to communicate with and assist families, and providing support for staff in service organizations. Providers and families indicated that actions by state and local leaders and certain state and local policies have underpinned the community response.

Looking ahead, providers identified a range of priorities, including continuing to integrate and coordinate services and filling gaps in mental health care and legal support. They suggested continuing to strengthen cross-sector partnerships so they are sustainable over time; addressing gaps in mental health and legal services by facilitating connections to existing services and increasing the supply of providers over the long-term; and providing resources to meet the increased demands on non-profit organizations and local governments. Other key priorities they identified included maintaining access to health care as people disenroll from Medi-Cal; addressing shifting demographics and growing needs in underserved areas; educating and informing families, service providers, and legislators about ongoing policy changes; increasing access to data; and developing philanthropic approaches that respond to evolving needs. Providers also pointed to the role state leaders can play in framing public discussion of immigration issues and supporting efforts to address family needs and fill service gaps moving forward.

In sum, families and providers report that the shifting policy and political environment is leading to increased fears and uncertainty among immigrant families that have wide-ranging negative effects on families’ daily lives and health. The growing fears and challenges among families also are increasing pressures on service providers and local communities. The San Francisco Bay Area and San Diego communities have responded to growing family needs in many ways that center on strengthening cross-sector partnerships and relationships and enhancing services and supports for families and service providers. Looking ahead, providers view continuing to support cross-sector collaborations and addressing gaps in services, particularly mental health and legal services, as key priorities. Providers also highlighted an ongoing need for trusted information and education about policy changes for families and service providers. Providers pointed to varied ways state and local leaders and philanthropy can support efforts to address families and service organizations moving forward, and stressed that addressing these needs is key for preventing erosion of California’s progress advancing health.

Introduction

Since taking office, the Trump Administration has implemented policies to curb immigration and enhanced immigration enforcement efforts. Amid this policy and political climate, immigrant families have reported increased levels of fear and anxiety and challenges affecting their and their children’s daily lives, health, and well-being. Families’ growing fears and needs also have implications for organizations serving immigrant families as well as their broader local communities. This brief presents findings from service providers across sectors (including health, legal, and education), local officials, and parents in immigrant families in the San Francisco Bay Area and San Diego about challenges facing families and providers in the current environment, how the local communities have responded to growing needs, and key priorities and opportunities identified for serving immigrant communities in the future. It is based on policy roundtable discussions and interviews with service providers and local officials (referred to as providers throughout this brief) and focus groups with parents in immigrant families conducted by the Kaiser Family Foundation in Summer 2019 (see Methods box for more information). Blue Shield of California Foundation supported this work.

Challenges Facing Families

Growing levels of fear and uncertainty. Providers and families reported that families are fearful of raids and deportation and being separated from their children. They noted that these fears extend to children who worry about being separated from their parents as well as to people of varied immigration statuses, including legal immigrants. Fears are leading some families to limit daily activities such as driving and social interaction. Some individuals also are fearful of interacting with the police, leading to concerns among providers and families that individuals may be less willing to report crimes, including incidences of domestic violence. Providers pointed out that the fears among families are not new, but have become more intense in the current environment. Families and providers also described how increased discrimination and bullying in schools is leading some children to feel isolated and disconnected from the local community and noted that Muslim communities have been particularly affected by these issues.

Economic pressures. Providers and families described how many immigrant families have faced challenges paying their monthly expenses, especially as costs of basic needs continue to increase. They indicated that the current climate has exacerbated these economic challenges because it has led some individuals to lose jobs, resulted in more limited job options, and made some individuals scared to seek a job or go to work.

Housing challenges. Providers and families reported that continually rising housing costs in these communities are pushing families into crowded living situations and/or out of communities. Providers emphasized that families often have unequal housing relationships with landlords and landlords sometimes use threats of immigration enforcement to intimidate families, leaving them vulnerable to unfair and/or unsafe housing situations. They also stressed that the administration’s recent proposed changes to housing assistance policies would limit access to assistance for mixed immigration status families, further amplifying the housing challenges they face.

Increased mental health needs. Families, including children, are experiencing high levels of stress, anxiety, and depression due to increased fear and uncertainty, according to providers and families. Moreover, they described effects on behavior and health, such as problems sleeping or eating; psychosomatic symptoms, such as headaches and stomachaches; and worsened chronic conditions, such as asthma and diabetes. Providers noted that, for many individuals, these issues compound existing mental health needs stemming from histories of violence and trauma. Families recognized that they and their children might benefit from mental health care but pointed to stigma, cost, and lack of providers as barriers to care. Similarly, providers highlighted the large gap in available mental health services to meet growing needs, especially providers who can offer linguistically and culturally appropriate care.

Potential long-term consequences. Providers expressed significant concerns about the long-term negative physical and behavioral health consequences of the fears and growing mental health needs among families. They are worried that the current environment will contribute to worsened physical and mental health outcomes and limit potential future contributions, particularly among youth. They noted that these consequences would not only affect immigrant families but also their broader communities.

 

Decreased Use of Programs and Services due to Fears

Fears of accessing programs and services. Providers said that proposed changes to housing assistance policies as well as proposed changes to public charge policy (which were finalized after the roundtables, interviews, and focus groups were conducted and recently halted under a court order) have made families increasingly wary of enrolling in programs or seeking services for themselves and their children. Families have a range of concerns about participating in programs stemming from confusion and uncertainty about the changes, including fear of increased risk of deportation, negative consequences on ability to adjust status or sponsor other family members, and being required to pay back benefits. Providers reported that an increasing number of families are disenrolling themselves and their children from programs, including Medi-Cal (California’s Medicaid program), and not renewing or not enrolling in programs even though they or their children are eligible and are not directly affected by the policy changes.

