In the spring and summer of 2019, KFF, working with Health Management Associates, conducted interviews with clinicians, social service providers, community-based organizations, researchers, and health care advocates, as well as a focus group with low-income women in five “medically underserved” communities. Based on the interviews and focus groups, the study addresses how national, state, and local policies, as well as cultural factors, shape access to contraceptive care, sexually transmitted infection prevention and treatment, obstetrical care, and abortion services.

EXECUTIVE SUMMARY

• The Executive Summary provides an overview of the major findings and cross-cutting themes, and is available under the Executive Summary tab.

CASE STUDIES

• In-depth case studies of each of the five communities are available under the Case Studies tab or by clicking on each one below.
  • Dallas County (Selma), Alabama
  • Tulare County, California
  • St. Louis, Missouri
  • Crow Tribal Reservation, Montana
  • Erie County, Pennsylvania

NEWS RELEASE

• A news release announcing the publication of Beyond the Numbers: Access to Reproductive Health Care for Low-Income Women in Five Communities is available here.

BRIEFING

• On Thursday, November 14, 2019, KFF held a briefing to release Beyond the Numbers: Access to Reproductive Health Care for Low-Income Women in Five Communities. A recording of the event and presentation slides are available here.

KFF: Usha Ranji, Michelle Long, and Alina SalganicoffHealth Management Associates: Sharon Silow-Carroll, Carrie Rosenzweig, Diana Rodin, and Rebecca Kellenberg

Introduction

In Washington, DC, and in state capitols across the nation, policy debates over the future of access to reproductive and sexual health services are shaping the range of services and providers available to low-income women. Access to these services, including contraceptive care, sexually transmitted infection (STI) prevention and treatment, obstetrical care, and abortion services, have a profound impact on women’s lives. While instructive, national statistics can mask wide regional and local variation, as well as disparities across socioeconomic, racial, and ethnic groups. In order to understand what is happening at the local level, we went beyond the statistics to see how these policies are playing out in diverse communities across the United States.

Service availability and policies related to health care, contraception, and abortion vary significantly across and within states. State policymakers determine whether to expand Medicaid coverage to low-income adults under the Affordable Care Act (ACA), establish and fund family planning programs for uninsured residents, and adopt rules that regulate abortion services. These state policies also intersect with local factors; the number and distribution of family planning and safety net providers, the content of school-based sex education, cultural traditions of local populations, and underlying social determinants of health all shape access to reproductive health care at the community level.

Shifting federal policies and priorities add to already complex state and local dynamics. New federal rules related to the Title X family planning program, for example, directly affect which organizations can receive funding to provide family planning services to low-income and uninsured women, and indirectly affect the availability of other basic health services.

Recognizing the large disparities in access to health care across the country and the importance of the local safety net for low-income populations, KFF, working with Health Management Associates (HMA), undertook a study to identify distinct challenges that low-income women face in obtaining reproductive health care in diverse communities. The research team examined access in five communities across the United States that represent urban and rural areas, regions that are federally designated as medically underserved and health professional shortage areas, and areas that have faced closure and consolidation of family planning providers and hospitals. These communities also vary in demographic characteristics, and have populations that face health inequities such as low-income women, African Americans, Native Americans, immigrants, and refugees. The study team went to: Dallas County (Selma), Alabama; Tulare County, California; St. Louis, Missouri; Crow Tribal Reservation, Montana; and Erie County, Pennsylvania. Between February and September 2019, staff from KFF and HMA conducted structured interviews with local safety net clinicians and clinic directors, social service and community-based organizations, researchers, and health care advocates (“interviewees”) that work on a range of reproductive and sexual health issues in each of the communities. Additionally, at each site we convened a focus group with low-income, reproductive age women to understand their perspectives on the care they receive and the challenges they face. Through this combination of interviews and focus groups, we learned about the experiences of women living in these communities and the reproductive health professionals caring for them.

This report summarizes the major findings, highlighting cross-cutting themes and the degree to which low-income women in diverse communities face challenges in accessing reproductive and sexual health care. We also report on promising initiatives established by community providers to address barriers and improve access to these basic services. In-depth case studies of each community are available at https://www.kff.org/womens-health-policy/report/beyond-the-numbers-access-to-reproductive-health-care-for-low-income-women-in-five-communities.

Key Findings

Despite their differences, low-income women in these communities faced many similar challenges in accessing health care. While each community had distinct environments and features, the barriers to reproductive health services and factors contributing to those barriers were largely consistent, suggesting that these challenges and themes are prevalent well beyond the five communities studied. The key findings are categorized into five areas:

• Cultural and Social Determinants of Health: In each of the communities, poverty, cultural factors, and social determinants were identified as having a considerable impact on women’s ability to prioritize, afford, and get to family planning or abortion services. In addition, the residual effects of historical abuses by the medical establishment result in persistent mistrust of providers in some communities. This was most prominent among the Crow tribe and residents of Dallas County, AL; both communities still feel the legacy of a history of injustices such as forced sterilization upon many Native American women and the Tuskegee syphilis study in a neighboring community in Alabama.
• Coverage: Interviewees identified lack of coverage options for basic health care services for low-income women as a prominent challenge in states that did not adopt the ACA’s Medicaid expansion. Interviewees also identified ways to strengthen Medicaid to improve services available to enrollees, such as eliminating pre-authorization for certain contraceptive methods, increasing provider participation in the program, and improving systems to connect uninsured women to Medicaid-funded family planning programs.
• Provider Supply and Distribution: There are provider shortages in many communities, especially in expansive, rural areas. Interviewees said that challenges with recruitment and retention of clinical staff create access barriers for women. Many interviewees identified gaps in the availability of female clinicians, language translation services, and the need for culturally-congruent care.
• Sex Education: All five communities emphasized the need for comprehensive sex and STI education. A lack of information was said to leave many girls and women uninformed or misinformed about their reproductive health care, contraceptive options, and how to access services.
• Abortion Environment: Abortion was difficult to access in all of the communities. Stigma, anti-abortion beliefs, and policy restrictions at the state and/or community level shape the accessibility of abortion services. Policy restrictions, such as those in Missouri, Alabama, and Pennsylvania, that mandate counseling and waiting periods and bar insurance coverage for abortions dissuade providers from offering services and raise costs for women. Anti-abortion beliefs and stigma were also raised as barriers in Montana and California, states that don’t impose these types of abortion restrictions.

The discussion below highlights perspectives and lessons learned from health care providers, leaders of local support agencies, and low-income women about key barriers as well as how to improve access to reproductive health services.

Cultural and Social Determinants of Health

Despite the differences in the racial and ethnic composition of the populations, local histories, and state-level policies, this theme was prominent and overarching in all five communities. Increasingly, policymakers, advocates, payors, and providers are acknowledging the impact of social determinants such as housing instability, food insecurity, limited education and job training, crime and violence, and unmet transportation needs on health care access and outcomes. For example, a growing number of states are requiring Medicaid health plans to address social determinants of health as part of contractual agreements. Still, unmet needs related to poverty continue to create significant barriers to reproductive care. The increase in anti-immigrant sentiment and ICE raids, as well as long-standing discriminatory practices and negative historical experiences with the health care system, not only affect access to reproductive health services but also utilization and quality of health and social services.

Erie County, Pennsylvania

Located in northwestern Pennsylvania on the shore of Lake Erie, Erie County has one large city (Erie), several smaller communities, and a significant rural population. It has a relatively large population of refugees and immigrants. The Roman Catholic Diocese of Erie and the large Catholic population in the region influence both the health care and educational systems.

Poverty, a shortage of affordable housing, and lack of education and employment opportunities leave many women struggling to meet basic needs and with few resources to seek reproductive health services. Interviewees in all regions reported that socioeconomic stresses often result in women prioritizing food and shelter above preventive health care and family planning. One interviewee noted that multi-generational poverty locks women in situations that prevent them from making their own choices. Anxiety and depression are common among low-income women, yet all five communities faced gaps in behavioral health care and related support services.

Immigration status affects women’s willingness and ability to seek family planning, health, and social services. Immigrants who are undocumented or who are not proficient in English face heightened challenges in seeking services due to language barriers, fear of deportation, or concerns about jeopardizing their immigration proceedings due to changes in the public charge rule. Interviewees in Tulare and Erie Counties, both communities with sizable immigrant populations, reported that racism and fear of ICE have increased in recent years. In Tulare County, interviewees noted there have been ICE raids on domestic violence shelters across California and said that women who call to report abuse may not seek services for fear of deportation. Several focus group participants recounted experiences delaying or going without health or pregnancy-related care when they were undocumented.

Trauma, prior negative experiences with the health care system, and lack of cultural competency among providers discourage women from accessing reproductive care. Some focus group participants reported that health care providers pressured them to use contraception or to choose certain methods. Others reported providers dissuading them from using particular types of contraception – sometimes based on outdated research and practices or personal attitudes about ideal family size or the age of the patient. In each community, different cultural and historical factors interacted with access to reproductive health care:

Crow Tribal Reservation, Montana

The Crow reservation, located about 60 miles southeast of Billings, is the geographically largest American Indian reservation in Montana and home to about 8,000 members of Crow Nation. The Crow Tribal Council governs the Nation and Indian Health Services (IHS) is responsible for providing health services, although other coverage options and providers are also utilized. The reservation has high unemployment and poverty rates.

• Refugee communities – In Erie, Pennsylvania, interviewees explained that reproductive health and family planning preferences vary widely among the large refugee community, reflecting diverse religious and cultural beliefs. While many refugees face language barriers when seeking care, case managers, dedicated service agencies, and a Federally Qualified Health Center (FQHC) focus on providing culturally appropriate care to support women’s access to their preferred methods of family planning.
• African Americans in the rural south – In Selma, Alabama, some interviewees reported that the legacy of slavery and the Jim Crow era, historical mistrust of the medical establishment (exacerbated by the Tuskegee syphilis study in nearby Macon county), and an insufficient number of female clinicians of color contribute to lack of engagement in early and preventive care. Focus group participants and interviewees also noted the influence of conservative religious beliefs among many in the community, particularly with regard to sex outside of marriage and abortion.
• Crow tribe – Crow interviewees in Montana described traditional beliefs that emphasize modesty, discourage the discussion of sexuality-related topics, and hold that babies are always a blessing. These beliefs, along with historical negative experiences with the federal and state health care systems, such as the coerced sterilization of indigenous women in the 1960s and 1970s, affect utilization of family planning services among Crow women and teens.

Domestic violence interacts with sexual health. Several interviewees reported that women in abusive relationships often experience reproductive coercion in which their partners prevent them from using contraception or sabotage their chosen method. As a result, women are not able to make their own reproductive decisions, and some have had multiple children they did not intend to have.

Availability of Coverage

Thirty-six states plus DC have expanded Medicaid coverage to low-income adults without dependent children under the Affordable Care Act. In states that have not expanded their Medicaid programs, these adults generally do not qualify for full-scope Medicaid coverage.¹  While Medicaid income eligibility levels for pregnant women in all states are higher than for people who are not pregnant, pregnancy-related coverage typically ends at 60 days postpartum. Two of the five communities in this study, St. Louis, Missouri, and Dallas County, Alabama, are in states that have not expanded Medicaid. As a result, they have lower rates of Medicaid coverage than the other three communities, which are located in expansion states.

Figure 1 shows the insurance coverage profile of reproductive age women in Tulare County, the St. Louis region, and Erie County. Comparable estimates were not available for Dallas County and the Crow tribal reservation. All of the communities that were studied are in states with a Medicaid-funded family planning program that provides contraception to uninsured, low-income women, except Missouri, which offers an entirely state-funded program.² 

Women in states that did not expand Medicaid have limited options for obtaining coverage for basic health care services. Interviewees in St. Louis, Missouri, and Dallas County, Alabama, both in non-expansion states, reported that most low-income women have no coverage for preventive, acute, or chronic care outside of pregnancy (Figure 2). Annual income eligibility for parents in a family of three is capped at $3,839 (18% FPL) in Alabama and $4,479 (21% FPL) in Missouri. Parents with incomes above these limits do not qualify for coverage. Adults without children in these states do not qualify for Medicaid regardless of income, unless they have a disability or are over age 65. Additionally, federally subsidized coverage through the ACA’s Health Insurance Marketplace is only available to those with incomes above the federal poverty level. This means many of these individuals are not eligible for financial assistance to purchase coverage on their own, creating a coverage gap. Many focus group participants in Dallas County reported that when they need health care, they go to the emergency room, where they are not required to pay fees upfront and would not be turned away. While many knew about the FQHC in their community, they noted that even a sliding fee schedule was too costly for them.

Loss of Medicaid eligibility after childbirth for women who live in non-expansion states and the lack of automatic transitions to state family planning programs result in gaps in reproductive health care for low-income women with infants. Both interviewees and focus group participants reported that losing full Medicaid coverage at 60 days postpartum, or due to small changes in income, disrupts continuity of care and creates barriers to family planning and other health care services. Also, providers in Missouri said that the state’s policy that disqualifies clinics that provide or are affiliated with abortion providers from participating in Medicaid has reduced women’s access to family planning, as well as to abortion services.

Focus group participants and providers reported experiencing challenges with certain Medicaid rules and low reimbursement rates. There was clear consensus that Medicaid coverage is important for facilitating access to family planning services; yet some clinicians and focus group participants raised concerns with various Medicaid policies. For example, in St. Louis, providers said that state Medicaid rules tie coverage for long-acting revisable contraceptive (LARC) devices (IUDs and contraceptive implants) to specific patients; if a patient does not show for her appointment, the device cannot be used for another woman and may go unused, thus discouraging providers from stocking supplies and providing same-day access. The state has reportedly eliminated this requirement, but one provider noted that there were not yet any guidelines from the state to define or help facilitate the process. Across study states, providers also discussed low reimbursement rates as problematic, and women discussed their frustrations with having a limited range of providers who participate in the program.

Provider Supply and Distribution

All five communities studied are “medically underserved,” and are health professional shortage areas, designated by HRSA as having too few primary care providers, high infant mortality, high poverty, or a large elderly population. In recent years, many rural areas have experienced a spike in hospital closures or a reduction in obstetrical services, particularly in states that have not expanded Medicaid. This has forced women to travel long distances to see medical providers, particularly for maternity care. In addition, the emergence of federal and state restrictions on funding for reproductive health services is starting to limit the supply of providers that receive funding to serve low-income and uninsured women. The Title X national grant program funds local clinics to provide free or low-cost family planning services to uninsured and low-income individuals. In 2019, the Trump administration finalized new regulations that prohibit any sites that receive Title X funding from providing abortion referrals. They also mandate referrals to prenatal services for all pregnant patients, and require complete financial and physical separation from sites that provide abortion services. These rules were not in effect at the time of the visits to these communities, but some family planning providers that were interviewed raised concerns that such policies would result in a considerable reduction in the share of providers participating in Title X and jeopardize their ability to continue providing family planning services to low-income and uninsured women.

While most focus group participants reported that they know where to go for family planning services, some faced obstacles to obtaining their preferred method in a timely fashion, and others were misinformed about their contraceptive options. In Missouri, pre-authorization and limitations on reimbursement for LARC preclude women from obtaining these methods on the day of their initial visit. This was raised as especially challenging for low-income women who have to take time off work, arrange for childcare, or travel long distances to a clinic. Some focus group participants shared misgivings and concerns about the side effects and safety of LARC methods based on prior personal or friends’ experiences. Interviewees in multiple regions noted a lack of training in LARC insertions and removals among community providers. In Selma, the county health department was in the process of training a clinician to insert IUDs, but at the time of the site visit, women had to go to another county health department or private provider participating in the state’s family planning program if they wanted to get an IUD inserted. Plan B, emergency contraception that helps prevent pregnancy when taken within 72 hours of unprotected sex, was generally available in most communities. However, interviewees and focus group participants cited cost as a barrier to obtaining it over the counter, and some women confused it with medication abortion. Costs associated with family planning in general were often a barrier for women who are uninsured, undocumented, and recent immigrants. In Dallas County, Alabama, fragmentation of the health care system meant that low-income women must go to different clinics for contraception, primary care, and obstetrical care, though a rural health center is in the process of implementing a more integrated approach to serve women in the community.

Tulare County, California

Tulare County sits in the Central Valley, a partially rural and conservative area located in the heart of the agricultural region of California. One of the poorest counties in the state, Tulare County has large migrant worker, immigrant, and Latinx populations. Rates of sexually transmitted infections (STIs) and teen pregnancy are much higher than the state average.

Rural areas, in particular, face severe provider shortages and persistent challenges in recruiting and retaining clinicians trained to offer reproductive and sexual health services. Focus group participants and interviewees described shortages of family planning providers in the rural and low-income areas. They also reported insufficient numbers of providers offering STI testing and treatment, HIV care, obstetrical care, trans-competent and LGBTQ-friendly services, and a scarcity of abortion providers. Practice consolidation in Erie County has resulted in limited choices of obstetricians for those enrolled in Medicaid. At the time of the site visit, the IHS facility on the Crow reservation did not have an ultrasound technician, but they have since hired someone for this position. Interviewees in Alabama reported that the state’s restrictive Medicaid eligibility limit and low reimbursement rates have contributed to a series of hospital closures in the region. This has left the Selma-based hospital with the only maternity ward and obstetrics clinic in the seven-county region. Interviewees in Selma, Tulare County, and the Crow reservation cited challenges attracting physicians to rural, low-income regions, and retaining them after they complete medical school loan forgiveness programs. Telemedicine was identified by many interviewees as an emerging solution to address barriers in these areas, but upfront costs can hinder these efforts, and not all communities have access to broadband. At the time of this study, none of the communities offered reproductive health services using telemedicine beyond e-prescriptions.