Health and economic impacts of decreased program use. Providers noted that families’ decreased participation in programs further increases the economic challenges they face. The also pointed to negative effects on health resulting from decreased participation in Medi-Cal and other support programs, such as increased risk of food insecurity and worse health outcomes due to delayed prenatal care, lack of access to specialty care, and less continuity of care.

 

Impacts on Service Providers and Communities

Increased pressures on service providers. Providers noted that staff in service organizations often come from shared backgrounds and experiences of the families they serve and experience secondary or vicarious trauma working with families in the current environment. Moreover, addressing families’ growing needs has strained organizational capacity, especially since organizations were typically operating at full capacity before needs increased. Providers said they are operating in a reactive, crisis-response mode, leaving them little time or opportunity to strategize and plan. Moreover, they described how the constantly shifting legal and policy environment makes it difficult for staff to stay up-to-date on changes and leaves them feeling uncertain about how to advise families on some topics. Providers also pointed out that many staff in service organizations face their own economic challenges living in high-cost areas, making it difficult to retain staff.

Growing complexity and challenges associated with providing legal support. Legal services providers noted that they have experienced major increases in case volume over the last few years. At the same time, the length of time to process cases has increased, often extending beyond the duration of funding available to support the work. They also noted that the constantly shifting legal environment has made it increasingly difficult to stay up-to-date on policies and determine legal strategies, even for experts. Other challenges they pointed to included changes in fee waiver programs that have created new cost barriers to avenues of immigration relief and lack of sufficient mental health resources to conduct psychological assessments often required to support cases. Providers noted that, while there have been substantial increases in resources for direct legal support in recent years, many of these resources cannot be used to support operations or infrastructure development, making it difficult for organizations to expand capacity to address growing needs. They stressed that, overall, legal services capacity remains insufficient to meet current needs, and pointed to a particularly large gap in availability of bilingual providers.

Addressing needs of new migrants. Providers and families noted that organizations and communities have shifted some resources and efforts away from longstanding immigrant populations to address needs of new migrants, particularly in border regions. Because newcomer populations are in crisis, organizations have focused on providing protection and crisis management for these groups. In addition, legal services providers have redirected some support to newcomers because they may have pathways to legal status, for example, through asylum, while opportunities for longstanding immigrants to naturalize or adjust status have become more limited due to declines in fee waivers and other policy changes.

Immigration enforcement in border areas. San Diego providers noted that, because they are close to the border, deportation can happen rapidly leaving little time for intervention or defense. Moreover, they indicated that the presence of interior checkpoints and controls and visible presence of Immigration and Customs Enforcement (ICE) and Department of Homeland Security (DHS) agents in the community increases fears among families and leads some to limit their activity and travel within the region. They emphasized that when agents bring individuals in custody to hospitals for care it raises fears among other patients and creates challenges for health providers, who lack clarity on their and their patients’ rights and health privacy rules in these situations. Providers further noted that federal officials have enhanced authority in border regions, such as being able to enter private property and interrogate without a warrant. Providers also pointed to the unique needs and challenges of binational families in border areas and indicated that it has become increasingly stressful for these families to cross the border, including children who cross the border daily for school.

 

Successful Strategies and Lessons Learned

Strengthening cross-sector partnerships and collaborations. Providers described a range of new cross-sector partnerships and relationships that have developed in recent years to provide more coordinated and integrated services to meet families’ needs. Some examples they cited included health care and legal services partnerships, a legal services provider working with a social worker to enhance support for families, a dental health clinic adding an on-site mental health counselor, and a legal services provider hiring a psychologist. Providers stressed that building on existing organizational strengths and capacities and existing partnerships or collaborations helps prevent duplication of efforts. They noted that public-private partnerships can be particularly effective since supportive local agencies can facilitate access to funding and communicate needs to the state, and community-based organizations have strong connections with the community. In San Diego, providers pointed to development of the rapid response network—a coalition of human rights and service organizations, attorneys, and community leaders—as key to supporting the community response, which has included creating a new shelter and providing health care and other services to asylum-seekers. Providers further noted that the rapid response network has facilitated the ability of local legal services providers to coordinate and prioritize their legal support to families, which has contributed to more efficient and effective use of funds.

Expanding capacity in other sectors to screen for and address mental health needs. As noted, one of the key challenges identified by providers and families is lack of sufficient mental health services to meet family needs. To help address this gap, some providers in other sectors have expanded their focus on and capacity to address mental health needs. For example, one provider described participating in a training for health care providers, including primary care providers and pediatricians, to provide mental health screenings and basic mental health treatment as part of their scope of care. It was noted that expanding health care providers’ ability to provide mental health screenings and treatment increases access to care for families and frees up capacity of behavioral health providers to address more complex and severe cases. Providers also reported that a growing number of teachers and staff in schools are being trained to screen for and identify mental health needs and link families to services. Further, providers pointed to cross-sector training in how to provide trauma-informed care and recognizing a broad scope of services as mental health care, including indigenous forms of healing and community support groups, as strategies to help address mental health needs.

Enhancing services and supports in schools. Providers described a number of ways schools have responded to growing fears and uncertainties among families. For example, some schools have added signage and messaging designed to create a safe and welcoming space and trained staff on how to respond if enforcement agents come on-site or if a student reports detention of a family member. Providers also indicated that teachers and staff in schools are increasingly recognizing stressors and factors that may be causing students to be late or tired and responding to these issues by linking students to mental health and other services rather than punishing them. Providers pointed to movement within some schools to offer more services “inside” (i.e. school-based clinics) rather than referring students out to services since having services available on-site reduces barriers to care. However, they recognized that schools face financial and resource constraints that limit their ability to expand their services.