Long travel distances and lack of public transportation in rural regions are major barriers to reproductive services, but transportation issues arose in urban communities as well. Women in some communities face logistical obstacles to obtaining services in a timely manner. This is particularly apparent in an area like Dallas County, Alabama, where many obstetrical care providers have closed, and there is no meaningful public transit infrastructure. Some focus group participants in Selma described having to pay friends or family to drive them to a clinic. Transportation was also problematic for women in the Crow tribe who must travel off the reservation to Billings, Montana, for prenatal services after 30 weeks of pregnancy. The sheer size of Tulare County also makes transportation difficult for low-income farmworkers who often do not have a car and must travel long distances for their care. Even in St. Louis, an urban community, women who lived in the county reported difficulty getting to care as public transit options fell short for them.

Sex Education

In all of the communities, insufficient sex education for youth emerged as a key issue. Today, about half of states (24 plus DC) require schools to provide sex education, and 34 plus DC require HIV education. A minority of states (18 plus DC), however, require sex education to include information on contraception, while 26 states require that programs stress abstinence. The Trump administration has increased investment in abstinence curricula, and state governments have awarded grants to crisis pregnancy centers (CPCs), faith-based organizations that counsel women against abortion, to teach abstinence. Furthermore, the Centers for Disease Control and Prevention (CDC) recently reported a rise in rates of many STIs, particularly among teens and young adults. In the case study interviews and focus groups, many individuals raised concerns about limited sex education and its contribution to poor health literacy about sexual and reproductive health.

Interviewees described variation in sex education across schools and felt that the content did not cover much of the information young people need; most areas stressed abstinence or “abstinence plus”³  curricula. Sex education curricula are typically selected at the local school district, school, or classroom level, which can cause wide variation in content even within the same community. Focus group participants perceived the availability and curricula of sex education as inconsistent among schools and often inadequate for high school-aged students. The Erie City School District adopted the evidence-based, comprehensive FLASH curriculum,⁴  while CPCs teach “character education” promoting abstinence in many Erie County schools. An interviewee reported that the CPCs receive state, federal, and private funding, enabling them to conduct more outreach and programs than the more comprehensive reproductive health care providers. An interviewee in St. Louis County recounted recent parent and teacher pushback to the limited sex education from faith-based groups, resulting in the adoption of comprehensive sex education curricula in several school districts. Interviewees in all of the communities concluded that lack of comprehensive sex education in schools contributes to high rates of STIs, HIV, and teen pregnancy. This sentiment was also expressed by many focus group participants who felt that young people were not getting the information they needed to avoid unintended pregnancy and prevent the transmission of STIs.

St. Louis, Missouri

On the eastern edge of Missouri, St. Louis stands out as a liberal region in an increasingly conservative state. The St. Louis metropolitan area is highly segregated, and deep health disparities exist between Black and White residents. St. Louis has a large Catholic population and concentration of Catholic-affiliated hospitals and schools.

Focus group participants and interviewees indicated that cultural influences and norms limit knowledge about contraception and STIs. In Dallas County, interviewees and focus group participants noted that most churches discourage discussion of sexual health, though a few have hosted events to promote HIV prevention and family planning. Some interviewees felt that formalized, comprehensive sex education in schools could be particularly important in more conservative communities, such as Tulare County, where discussions about sexual and reproductive health may not be commonplace at home. Providers on the Crow reservation also pointed out that discussions in the family about sexuality and reproductive health are not part of the cultural norm, and many young people lack access to basic health information.

Abortion Restrictions

Federal and state regulations shape access to abortion, and this was evident in all of the communities included in this study (Table 1). The federal Hyde Amendment restricts state Medicaid programs from using federal funds to cover abortions beyond the cases of life endangerment, rape, or incest. However, 16 states use their own state funds to cover abortions in other circumstances. Many other states have imposed restrictions on abortions including waiting periods, abortion facility requirements, and gestational age limits, some with the intent to overturn Roe v. Wade. These restrictions have translated to clinic closures in several states and the total absence of abortion clinics in many communities. This makes abortion effectively inaccessible for some women, particularly those who are poor or who live long distances from the nearest abortion provider.

Access to abortion in the five communities is severely limited, due to restrictive state policies resulting in a shortage of abortion providers and/or long travel times, plus a lack of transportation options. Alabama and Missouri have enacted some of the strictest abortion regulations in the nation, contributing to closures that leave just one abortion provider in Missouri (located in St. Louis), and one abortion provider in Montgomery, Alabama, that serves all of southern Alabama, parts of Mississippi and the Florida panhandle. Recent laws passed in these states would have essentially outlawed abortions if they had not been (temporarily) blocked by the courts.⁵  Yet, outside of Missouri’s attempt to ban abortion legislatively, the clinic in St. Louis remains vulnerable to closure. It is at the center of a state-level investigation about facility licensing that has generated national attention. A decision is expected in early 2020 as to whether the clinic can remain open.

Three of the counties studied (Erie, Tulare, and Dallas) have no abortion providers. Even in Tulare County and the Crow reservation, which are in states that cover abortion services under their Medicaid program and have very few restrictions on the provision of abortion, women must travel at least an hour to reach the nearest provider. Crow women must travel to Billings because the Indian Health Service, as a federal agency, is prohibited from providing abortion.

In each of the communities studied, anti-abortion sentiment played a significant role in limiting access to abortion services. Interviewees reported intense protesting outside abortion clinics in Montgomery and St. Louis and noted that protestors contributed to the closing of clinics in Erie and Selma. In Tulare County, California, anti-abortion billboards lined the highway and the Planned Parenthood of Visalia in Tulare County had been vandalized numerous times despite not providing any abortion services onsite. Focus group participants shared that protestors and cultural stigma surrounding the procedure made them feel ashamed or afraid, or deterred them from discussing or seeking an abortion. Interviewees in Dallas County and St. Louis reported that some providers and health center staff discourage abortions. Some focus group participants in St. Louis felt the state-mandated counseling was intended to make them second guess their own decisions. In many of these communities, churches play a prominent role in daily life, and religious influences discourage women from seeking abortions. In Selma, Tulare, and the Crow reservation, many focus group participants expressed opposition to abortion and said they would not consider it an option for themselves. In every focus group, however, there were a few women who said they had had an abortion or knew of someone who had one.  

Dallas County (Selma), Alabama

Dallas County is one of 18 counties comprising the largely rural, agricultural Black Belt region of Alabama, with a majority African American population. Selma, the largest town in Dallas County, played a pivotal role in the Civil Rights Movement. Selma faces high poverty and unemployment rates and poor health outcomes. Churches are central pillars of community life.

There was misinformation or lack of information about where women could obtain an abortion, and in some communities, focus group participants believed abortion was illegal in their state. In the communities with strict anti-abortion laws and strong anti-abortion environments, some interviewees and focus group participants incorrectly believed that abortion is illegal in their states. One crisis pregnancy center (CPC) in Erie had a large presence and offered a range of services such as pregnancy tests, STI screening, ultrasounds, and referrals to prenatal care, all at no cost to clients. Many interviewees referred women to the site because they mistakenly thought the CPC offered contraception and abortion referrals. More than one interviewee in Selma mistakenly thought that a local CPC offered abortions, and one listed them on their patient referral sheet for “abortion services,” just above the abortion providers in Montgomery and Tuscaloosa.

Limitations on Medicaid coverage for abortion services in some states, as well as procedure costs, make abortion unaffordable for many low-income women. The California and Montana Medicaid programs cover abortion services beyond the Hyde Amendment exclusions for life endangerment of the woman, rape, and incest. Alabama, Pennsylvania, and Missouri limit Medicaid coverage to the Hyde provisions, but an abortion provider in Alabama noted that she has never been able to obtain reimbursement even under the permitted circumstances. Focus group participants cited cost as a major barrier to accessing abortion care, with procedure costs reportedly ranging anywhere from $400 to $1,500. Many women face additional costs associated with transportation, childcare, and overnight lodging when state laws require women to wait 24-72 hours between state-mandated counseling and obtaining the abortion, as is the case in Missouri, Alabama, and Pennsylvania. There are local and national organizations that provide financial and practical assistance to some women seeking abortion; however, they do not have the resources to assist all the women who seek abortion and who cannot afford the services and the associated travel and lodging costs. Even when funds are available, logistical challenges may remain. For example, an Alabama-based organization provides financial assistance for transportation to women traveling long distances for abortions, but described barriers transferring funds to low-income women who do not have bank accounts.

Community Strengths and Initiatives

Across the communities, providers and community organizations were engaged in initiatives intended to address barriers to reproductive health care. Although interviewees emphasized that much more needs to be done to eliminate the structural, cultural, political, and economic barriers to reproductive health services for low-income women, there were multiple organizations and individuals in each community leading various efforts to fill gaps and meet community needs. In many cases, community-based organizations took active roles in family planning, STI, or HIV education and advocacy, while others provided direct, practical assistance. Some of these strategies include:

• Supporting Positive Opportunities with Teens (SPOT) is a freestanding clinic in St Louis, Missouri, that provides teen-friendly primary care, mental health care, and express STI testing at no cost. They also offer case management to address social determinants of health. The clinic has a school-based health center (SBHC) in an area public high school, which is one of the first comprehensive SBHC programs in the area. SPOT served 3,253 St. Louis teens in 2018 (80% African American, 15% LGBT and unstably housed, and 2-3% gender nonconforming youth).
• ACT for Women and Girls (ACT), a reproductive justice grassroots organization in Tulare County, California, offers youth-led programming with a focus on reproductive health and provides comprehensive sex education in schools. The organization also has conducted a pharmacy access project since 2009 where youth secretly shop at 60-70 pharmacies each year in Tulare County to assess availability of over the counter emergency contraception (EC).
• Medical Advocacy and Outreach (MAO) is a non-profit health and wellness organization based in Montgomery, Alabama. Together with their regional partner, Selma AIDS Information and Referral (AIR), the two organizations make up a comprehensive network of full-service and Bluetooth-enabled telehealth satellite clinics providing health and social services to individuals diagnosed with HIV. This includes medical services such as primary care, gynecological and sexual health services, dental care, and mental health and substance use treatment. They also provide social services such as group and peer counseling, transportation to appointments, housing support, medication assistance, and a food bank. Special outreach and services are provided for pregnant women and formerly incarcerated individuals.
• Messengers for Health is a non-profit organization addressing health equity among the Crow tribe in Montana. They rely on “messengers” from the community to educate the Crow people about risk factors for cancer and assist them to seek out preventive screening. Their first program educated Crow women and girls about the prevention of cervical cancer and related sexual risk factors using a culturally competent curriculum. They also started the Crow Warriors for Health program to increase colorectal, prostate, and lung cancer knowledge among men in the community. In Crow culture, cancer reportedly used to be considered a taboo topic, but due to the work of Messengers for Health, women and men are now discussing it openly and regularly seeking preventive screenings such as pap tests, mammograms, and colorectal screenings.
• Multi-Cultural Health Evaluation Delivery System (MHEDS) in Erie, Pennsylvania, is an FQHC “look-alike” center that conducts health screenings for the area’s refugee population, which grew considerably in the early years of the decade. The health center has tailored its services and staffing to address the particular concerns of Erie’s refugee communities, who come from a wide array of countries, including Nepal, the Democratic Republic of Congo, Bhutan, and others. MHEDS offers interpreters to help bridge language and cultural barriers and is working to shore up provider capacity on specific topics that affect some communities, such as female genital mutilation and differing views on the provision of prenatal care.

Conclusion

A close examination of low-income women’s experiences with reproductive health care in five diverse communities reveals challenges and strengths that are not evident in statistics alone. In-person interviews, focus groups, and first-hand, on-the-ground experiences in each of the communities uncovered barriers to care common to all the communities, as well as obstacles unique to specific locales and populations. These case studies also revealed some surprises. For example, Missouri, which has not expanded Medicaid under the ACA, places significant limits on abortion and prohibits Medicaid payments to its sole abortion clinic for non-abortion services such as contraceptives; yet the St. Louis region is home to a wide variety of providers and community-based organizations that are working to improve access to the full range of family planning services. In contrast, California, expanded Medicaid eligibility under the ACA, imposes few state-level restrictions on abortion access, and operates the nation’s largest Medicaid-funded family planning program; nonetheless, access to abortion services for women in Tulare County is limited, as the nearest abortion provider is at least 50 miles away. These findings underscore that particularly for rural or underserved communities throughout the country, federal and state policies alone do not guarantee or determine access, but rather intersect with local influences.

The factors influencing reproductive health access are a complex web of social determinants of health; coverage policies; state and local investments and leadership; provider supply and distribution; sex education; the political, cultural, and religious environment; and the legacy of discrimination in many parts of the country. Across all of these communities, we met many leaders working in challenging environments to assure that reproductive care is high quality and equitable and that information is accessible to all members of their community. Importantly, talking to low-income women on the ground underscored what they expect of the health care system in providing access to reproductive health services, and the challenges in making affordable access a reality.

KFF: Usha Ranji, Michelle Long, and Alina SalganicoffHealth Management Associates: Carrie Rosenzweig and Sharon Silow-Carroll

Introduction

Dallas County is one of 18 counties comprising the largely rural, agricultural Black Belt region of Alabama. Originally a reference to the region’s dark, fertile soil, the term Black Belt later became associated with African American enslavement on plantations, and more recently with its majority African American population (Figure 1).

Selma, the largest town in Dallas County, played a pivotal role in the Civil Rights Movement. While considered the “Queen City of the Black Belt,” Selma faces high poverty and unemployment rates and poor health outcomes. Dallas County is federally designated as medically underserved and as a health professional shortage area. Alabama’s decision not to expand Medicaid, coupled with the state’s extremely low Medicaid income eligibility limits (18% of the federal poverty level for parents), leaves many low-income residents without access to coverage for basic health care services. Approximately 20% of Dallas County residents age 19-64 were uninsured in 2017.⁶  Several community hospitals have closed in recent years, leaving one hospital in Selma with the only obstetric delivery services in the seven-county region. Alabama has recently been thrust into the national spotlight with its passage of a near-total abortion ban, punishable by up to 99 years in prison for the provider. This law has been blocked by a federal court ruling, but it is expected that the state will continue to challenge it. Churches are central pillars of community life, and many have strict beliefs about sex and reproductive health and tend to oppose abortion.

This case study examines access to reproductive health services for low-income women in Selma and Dallas County, Alabama. It is based on semi-structured interviews conducted by staff of KFF and Health Management Associates (HMA) with safety net clinicians and clinic directors, social service and community-based organizations, researchers, and health care advocates (“interviewees”), as well as a focus group with low-income women in April 2019. Interviewees were asked about a wide range of topics that shape access to and use of reproductive health care services in their community, including availability of family planning and obstetrical services, provider supply and distribution, scope of sex education, abortion restrictions, and the impact of state and federal health financing and coverage policies locally. An Executive Summary and detailed project methodology are available at https://www.kff.org/womens-health-policy/report/beyond-the-numbers-access-to-reproductive-health-care-for-low-income-women-in-five-communities.

Medicaid Coverage and Continuity

Alabama’s decision not to expand Medicaid and its low Medicaid reimbursement rates and income eligibility limit leave many low-income residents without health care coverage for most basic health care services outside of pregnancy (Table 1). As a result, low-income women rely heavily on the state’s family planning waiver program (Plan First), the federal Title X family planning program, and some targeted, limited public programs.

The vast majority of low-income women in Alabama do not have a pathway to basic health coverage outside of pregnancy-related coverage under Medicaid. Alabama has not expanded Medicaid under the Affordable Care Act, and women with dependent children who earn more than 18% of the federal poverty level (FPL), or roughly $3,800 a year for a family of three, exceed the state’s eligibility threshold, which is the second lowest in the United States. Adults without children at any income level who are not pregnant are not eligible. Pregnant woman are eligible for Medicaid up to 146% FPL, though that coverage ends 60 days after delivery. Several interviewees mentioned lack of Medicaid expansion as a significant barrier to accessing care. One focus group participant said that she lost her Medicaid coverage and became uninsured after her husband started collecting Social Security checks. Few low-income focus group participants had full-benefit Medicaid, while many more only had coverage for family planning (Figure 2).

The Dallas County Health Department participates in the Well Woman Alabama program, offering free health counseling, preventative services, screenings, and management of chronic diseases such as elevated cholesterol and hypertension for women ages 15-55. A Federally Qualified Health Center (FQHC) in Selma provides health services to uninsured women on a sliding fee scale; however, many focus group participants reported that when they need health care, they go to the emergency room where they do not need to pay anything upfront.

Alabama’s family planning program, Plan First, is often the only source of contraceptive coverage for low-income women. The Plan First⁷  program covers all FDA-approved contraceptive methods, STI and HIV testing, and an annual exam at no cost for women ages 19-55 with income up to 146% FPL. The program also covers tubal ligations and vasectomies for adults 21 and older. In Dallas County, the only providers participating in Plan First are located in Selma. This reportedly poses a barrier to women who live in the outlying areas of the county because there is no public transit infrastructure, and many low-income families do not own cars. Because women who have undergone sterilization are not eligible for the program, some focus group participants reported that they lost access to needed services after they had a tubal ligation or hysterectomy. Interviewees recognized the important role that the Plan First program plays to fill gaps in women’s health services, but felt that expanding full-benefit Medicaid would go much farther in meeting the health needs and providing continuity of care for Alabama’s low-income residents.

Provider Distribution

Because there is only one remaining hospital offering Ob-Gyn and labor and delivery services across much of central and southern Alabama, many women must travel long distances for maternity care and have limited options. Some providers are developing innovative solutions to address transportation difficulties, provider shortages, and health care system fragmentation.

Dallas County has a shortage of obstetric providers, and both focus group participants and interviewees expressed concerns about the quality of care available due to challenges in recruiting and retaining physicians. Providers in Dallas County, one of the poorest counties in the state, reported that it is hard to recruit qualified employees — from front desk staff to physicians — because many people living in the area do not have the required education or work experience, and those who are qualified leave for better opportunities elsewhere. Interviewees reported that the number of Ob-Gyns providing the full range of obstetric and gynecological services in the region has declined to just two, both of whom are employed by the Selma hospital’s outpatient obstetric clinic. Focus group participants and interviewees expressed concerns about the limited choice of providers and quality of care as a result of these shortages. Individuals needing specialty care must travel to Birmingham (90 miles) or Montgomery (50 miles).

Hospital closures throughout the state have left only one community hospital serving five counties, and the only hospital with inpatient labor and delivery services in a seven-county region. The lack of Medicaid expansion and low reimbursement rates were mentioned by providers and other interviewees as contributing factors to hospital closures in smaller towns across southern and central Alabama. As a result, Selma’s community hospital (Vaughan Regional Medical Center) has become the main place people go for health care, and the only site for inpatient labor and delivery services and outpatient obstetric care in the entire region. In addition, there is no Neonatal Intensive Care Unit (NICU) or pediatric surgery unit in Dallas County; newborn infants needing emergency care must be taken by helicopter to facilities in Birmingham. One interviewee commented on the high rates of infant and maternal mortality in the area and said that the lack of Medicaid expansion, education, and providers have all played a role.

Telemedicine is emerging as a promising solution to address the transportation and distance barriers in Dallas County. There is no public transit infrastructure in Dallas County and women in outlying parts of the county must travel long distances to access health care, impeding access to all health care services. Although West Alabama Public Transportation, a Medicaid transportation program, is an option, individuals reported that they may have to wait all day to be picked up to return home. Many interviewees and focus group participants reported having to pay their family or friends as much as $20 for a ride to get health services.

Because of transportation barriers and difficulties recruiting clinical staff, several providers are implementing highly sophisticated and successful telemedicine networks. Medical Advocacy and Outreach (MAO) is a Montgomery-based health and wellness service provider serving nearly 2,000 people living with HIV/AIDS, Hepatitis C, and other life-threatening illnesses annually across 28 counties; they have established one of the only telemedicine networks that provides direct medical care in the region. As of April 2019, they had 10 units installed, with a goal to put a telemedicine unit in every county health department. Their local AIDS services partner in Selma, Selma AIDS Information and Referral (AIR), also offers videoconferencing for substance use and mental health counseling. Nonetheless, a lack of broadband throughout the most rural parts of the county limits the utilization of digital health solutions and emphasizes the importance of both transit and communications infrastructure development in rural communities. The Rural Health Medical Program (RHMP), the only FQHC in the county, offers medical consultations across sites between nurse practitioners and collaborating physicians and with partnering specialists. RMHP also has a telepsychiatry program, and they are renovating a mobile van they expect to be operational in fall 2019 that will offer medical care, optometry, as well as behavioral and mental health services in satellite towns, school-based programs, and community health fairs.

 The health care delivery system in Selma and Dallas County is significantly fragmented, and providers face challenges with care coordination. Low-income women generally go to the health department for family planning needs and STI care, the hospital and outpatient clinic for obstetrical care, and the RHMP or the emergency room for all other services. One provider felt that although the system was fragmented, providers communicate with one another and patients know where they need to go for each service. The RHMP, however, is trying to integrate care with other providers and centralize services for their patients. They explained that the fragmentation of the health care system places pressure on social workers, who are scarce in Selma, to coordinate and direct patients to care.

There is a severe mental health provider shortage, and many focus group participants reported experiencing stress, anxiety, and depression. Focus group participants described significant stress related to finances, family, and health. A few had seen a doctor and were taking medication for their depression and anxiety, but they felt that the medications’ side effects often made them unable to take care of their children or perform daily activities. Some local providers have expanded their mental health programs, but an interviewee still noted a significant shortage in mental health providers.

STI and HIV Screening, Prevention, and Treatment

There are not enough providers distributed around the county to meet the need for STI testing and treatment. Alabama has some of the highest STI rates in the nation, and the Black Belt region is especially hard hit. The Dallas County Health Department offers free testing, treatment, and annual screening for all STIs, HPV vaccines, and discusses HIV and pre-exposure prophylaxis (PrEP) with their patients. They also employ an HIV coordinator, and their disease control staff does extensive education and outreach in colleges and churches. Still, people in the outskirts have difficulty getting to the health department.

Dallas County has a comprehensive, integrated provider network for individuals diagnosed with HIV, but there are not enough providers conducting routine HIV screening, testing, or prevention. In 2017, Dallas County had a new HIV diagnosis rate of 17.9 per 100,000 people (compared to 11.8 nationwide), one of the highest in the state (Figure 3). Interviewees reported that HIV disproportionately affects young African American men who have sex with men. MAO serves as a “one-stop shop” for individuals diagnosed with HIV, providing HIV treatment and comprehensive health care services. Selma AIR conducts HIV testing and refers patients who test positive to the MAO satellite clinic housed at UAB Selma Family Medicine for treatment.

However, updates in testing policies have not yet been fully adopted by many individual clinicians. For example, MAO has been educating hospital administrators about the removal of a requirement for a separate consent for HIV testing, but the change in practice has not yet been implemented at all levels of the system. The hospital’s outpatient obstetric clinic routinely tests for HIV, but interviewees suggested that other doctors are not discussing HIV risks with patients due, in part, to competing priorities like the high burden of chronic diseases, and the continued stigma around HIV.

Interviewees reported there is limited funding for HIV prevention efforts. Although PrEP is a highly effective preventive medication for HIV and is available free of cost for lower-income individuals through an assistance program from the manufacturer, that option does not appear to be fully leveraged. In fact, interviewees reported that most of their patients hit roadblocks because they lack health insurance to cover PrEP.

Stigma and confidentiality concerns were cited as significant barriers to HIV testing and treatment. Interviewees discussed local resistance to HIV testing due to homophobia and assumptions about “what someone with HIV looks like.” They also suggested that some providers in private practice do not want to care for patients with HIV. Additionally, there is a lack of awareness among some providers that women living with HIV can give birth without transmitting it to her infant.

Because Selma is a small community, there is also concern about confidentiality. Selma AIR provides transportation to appointments, but they reported that they have patients who do not want to be seen in their van or in a clinic known to be associated with AIDS, and some have stopped coming in for medical services due to a fear of encountering someone they know.

Social Determinants of Health

Social determinants such as housing, employment, education, and poverty play a sizable role in the health of Dallas County residents, contributing to high rates of chronic conditions. In addition, historical and current racism has reportedly fostered mistrust of the medical establishment among the African American community.

High poverty rates, limited affordable housing, lack of vocational training and employment opportunities, and other socio-economic stresses lead many women to prioritize other needs before health care and family planning. Almost a third of the population (32%) in Dallas County lives below the federal poverty level.⁸  Focus group participants discussed a scarcity of well-paying jobs and challenges with childcare among their daily concerns. One provider pointed out that without transportation or childcare, women living in rural areas will not come into Selma for health care unless they are in pain and that other financial priorities such as food and housing are more pressing. These factors also contribute to high rates of chronic conditions such as diabetes (including among pregnant women), hypertension, obesity, and kidney disease.

Historical mistrust of the medical establishment among the African American community may contribute to lack of engagement in early and preventive care. Some interviewees commented on the lasting effect of slavery, racism, and the notoriously unethical Tuskegee syphilis study, conducted by the U.S. Public Health Service in the mid-1900s in nearby Macon County. The legacy of that experiment, slavery, and the Jim Crow era still lives on in the area today. Interviewees discussed a need for more African American providers who could provide culturally congruent care, along with cultural sensitivity training for existing providers. A new Ob-Gyn at the hospital OB clinic is an African American female, which she views as important for her patients.⁹ 

Contraceptive Provision, Access, and Use

Focus group participants and interviewees said that a lack of sex education, the influence of the churches, and cultural norms have contributed to the high rates of teen pregnancy in the area. The Dallas County Health Department is a key provider of contraception for low-income women.

The Dallas County Health Department, the local Title X provider, is the primary resource for contraception in the community and has an extensive case management program; however, resources and capacity are limited. The health department located in Selma serves approximately 3,000 women a year from Dallas County and some of the surrounding counties. It assists uninsured women to enroll in Plan First and is the primary provider of family planning for low-income women in the region. They offer a wide range of methods including emergency contraception, the Depo-Provera shot, oral contraceptives, and implants. At the time of the site visit, women requesting IUDs were referred to a community provider, but the health department was training a clinician to insert IUDs onsite. The health department also provides family planning education and counseling, and extensive case management for patients with myriad challenges related to housing, food, domestic violence, and other needs. Social workers work with teens, reminding them to come in to refill their contraception on time. They also conduct outreach, but interviewees reported that health department does not have the resources to fully meet the needs of the community.

There are a range of Plan First providers in the county including private physicians’ offices, the RHMP, and the hospital outpatient obstetric clinic, but most focus group participants go to the health department because it is convenient, the providers “understand” them, and services are confidential and free.

Interviewees and focus group participants reported that most women use Depo Provera to prevent pregnancy. Focus group participants said they could get the Depo shot right at the health department, but they noted a “two-step” process at other clinics in which they had to go to the clinic to get a prescription, go to the pharmacy to pick up the shot, and then return to the clinic to get the shot. For women seeking an IUD after giving birth, the Selma hospital does not offer immediate postpartum IUDs. Focus group participants also described challenges obtaining tubal ligations after delivery related to Medicaid policies and scheduling. Some focus group participants said that it is difficult to get an appointment with the hospital outpatient OB clinic. At the time of this study, RHMP was in the process of establishing an MOU with Ob-Gyns serving Medicaid patients to facilitate easier referrals.

Role of Religion and Sex Education

Comprehensive, medically accurate sex education is not usually offered in Dallas County schools. Interviewees and focus group participants said that the lack of health literacy and sex education in the schools contributes to high rates of STIs, HIV, and teen pregnancy. Alabama requires two weeks of HIV education be provided in public schools but does not require general sex education. Interviewees felt that the HIV education requirement is not enforced uniformly within the state, and that schools vary in whether and how they teach sex education, generally focusing on abstinence rather than more comprehensive approaches. Interviewees reported that these factors resulted in a lack of knowledge about STIs, misinformation about contraceptive methods, and numerous HIV cases among students in the area. Selma AIR, which provides HIV education from 5^th through 12^th grade in every school in its service region, reported that some school nurses and teachers invite them in to teach abstinence as a method of HIV prevention, but that they would prefer to teach more effective evidence-based approaches. A local community development organization highlighted the impact of the lack of resources at the state and local level; they added that sex education is not a priority because schools “are trying to figure out how to keep the lights on.”

Interviewees reported that although there are a small number of churches (e.g., Methodist, Unitarian Universalist) that promote family planning and STI information at community events, the majority of churches do not. Interviewees noted that some churches are strongly opposed to discussing family planning and STI prevention because they believe that sex or pregnancy before marriage is shameful. At the same time, several interviewees suggested that teen pregnancy has been normalized because it is so common.

Access to Abortion Counseling and Services

There are no clinics providing abortion in Dallas County. Substantial local opposition to the service was noted among both focus groups participants and interviewees.

There is no abortion provider in Dallas County, and obstacles such as transportation, anti-abortion sentiment, and cost make it difficult for women to obtain an abortion. The closest abortion clinic to Selma is located 50 miles away in Montgomery, where staff reported seeing many patients from the Selma area. There used to be an abortion provider in Selma, but intense protesting and a reported problem with state licensure caused it to close. The sole hospital in Dallas County does not perform abortions even in cases of life endangerment or lethal fetal anomalies. Instead, they refer patients to tertiary clinics in Birmingham or Montgomery. Women whose pregnancies are a result of rape or incest are reportedly referred to rape counseling. According to one interviewee, many health care providers are anti-abortion, and some women seeking an abortion are reportedly told “to get out of their office and never come back.”

Cost is cited as a barrier to abortions for many low-income women, with the procedure fees ranging from about $600 to $1,500, depending on the gestational age. In Alabama, Medicaid will not pay for abortion outside of the exceptions of rape, incest, or life endangerment of the woman, but the Montgomery-based clinic reported that they have never been able to get an abortion paid for even under these circumstances. The Yellowhammer Fund assists women seeking abortions with the cost of the procedure; they reported providing about $80,000 in financial assistance in 2018. Since the state passed its near-total abortion ban in 2019, donations to Yellowhammer have risen, and the Fund has increased assistance to cover the procedure from about $650 per week to about $9,000 per week, helping 20 to 40+ women per week pay for abortion services. The Fund also has a budget of $4,000 per month for other logistical support such as transportation. Because many low-income women do not have bank accounts, especially those from rural areas, the Fund also provides gift cards (rather than transferring funds into an account electronically) to women to pay for gas or to rent a car to travel to their appointment.

Highly restrictive state laws and widespread anti-abortion sentiment in the community make it difficult to provide or obtain an abortion. Interviewees cited the 48-hour waiting period and requirement that abortion practitioners have admitting privileges at a local hospital as particularly limiting. The Montgomery abortion clinic explained that the 48-hour waiting period is misleading; because they are a small clinic, they perform abortions only one day a week, so depending on when the woman comes in, she may have to wait up to nine days for her procedure.

Providers also spoke of the anti-abortion sentiment in the community. There are protesters outside the Montgomery abortion clinic every day, which escalates on procedure days. Interviewees reported that many clinics would not last long in the area because “people are very against abortion in this state.” They reported that abortion providers cannot live in the same community in which they work due to harassment. Montgomery Area Reproductive Justice Coalition provides escort services into the clinic, overnight accommodations, and other supports for women traveling to Montgomery for abortion services.

Alabama signed the most restrictive anti-abortion measure into law on May 15, 2019. Scheduled to begin in November 2019, it would make abortion a felony except when necessary to prevent serious health risk to the woman, punishable by up to 99 years in prison for the providing physician. This law, passed after this case study was conducted, is temporarily blocked by court order. At the time of this publication, state law allows abortion up to 20 weeks.

Some providers refer women to the crisis pregnancy center (CPC) in Selma for assistance, unaware of its anti-abortion mission. CPCs typically offer limited medical services such as pregnancy tests and ultrasounds, and discourage women from seeking abortions. The health department in Selma lists Safe Harbor, a local CPC, as a referral for “abortion services” above abortion providers in Montgomery and Tuscaloosa. About half of the focus group participants reported knowing that Safe Harbor provides free pregnancy tests but not contraception. Participants who had gone there reported that they were shown a video about abortion. Two other focus group participants had gone to CPCs in Montgomery and Birmingham for pregnancy tests, where clinic staff pushed adoption as an option and asked the women to read the Bible.

Focus group participants were opposed to abortion, and most thought the procedure is illegal in Alabama. Some interviewees believed that a lack of education about abortion contributes to the anti-abortion environment. One interviewee stated, “If everything they have heard is negative about abortion, if they have heard these messages and no one has sat down to explain to them the positives and negatives, the planning beforehand, there is a huge gap.” All focus group participants expressed opposition to abortion, but some said they were okay with abortion if the pregnancy is life threatening. Two participants shared that they had had an abortion; one said it was a Medicaid-funded abortion because of life-threatening pregnancy and the other was due to a fetal anomaly.

The focus group identified considerable misinformation about abortion services among women in the community. Most focus group participants incorrectly believed that abortion is illegal in the state, and only half knew where you could get one. Most also incorrectly equated emergency contraception (EC) with abortion, but they knew that you could get EC at the health department or buy it over the counter. Another participant incorrectly thought abortion threatens future pregnancies.

Conclusion

Dallas County has a network of community-based organizations and health care providers that are committed to improving the health and well-being of women living in the Black Belt region of Alabama, despite considerable structural challenges in the community. Several interviewees said that Alabama’s decision not to expand Medicaid and its strict eligibility limits means many low-income women remain uninsured or only have coverage for family planning services. Women in the county, including those in Selma, suffer from high rates of chronic health conditions and face substantial barriers to care including poverty, unemployment, lack of transportation, unaffordable housing, and limited education. In addition, due in part to provider shortages and hospital closures, women living throughout the Black Belt have to travel long distances to access obstetrical care, exacerbating high rates of infant and maternal mortality. The heavy influence of churches and the state’s politically conservative climate have resulted in limited sexual health education, and stigmatization and restriction of abortion care.

Acknowledgements

The authors thank all of the interviewees that participated in the structured interviews for their insights, time, and helpful comments. All interviewees who agreed to be identified are listed below. The authors also thank the focus group participants, who were guaranteed anonymity and thus are not identified by name.

June Ayers, Director, Reproductive Health Services

Keshee Dozier-Smith, CEO, Rural Health Medical Program, Inc.

Meneka Johnson, PhD, COO, Rural Health Medical Program, Inc.