Identifying trusted individuals and organizations. Amid growing fears and uncertainties, providers and families noted that families trust few individuals and organizations. They indicated that churches and schools remain key trusted resources and described how clergy and faith leaders have assumed new roles helping families respond to and navigate different experiences, including detention or deportation of a family member. They recognized that health care providers and schools also serve as trusted resources for families, although, in some cases, families feel wary about sharing information about their family’s immigration status with their health care provider or children’s school.

Increasing support for staff in service organizations. Given the growing intensity and stress associated with serving immigrant families, providers reported it has become increasingly important to provide support to staff in service organizations. For example, some have implemented wellness initiatives and are providing counseling support for staff. Providers also described challenges retaining staff, particularly in high-cost areas, and some indicated they are focusing on increasing wages and enhancing equity in organizational leadership to increase retention.

State and local policies and leaders supporting families and providers. Providers and families described how certain state and local policies have underpinned the community response. For example, they noted that state and local sanctuary policies help families feel safe in their local communities and policies that protect people’s privacy and minimize requested information can facilitate access to services. Providers also explained how state and local leaders have taken supportive actions. For example, they noted that Governor Gavin Newsom has supported the community through symbolic actions, such as visiting the border, as well as through direct actions, by increasing state funding for services. Providers in San Diego described how leadership by a local council member was instrumental for establishing the new shelter for asylum-seeking families.

 

Future Priorities Identified by Providers Serving Immigrant Communities

Continued development of cross-sector partnerships and collaborations. Looking ahead, providers suggested building on networks and collaborations to expand integrated support for families. They noted that this entails identifying mechanisms and resources to make partnerships and collaborations sustainable over time and continuing to identify systems and structures to facilitate referrals and connections across sectors. For example, one provider suggested creating multi-sector resource centers that could serve as a central point to direct resources and for families to obtain a diverse range of services. Another suggestion was to expand training of community workers, such as promotoras and community health workers, to provide a broader array of multi-sector supports and linkages.

Addressing gaps in mental health and legal services. Providers highlighted the need to implement long-term strategies to expand the supply of mental health providers and immigration attorneys, particularly those that can provide linguistically and appropriate care. In the short-term, they pointed to strategies such as creating inventories of available services within a local area to assist with linking families to assistance, expanding capacity in other sectors to conduct basic mental health screenings and treatment, and incorporating more mental health services into schools. Providers also noted that, as border policies continue to evolve, they are examining how to provide legal representation to people being required to wait on the other side of the border.

Meeting increased demands on non-profit organizations and local resources. As family needs have evolved and increased, providers noted that non-profits have stepped in to meet new challenges and fill gaps, often without readily available funding. They further noted that, although there have been increases in funding for some services, funding often is tied to direct services, leaving non-profits without resources to support infrastructure development or operating costs. They suggested that flexible funding that meets organizations’ evolving needs, including resources to support infrastructure development and operating costs, would help in sustaining their ability to serve families. Providers also emphasized that local government is facing new demands, including responding to needs of new migrants and increased use of local resources and services as families disenroll from public programs.

Maintaining access to health care to prevent erosion of progress advancing health. Providers described how families are increasingly turning to informal support services as they disenroll from public programs. They stressed that maintaining families’ access to health care despite their disenrollment from programs would help prevent erosion of progress achieved advancing health through the state’s earlier coverage initiatives, such as its Medi-Cal expansion to pregnant women and children regardless of immigration status. Providers also noted that the state will likely face challenges implementing its new Medi-Cal expansion to young undocumented immigrant adults due to families’ fears about participating in public programs. They suggested that continuing education and messaging in the community could help promote enrollment and minimize disenrollment due to fears, but recognized that overcoming fears is challenging in the current environment.

Addressing shifting demographics and growing needs in underserved areas. Providers indicated that communities have emerging language needs, for example among a growing Mayan community, for whom they do not have sufficient language resources to meet. They also discussed how the displacement of families due to continually increasing housing and living costs has resulted in a growing number of families living in areas with a dearth of services to meet their needs.

Continuing to educate and inform families and service providers about policy changes. Families and providers said it is difficult to stay up-to-date on and understand continually evolving policies. They want more access to information about changing policies and their rights. Providers pointed to the ongoing need to educate staff in various organizations (e.g., health care providers, hospitals, schools, etc.) about their rights and how to respond if immigration agents come on site as well as to equip service providers with tools and information to communicate with families. In San Diego, providers stressed that legal analysis to provide increased clarity on how federal border enforcement authorities interact with state laws and health-related rules and rights would be helpful for health care providers.

Utilizing data to document needs and impacts of policy changes. Providers pointed to the need for more local and disaggregated data to understand different population needs and how the shifting legal and policy environment is affecting groups. They noted that non-profits generate data but often lack capacity to analyze it and suggested that community-based organizations can collaborate with universities or other research organizations to enhance analytic capacity. They emphasized that when community-based organizations engage in these types of partnerships, they have an opportunity to identify return benefits they might realize from engaging in the research—for example, one organization was able to increase screenings for patients through participation in a research project. They also emphasized the value of utilizing a community-based framework for research that allows community-based organizations to serve as equal partners in the research.

Recognizing the role of philanthropy, state and local leaders, and communications strategies to address needs and frame public discussion. Providers suggested it is helpful for funders to recognize the full cost of projects by taking into account operations and administrative costs of grantees. They indicated that some funders are shifting toward multi-year operating grants to allow for more flexibility and responsiveness among grantees. Providers pointed to a number of areas where funding could be directed beyond direct services, including community building, communication strategies, data collection and research, and transnational work across the border. It was also noted that having a funding collaborative focused on issues affecting immigrant families facilitates a coordinated philanthropic response. Providers also pointed to the role state leaders can play in framing public discussion of immigration issues and supporting efforts to address family needs and fill service gaps moving forward. They also suggested that it will be important to continue to foster leadership development within the affected communities and discussed the value of focusing on the strengths and resiliency of immigrant families. They suggested incorporating voices from directly impacted groups into communications strategies and noted that funders could support these efforts through funding for ethnic and social media.

 

Conclusion

In sum, the findings from these roundtables, interviews, and focus groups illustrate that the shifting policy and political environment has substantially increased fears and uncertainty among immigrant families. As described by providers and families, these fears are having broad negative effects on families’ daily lives and health and well-being and increasing pressures on local organizations and communities. The San Francisco Bay Area and San Diego communities have responded to growing family needs in multiple ways, including developing cross-sector partnerships and relationships, expanding the focus on and capacity to provide mental health care in other sectors, enhancing services and supports in schools, identifying trusted individuals and organizations, and increasing support for staff in service organizations. Providers and families also indicated that state and local leaders and policies have underpinned the community response.

Providers identified a range of priorities to sustain and enhance support for families looking ahead, including continued development of cross-sector partnerships and collaborations; addressing gaps in mental health and legal services; meeting increased demands on non-profit organizations and local resources; maintaining access to health care; addressing shifting demographics and growing needs in underserved areas; educating and informing families and service providers about ongoing policy changes; increasing access to data; and developing philanthropic approaches that respond to evolving needs. They also pointed to the importance of messages that focuses on the strengths, resiliency, and benefits of immigrant families for their communities and the nation as priorities moving forward. As the ongoing national debate over immigration policy and enforcement continues, these discussions with service providers and families illustrate the effect it is having on immigrants themselves and the organizations that serve them.

 

 

For more than 50 years, a network of public programs and providers have assisted millions of low-income women of childbearing age in the U.S. to obtain sexual and reproductive health services. Medicaid, the Title X Family Planning Program, and Section 330 of the Public Health Service Act (PHSA) provide critical support to more than 10,000 safety-net clinics across the country that provide reproductive health services to low-income women, men, and teens. Since the 2016 election, state and federal efforts to restrict public funding to Planned Parenthood and other abortion providers and to funnel new federal funds to faith-based providers who oppose contraceptives and abortion have gained traction and begun to shift the family planning landscape across the nation.

One in three low-income women in the US relies on a clinic, either a health center, Planned Parenthood or other publicly-funded clinic to get contraception (Figure 1). These providers also offer STI screening and treatment services, and other preventive care and for some women are the sole source of their medical care. Medicaid, Title X, and other federal and government programs are critical sources of funding for these clinic-based providers. Poor women are more likely to experience an unintended pregnancy, have an abortion, contract a sexually transmitted infection (STI) and have less access to care than higher income women. In 2017, approximately 30% (21 million) of reproductive-age women lived in households that earned less than 200% of the federal poverty level ($40,840 for a family of three).

Over the past three years, policy changes at the state and federal level in Medicaid and Title X have restricted providers from receiving federal and state funds if they provide abortion services in addition to family planning care. This brief reviews the role of these public programs and providers in financing care and enabling access to family planning services. It also addresses the impact of actions taken by President Trump and Congress to block federal funds from Planned Parenthood and other entities that provide abortion.

Medicaid is the Primary Source of Public Funding for Family Planning

Medicaid, a jointly operated and funded federal/state program, covers more than four in ten (44%) low-income women of reproductive age, the leading source of coverage among this population (Figure 2). Across the nation, the share of low-income reproductive-age women enrolled in Medicaid varies considerably by state. These differences are the result of state choices about Medicaid eligibility, particularly whether the state has expanded Medicaid to all adults up to 138% FPL as permitted by the ACA and state-established income eligibility thresholds for parents in the non-expansion states. Coverage rates range from a high of 71% of reproductive age women in Vermont to a low of 22% in Utah (Appendix Table 1). In 2014, the most recent year in which national enrollment data is available, 19.1 million reproductive-age women were enrolled in the program. For these women, Medicaid provides comprehensive affordable coverage to help meet the full range of their health care needs, and guarantees that they will not have any out of pocket costs for family planning services and pregnancy-related care.

Medicaid accounted for 75% of all public funds spent on contraceptive services and supplies in 2015. Federal law stipulates that family planning is a “mandatory” benefit that states must cover under Medicaid, but provides states, with considerable discretion in specifying the services and supplies that are included in the program. Most state Medicaid programs make the full range of FDA approved contraceptives available to women, and nearly all cover counseling on STIs and HIV as well as screening for cervical cancer.