Felecia Lucky, President, Black Belt Community Foundation

David McCormack, CEO, Vaughan Regional Medical Center

Clara Moorer, Director, Women’s Health Services, Vaughan Regional Medical Center

Rhonda Parr, Nurse Coordinator, Dallas County Health Department

Mia Raven, Founder & Executive Director, Montgomery Area Reproductive Justice Coalition (MARJCO)

Amanda Reyes, Executive Director, Yellowhammer Fund

Terri Sewell, U.S. Rep. (AL-07)

Sarina Stewart, LMSW, Social Work Manager, Dallas County Health Department

Suzanne Terrell, LMSW, Assistant Administrator, Dallas County Health Department

Medical Advocacy & Outreach (MAO) Staff:

Marguerite Barber-Owens, MD, AAHIVS

Laurie Dill, MD, AAHIVS, Medical Director

Stephanie Hagar, LBSW Lead Administrative Social Worker

Rozetta Roberts, NP, Clinic Director

Dianne Teague, Governmental/Donor Affairs

Jennifer Thompson, LICSW, Division Manager of Social Work

K.C. Vick, Director of Capacity Building

KFF: Usha Ranji, Michelle Long, and Alina SalganicoffHealth Management Associates: Carrie Rosenzweig and Sharon Silow-Carroll

Introduction

The state of California has a wide range of legal protections for reproductive health care access and coverage. Its decision to expand its Medicaid program, Medi-Cal, through the Affordable Care Act (ACA) greatly broadened health insurance coverage for its low-income populations, and the state’s Family PACT program ensures coverage for family planning services to uninsured women up to 200% of the federal poverty level (FPL). California requires that Medicaid and private insurance plans cover abortion. However, these coverage protections have not guaranteed equal access in all parts of the state. Tulare County sits in the Central Valley, the heart of the agricultural region of California. The majority of its population is concentrated in a few small cities in an otherwise sparsely populated county. The area is more politically and socially conservative than many parts of the state. As one of the poorest counties in California, Medicaid expansion has been a significant source of coverage for low-income individuals living there. Still, the area is federally designated as medically underserved and as a health professional shortage area, and residents can face significant barriers in accessing basic health care and family planning services. Tulare County’s rates of some sexually transmitted infections (STIs) and teen pregnancy are much higher than the state average. Tulare County’s large migrant worker, immigrant, and Latinx populations, as well as individuals who identify as LGBTQ, face heightened barriers to care.

This case study examines access to reproductive health services for low-income women in Tulare County, California. It is based on semi-structured interviews conducted in March and April 2019 by staff of KFF and Health Management Associates (HMA) with local safety net clinicians and clinic directors, social service and community-based organizations, researchers, and health care advocates, as well as a focus group with Spanish-speaking, low-income women living in the community. Interviewees were asked about a wide range of topics that shape access to and use of reproductive health care services in their community, including availability of family planning and maternity services, provider supply and distribution, scope of sex education, abortion restrictions, and the impact of state and federal health financing and coverage policies locally. An Executive Summary and detailed project methodology are available at https://www.kff.org/womens-health-policy/report/beyond-the-numbers-access-to-reproductive-health-care-for-low-income-women-in-five-communities.

Medicaid Coverage

Many Tulare County residents live in extreme poverty, and there are a significant number of immigrants, including many monolingual Spanish speakers. These communities face serious barriers to health care despite the availability of expanded coverage under Medicaid and the state family planning program.

California’s decision to expand Medi-Cal provided broad coverage to many who were formerly uninsured and drastically reduced the uninsured rates in the state; however, gaps remain for undocumented individuals. The 2013 Medicaid expansion greatly increased coverage in Tulare County. California’s Medicaid program covers parents with incomes under 138% of the Federal Poverty Level (FPL), and pregnant women up to 322% FPL under the CHIP “unborn child” option.¹⁰  California also extends coverage for family planning services to men and women with incomes below 200% FPL through the Family PACT program, which serves as a major revenue source for clinics serving low-income women across the state. However, several women who participated in the focus group, many of whom were previously undocumented, had not heard of the Family PACT program or did not know that they were eligible for its family planning services. Federally Qualified Health Centers (FQHCs) in the area reported that they still see a significant number of patients who are uninsured, usually because of documentation reasons. Among women of reproductive age in Tulare County, approximately seven in ten are Latinx and nearly three in ten are foreign-born (Figure 1). Agriculture is the dominant industry in the region, and the county is home to many farm workers and their families. In June 2019, following the site visit, California became the first state to expand full Medi-Cal benefits with state-only funding to low-income, undocumented adults ages 19-25, expected to take effect in 2020.

Provider Distribution

Tulare County’s large area and lack of public transit make it difficult for women to travel to larger towns for health care appointments. While prenatal and contraceptive care are generally accessible in the county, there is a significant shortage of providers of specialty care and even fewer specialists who accept Medicaid.

Tulare County is an expansive county, about the size of Connecticut, with a sizable rural footprint. There are provider shortages in the more rural areas, and services are concentrated in the larger towns. Outlying areas that are farther away from the population centers in Tulare and Visalia have limited or no public transportation options, which reduces access to health care services for residents without cars. Interviewees also reported difficulty recruiting doctors to live and work in the area. Some FQHCs are trying to improve access and expand their presence throughout the county using mobile units, satellite clinics, and a transportation fleet to bring patients to and from their appointments free of charge. However, they acknowledge it is not financially viable to build clinics in outlying communities with 100 people (or fewer), and some interviewees suggested that patients do not always know about available transportation services; for example, Medicaid covers transportation to medical appointments in certain cases. The combination of geographic distance, limited public transportation and knowledge of available services means that it is difficult for people in some outlying communities to obtain care.

Focus group participants reported that prenatal care is readily accessible, though their provider choices are limited. Some interviewees expressed that while there may be enough Ob-Gyns in the county, they are not evenly distributed, and the range of Ob-Gyns does not fully meet patient preferences. For example, interviewees and women in the focus group said that the field is male-dominated in the area, and the few doulas and midwives in the county, who are generally female, are overbooked. FQHCs suggested telehealth could help, but they do not currently use this technology for reproductive health or obstetrics. One interviewee commented that there are limited obstetric specialists, so providers refer patients to nearby hospitals for specialty care; however, recent hospital closures have reduced the number of obstetric departments in the area. As in other communities, many private providers do not accept Medi-Cal due to the state’s low reimbursement rates, which are among the lowest in the nation. One interviewee suggested this creates a “two-track system” in which patients with Medicaid are limited to a smaller number of providers.

 Women have access to a variety of contraceptive providers, but limitations remain. Women can get same-day contraception from several FQHCs and a Planned Parenthood clinic in the area. The two county public health clinics also offer some contraceptive services. Planned Parenthood in Visalia was identified by multiple interviewees as the most comprehensive, and the only specialized provider of contraception; however, Planned Parenthood is only open three days a week with limited hours. These limitations are particularly exacerbated for residents in the outlying areas of the county who have to travel farther to get care. In California, pharmacists can prescribe and provide some hormonal contraception (oral contraceptive pills, the patch, injection, and the ring) directly to women. One interviewee noted that pharmacies are one of the “cornerstones” of access in the community, but that not many pharmacists in the area participate in the program due to personal beliefs. A local social justice organization that conducts “secret shopping” at local pharmacies to identify barriers to obtaining emergency contraception (EC) has greatly improved access. Cost is still a barrier since EC costs $40-60 without a prescription, but it is also available at local FQHCs and Planned Parenthood on a sliding fee scale.

Mental health needs are not being met within the community. Although many focus group participants had suffered from anxiety and depression, they said that doctors only talk to them about it when they are pregnant. Long wait times for appointments at the limited number of mental health providers in the county is a barrier to care. One interviewee reported there is a two-month wait for a pediatric mental health assessment, though the victims’ services provider can offer counseling for children who have been exposed to violence, or experienced neglect, endangerment, or abuse within about two weeks. Adults can get mental health services in Visalia or Kingsview, but these services reportedly focus on severe mental health diagnoses only.

Sex Education and STIs

The availability of sex education in the schools is limited in the region despite robust state requirements. Nurses play a large role in educating their patients about sexually transmitted infections (STIs).

Sex education is not consistently taught across the 45 school districts in the county despite a state mandate that schools provide comprehensive sex education. Interviewees report a lag between the state’s passage of legislation and implementation on the ground due to limited resources and lax oversight. The local school board is also resistant to sex education, tied to strong conservative and anti-abortion Roman Catholic influences in the community. Tulare-Kings Right to Life has historically provided abstinence-only sex education in the schools; many interviewee and focus group participants noted this limited curriculum does not offer young people the information they need to make fully informed decisions about their health. Some also noted that as sex education comes into compliance with state law, some parents are choosing to opt their children out of the more comprehensive programs. One interviewee described backlash when an advocacy organization handed out condoms at a high school prom and performed rapid HIV testing at a homelessness event.

Health educators and nurses at local clinics play an important role in educating women about STIs and their contraceptive options. FQHC nurses reported that their patients are uneducated about their sexual health and are often surprised when they learn about STI symptoms and risk factors. However, providers feel limited in their reach because they are only able to educate people who walk into their clinic. On the other hand, focus group participants did not think that providers sufficiently discuss STIs with them. They reported receiving pamphlets but stated they would prefer in-person counseling with reader-friendly guides.

In recent years, the county has experienced a rising rates of some STIs, especially syphilis and HIV. Providers have seen an influx of new STI diagnoses (Figure 2), especially among young people. Some attribute this to the small communities of students who are dating each other. Interviewees had mixed views about whether there are enough providers offering STI or HIV testing in the county. One interviewee suggested that many providers do not test for syphilis, and as a result, Tulare County experienced a large outbreak a few years ago; one provider reported they are still seeing one new case of syphilis each week on average. Clients diagnosed with HIV are often 20-25 years old and mostly male. Another provider suggested that most of the testing happens at the county public health clinics where there are concerns about confidentiality and a mistrust of some providers. Sometimes there is also a fear among patients of being “put on a list” [related to immigration] resulting in people going without care.

Access for Special Populations

Undocumented immigrants, people in remote areas, women experiencing domestic violence, LGBTQ individuals, and teens face increased barriers to health care. Tulare County has a variety of community organizations that offer innovative programs focused on improving access for many of these populations.

Immigrants

Barriers affecting low-income women living in Tulare County are amplified for undocumented women. They face additional challenges related to language, costs, and confidentiality. While most of the region’s population is Latinx (65%), there are a number of smaller immigrant communities, including from South and Southeast Asia. Interviewees said that most providers have materials in Spanish and interpretation services or Spanish-speaking staff, but they often do not have the capacity to provide intepretation services for the community’s Southeast Asian populations. Furthermore, providers reported that interpretation in all languages, including Spanish, for ongoing services such as case management is challenging. Many women bring in family members or friends to interpret for them, but providers expressed concern about confidentiality, especially in smaller communities.

Undocumented individuals delay or avoid seeking health, social, or financial services. They may limit their time outside because they fear deportation or a negative impact on their legal status. Multiple interviewees reported that racism and fear of ICE raids have increased in recent years. Several focus group participants recounted experiences in which they delayed or went without health or pregnancy-related care because they were undocumented and afraid of deportation. Women seeking legal status have also forgone needed public assistance, fearing being seen as a “public charge” and jeopardizing the immigration process. There have been ICE raids on domestic violence shelters across California, and interviewees said that women who call to report abuse will not seek services for fear of deportation.

Undocumented women in California are eligible for emergency Medicaid coverage of labor and delivery, but their eligibility for Medicaid ends after childbirth. However, under the state’s new expansion of Medi-Cal benefits to young adults 19-25, some would remain eligible for coverage. Several women in the focus group became uninsured following delivery or the 6-week follow up visit. As a result, they did not seek additional care for themselves because they were not covered and felt they could not afford it.

Poverty and Access in Outlying Areas

Women in the focus group and other interviewees reported that poverty is disproportionately hard on women and plays a role in access to contraception. Visalia, Tulare, and Porterville are the largest towns in the county, but a significant portion of the population lives in unincorporated communities that may not have a grocery store, pharmacy, or health clinic. This leaves many women without even a place nearby to purchase condoms. Some smaller communities do not have running water. Many residents are under- or unemployed and cannot afford housing, food, and hygiene items. Social service providers asserted that when women must make a choice among basic needs, their health is low on the list. One interviewee added that multi-generational poverty locks women who are financially dependent or must work multiple jobs into family environments that prevent them from making their own choices, particularly women in abusive or coercive relationships.

Domestic Violence

Domestic violence is prevalent in the area, but there is a shortage of services and lack of appropriate training among health care providers and law enforcement. The largest victims’ services provider in the county operates the only rape crisis center serving Tulare County. They serve about 350 clients a year, 100 of whom require rape kits/forensic exams. They also operate one of the two emergency shelters in the area; the other is religiously affiliated. Both shelters have long waiting lists due to their limited capacity, housing only eight to ten women, many of whom have multiple children. In addition, barriers facing undocumented individuals in seeking health care services, such as fear of deportation, have also prevented women from utilizing shelters.

While screening for domestic violence is recommended as a routine part of primary and prenatal care, health care providers may not screen for it because they do not feel equipped to address the patient’s needs if they disclose abuse. In order to increase domestic violence screening, the victims’ services provider has established operating agreements with hospitals and other health care providers to offer training and education to identify and address domestic violence and abuse among patients. However, they reported implementation challenges at the provider level and that they are not receiving the expected volume of referrals from the clinics.

Most women in the focus group reported that their doctor had discussed domestic violence with them. A few had negative experiences with law enforcement; one focus group participant described how police threatened to remove her children from her custody while she was at the hospital seeking medical attention for injuries due to domestic violence. Because she did not want to accuse her partner, the police implied that the situation was her fault instead of connecting her with resources and support. A few women had positive experiences with police and social workers who helped them obtain the support they needed.

Women who are involved in abusive relationships often experience reproductive coercion. A victims’ services provider and a family resource center reported that women in abusive relationships often experience reproductive coercion where their partners prevent them from using contraception or sabotage their chosen method. As a result, women are not able to make their own reproductive decisions, and many have had multiple children they did not intend to have. These interviewees reported that when they speak to their clients, it is often their first time learning about family planning options and where to obtain those services. Their staff are trained in identifying women and children who might be experiencing abuse.

LGBTQ Individuals

Individuals who identify as LGBTQ in Tulare County experience significant stigma, and interviewees spoke about a severe shortage of culturally competent providers. The stigma that LGBTQ individuals experience plays a large role in discouraging them from seeking appropriate care. This is compounded for LGBTQ individuals who are Latinx, migrant workers, undocumented, or live in the outlying more rural areas. Some interviewees are also concerned that there is a lagging standard of care for this population compared to other metropolitan areas of the state. For example, providers are still drawing blood to test for HIV rather than using a rapid result test which delays results. In addition, some interviewees said that patients are not always aware that they need to request the specific HIV and STI tests they want to receive.

There is reportedly only one provider in the area who provides culturally competent care for transgender patients, but he will not initiate hormone replacement therapy (HRT). Patients seeking this treatment must travel far out of the county to obtain it.

There is a lack of primary care doctors who are trained to prevent HIV among at-risk patients. Preliminary data on HIV rates in Tulare County show a 68% increase from 2017 to 2018.¹¹  California state law requires medical providers to educate patients who are at high risk for HIV infection about methods to reduce their risk, including pre-exposure prophylaxis (PrEP). However, one interviewee asserted that no providers in the Tulare County area are complying with the mandate. There are no self-reported PrEP providers on official listings online, and an interviewee noted that providers in the area refer individuals seeking PrEP to the one infectious disease physician serving patients with HIV, who has a months-long waiting list. Notably, most women in the focus group had not heard of PrEP or its brand name, Truvada. Providers are also not providing expedited partner therapy (EPT) or HIV/STI prevention education. The SOURCE, the single LGBTQ advocacy resource organization in the county, is trying to change this by working with the FQHCs in the area and conducting clinic visits. The SOURCE is also a PrEP Medication Assistance Program site, through the AIDS Drug Assistance Program (ADAP) and Gilead’s PrEP Assistance Program (PrEP AP) which helps under- or uninsured individuals pay for the drug.

Teens

Access to Abortion Counseling and Services

Compared to many other states, there are fewer restrictions on abortion in California; however, access to and cultural attitudes about abortion vary throughout the state. There are no abortion providers in Tulare County, and interviewees and women in the focus group stated that the community is conservative, creating substantial local resistance among both women and providers to the service.

There are no abortion clinics in Tulare County, and there are significant barriers to providing or obtaining these services. The closest clinic providing abortion services is in Fresno, which is at least 50 miles away. Women face barriers related to transportation, cost, stigma, and fear of family members finding out.

Interviewees suggested abortion access is most affected by political and cultural norms, and that anti-abortion groups and crisis pregnancy centers (CPCs), which typically offer limited medical services like pregnancy testing and ultrasounds, and discourage women from seeking abortion services, have considerable local power. Planned Parenthood’s Visalia Health Center has experienced repeated vandalism over the past few years, even though it does not provide abortion services. Local FQHCs fear losing federal funding if perceived as supporting abortion. One interviewee remarked that there is significant bias against abortion among providers and believes that most do not discuss or provide referrals for abortion. Some providers are aware of the potential impact of the new Title X regulations that ban Title X funds from going to providers who offer or refer for abortion services. However, they do not think it will have much of an impact in their community because, “no one is really doing those activities now.”

Half of the focus group participants knew where they could get an abortion, though some suggested that many in the Latinx community oppose abortion. One woman had a friend who wanted an abortion but could not get one because it was too expensive; in the end, she gave birth and placed the baby for adoption. Another woman said she decided to have her provider induce a “miscarriage” after she found out her fetus was developing abnormally, but later doubted her decision. A Title X provider remarked that “we don’t get that many women who want to terminate their pregnancy,” though many interviewees reported a general lack of knowledge and education about abortion as an option.