Other federal requirements that shape family planning policy under Medicaid include:

• The federal government pays 90% of all family planning services and supplies, and states pay 10%. This is considerably higher than the federal match that states receive for most other services, which ranges from 50% to 78%, depending on the state.
• Federal law prohibits cost sharing for any family planning (and pregnancy-related) services.
• States must allow “any willing provider” to participate in the Medicaid program unless there is “evidence of fraud or criminal action, material non-compliance with relevant requirements, or material issues concerning the fitness of the provider to perform covered services or appropriately bill for them.” While this provision is not specific to family planning, the policy means that states cannot bar providers from the program simply because they provide abortion services.
• Medicaid beneficiaries have “freedom of choice” to obtain family planning services from any provider participating in the program. For those enrolled in managed care plans, there is an additional protection, ensuring that beneficiaries may seek family planning services even if the provider is outside of the plan’s network.
• The Hyde Amendment prohibits any federal dollars, including Medicaid reimbursements, from being used to pay for abortions except in cases of rape, incest or life endangerment of the woman. Clinics, including some Planned Parenthood sites, which provide both family planning and abortion services, cannot be reimbursed with federal Medicaid dollars for abortions, but they can be paid for all services including contraceptives, cancer screenings, and STI testing and treatment.
• States may establish limited scope programs through Medicaid Section 1115 Research and Demonstration Waivers or through State Plan Amendments (SPAs) to provide family planning services to individuals who do not qualify for full-scope Medicaid. Today, more than half of states have established such programs (Figure 3).

Title X Funds Support Clinics That Provide Family Planning Services to Low-Income People

The Title X National Family Planning Program, a federal block grant administered by the HHS Office of Population Affairs (OPA), is the only federal program specifically dedicated to supporting the delivery of family planning care. The program funds organizations in each state to distribute federal dollars to safety-net clinics to provide family planning services to low-income, uninsured, and underserved clients. In June of 2019, approximately 4,000 clinics nationwide received Title X funding, including specialized family planning clinics such as Planned Parenthood centers, primary care providers such as federally qualified health centers (FQHCs), and health departments, school-based, faith-based, and other private nonprofits (Appendix Table 2). In 2018, two-thirds (65%) of clients seen at Title X clinics had family incomes at or below the poverty level, 38% were covered by Medicaid or another public program, and four in ten (40%) were uninsured.

Title X grantees must serve low-income populations at low or no cost, and have historically been required to provide clients with a broad range of contraceptive methods as recommended by the national Quality Family Planning Guidelines (QFP), and ensure that the services are voluntary and confidential. In addition to providing clinics with funds to cover the direct costs of family planning services and supplies such as contraceptives, Title X funds enable clinics to pay for patient and community education services about family planning and sexual health issues, as well as infrastructure expenses such as rent, utilities, information technology, and staff salaries. Title X clinics are also eligible to obtain discounted prescription contraceptives and devices through the federal 340B program. No other federal program makes funds available to support clinic infrastructure needs specifically for family planning. In contrast, Medicaid reimburses for specific clinical services.

Signed into law by President Nixon in 1970, the Title X program is currently funded at $285 million. The program budget, however, has not kept pace with medical price inflation over time. Clinics that provide family planning services have a mix of revenue sources, including grant funds from Title X and other programs, reimbursement for patients covered by Medicaid or private insurance, and some out of pocket payments from patients. Title X clinics received 19% of their revenue from the Title X grant, while Medicaid reimbursement accounted for 39% of revenue in 2018.

Over the past decade, the Title X program has experienced significant financial cutbacks due to federal budget reductions and freezes. In addition, some Congressional leaders have questioned the need to continue to fund the program, the types of services that the program can cover and the providers who qualify for funding. In March 2019, the Trump administration published a new regulation that alters the program significantly. In particular, the new rules block the availability of federal funds to family planning providers, such as Planned Parenthood, if they also offer abortion services with non-Title X funds. The regulation also prohibits Title X-funded providers from making referrals to abortion services for pregnant women seeking that care and requires providers that receive Title X support to refer all pregnant women to prenatal care even if a woman wants to terminate the pregnancy.

Currently, the new regulation is in effect, but it has been challenged by 23 states, major family planning organizations, and the American Medical Association in federal court, claiming the new rules violate the Constitution and federal law. As of October 2019, 18 of 90 grantees that had received funding in April 2019 are no longer participating in the program because they are unwilling to comply with the new federal regulations that limit their ability to provide clients with abortion referrals and block them from participating if they also offer abortion services. In addition, one quarter of the family planning (approximately 1,000 clinics) network no longer receive Title X funding to support family planning services to low-income women in the community and some states are no longer participating in the Title X program. The loss of Title X funding may force some clinics to close and others to reduce hours, services, and staff training.

Many Health Centers Offer Family Planning Services, but the Range and Volume of Services They Provide Varies

Under Section 330 of the PHSA, the Health Resources and Services Administration (HRSA) provides grants to health centers whose main focus is providing primary and preventive care to underserved and vulnerable populations. These clinics, called Federally Qualified Health Centers (FQHCs), are required to provide “voluntary family planning” services along with a wide range of health care services. Although it is not specifically defined in FQHC guidelines, voluntary family planning services can include preconception care, screening and treatment of STIs, and contraception. A survey of FQHCs found that virtually all reported they provided at least one method of contraception at one or more of their clinical sites.

However, research has documented differences between clinic types in their ability to offer direct access to the most effective contraceptive methods (Figure 4). For example, about eight in ten Planned Parenthood clinics (83%) and three-quarters of health department clinics (76%) can provide initial supply and refills of oral contraceptives on site, compared to one-third (34%) of FQHCs. Similarly, there are differences in capacity for family planning care within the FQHC network. In a 2017 Kaiser Family Foundation/ George Washington University study of FQHCs, 80-90% of centers that received Title X funds reported they provide LARCs, compared to just about half of FQHCs that did not receive Title X support (Figure 5).

FQHCs are paid using the Prospective Payment System (PPS), which is a higher rate to ensure their costs are coverage and clinics are fully reimbursed for Medicaid patient services, allowing them to utilize their federal 330 grant to care for uninsured and under-insured patients. FQHCs must have a sliding fee scale for patients with incomes below 200% FPL and offer services to all patients regardless of their ability to pay. Of those served in 2017, 69% lived at or below the poverty line, 23% were uninsured, and 49% were covered by Medicaid or CHIP.Similar to Title X clinics, FQHC funding comes largely from Medicaid payments, which made up 44% of revenue in 2017, followed by Section 330 grants (18%) and state, local, and private grants (38%).

Recent Federal and State Efforts Have Moved to Disqualify Planned Parenthood Clinics from Receiving Title X Support and Reimbursements under Medicaid

In the first three years of the Trump Administration, the President and many Congressional Republicans pursued multiple avenues to restrict public funds from going to Planned Parenthood and other clinics that provide both contraception and abortion services. In 2017, the Administration reversed an Obama era regulation that would have prevented states from blocking Title X funds from going to Planned Parenthood and other clinics that provide abortion using other funds. In 2017, every version of Republican legislation to replace the ACA included provisions that would have banned federal Medicaid payments to Planned Parenthood clinics. While none of these bills were enacted, this would have upended Medicaid’s “free choice of provider” requirement and would have resulted in a significant revenue loss for Planned Parenthood.

A common theme among proposals to block Planned Parenthood and other specialized family planning clinics from the Medicaid program is the redirection of funds to other providers, such as community health centers (CHCs), with the expectation that CHCs could meet the needs of those formerly served by Planned Parenthood. However, Planned Parenthood served approximately one-third (32%) of women seeking contraceptives at safety-net clinics in 2015. In contrast, while there are considerably more FQHCs (representing 54% of safety-net clinics), they served roughly the same share (30%) of women seeking contraceptive care as Planned Parenthood (Figure 6). CHCs and other remaining clinics would not likely be able to meet additional demands that would be placed on them to provide the full range of family planning services.

The impact of banning federal Title X funds and Medicaid reimbursement to family planning clinics would vary across the country. In some states there are very few Planned Parenthood clinics, while in other states they are the predominant provider for low-income people seeking contraceptive services. In 13 states, Planned Parenthood clinics were the site of care for over 40% of women who obtained publicly funded contraceptives.

Experience at the state level has shown that blocking Planned Parenthood from receiving Medicaid reimbursements or Title X funding reduces low-income women’s access to contraceptives. In 2013, Texas replaced its federally funded family planning waiver program with a 100% state funded program that excluded Planned Parenthood as a participating provider. Following the policy change, there was a sharp drop in the number of women served by the state’s program, and access problems have persisted. A recent study found that approximately one-third of publicly insured women in Texas reported difficulty finding a provider (36%) that accepts their coverage and locating a provider that offers services (33%). Furthermore, there was a sizable drop in Medicaid claims for IUDs, contraceptive implants, and injectable contraceptives (IUDs and implants are the most costly and effective methods) and an increase in Medicaid-funded births. In 2013, the Wisconsin legislature approved family planning cuts directed at Planned Parenthood, which resulted in the closure of five Planned Parenthood clinics in rural areas. Women who used the Planned Parenthood clinics were referred to other clinics that were usually further away with wait lists that did not provide the full range of contraceptive methods. A study conducted by Health Management Associates for Planned Parenthood concluded that women in seven Wisconsin counties would have no alternative family planning provider should Planned Parenthood centers close there.

Several other states have also attempted to limit public funds to clinics that provide contraception and abortion services, including Planned Parenthood. Three states – Texas, Tennessee, and South Carolina, have applied to CMS for a federal waiver to exclude abortion providers from their Medicaid networks for non-abortion services, while Arkansas and Missouri have already done so, despite the federal free choice of provider requirement. Several other states have blocked state and Title X funds to clinics that provide both family planning and abortion (Table 1). These restrictions were in place prior to the Trump Administration’s change to the Title X program, which affect the entire nation. Should the federal Title X rules get reversed in court, state-level limits would remain in place.

Looking Forward

Federal and state funding that supports Medicaid, the Title X program, and Section 330 of the PHSA is the financial core for safety-net clinics that provide family planning services to the uninsured and other vulnerable populations. This federal funding of family planning services and Planned Parenthood receives considerable public support. Almost nine in ten (86%) people say it is important for the federal government to provide funding for reproductive health services, including family planning and birth control for lower-income women, and 69% say they support continued federal Medicaid funding to Planned Parenthood for non-abortion services (Figure 7). The Trump Administration’s changes to health care policy under Title X as well as state actions to restrict funding to Planned Parenthood under Medicaid are still playing out, with the likelihood that they will create gaps in access for low-income individuals that rely on these programs for their family planning care.

Medicare Advantage plans have taken a large and growing role in the Medicare program over the past decade, with more than 22 million Medicare beneficiaries (34%) enrolled in Medicare Advantage plans in 2019, a private plan alternative to the traditional Medicare program. This brief provides an overview of the Medicare Advantage plans that will be available for 2020, based on an analysis of data from the Centers for Medicare and Medicaid Services (CMS). Findings include:

• Number of Plans. Nationwide, 3,148 Medicare Advantage plans will be available for individual enrollment for the 2020 plan year – an increase of 414 plans since 2019. The average beneficiary will be able to choose among 28 plans in 2020, up from 24 in 2019 (ES Figure). The number of Special Needs Plans (SNPs) will also increase from 717 plans in 2019 to 855 plans in 2020.