Conclusion

California is known for its progressive policies and has extensive protections for health care coverage including family planning and abortion; however, many residents of Tulare County lack access to these services. While the county has a large Medicaid-eligible population, the shortage of providers, particularly specialists and abortion providers, presents barriers to sexual and reproductive health care. In addition, the region’s rural population has little access to public transportation, and faces extreme poverty, making it difficult to afford even basic items. The county’s large Latinx immigrant community, many of whom are undocumented migrant workers, faces heightened challenges; they are often deterred from seeking care due to language barriers, ineligibility for public programs, and a fear of deportation. There is limited support for women experiencing domestic violence, and many face barriers to leaving violent relationships. All these obstacles are amplified for undocumented individuals without health coverage and who fear deportation, and for those who identify as LGBTQ dealing with stigma and a lack of culturally competent providers.

Acknowledgements

The authors thank all of the individuals that participated in the structured interviews for their insights, time, and helpful comments. All interviewees who agreed to be identified are listed below. The authors also thank the women who participated in the focus groups, who were guaranteed anonymity and thus are not identified by name.

Angel Avitia, Assistant Director, Tulare County Family Resource Center Network

Gabriela Beltran, Title X Patient Care Coordinator, Altura Centers for Health

Brandon Foster, PhD, Chief Quality and Compliance Officer, Family HealthCare Network

Erin Garner-Ford, Executive Director, ACT for Women and Girls

Raquel Gomez, Director of Community Initiatives, Tulare County Family Resource Center Network

Caity Meader, CEO, Family Services of Tulare County

Brian Poth, Executive Director, The Source

Leonora Sudduth, RN, Title X Nurse, Altura Centers for Health

Dawn Wells, Grants Specialist, Altura Centers for Health

KFF: Usha Ranji, Michelle Long, and Alina SalganicoffHealth Management Associates: Sharon Silow-Carroll and Carrie Rosenzweig

Introduction

Over the past couple of decades, Missouri has increasingly become a battleground for reproductive rights and health services. The state has passed a number of regulations that restrict access to reproductive care, and in May 2019, along with several other states, the Republican-controlled Missouri state legislature passed a law banning abortions after 8 weeks. As of this publication, it is temporarily blocked by a federal judge as a legal challenge plays out in court. State regulatory policies and enforcement actions put Missouri at risk of becoming the first state with no operating abortion clinic since Roe v. Wade was decided in 1973. In addition to restrictions on abortion access, Missouri has not expanded Medicaid eligibility under the ACA.

In contrast to the rest of the state, St. Louis stands out as a liberal area, electing Democrats as mayor of the City of St. Louis and to the state senate and House of Representatives.¹²  The St. Louis metropolitan area (Figure 1) is highly segregated and deep health disparities exist between black and white residents. The region is federally-designated as medically underserved and as a health professional shortage area. One recent study found that there was an 18-year difference in life expectancy between the wealthier, predominantly white, suburbs of Clayton and North St. Louis City, a majority Black area less than 10 miles away. St. Louis also has a large Catholic population and concentration of Catholic-affiliated hospitals and schools, which shape how local health systems offer sexual and reproductive health services and education.

This case study examines access to reproductive health services among low-income women in St. Louis City and County, Missouri. It is based on semi-structured interviews conducted by staff of KFF and Health Management Associates (HMA) with a range of local safety net clinicians and clinic directors, social service and community-based organizations, researchers, and health care advocates, as well as a focus group with low-income women during March and April 2019. Interviewees were asked about a wide range of topics that shape access to and use of reproductive health care services in their community, including availability of family planning and maternity services, provider supply and distribution, scope of sex education, abortion restrictions, and the impact of state and federal health financing and coverage policies locally. An Executive Summary and detailed project methodology are available at https://www.kff.org/womens-health-policy/report/beyond-the-numbers-access-to-reproductive-health-care-for-low-income-women-in-five-communities.

Medicaid Coverage and Continuity

Missouri’s decision not to expand Medicaid, its policies restricting Medicaid reimbursement for providers that offer both contraception and abortion services, as well as the establishment of a state-funded family planning program that excludes providers who offer abortion services and their affiliates, have extensive implications for women’s access to sexual and reproductive health and maternity care. A temporary health care program for low-income adults in St. Louis helps fill some of the gaps in coverage and access to care.

Missouri chose not to adopt the Affordable Care Act’s Medicaid expansion. Medicaid enrollment has declined dramatically over the past year, causing coverage gaps and discontinuity of care for women and children. Missouri’s Medicaid program (Table 1), MO HealthNet, covers parents with incomes under 21% of the Federal Poverty Level (FPL), and pregnant women up to 305% FPL under the Children’s Health Insurance Program (CHIP) “unborn child” option (Show-Me Healthy Babies).¹³  Adults who are not parents are not eligible unless they are low-income and seniors or have a disability. Missouri’s Women’s Health Services program provides family planning services for women ages 18-55 who are ineligible for full Medicaid, with incomes up to 206% FPL, as long as they seek care at a family planning provider that does not also offer abortion services. Coverage gaps for women who do not qualify for Medicaid or who lose coverage due to small changes in income disrupt continuity of care and create barriers to family planning and other health care services (Figure 2). MO HealthNet enrollment declined roughly 9.5% from May 2018 to May 2019 (Figure 3), the steepest drop in Medicaid and CHIP coverage across all states. Missouri’s state government argues this decline is due to improvement in the economy, but a study by the Center for Children and Families at the Georgetown University Health Policy Institute suggests it resulted at least in part from flawed redetermination processes.

In St. Louis City and County, uninsured adults living at or below 100% FPL, who do not qualify for Medicaid, can apply for the Gateway to Health program, a federal demonstration program that provides temporary coverage. Benefits include primary care, generic prescriptions, substance use treatment, and specialty care referrals to contracted health centers. There are no premiums and copays are no more than $3.00.

Lack of Medicaid expansion creates barriers to postpartum care. Missouri’s Medicaid income eligibility threshold for parents (21% FPL) is considerably lower than for pregnant women (305% FPL). Pregnancy-related coverage ends 60 days after delivery, so many poor women whose incomes exceed the 21% FPL threshold for parents (roughly $4,500 a year for a family of three) lose coverage two months after delivery. Furthermore, women with incomes below the federal poverty level are not eligible for subsidies to purchase private coverage through the ACA’s health insurance marketplace, meaning that many poor women do not have a pathway to coverage and become uninsured. One provider lamented that they are only able to see women once they are pregnant, but then must “drop them when they lose coverage.” There is no automatic enrollment into the state-funded family planning program for women who lose full Medicaid coverage, leaving many low-income women without coverage for needed contraceptive services after they have a baby. Providers suggested that the Federally Qualified Health Centers (FQHCs) in the area are positioned to provide ongoing care to women who lose their Medicaid coverage, but reported some FQHCs are facing steep financial challenges. In July 2019, the state announced plans to submit a Section 1115 Demonstration waiver to CMS that, if approved, would allow low-income women who have recently given birth and are diagnosed with a substance use disorder (SUD) to maintain coverage for SUD and related mental health treatment, including transportation to appointments, for up to 12 months following the end of their pregnancy benefits.

State policies bar Medicaid reimbursement for services obtained from providers who offer or are affiliated with abortion services. This reduces access to contraception for low-income women. To exclude abortion providers from participating in its Medicaid family planning program, in 2016, Missouri replaced its federal family planning waiver program with a state-funded family planning program called the Women’s Health Services Program. This program denies reimbursement to any organization that performs or counsels on abortion regardless of the other services that are provided. Additionally, in 2018, Missouri enacted legislation that denies Medicaid reimbursement to abortion facilities or their affiliates regardless of the other services that are provided.

Planned Parenthood of the St. Louis Region (PPSLR) had not received reimbursement for any of the Medicaid beneficiaries they served since July 2018, which makes up a significant portion of their budget. However, a state court judge ruled in June 2019 that Missouri unlawfully restricted Medicaid payments to abortion providers for non-abortion services and ordered the state to restore reimbursements to PPSLR.¹⁴  Medicaid reimbursement restrictions also create confusion among health care providers, which one interviewee suggested causes fewer providers to participate in the state family planning program even if they are qualified. Between June 2018 and May 2019, enrollment in the Women’s Health Services Program dropped by almost 12,000 members, or almost 19% (Figure 3).

These policies also threaten the financial stability of clinics that provide free or affordable contraception to low-income women, even if they do not provide abortion. For example, the Contraceptive Choice Center (C3), part of the Washington University School of Medicine in St. Louis, was excluded from the state family planning program due to its affiliation with a hospital that provides abortions in cases of severe fetal anomalies or when a woman’s life is in danger.

The state’s Title X clinics may be strained after the Trump Administration’s new program rules are fully implemented. In addition to Medicaid, funds from the federal Title X family planning program support clinics that provide services to low-income women. In March 2019, the Trump Administration issued new rules barring Title X funding from organizations that provide or refer for abortion. At that time, a C3 clinic interviewee stated that should the new rules be implemented, the clinic may have to shut down entirely. Since the time of the interview, the rule has gone into effect and Planned Parenthood has withdrawn from Title X nationwide; the effect on C3 remains to be seen.¹⁵ 

Focus group participants cited cost as a major barrier to health insurance coverage and care. Most focus group participants reported that they are getting their basic health needs met, but a few uninsured women are going without some types of health care such as preventive care, dental care, mental health services, or their preferred method of contraception. For uninsured women, the cost of birth control ranged from $25 to $48 per month. One focus group participant said she wanted to change methods but could not afford the $170 appointment to have her intrauterine device (IUD) removed, and another could not afford a tubal ligation she desired.

Provider Distribution and Religious Health Systems

Provider distribution remains a problem in the St. Louis area, especially in low-income areas, and the prevalence of faith-based hospitals may cause delays in care. While overall there are sufficient numbers of providers offering affordable contraceptive and pregnancy-related care, maldistribution of providers translates into access problems for many women.

While interviewees reported there are enough providers of publicly-funded contraception within the city limits, they do not feel that they are distributed equitably throughout the county. Interviewees identified provider shortages in North City and North County, areas that are majority low-income and African American, and in other pockets of poverty throughout the county. There are four Title X providers in St. Louis, but there is no public hospital in the area; this need is primarily filled by private or faith-based hospitals. Some reported that there is also a lack of providers trained in long acting reversible contraception (LARC) insertion in publicly funded clinics.

Several health care leaders stated that there is insufficient capacity to meet the demand for sexually transmitted infection (STI) testing and treatment in the face of high and increasing rates of syphilis, chlamydia, and gonorrhea. Following nationwide trends, rates of STIs are increasing in St. Louis, with the highest prevalence among people living with HIV, African Americans, and youth ages 16 to 24. Access to STI testing and treatment is limited by a lack of affordable providers and decreasing federal and state funding. After the city health department closed its STI clinics in the early 2000’s, the county clinic in North County became the only public provider in the area, with lines out the door on most of their STI clinic days. Focus group participants reported that men in particular are not receiving adequate STI testing and treatment services because they are not as connected with the health system and usually ineligible for Medicaid. Therefore, most are not getting preventive care or education about STI prevention, which reduces the likelihood they will seek treatment if they have an infection.

Interviewees and focus group participants felt that there was generally an adequate supply of providers for pregnancy and postpartum services in the St. Louis region and that access was better than in the rest of state. Overall, women participating in the focus group participants reported having positive experiences at the hospitals where they received maternity care and felt their physicians understood their cultural beliefs. They also reported their physicians discussed contraceptive options with them during the 6-week postpartum visit. The County Health Department is a service site for the Nurse Family Partnership program, one of the local programs that makes home visits to low-income first-time mothers and has been effective in improving the utilization of contraceptives during the postpartum period.

Religious health systems do not offer most methods of contraception, but clinicians affiliated with those systems often refer to other providers for a broader range of options. Most focus group participants had received care from one of the area’s many Catholic hospitals, and they did not report any significant impact on their reproductive health care. Although they knew that these hospitals would not perform tubal ligations, they said that their physicians shared information about contraceptive methods and would provide referrals to other hospitals or clinics where they could obtain these services. None of the women knew that there was a non-religiously affiliated hospital in the area. Community stakeholders similarly reported that individual providers affiliated with religious health systems may refer to other providers for contraceptive services not permitted by their institution.

Contraceptive Provision, Access, and Use

Overall, interviewees felt that women living in the St. Louis region can obtain their preferred method of contraception, but cited barriers related to transportation and poverty. They also noted that a lack of comprehensive sex education can impede knowledge of the full range of methods. Several promising efforts are underway to address these barriers and improve access for low-income women.

Family planning providers offer a wide range of contraceptive choices including IUDs and implants, but certain Medicaid policies challenge their ability to offer same-day or timely access to LARCs. Most providers reported they offer comprehensive family planning services. Missouri’s state Medicaid program covers LARC at the time of delivery with a separate provider reimbursement to promote immediate postpartum LARC insertions. Interviewees reported, however, that some hospitals are not aware of this policy or need additional training in LARC insertion to make this option fully available after delivery. Furthermore, several providers noted that Medicaid policies governing payment for LARC cause delays that prevent same-day access. These policies include preauthorization and utilization requirements that limit a patient to one LARC device per FDA-approval period for the device (e.g. up to five years for a Mirena IUD), and policies tying LARC devices to a specific patient. As a result, most patients must return for a second appointment to get their device inserted, and many interviewees reported instances of patients missing appointments or getting pregnant before they are able to return. One focus group participant explained she had to wait three months for her IUD to be delivered because of Medicaid’s pre-authorization requirement. Many clinics cannot afford the high upfront costs to stock LARCs onsite, which would facilitate same-day access for women seeking those methods. In 2018, legislation was passed that allows a provider to transfer a new, unused LARC to a different MO HealthNet patient instead of discarding it. However, one provider noted that there were not yet any guidelines from the state to define or help facilitate that process.

While most focus group participants reported that they can get contraception, many described barriers to getting the methods they want, when they want them. Several focus group participants said they are happy with the treatment they receive from their providers when seeking contraception and are familiar with a wide range of contraceptive methods. However, it can take multiple visits and long wait times between appointments is common. One woman who now goes to a public health clinic after losing her private insurance said she has been waiting months for an appointment because of staff shortages due to furloughs. Several focus group participants had experienced negative side effects from hormonal methods that resulted in their changing or discontinuing contraception. Focus group participants were knowledgeable about emergency contraception, and four had used it in the past. They said it is available at drug stores, but that they must ask for the pharmacist to take it out of a locked case, creating additional barriers to access.

Some low-income women experience financial, logistical, and language barriers to accessing family planning services. Poverty and other socioeconomic factors also affect sexual health outcomes. Interviewees noted a lack of reliable public transportation, scheduling conflicts, long waiting times for appointments, and lack of interpretation services as barriers to care. Providers stated that the safety net was over capacity, with six to eight-week wait times for a women’s health appointment for new FQHC patients. One focus group participant liked that her usual place of care had extended hours during the evening, so she could go after work. Factors such as unstable housing, lack of transportation, poverty, and a lack of education were raised as challenges for low-income women, and these are fundamentally intertwined with sexual and reproductive health services.

Clinicians face time constraints during family planning visits, and some are influenced by their own beliefs or outdated standards of care. Several clinic staff mentioned that clinicians do not have enough time to provide in-depth contraceptive counseling given the clinic flow and the level of demand. Likewise, focus group participants reported that the physicians are too busy to spend much time with them. Lack of provider training and misinformation also impede family planning access, especially around LARC provision. Some providers still adhere to outdated protocols restricting IUD use for women who have not had children. Others may not be providing comprehensive counseling on the full range of methods due to their own cultural or religious beliefs. One interviewee reported that there may be variation within organizations, with pushback from some individual providers and nursing staff regarding the use of LARCs or emergency contraception.

Sex Education Policy and Provision

Sex education in schools is not mandated and varies by district. “Abstinence-plus” is the most common approach. In 2007, Missouri passed a law that prohibited school districts from allowing a person or an organization to offer sex education or related materials to its students if they provide or refer to abortion services. One interviewee said that this policy leads to a lot of confusion and individual interpretation at both the administrative and teacher level. It also opens the door for faith-based organizations, such as Crisis Pregnancy Centers (CPCs), which often do not offer a medically-accurate, comprehensive curriculum, to step in. While parent pushback resulted in some schools no longer using CPCs to provide sex education, other schools reportedly continue to use “abstinence only” education or “abstinence-plus” curricula, which stress abstinence but also include information on contraception and condoms. PPSLR offers comprehensive sex education at no cost to hundreds of partners a year, but interviewees say the rule barring abortion providers from offering sex education in schools has a chilling effect despite their legal separation from Reproductive Health Services (RHS), the Planned Parenthood clinic that conducts abortions. Interviewees and focus group participants agree that as a result, youth are not adequately informed of sexual health risks or ways to prevent unintended pregnancy and STIs. Focus group participants believed that most young women rely on their friends for information, and that the gaps in sex education results in teen pregnancies.

Access to Abortion Counseling and Services

Abortion is highly regulated in Missouri, and women face significant barriers to accessing abortion counseling and services.

The only clinic that provides abortions in the state of Missouri is in St. Louis. Women are increasingly crossing state lines to seek services at clinics in Illinois where there are fewer state restrictions. As of November 2019, RHS of PPSLR, located in the city of St. Louis, is the only clinic providing abortions in Missouri, down from three clinics in 2018.^16 ,17  Notably, there is no access to medication abortion in Missouri. RHS provides surgical abortion services, but stopped providing medication abortion because Missouri regulations require providers to conduct a pelvic exam prior to medication prescription; RHS providers consider this medically unnecessary and unethical. Instead, they refer women seeking medication abortion to a Planned Parenthood clinic in Illinois. Consequently, more women are reportedly going across the river to the Planned Parenthood and Hope Clinic for Women, an independent provider, in Illinois, where there are fewer state restrictions including no waiting period. Planned Parenthood is expanding services in their southern Illinois facility to help meet demand for the surrounding region. While access is difficult in St. Louis City and the surrounding county, interviewees agree that access is significantly harder in the rest of the state where there are no nearby abortion providers, and women may have to travel up to five hours to St. Louis for care.

Focus group participants reported that cost is the largest barrier to abortion care but that many other abortion-specific restrictions also make abortion access challenging. Focus group participants said the cost for the abortion pill is between $500 and $600, and surgical abortion costs around $700, making it out of reach for many women. They also cited other barriers such as transportation, a shortage of providers, and regulations such as the 72-hour waiting period, mandated informed consent counseling, parental consent for minors, and gestational age limits. Some focus group participants felt the state-mandated counseling was intended to make them second guess their own decisions. A few focus group participants were well informed about the state’s abortion laws, and most felt that it was getting harder to get an abortion in Missouri. Some women said they have gone to neighboring clinics in Illinois where there are fewer restrictions.

The volume of state and federal restrictions on abortion have a profound impact on providers and the low-income women they serve. Providers reported that the 72-hour waiting period coupled with the rule that requires the same physician to conduct the informed consent and the procedure three days later are especially burdensome. As a result, RHS had to reconfigure their scheduling to accommodate these policies, losing four providers who could no longer fit it into their schedule. The new Title X rule, which blocks funding for family planning providers who refer women for abortions, is confusing to providers regardless of whether they participate in the Title X program; they reported that when the rules constantly change, they are wary of even providing a referral for abortion. One interviewee reported that FQHC providers have been told never to talk about abortion and are worried about doing anything that would put their federal funding in jeopardy.¹⁸  One provider noted that the media mainly discuss the rule’s impact on Planned Parenthood affiliates but believes there would be a much more dramatic effect on other providers, either because they would not want to comply with the rules and choose not to participate in the Title X program, or they were not able to participate. This would mean that they would lose an important source of funding to provide family planning services to poor and uninsured women.

Abortion providers and women who utilize their services feel stigmatized and sometimes fearful by the political and social barriers they face in providing and seeking abortion care. Stigma, intimidation, and fear about confidentiality serve as major barriers to women seeking abortion services. There are protestors outside PPSLR and RHS daily, and focus group participants reported that these protestors make them feel afraid and ashamed of their decisions. Crisis pregnancy centers (CPCs), which typically offer limited medical services like pregnancy tests and ultrasounds, and discourage women from seeking abortion, have a large presence in the area. Abortion providers also face a series of obstacles, including myriad state restrictions (see Appendix) and significant cultural and political stigma. One clinician noted she chose not to provide abortion services because the associated stigma would make it difficult for her to be effective in other areas of health care and state health policy due to the political environment. Another interviewee said their organization is seeking long-term political solutions such as the “Clean Missouri” bill that addresses gerrymandering in the state to help elect officials who are supportive of reproductive health and abortion services.

Conclusion

While St. Louis has an extensive network of family planning and maternity providers, women who live in the poorest areas of the city and county are especially disadvantaged due to the dearth of providers in their communities and the lack of reliable public transportation to clinics in other areas. Several organizations in the region have undertaken efforts to expand access to contraception, especially to highly-effective, long-acting methods such as IUDs and implants. However, there is a large contrast between the efforts to improve access in St. Louis and state-level policy decisions that have targeted family planning providers that also offer or are affiliated with abortion providers. Providers said that these policies limit their ability to participate in programs like the state family planning program and Title X. The state’s decision not to expand Medicaid and recent efforts to further restrict access to abortion have not only significantly reduced the availability of abortion services, but also have had an impact on contraceptive access, STI care, and other basic health services. More women are reportedly choosing to travel to Illinois for abortion services, where they have far fewer restrictions on abortion.

Acknowledgements

The authors thank all of the interviewees for their insights, time, and helpful comments. All interviewees who agreed to be identified are listed below. The authors also thank the focus group participants, who were guaranteed anonymity and thus are not identified by name.

Meg Boyko, Executive Director, Teen Pregnancy & Prevention Partnership

David Eisenberg, Board-Certified Ob-Gyn and Former Medical Director, Planned Parenthood of St. Louis Region (PPSLR)

Linda Locke, Board President, (PPSLR)

Tessa Madden, MD, MPH, Contraceptive Choice Center (C3), Washington University School of Medicine

Katharine Mathews, MD, MPH, MBA, Associate Professor and Research Division Director, Department of Obstetrics, Gynecology, and Women’s Health, Saint Louis University School of Medicine

Thomas McAuliffe, Director of Health Policy, Missouri Foundation for Health

Tim McBride, PhD, Professor and Co-Director of Center for Health Economics and Policy, Institute for Public Health, Washington University in St. Louis

Colleen McNicholas, DO, Chief Medical Officer, PPSLR

Katie Plax, MD, Medical Director, Supporting Positive Opportunities with Teens (The SPOT), Washington University in St. Louis

Angie Postal, Vice President, Education, Policy, and Community Engagement, PPSLR

Becky Schrama, MA, BSN, RN, Public Health Nursing Manager, St. Louis County Department of Public Health

Melissa Tepe, MD, MPH, FACOG, VP/CMO at Affinia Healthcare, St. Louis, MO

Michelle Trupiano, MSW, Executive Director, Missouri Family Health Council, Inc.

Appendix

KFF: Usha Ranji, Michelle Long, and Alina SalganicoffHealth Management Associates: Rebecca Kellenberg, Carrie Rosenzweig, and Sharon Silow-Carroll

Introduction

The Crow reservation is the geographically largest Native American reservation in Montana, and home to approximately 8,000 members of Crow Nation, about 75% of the total enrolled membership. Located about 60 miles southeast of Billings, the reservation covers most of Big Horn County, but a small portion extends into Yellowstone County. The Crow Tribal Council governs the Nation, and Indian Health Services (IHS) is responsible for providing health services, although other coverage options and providers are also utilized. Montana offers coverage for reproductive health services for low-income women through its Medicaid expansion program¹⁹  and its Plan First family planning Medicaid waiver. These programs have had a significant impact in a community with high unemployment and poverty rates (Figure 1) and where stark health disparities between the white and Native American populations persist.

Although Montana maintains many policies that protect access and coverage for reproductive health services, Crow women living on the reservation face sociodemographic, systemic, and cultural barriers that prevent many from readily accessing services. In many parts of the reservation, the nearest health care provider is an hour drive away; yet, transportation is not readily available in this low-income, rural community, which is federally-designated as medically underserved and as a health professional shortage area. IHS operates a hospital and two health clinics on the reservation, but a legacy of mistrust of IHS, long wait times, and confidentiality concerns prevent some Crow women from using their services. Some of these themes, particularly concerns about confidentiality, are common in small, rural communities across the country, and are not limited to the Crow reservation. While IHS offers a wide range of services including behavioral health, obstetrics and gynecology (Ob-Gyn), dental care, and surgery, pregnant women must transfer to Billings for labor and delivery. Traditional and religious beliefs prevent many Crow women from talking openly about sexual health, which may contribute to high rates of sexually transmitted infections (STIs) and teen pregnancy, and many consider abortion taboo or do not consider it an option when faced with an unplanned or unintended pregnancy.

This case study examines access to reproductive health services for low-income residents of the Crow reservation, Montana. It is based on semi-structured interviews conducted June–July 2019 by staff of KFF and Health Management Associates (HMA) with a range of local safety net clinicians and clinic directors, social service and community-based organizations, researchers, and health care advocates. We also conducted a focus group with low-income women. Interviewees were asked about a wide range of topics that shape access to and use of reproductive health care services in their community, including availability of family planning and maternity services, provider supply and distribution, scope of sex education, abortion restrictions, and the impact of state and federal health financing and coverage policies locally. An Executive Summary and detailed project methodology are available at https://www.kff.org/womens-health-policy/report/beyond-the-numbers-access-to-reproductive-health-care-for-low-income-women-in-five-communities.

Indian Health Service and Medicaid Coverage

Medicaid expansion has played a significant role in improving coverage rates for Native Americans in Montana, which has allowed Crow tribal members to access a broader set of services and providers beyond those available at IHS. The additional funding provided through the expansion program has also allowed IHS Service Units to expand their scope of services, a move that is essential to addressing the tremendous disparities in health for native women of reproductive age.

The Indian Health Service (IHS) provides health care services to Native Americans, including the Crow tribe, at no-cost. Nationwide, IHS services are administered through 12 area offices and 170 IHS and tribally managed service units, and 41 urban Indian health programs including hospitals, health stations, and clinics. As of April 2019, IHS served 2.56 million Native Americans. The Crow Service Unit has three sites on the reservation: the Crow/Northern Cheyenne Hospital located at the Crow Agency headquarters, the Lodge Grass Health Clinic, and Pryor Health Station. There is also an Urban Indian Health and Wellness Center in Billings. Because IHS-funded services are paid in full by the federal program, focus group participants expressed that out-of-pocket cost is not an issue for them despite high levels of poverty on the reservation. However, IHS staff did discuss that overall funding is often limited.

Medicaid expansion and changes in Purchased/Referred Care reimbursement policy have supported increased access to health care and reproductive health care services. In 2015, the Montana legislature passed the bipartisan Health and Economic Livelihood Partnership (HELP) Act, extending Medicaid coverage (Table 1) to adults with incomes up to 138% of the federal poverty level (FPL). As of 2018, an additional 15,495 Native Americans gained Medicaid coverage through the expansion program in Montana. Expanded Medicaid coverage has allowed Native Americans throughout the state to seek a broader range of services from any provider that accepts Medicaid, allowing them more flexibility and choice in their provider and the care they receive. The increase in Medicaid coverage has also provided a significant influx in funding for Indian Health Service units, which can bill for services provided to Medicaid-enrolled Native Americans with a 100% federal matching rate. Importantly, in addition to the services that IHS facilities and tribal health departments can provide directly, they can also refer patients to additional services at non-tribal providers through the Purchased/Referred Care (PRC) Program. As a result, Native Americans, including Crow tribal members, now have greater access to reproductive health care, including fertility treatment, which is not provided within the IHS system. Approximately 35% of patients at Planned Parenthood of Montana in Billings are covered by Medicaid expansion or the state’s family planning waiver program, Plan First.

Provider Distribution

The Crow Agency IHS Service Unit employs one Ob-Gyn and one midwife, who are the only family planning providers in the community. A shortage of providers on the reservation and lack of transportation are barriers to accessing care in a timely manner. Many women seek care at one of the non-IHS clinics off the reservation in nearby Hardin or farther away in Billings.

Provider recruitment and retention is a key challenge both on and off the Crow reservation. Interviewees reported a significant staffing shortage at the Crow Indian Health Service, not only in obstetrics and gynecology, but also in behavioral health and nursing. IHS is in the process of building a housing unit for staff across from the hospital, which they hope will draw more providers to work there. Planned Parenthood in Billings also reported staffing challenges due to competition with other health care providers in the area. Staffing shortages mean the Planned Parenthood clinic must shorten their hours, limiting availability for working women who can often only come in the evening and on the weekends.

Publicly-funded contraceptive services are available on the Crow reservation, but some women experience barriers to obtaining timely services. The Crow-Northern Cheyenne Hospital offers a broad range of services including behavioral health, Ob-Gyn, dental care, and surgery. All three of the IHS locations also provide family planning services, including STI testing and treatment, and on-site insertion of implants and IUDs (at the hospital and Lodge Grass clinic). Sterilization services are not provided, but IHS clinicians said they will refer patients seeking sterilization to providers in Billings. While some providers are able to see patients on the same day the appointment is made, some interviewees noted they double and triple book appointments to account for no-shows. Several focus group participants reported experiencing long waiting room times.

There are several other key health care providers serving the Crow population. In nearby Hardin (13 miles away), the Bighorn Valley Health Center’s (BVHC) client population is roughly two-thirds Native American, 80% of whom are Crow, and the clinic offers the full range of contraceptive methods and STI testing and treatment. In addition, the Billings Urban Indian Health and Wellness Center, approximately 60 miles away in Billings, operates as part of the federal Urban Indian Health Program as a nonprofit, full-service medical clinic. They provide low- and no-cost health services including oral contraceptives, STI testing and treatment, and free transportation to and from the Crow-Northern Cheyenne Hospital and Pryor Health Station. The Yellowstone County Health Department and multiple primary and specialty care providers are also in Billings, in addition to two Planned Parenthood clinics offering the full range of contraceptive options and abortion services. BVHC and Planned Parenthood were the only clinics in the area receiving federal Title X family planning funds. However, at the time of this site visit, interviewees noted that if the Trump administration’s Title X rule changes take effect, Planned Parenthood will have to leave the program. Subsequent follow up calls with Title X providers found that this requirement has been challenging, and on August 19, 2019, Planned Parenthood formally withdrew from the Title X program nationally following implementation of the rule.

Crow women may go to Crow-Northern Cheyenne Hospital for prenatal care, but the hospital does not offer labor and delivery services. Some Crow women travel to non-IHS providers in Billings for all of their pregnancy care. There is one Ob-Gyn physician at Crow-Northern Cheyenne Hospital. However, the hospital is not approved for labor and delivery services, so women living on the reservation are referred to Billings after 30 weeks gestation, which can be more than an hour drive away. In emergency situations, women have delivered at the emergency room of Big Horn County Memorial Hospital in Hardin. Several focus group participants shared stories of women they knew who had experienced pregnancy loss or preterm births because they were not able to detect a problem with the pregnancy early enough. Although the Crow-Northern Cheyenne Hospital did not have an ultrasound technician at the time of the site visit, they have since hired someone for this position. Historically, midwifery was a common practice within the Crow tribe²⁰ , but none of the focus group participants had used a midwife. One interviewee noted that St. Vincent in Billings has an active midwifery clinic and provides prenatal care to many women in the area. IHS is also working to restart their midwifery program at the Crow-Northern Cheyenne Hospital. The hospital employs one female midwife who is available for family planning services and has plans to hire another. Transportation is a significant barrier for women traveling for prenatal or pregnancy-related services. Some focus group participants noted they try to use the Crow Transit bus, but it leaves Crow Agency (the seat of the reservation) once a day at 6:00 am and is reportedly unreliable. In addition, many areas of the reservation are over an hour away from Crow Agency. Medicaid will pay for transportation costs for pregnancy care, but that is of little use if reliable transportation is unavailable. One focus group participant said she has had to hitchhike to and from Billings to get to her health care appointments.

Several statewide and Crow-specific maternal health programs have existed in the past. The state used to administer the Montana Initiative for the Abatement of Infant Mortality (MIAMI) Project to increase access to prenatal, delivery, and postpartum care for high-risk pregnant women and their infants. Additionally, the Crow Healthy Mothers and Healthy Babies program previously provided outreach and education to pregnant women. Recently, the Montana Healthcare Foundation has supported Native American perinatal behavioral health program development efforts statewide, but it is unknown how this will impact the Crow tribe. BVHC provides fully-integrated care for pregnant women including access to substance use treatment with on-site behavioral health providers.

Substance Use Disorder and Pregnancy

Substance use disorder is a serious concern on the Crow reservation, and a recent policy announced by the Big Horn Attorney’s office to “crack down” on pregnant women using drugs or alcohol has made outreach and engagement even more difficult. Interviewees reported high rates of substance use among youth and adults on the reservation. Focus group participants explained that children whose parents have substance use disorders (SUD) are often sent into foster care out of state, and interviewees said that grandmothers often step in to raise young grandchildren in the absence of parents who are dealing with addiction. BVHC has a robust SUD treatment program for pregnant women. The clinic conducts outreach and screening, performs a warm handoff to internal providers for treatment, and offers Medication-Assisted Treatment (MAT) for those with opioid use disorders. Messengers for Health, a health outreach and education program on the Crow reservation, also teaches substance use prevention to youth within the schools. Still, interviewees reported significant stigma around substance use during pregnancy. In January 2018, the Big Horn County Attorney announced he would seek to jail pregnant women found to be using drugs or alcohol. In response to strong backlash, the attorney has backed away from the policy (although has not yet changed it as of October 2019) and has been participating in workgroups about how to provide holistic care to those with SUD. One interviewee noted the attorney’s actions had a noticeable “chilling effect” on women presenting for prenatal, family planning, and postpartum care and made outreach to these women even more challenging than it already was.

Contraceptive Provision, Access, and Use

The full range of contraceptive methods are available at IHS; however, contraception use is reportedly low, particularly among teens, contributing to the Crow tribe having the highest teen pregnancy rate in Montana. Lack of transportation, confidentiality concerns, cultural beliefs, lack of awareness, and historical mistrust of health care providers among the Crow population are barriers to care.

Provider shortages, traditional beliefs, and a lack of health literacy all contribute to the higher rates of teen pregnancy among Crow youth. The overall Montana teen birth rate is 26 births per 1,000. Big Horn County, where Crow reservation is located, is ranked highest in the state for teen births, at 85 births per 1,000. Contraceptive care for low-income women is available at IHS and various providers in Hardin and Billings. However, interviewees explained that babies are viewed as a blessing in many traditional families, even for teens, and given this perspective, family planning is not always prioritized. Low health literacy was also reported as a limitation to contraceptive use.

A legacy of forced sterilization and experimentation, confidentiality concerns, and turnover at the IHS administration has led to a distrust of IHS and other western providers. Several interviewees discussed the lasting impact the history of nonconsensual research and forced sterilization has had on the Crow tribe. Native American women,²¹  including Crow women,^22 ,23  were sterilized without their consent by U.S. government employees as recently as 50-60 years ago.