• Variation in Number of Plans. The number of Medicare Advantage plans will vary greatly across counties in 2020, from 31 plans, on average, in metropolitan counties to 16 plans, on average, in non-metropolitan counties. More than 60 plans will be available in six counties (in OH and PA), while no plans will be offered in 77 counties (accounting for less than 1% of beneficiaries) in 2020.
• Number of Firms. The average beneficiary will be able to choose from plans offered by seven firms in 2020, similar to 2019. Four percent of all Medicare beneficiaries will have a choice of plans offered by two or fewer firms while 24 percent will be able to choose from plans offered by 10 or more firms.
• Market Entrants and Exits. Thirteen insurers will be entering the Medicare Advantage market for the first time, and one insurer will be exiting in 2020. In all, well over 100 firms will offer Medicare Advantage plans in 2020.
• Extra Benefits. Nearly all beneficiaries (97%) have access to a Medicare Advantage plan that provides dental, fitness, vision, and hearing benefits, which are not covered by traditional Medicare. Many beneficiaries also have access to some transportation assistance (92%) and a meal benefit (96%), but some benefits are less frequently available, such as in-home support (54%), bathroom safety (49%), telemonitoring services (29%), and support for caregivers of enrollees (12%).

Plan Offerings in 2020

Number of Plans

Total Number of Plans. In total, 3,148 Medicare Advantage plans will be available nationwide for individual enrollment in 2020 – a 15 percent increase (414 more plans) from 2019 and the largest number of plans ever available (Figure 1; Appendix Table 1). These numbers exclude employer or union-sponsored group plans and Special Needs Plans, which are only available to select populations. Similar to prior years, HMOs continue to account for about two-thirds (64%) of all plans offered in 2020.

The growth in number of plans varies across states and counties, with the preponderance of the growth in plans occurring in California and Florida (61 more and 42 more plans, respectively; data not shown). Indiana and Puerto Rico will have 5 fewer plans available in 2020 than in 2019, while Utah will have 2 fewer plans, and Maryland and Hawaii will each have one fewer plan available in 2020 than in 2019.

While many employers and unions also offer Medicare Advantage plans to their retirees, no information about these plans is made available by CMS to the public during the Medicare open enrollment period because these plans are not available to the general Medicare population.

Special Needs Plans (SNPs). More SNPs will be available in 2020 than in any year since they were authorized, increasing from 717 plans in 2019 to 855 plans in 2019, a 19 percent increase (Figure 2). The SNP market may be an especially attractive market because potential overpayments to plans may be largest for those plans that are serving the sickest beneficiaries.

The rise in SNPs for people who require an institutional-level of care (I-SNPs) has been particularly notable, more than doubling from 69 plans in 2016 to 150 plans in 2020. I-SNPs may be attractive to insurers because they tend to have much lower marketing costs than other plan types since they are often the only available option for people to receive their Medicare benefits in certain retirement communities and nursing homes. The number of SNPs for people dually eligible for Medicare and

Medicaid (D-SNPs) has also greatly increased over the past five years (58% increase since 2016), suggesting insurers’ continue to be interested in managing the care of this high-need population.

Most SNPs for people with chronic conditions (C-SNPs) will continue to target people with diabetes, heart disease, or lung conditions in 2020, as has been the case since the inception of SNPs. In 2020, three firms will offer C-SNPs for people with dementia (up from two firms in 2019) and one firm will continue to offer a C-SNP for people with mental health conditions in California. Four firms will continue to offer C-SNPs for people with end-stage renal disease (similar to 2019) and two firms will offer C-SNPs for people with HIV/AIDS (similar to 2019).

Number of Plans Available to Beneficiaries. In 2020, the average Medicare beneficiary will have access to 28 Medicare Advantage plans available for individual enrollment, the highest number of plans available to the average beneficiary since 2011 (Figure 3). Among the 28 Medicare Advantage plans available to the average Medicare beneficiary, 24 of the plans will include prescription drug coverage (MA-PDs); 90 percent of all Medicare Advantage plans offered will include prescription drug coverage in 2020.

Variation in the Number of Plans, by Geographic Area. On average, beneficiaries in metropolitan areas will be able to choose from more than twice as many Medicare Advantage plans as beneficiaries in non-metropolitan areas (31 plans versus 16 plans, respectively). In ten percent of counties (accounting for 40% of beneficiaries), beneficiaries can choose from more than 30 plans in 2020, including four counties in Ohio (Mahoning, Medina, Trumbull, and Summit) and two counties in Pennsylvania (Bucks and Lancaster) where more than 60 plans will be available (Figure 4). In contrast, in 6 percent of counties (accounting for 1% of beneficiaries), beneficiaries can choose from two or fewer Medicare Advantage plans, including 59 counties in which only one plan will be available to beneficiaries. The number of counties with no Medicare Advantage plans will decline from 115 in 2019 to 77 in 2020. Additionally, no Medicare Advantage plans are available in territories other than Puerto Rico, similar to previous years.

Access to Medicare Advantage Plans, by Plan Type

As in recent years, virtually all Medicare beneficiaries (99%) will have access to a Medicare Advantage plan as an alternative to traditional Medicare, including almost all beneficiaries in metropolitan areas (99.9%) and the vast majority of beneficiaries in non-metropolitan areas (97%). In non-metropolitan counties, a smaller share of beneficiaries will have access to HMOs (81% in non-metropolitan versus 99% in metropolitan counties) or local PPOs (86% in non-metropolitan versus 95% in metropolitan counties), and a slightly larger share of beneficiaries will have access to regional PPOs (77% in non-metropolitan counties versus 72% in metropolitan counties).   