Confidentiality concerns are also a significant barrier to family planning and STI testing services on the reservation, as is common in many small communities. Several interviewees expressed concern that patients’ relatives and friends working at IHS do not always adhere to robust confidentiality standards. In addition, turnover in the service unit director position at IHS and within the tribal administration also serves as a barrier to social service and health education programs such as Messengers for Health, whose leaders must gain each new administration’s buy-in for their existing programs.

St. Vincent is the only religious health system in Billings, and in practice, it has few restrictions on contraception, although it recently stopped performing tubal ligation. There are two major health systems in the area, St. Vincent and Billings Clinic, both of which provide the full range of contraceptive methods including LARC. However, St. Vincent stopped providing tubal ligation in June 2019, and interviewees reported that St. Vincent providers often refer to Planned Parenthood for long-acting reversible contraception (LARC), such as IUDs and implants, because of their own beliefs or they lack experience due to low volume. Several focus group participants noted they typically do not go to St. Vincent for contraception simply because Billings Clinic, the other major hospital in the area, is closer to the reservation.

Sex Education Policy and Provision

Sex education is mostly discussed informally in the home, with intermittent efforts to provide formal education in schools. Education about STIs and HIV is lacking, and there is significant stigma associated with HIV.

Sex education on the Crow reservation is influenced by strong cultural and gender roles within the Crow tribe. As some interviewees described it, Crow families are closely knit, and the tribe has a tradition of matrilineal kinship. Older women, especially, adhere to strong beliefs in modesty and treat topics about sexuality, family planning and abortion as taboo. Crow girls often look to their grandmothers for education on these issues. This is significant given many grandmothers are raising their grandchildren. However, family planning is not typically prioritized, and focus group participants said many girls and young women do not know where to get contraception. Two focus group participants shared they each had friends who became pregnant at 11 and 14 years old, respectively. Abortion was not considered an option for either, and someone else raised the babies for them. “This is common,” said one focus group participant.

Outside of the family, several school-based sex education programs exist but are not adopted consistently. Messengers for Health was invited into schools on the reservation by Crow women in the community to educate girls from 5^th to 12^th grade about sexual risk factors for cervical cancer using a culturally competent curriculum. Topics reflected cultural values and covered self-respect, peer pressure, substance use, and discussions about what students have heard about sex from their families. Over the years, adoption of this program has varied depending on level of support from the Crow administration. Planned Parenthood in Billings employed a Health Educator who is Native American and has worked with several schools in and around the Crow reservation. In several Crow communities on the reservation, she taught the culturally-tailored “Making Proud Choices” curriculum to high school students. In one town, she was only allowed to work with female students due to Crow cultural norms. However, in another community, both boys and girls participated. Interviewees felt the latter community’s remoteness from Crow Agency and overall lack of services led to greater appreciation and acceptance of the education and outreach. Interviewees added that there appears to be more openness to this type of education as staff gets younger and more aware of these issues, particularly as they relate to substance use.

STI and HIV rates are on the rise, and there is significant stigma associated with HIV. Interviewees report that STI rates have increased dramatically in both Big Horn and Yellowstone counties. The STI incidence rate (including chlamydia, gonorrhea, and syphilis) for Big Horn County, where most of the Crow reservation is located, was 5,484.9 per 100,000 in 2017 compared to 551.6 per 100,000 across the entire state of Montana. Due to confidentiality concerns and lack of awareness, many people do not get tested for STIs or HIV. Stigma, particularly related to HIV, is a growing concern as HIV rates increase due to drug use. Several interviewees said HIV patients travel to Billings for their care to avoid confidentiality concerns at IHS. Another interviewee noted that 20 years ago, tribal public health nurses would go out into the community and provide condoms and testing, but that IHS does not currently do any outreach related to STIs or HIV. Focus group participants said the providers they see in Billings do talk with them about STIs and provide information about prevention and testing services.

Sexual and Domestic Violence

As in many tribal communities, the Crow tribe has a history of sexual abuse and domestic violence dating back to colonization and boarding schools. In 1871, the U.S. Congress declared Native Americans wards of the U.S. government and began a forced assimilation campaign to integrate children into the dominant white culture. Native American children were taken from their families at the age of 4 or 5 and placed in government and Catholic church-run boarding schools where communication with their families was prohibited. Many suffered physical and sexual abuse. In the absence of healing, the effects on the community continue, and is exacerbated by substance use, limited access to employment, and poverty.

Interviewees noted that sexual and domestic violence remain major problems in current times. The Crow Agency has a domestic violence program that supports women who are victims of abuse. Advocates visit women who are referred by the police to connect them with needed services including a safe house, restraining orders, and health care. However, interviewees and focus group participants noted that women may wait a long time for the police to come if they call from the reservation, so these advocates often encourage women to go to Billings. Issues with law enforcement jurisdiction can also complicate problems. The FBI, county sheriff, and tribal police all have overlapping roles on these issues, which can result in re-traumatizing victims and missteps in investigations. One interviewee shared a story of an FBI agent barging in on a victim’s family planning appointment. Another provider pointed to domestic violence’s impact on women’s reproductive choices in instances where abusers prohibit women from using contraception, causing pregnancy and increased dependency on the abuser. Focus group participants also raised the issue of the disappearance of tribal members as a key concern of their community. Native Americans make up less than 7% of the state’s population but accounted for 26% of all missing person reports between 2016 and 2018, and Native women and girls account for 30-40% of human and sex trafficking victims in Montana. The emergency department at the Crow-Northern Cheyenne Hospital has Sexual Assault Nurse Examiner (SANE)-trained nurses, and all of the hospital staff have been trained in trauma-informed care. Interviewees also discussed the importance of the availability of female providers to reduce barriers for victims seeking family planning and reproductive health care.

Access to Abortion Counseling and Services

Crow families typically do not discuss abortion, and many are opposed to it. The nearest abortion services are located in Billings.

Many Crow women and girls do not consider abortion an option, and often relatives will raise the child. Some Crow women used to practice abortion using plants/herbs. In fact, women from other tribes used to come to Crow communities for this purpose. However, these practices are not common today due to general opposition to abortion. The Christian church is very influential on the Crow reservation, and abortion is considered taboo due to both traditional and religious beliefs. Interviewees explained that babies are considered a blessing among traditional Crow families, regardless of the circumstance of the pregnancy. When needed, relatives will step in and raise the child. A few of the focus group participants noted they knew of a friend who had an abortion, but most were reluctant to discuss it or said they did not believe in abortion, and it had never crossed their mind as an option.

Abortion counseling and services are not available on the reservation, but there are two Planned Parenthood locations in Billings that offer abortion services. Montana does not have any of the state-level abortion restrictions that some other states have, such as waiting periods, mandated parental involvement, or limitations on publicly-funded abortions. However, IHS providers are federal employees, and therefore do not provide abortions. Some providers make abortion referrals to Planned Parenthood in Billings. Under court order, Montana’s Medicaid program is one of 15 state Medicaid programs that uses state funds to pay for abortion beyond the circumstances of rape, incest, and life endangerment permitted by the federal Hyde amendment, and Planned Parenthood reported they have had no issues receiving reimbursement.

Even though Big Horn County is considered “blue in a red state,” as one interviewee put it, there is strong anti-abortion sentiment in Big Horn and Yellowstone Counties. As a result, women who are seeking abortions, and providers who want to refer them, do so with discretion. Despite abortion being highly stigmatized in the area, Planned Parenthood staff reported they do see Crow patients seeking abortion services.

Conclusion

Montana offers broad coverage for reproductive health services through the expanded Medicaid program and family planning waiver. Medicaid expansion has significantly improved the financial health of both IHS and non-tribal providers, leading to increased capacity to meet the overall health care needs of the Crow tribal community. Tribal members can access most methods of contraception at IHS service units on the reservation at no cost. However, there are not enough providers to meet the reproductive health care needs of Crow women on the reservation. Confidentiality concerns, historical mistrust of the health care system, and lack of transportation are barriers to care. Many topics related to contraception, abortion, and STIs are not discussed openly, contributing to the highest teen pregnancy rates in the state and high rates of STIs. However, several organizations, including Messengers for Health and Planned Parenthood of Montana have had success with outreach and education in schools, and continue to look for ways to engage youth. Substance use also influences family roles, particularly in cases where grandmothers step in to raise children when parents are absent due to challenges with substance use. Sexual and domestic violence affects many Crow families; interviewees reported that enhancements to both victims support services and law enforcement systems are needed to address these issues.

Acknowledgements

The authors thank all of the interviewees that participated in the structured interviews for their insights, time, and helpful comments. All interviewees who agreed to be identified are listed below. The authors also thank the focus group participants, who were guaranteed anonymity and thus are not identified by name.

Nona Main, former Health Educator, Native Outreach Project, Planned Parenthood of Montana

David Mark, MD, CEO, Bighorn Valley Health Center

Timothy P. McCleary, Ph.D., Department Head, General Studies Department, Little Big Horn College

Alma McCormick, Executive Director, Messengers for Health, Crow Nation

Lucille Other Medicine, MSW, Program Assistant, Messengers for Health, Crow Nation

KFF: Usha Ranji, Michelle Long, and Alina SalganicoffHealth Management Associates: Diana Rodin, Carrie Rosenzweig, and Sharon Silow-Carroll

Introduction

Located in northwestern Pennsylvania on the shore of Lake Erie, Erie County has a large city (Erie), where 80% of the population lives, several smaller communities, and a large swath of rural area. Although the state expanded Medicaid under the Affordable Care Act, the county is federally designated as medically underserved and as a health professional shortage area (Figure 1). However, the city of Erie has a relatively strong health care safety net that includes family planning services, and the local health care system is working to meet the needs of a relatively large population of refugees and immigrants. As a whole, Erie County is more politically conservative than the city of Erie, and the Roman Catholic Diocese of Erie and the large Catholic population in the region influence both the health care and educational systems. The conservative culture plays a role in reproductive health care access in the region, particularly as it affects the availability of abortion services.

This case study examines access to reproductive health services for low-income women in Erie County, Pennsylvania. It is based on semi-structured interviews conducted by staff of KFF and Health Management Associates (HMA) with safety net clinicians and clinic directors, social service and community-based organizations, researchers, and health care advocates (“interviewees”), as well as a focus group with low-income women in April 2019. Interviewees were asked about a wide range of topics that shape access to and use of reproductive health care services in their community, including availability of family planning and obstetrical care, provider supply and distribution, scope of sex education, abortion restrictions, and the impact of state and federal health financing and coverage policies locally. An Executive Summary and detailed project methodology are available at https://www.kff.org/womens-health-policy/report/beyond-the-numbers-access-to-reproductive-health-care-for-low-income-women-in-five-communities.

Contraceptive Provision, Access, and Use

Family planning providers offer a wide range of contraceptive choices including long-acting reversible contraceptives (LARCs), but barriers persist for some patients and for same-day access among some providers.

Erie County’s Title X clinic is the only provider offering same-day access to long-acting reversible contraceptives (LARCs), including IUDs and implants. Adagio Health, the most comprehensive provider of family planning services in the county, has a clinic in the city of Erie and one in nearby Edinboro. These clinics are supported by funds from the federal Title X program and are reportedly the only providers offering same-day access to most contraceptive methods including LARCs. Interviewees noted that the need for multiple appointments at other providers can be a barrier to LARC access. A clinician commented that more immigrant and refugee patients were requesting LARCs recently because they feared access to services would soon be restricted under federal policy changes related to immigrants. Federally Qualified Health Centers (FQHCs) in the region offer far fewer contraceptive methods, typically the pill. Interviewees perceived primary care providers as similarly limited in their provision of family planning services, particularly in that they do not provide LARC. One interviewee noted that referral loops between the large Ob-Gyn group and FQHCs are not always closed, leaving clinicians uncertain whether their patient made their appointment or received services. However, these entities are working to improve their coordination.

Challenges getting patient-centered, respectful care are widespread. While many focus group participants had been able to access family planning services they needed, many also had negative experiences with reproductive services over the course of their lives. Focus group participants described: pressure from providers to use or not use contraception based on the providers’ own preferences and attitudes about ideal family size, the age of the patient, or the provider’s own religious beliefs; traumatic birth experiences or obstetric care; and racial and socioeconomic discrimination in the health care system. Interviewees and focus group participants reported that women who are uninsured or covered by Medicaid are not always treated with respect by private providers and have limited alternatives to switch providers if they have a negative experience.

Sex Education Policy and Provision

Interviewees described variation among school districts in their willingness to provide sex education and their use of evidence-based programs. The student parenting program associated with Erie City School District recently implemented the evidence-based, comprehensive FLASH curriculum.²⁴  At the same time, there is a significant presence of crisis pregnancy centers (CPCs) in schools from elementary through high school that provide more limited “character education.” A stakeholder reported that the CPCs, which usually promote abstinence, receive state, federal, and private funding which enables them to conduct more outreach and programs than the more comprehensive reproductive health care providers. Focus group participants perceived availability of sex education as inconsistent across schools and not necessarily adequate for high school-aged students.

Religious and Cultural Factors

Erie County, including the city, has a large Roman Catholic population, and the church’s policies on family planning and abortion have influenced the health care and educational systems. The Catholic Diocese of Erie includes 12 northwestern Pennsylvania counties in addition to Erie, and claims 202,000 members, almost half of whom are in Erie County. Although Erie County’s formerly-Catholic hospital, St. Vincent, no longer has a religious affiliation,²⁵  some interviewees and focus group participants were unsure whether all faith-based restrictions on care, such as limits on sterilization, have been eliminated. More broadly, Catholic and Evangelical Christian opposition to abortion is reflected in the community, with focus group participants stating that people are “closed off” and reticent to discuss abortion, and to some degree, contraception and other reproductive health issues.

Members of the extremely diverse refugee and immigrant communities in Erie have a wide variety of religious affiliations and beliefs, with varied preferences related to reproductive health care. The health center that provides culturally competent care predominantly to refugees provides referrals to the full range of reproductive health care, including family planning and abortion services. Staff noted that it was rare for patients to seek abortion services, but they had provided referrals when asked.

Specialized Services for Erie’s Refugee Communities

The local health care system is focused on meeting the health and family planning needs of a significant refugee population.

Erie is home to one of the largest refugee resettlement populations in Pennsylvania, and refugee resettlement agencies as well as a refugee-focused health center, the Multi-Cultural Health Evaluation Delivery System (MHEDS), are focused on meeting their health needs including family planning services. According to one interviewee, from 2012 through 2016, Erie settled almost 3,500 refugees from countries including Bhutan, Nepal, the Democratic Republic of Congo, Russia, Somalia, South Sudan, Syria, and Ukraine. Some interviewees mentioned that there has been a significant reduction in the number of refugees seeking services in Erie, which they attribute to the current national political climate. The State Department’s Refugee Processing Center reports that refugee arrivals to Erie has plummeted since 2016.²⁶  Women who are part of those communities have varying preferences and use of family planning services, and the local health care system is building capacity to better meet their needs. MHEDS is an FQHC “look-alike” health center and the sole provider in Erie for the refugee resettlement program, with which it contracts to complete health screenings for newly arrived refugees. MHEDS, along with the Title X program, also provides services to migrant agricultural workers and Amish and Mennonite communities in Erie County.

MHEDS has tailored its services and staffing to address the particular concerns of Erie’s refugee communities and to provide culturally competent care. The health center has medical interpreters from many refugee communities in Erie to address language and cultural barriers. Some women have experienced genital mutilation, and MHEDS is focused on improving provider capacity in Erie to address the associated physical and mental health consequences and competently care for these women. They plan to add well women visits to further develop their onsite women’s health services. Refugees also have varied views of the highly medicalized American model of prenatal care. Some women are not accustomed to the frequent prenatal appointments or standard testing, which can lead to tension with providers. Refugees have Medicaid coverage and are assigned case managers for their first five years in the United States, which helps support access to health care services. However, outside MHEDS, women who need services in languages other than English often face barriers, particularly when providers do not follow requirements to offer interpretation services.

Cost and Coverage

Access to contraceptives is shaped by state policies that have expanded Medicaid and promoted availability of all family planning methods, but on the local level, providers are concentrated in the population centers, limiting access for women in the rural parts of the county. Cost is a barrier to contraception for some uninsured women, even at publicly-funded health centers or Title X clinics using sliding fee scales.

Medicaid expansion has supported increased access to health care broadly and to family planning services in recent years. Pennsylvania’s Democratic governor presided over Medicaid expansion in 2015.²⁷  Between 2010 and 2017, Pennsylvania’s uninsured rate decreased from 10.2% to 5.5%. As of early 2019, nearly 700,000 Pennsylvanians were enrolled in the Medicaid expansion. Pennsylvania also has a family planning program established through a Medicaid State Plan Amendment that covers comprehensive family planning services for eligible men and women with incomes up to 220% FPL (Table 1).

Erie County’s Title X grantee, Adagio Health, is the key provider of comprehensive family planning services to low-income women, though access to all health care services is limited in rural areas. While Medicaid expansion has increased the number of providers in Pennsylvania, interviewees reported that it remains difficult to recruit and retain clinicians and staff in Erie County, resulting in provider shortages. As a result of competing demands on patients’ time, many providers struggle with high no-show rates which lead to scheduling difficulties. Transportation is a barrier to all health care services. Unreliable buses and lack of access to cars limit low-income women’s ability to travel, particularly in rural areas, but also within the city of Erie where severe winter weather can compound travel challenges.