Number of Firms

The average Medicare beneficiary will be able to choose from plans offered by 7 firms, on average, in 2020, similar to 2019 (Figure 5). Almost one-quarter of beneficiaries (24%) will be able to choose from plans offered by 10 or more firms. Fourteen firms will offer Medicare Advantage plans in six counties: Los Angeles, Orange, Riverside, and San Bernardino counties in California, Cook County (Chicago) in Illinois, and Summit County (Akron) in Ohio. In each of these metropolitan counties, per capita spending for traditional Medicare and the share of beneficiaries enrolled in Medicare Advantage plans are much higher than the national average. In contrast, in 146 counties, most of which are rural counties with relatively few Medicare beneficiaries, only one firm will offer Medicare Advantage plans in 2020, a reduction from 194 such counties in 2019.

UnitedHealthcare and Humana, the two firms with the most Medicare Advantage enrollees, have large footprints across the country, offering plans in most counties. UnitedHealthcare is offering plans in 60 percent of counties, Humana is offering plans in 83 percent of counties, and both firms are offering plans in more than half of all counties (53%) in 2020 (Figure 6). More than 8 in 10 (85%) of Medicare beneficiaries have access to at least one Humana plan and 82 percent have access to at least one UnitedHealthcare plan.

New Market Entrants and Exits

Medicare Advantage continues to be an attractive market for insurers, with 13 firms entering the market for the first time in 2020, collectively accounting for about 7 percent of the growth in the number of plans available for general enrollment and about 5 percent of the growth in SNPs (Table 1). Ten new entrants will be offering HMOs available for individual enrollment. Five of the new entrants will be offering SNPs; three firms will be offering D-SNPs and two firms will be offering I-SNPs, including one firm (MoreCare) that will also be offering a C-SNP for people with HIV/AIDS. All of the new entrants are offering plans in one of ten states (FL, IL, LA, MI, NC, NY, SC, TN, TX, and VA).

Similar to prior years, some of the new entrants, such as Oscar and Troy Medicare, are funded by venture capital firms, joining about a dozen other venture capital-funded firms offering Medicare Advantage plans in 2020. While well over 100 insurers offered Medicare Advantage plans in 2019, only one insurer will be exiting the market in 2020, a sign that the vast majority of plans in the Medicare Advantage market are profitable. The exiting insurer had about 8,000 enrollees in Puerto Rico in 2019.  

Premiums

The vast majority of Medicare Advantage plans for individual enrollment (90%) will include prescription drug coverage (MA-PDs), and 49 percent of these plans will charge no premium, other than the Part B premium, similar to 2019. More than nine out of ten beneficiaries (93%) will have access to a MA-PD with no monthly premium in 2020. However, in three rural states (AK, MT and WY), beneficiaries will not have access to a zero-premium MA-PD, and in four other states (MD, SD, ID, and ND), less than half of beneficiaries will have access to a zero-premium MA-PD. The average premium for MA-PDs (not weighted by enrollment) will be $36 per month in 2020, down from $40 per month in 2019. Medicare Advantage enrollees typically choose low premium plans, and enrollment-weighted premiums are often lower than the average premium across plans.

Extra Benefits

Medicare Advantage plans may provide extra benefits that are not offered in traditional Medicare, and can use rebate dollars (including bonus payments) to help cover the cost of these extra benefits. Beginning in 2020, Medicare Advantage plans can offer extra benefits that are not primarily health related. Plans may also restrict the availability of these extra benefits to certain subgroups of beneficiaries, making different benefits available to different enrollees. Further research is needed to assess the comprehensiveness of coverage for these extra benefits, and the extent to which the benefits are only available to certain subgroups of enrollees.

Availability of Extra Benefits in Plans for General Enrollment. More than 80 percent of plans provide some dental, vision, hearing, or fitness benefits (Figure 7); nearly 6 in 10 plans (58%) provide all of these four benefits in 2020. One-third of plans (33%) provide some transportation benefit in 2020, and almost half (46%) provide a meal benefit, such as a cooking class, nutrition education, or meal delivery. Less than 10 percent of plans provide bathroom safety devices (6%), in-home support (4%), telemonitoring (4%), or support for caregivers of enrollees (2%).

Availability of Extra Benefits in Special Needs Plans. SNPs are designed to serve a disproportionately high-need population, and a somewhat larger percentage of SNPs than plans for other Medicare beneficiaries provide their enrollees with transportation benefits (84%) and meal benefits (60%). Similar to plans available for general enrollment, a relatively small share of SNPs provide bathroom safety devices (7%), in-home support (13%), telemonitoring (10%), and support for caregivers (8%).

Access to Extra Benefits. Nearly all Medicare beneficiaries have access to a Medicare Advantage plan with some extra benefits not covered by traditional Medicare, with 97% having access to some dental, fitness, vision, and hearing benefits in 2020. The vast majority of beneficiaries also have access to transportation assistance (92%) and a meal benefit (96%), but far fewer have access to in-home support (54%), bathroom safety (49%), telemonitoring services (29%), and support for caregivers of enrollees (12%).

Discussion

More Medicare Advantage plans will be offered in 2020 than any other year. Thirteen insurers will be entering the Medicare Advantage market for the first time, and only one insurer will be exiting the market, suggesting that the Medicare Advantage market remains an attractive, profitable market for insurers. As in prior years, some (mostly non-metropolitan) counties are less attractive to insurers, with fewer firms and plans available. Overall, less than 1 percent of beneficiaries will not have access to a Medicare Advantage plan in 2020, similar to prior years. With more firms offering SNPs and the number of SNPs rapidly growing, there may be greater focus on how well high-need, vulnerable beneficiaries are being served by Medicare Advantage plans, including SNPs as well as plans for general enrollment. As Medicare Advantage enrollment continues to grow, insurers seem to be responding by offering more plans and choices to the people on Medicare.