According to an interviewee, between 10% and 20% of patients served by Adagio Health are uninsured. Because Title X patients pay for care based on a sliding scale, some can face fees up to 50% of the cost of the family planning method, which can be as much as $250 for an IUD. Emergency contraception is available at pharmacies or from a doctor, but focus group participants found it expensive to buy over the counter and hard to get a prescription; one participant described a provider refusing to dispense emergency contraception because of their own religious beliefs.

Provider Distribution and Ob-Gyn Consolidation

Rural areas of Erie County have less access to health care. The Title X grantee is the primary family planning provider for low-income women, while one Ob-Gyn practice dominates the perinatal care landscape.

Maternity Care

Provider consolidation has resulted in fewer options for maternity care in the county. There are no longer any maternity facilities outside of the city of Erie, so most deliveries take place at one of the three major hospitals in the city. Nearly all perinatal care is provided by a single physician group, with two locations in the city of Erie and two satellite offices in Corry and Union City, smaller towns in Erie County. Interviewees highlighted that there is little competition or alternative to this large provider group. The Title X grantee, Adagio Health, also provides prenatal care to some low-risk women, working with physicians in the large Ob-Gyn practice who track their charts weekly and provide delivery and postpartum services. Many interviewees and focus group participants raised concerns that having only one major Ob-Gyn practice could result in lower quality of care and noted they had heard or directly experienced that some of the practice’s providers do not treat patients with Medicaid coverage with respect. Focus group participants also expressed preferences for greater continuity of care than offered by this practice where patients may see a different prenatal provider during each visit and at delivery. Several focus group participants had used midwifery or doula services, but this was not reported to be the dominant model.

Provider practices around postpartum care and related family planning services vary and often lack continuity. Some providers discuss postpartum resources including family planning during prenatal visits, while others do so after delivery. One interviewee noted that some women do not know where to go for postpartum services; and some return to their prior source of care, only to be directed back to the Ob-Gyn for their postpartum follow-up visits. Most providers refer low-income women to the Title X provider for family planning after their pregnancy Medicaid ends; however, women seeking sterilization are referred to the hospitals in the city of Erie.

Other Reproductive Health and Social Service Providers

The Erie County Department of Health (DOH) operates a sexually transmitted infection (STI) clinic providing testing and treatment, infectious disease surveillance, education, and robust HIV follow-up care. The STI clinic provides free testing and treatment two days per week or by appointment, with a particular focus on pregnant women and their partners. DOH recently identified an increase in syphilis among infants in Erie, reinforcing the need to screen all pregnant women. DOH collaborates with partners including the Title X grantee, which also provides free HIV testing and treatment services. The department also conducts rapid HIV screening, counseling, pre-exposure prophylaxis (PrEP), and ongoing follow-up with each person who tests positive for HIV to ensure that they are connected with and maintain access to treatment, including home visits if needed. Multiple interviewees and focus group participants stated that there is a lack of knowledge about STIs among youth in the community. Stigma continues to be a barrier to STI testing and treatment, but DOH conducts community-based education programs as funding allows.

The Erie County Women Infants and Children (WIC) program and the Nurse Family Partnership provide social and medical services and referrals for family planning. The WIC program is well-established, long-standing, co-located with community centers in the city of Erie, and serves a “unique and diverse” caseload of about 7,500 people annually with a wide variety of community-based programs for parents and infants. Two of its centers are located close to Erie’s largest public housing facilities. Enrollment in WIC services has been declining due to fears among the large immigrant population about use of public programs creating risks to immigration status (“public charge”). The Nurse Family Partnership program, based at the DOH, provides evidence-based nurse home visiting services free of charge to low-income women who are pregnant with or parenting their first child, up to the age of two. The program serves an average of 95 women per year, with the goals of improving pregnancy outcomes, child health and development, and economic self-sufficiency.

Access to mental health care is very limited in Erie County. There is a lack of access to treatment for postpartum depression and to mental health services more broadly. Focus group participants highlighted stigma, concerns about child welfare involvement, and a shortage of mental health services in the city and county as the key barriers.

Access to Abortion Counseling and Services

The lack of abortion providers in Erie County and the anti-abortion climate make it difficult to access abortion counseling and services.

There are no clinics providing abortion services in Erie County, and residents seeking abortion care must travel at least 100 miles away to Pittsburgh, New York, or Ohio. Travel time, transportation, and the cost of the procedure are barriers to abortion access for Erie County residents. Compounding the challenges for low-income women, Pennsylvania Medicaid does not cover most abortions, and the 24-hour waiting period in Pennsylvania (and Ohio) results in women having to make two trips. Furthermore, earlier in 2019, Ohio passed a bill that could prohibit any abortions in the state as early as six weeks of gestation. While the law is currently blocked under judicial order, if implemented, it would further diminish options for abortion services for women in western Pennsylvania. One focus group participant recounted an experience in which she and her husband could not save enough money for the transportation to the clinic, which ultimately prevented her from having the procedure she sought. Several interviewees and focus group participants mentioned that there used to be a local abortion provider, but the clinic closed several years ago. Many interviewees were unfamiliar with the state’s policies and restrictions on abortion, and some focus group participants and more than one interviewee believed, incorrectly, that abortion is not legal in the area.

Many providers said they provide women with information on where to obtain an abortion if they ask. It is often hard for women to get information about abortion, or to know which providers can make a referral to services. Some providers discussed looking up information for women who needed abortion counseling or services, and some said they would refer to the Title X program, which could provide abortion referrals. At the time of the interviews, most providers did not view the new Title X regulation that prohibits grantees from making referrals for abortion as having a significant impact in the area because they felt that the number of referrals is already low. (These interviews took place before the new rule took effect.) Subsequent follow up conversations with Title X providers have found that this requirement has in fact been challenging as they have not been able to offer referrals, and this has eroded trust between the providers and the women who seek abortion care.

Crisis pregnancy centers (CPCs) have a large presence in the community, and many providers refer to CPCs without knowing what services they do and do not offer. CPCs typically offer limited medical services and all discourage women from seeking abortion services. In Erie County, the largest CPC offers pregnancy tests, STI screening, ultrasounds, referrals to prenatal care, adoption counseling, smoking cessation services, and classes on topics such as breastfeeding and childbirth, all at no cost to clients as they receive state and federal funding. Some interviewees suggested that the CPCs provide biased information, and that many providers refer women to the largest CPC in Erie without understanding its limited scope or anti-abortion mission. The major CPC in Erie County reported that they counsel women on all their options; however, this appears to be at odds with its mission, the priorities of its funders, and the typical policies of CPCs. A focus group participant reported feeling pressured by CPC staff to adhere to its faith-based principles, which include opposition to abortion. Focus group participants were aware of the CPCs in the area and knew these organizations provide adoption counseling and pregnancy tests (a few had gone for pregnancy tests in the past) and do not offer abortion services.

Conclusion

Family planning services are generally available in the city of Erie, but access is more limited in the rural parts of the county and for uninsured women. Medicaid expansion, a Medicaid-funded state family planning program, and targeted programs to serve the refugee communities in Erie County facilitate access to contraception for most low-income people. However, lack of integration between primary care and reproductive health services, gaps in referral follow-up, heavy reliance on the area’s sole Title X provider, and language barriers are ongoing challenges to the provision of comprehensive reproductive health services. Further, with no abortion providers in Erie County, a conservative political and cultural environment, and no abortion coverage through Medicaid, low-income women seeking abortion services face cost and transportation barriers as well as stigma.

Acknowledgements

The authors thank all of the interviewees that participated in the structured interviews for their insights, time, and helpful comments. All interviewees who agreed to be identified are listed below. The authors also thank the focus group participants, who were guaranteed anonymity and thus are not identified by name.

Laura Beckes, CHES, HIV Disease Intervention Specialist, Erie County Department of Health

Amanda Cox, Medical Advocate, Safe Journey

Kathy Dahlkemper, Erie County Executive

Heather Goodwin, Medical Assistant, Primary Health Network

Dylanna Grasinger, Director, USCRI-International Institute

Toni Gromacki, Medical Coordinator, Community Health Net

Debora Jamison, Director, Erie County WIC

Chris Kain, Nurse Practitioner, Community Health Net

Juliette Mannino, Nurse Practitioner, Independent Consultant

Wendy Neilsen, RN, Nurse Family Partnership/Immunization Supervisor, Erie County Department of Health

Myrna Otero, Practice Manager, Primary Health Network

Susan Scriven, Nurse Practitioner, Adagio Health

Patricia Stubber, CEO, Multi-Cultural Health Evaluation Delivery System (MHEDS) (and team)

Lisa Szymanski, BSN, RN, Public Health Nurse, HIV/AIDS Surveillance and Partner Services, Erie County Department of Health

This project was designed and carried out by staff of KFF and HMA. Major components of the project were the selection of sites, review of documents about state and local policies, structured interviews with providers and organizations in each community, focus groups with women in each community, analysis, and preparation of reports.

Overall design: Site visits by 4-person teams from KFF and HMA including in-depth, semi-structured interviews with local clinicians and representatives from health and social sector organizations caring for low-income, reproductive age women, and focus groups in five communities: Dallas County (Selma), Alabama; Tulare County, California; St. Louis, Missouri; Crow Tribal Reservation, Montana; and Erie County, Pennsylvania.

Site selection criteria: Based on variation in state Medicaid expansion, presence of state-funded family planning program, state laws governing abortion, geographic region in US, racial/ethnic makeup, presence of religiously-affiliated providers and CPCs (Table 1).

Document and policy reviews: Included but not limited to Medicaid eligibility and covered services, state family planning programs and restrictions on use of public funds, sex education, abortion, community health needs assessments, and provider shortage areas.

Structured interviews: The research team, comprised of staff from KFF and HMA, conducted interviews in-person or by phone with key reproductive health safety net clinicians and clinic directors, social service and community-based organizations, researchers, and health care advocates. Qualitative interview guides (master guide available upon request) were developed and included questions and probes regarding policies, access, facilitators and barriers related to contraception/family planning, sex education, STIs, obstetrical care, and abortion services. The interviews were tailored to individual regions and interviewee roles. After obtaining verbal consent, interviews were recorded and typically lasted 60-75 minutes. Interviewees who are quoted by name in this report gave approval for their attribution. Notably, not all individuals who were contacted agreed to be interviewed, and the research team was not able to speak to all providers in the community. Interview responses are self-reported, based largely on perception and experience not verifiable by investigators.

Focus groups: A focus group in each region was conducted with low-income women ages 18-40, with race and language reflecting the community/regions. The number of women in the groups ranged from 9 to 12. Recruitment and facilitation was provided by Perry Undem Research/Communication using a KFF staff-developed moderator guide with questions about their access to and use of family planning, obstetrical, and abortion services. The groups were comprised of a mix of women who were uninsured, on Medicaid, and covered by private insurance. All of the groups were conducted in English, except for Tulare County, which was conducted in Spanish. While the focus groups were audio recorded for preparation of this report, all participants were guaranteed anonymity. Thus, none of the participants are identified in this report. Each woman was paid $200 for her time and participation.

Analysis: Included but not limited to reviews of relevant policies, statistics and background information; qualitative review of interview notes and recordings; development of comparative grid summarizing, comparing and contrasting interviewee responses; focus group transcripts and moderator outlines of key themes; development of individual site case study reports.

1. Wisconsin covers adults up to 100% FPL in Medicaid but did not adopt the ACA Medicaid expansion. ↩︎
2. Missouri’s Women’s Health Services Program covers family planning services and approved methods of contraception to uninsured women ages 18-55 with income up to 201% FPL. The program does not permit payments to family planning providers if they also provide abortion services. ↩︎
3. Abstinence Plus models typically stress abstinence, but also include information on contraception and condoms. ↩︎
4. FLASH is a widely used, comprehensive sexuality education curriculum developed by Public Health Seattle–King County and intended to prevent teen pregnancy, sexually transmitted infections and sexual violence. More information is available at https://www.etr.org/flash/. ↩︎
5. In 2019, the state legislatures in Alabama and Missouri passed laws that would have effectively banned abortion services in those states. Federal court rulings have temporarily blocked the enactment of those laws; the states are appealing those rulings. ↩︎
6. 2013-2017 American Community Survey 5-Year Estimates. ↩︎
7. Established through a waiver agreement between Alabama and the federal government. ↩︎
8. 2013-2017 American Community Survey 5-Year Estimates. ↩︎
9. Healthy Horizons magazine, 2018. ↩︎
10. This reflects the highest eligibility limit for pregnant women in the state under the CHIP program’s “unborn child” option. California Medicaid’s pregnancy eligibility limit is 213% FPL. ↩︎
11. HIV/AIDS cases reported by year, preliminary 2018 data, Tulare County, HHSA Public Health. ↩︎
12. St. Louis County, which encompasses all the suburban municipalities, is separate from the adjacent but independent St. Louis City. ↩︎
13. This reflects the highest eligibility limit for pregnant women in the state under the CHIP program’s “unborn child” option. Missouri Medicaid’s pregnancy eligibility limit is 201% FPL. ↩︎
14. As of November 2019, this ruling has not had an immediate effect and the state is expected to appeal. ↩︎
15. On June 20, 2019, a panel of federal appeals court judges ruled that parts of the Title X rule, such as the ban on abortion referrals, would go into effect immediately, with physical separation requirements going into effect in March 2020. ↩︎
16. The largest hospital in the city provides abortions in cases of health complications and fetal anomalies. ↩︎
17. PPSLR and the state of Missouri are involved in a legal battle over their licensure. The case was heard by an Administrative Hearing Commission in October 2019. If the panel sides with the state, Missouri could become the first state without an abortion clinic. ↩︎
18. Section 330 of the Public Health Service Act defines federal grant funding opportunities for organizations, such as community health centers, to provide care to underserved populations. ↩︎
19. Montana’s Medicaid expansion program, HELP, covers adults with incomes up to 138% FPL, and the Plan First family planning Medicaid waiver covers women ages 18-44 with incomes up to 216% FPL. Also, pregnant women with incomes up to 162% FPL are eligible for Medicaid, with coverage extending 60 days postpartum. ↩︎
20. For more information about the history of midwifery among Native American women, see Theobald, B. Reproduction on the Reservation. ↩︎
21. Lawrence, J. (2000). The Indian Health Service and the Sterilization of Native American Women. American Indian Quarterly 24(3). Retrieved from http://bixby.ucla.edu/journal_club/Lawrence_s2.pdf. ↩︎
22. Jaimes, M. A. (1992). The State of Native America: Genocide, Colonization, and Resistance. Boston, MA: South End Press. ↩︎
23. Theobald, B. (2019). Reproduction on the Reservation. Pregnancy, Childbirth, and Colonialism in the Long Twentieth Century. Chapel Hill, NC: The University of North Carolina Press. ↩︎
24. FLASH is a comprehensive sexuality education curriculum developed by Public Health Seattle–King County and intended to prevent teen pregnancy, sexually transmitted infections and sexual violence. It is widely used and includes curricula for elementary, middle, and high school and special education classrooms. More information is available at https://www.etr.org/flash/. ↩︎
25. Saint Vincent Hospital merged with Allegheny Health Network, operated by the insurer Highmark. ↩︎
26. Kaiser Family Foundation analysis of Department of State Worldwide Refugee Admissions Processing System, 2012-2018. Accessed October 2019. ↩︎
27. After Pennsylvania’s Medicaid expansion, adults at or below 138% of the federal poverty level are eligible for Medicaid. Pregnant women are eligible for Medicaid up to 220% FPL. ↩︎

This report provides an analysis of donor government funding to address family planning in low- and middle-income countries in 2018, the latest year available, as well as trends over time. It is part of an effort by the Kaiser Family Foundation to track such funding that began after the London Summit on Family Planning in 2012. Key findings include the following:

• DONOR GOVERNMENT FUNDING FOR FAMILY PLANNING REACHED ITS HIGHEST LEVEL IN 2018. In 2018, donor government funding rose from $1.26 billion in 2017 to $1.50 billion (an increase of $237.3 million or 19%, as measured in current terms); funding increased even after accounting for inflation and currency fluctuations.¹  This was the second year of increases after two years of declines, and the highest level of funding since the 2012 Summit.
• MOST DONORS INCREASED BILATERAL FUNDING FOR FAMILY PLANNING IN 2018. Among the 10 donor governments profiled, seven provided increased bilateral funding (Canada, Denmark, Germany, the Netherlands, Norway, the U.K., and the U.S.) and three decreased (Australia, France, and Sweden); these trends were the same in currency of origin. The U.S. increase in 2018 was largely due to the timing of disbursements and does not reflect an actual increase in U.S. appropriations by Congress, which have been flat for several years.
• THE U.S. CONTINUES TO BE THE LARGEST DONOR TO FAMILY PLANNING. The U.S. was the largest bilateral donor to family planning in 2018, providing $630.6 million or 42% of total bilateral funding from governments. The U.K. (US$292.2 million, 19%) was the second largest donor, followed by the Netherlands (US$215.6 million, 14%), Sweden (US$107.0 million, 7%), and Canada (US$81.8 million, 5%).
• SINCE THE LONDON SUMMIT IN 2012, MOST DONOR GOVERNMENTS HAVE INCREASED FUNDING AND OVERALL FUNDING HAS RISEN BY MORE THAN US$400 MILLION. Among the 10 donor governments profiled, eight have increased bilateral funding since the London Summit in 2012 (Canada, Denmark, Germany, the Netherlands, Norway, Sweden, the U.K., and the U.S.). The U.S. increase was the largest over the period (US$145.6 million), followed by the Netherlands (US$110.2 million), Sweden (US$65.8 million), Canada (US$40.3 million), and the U.K. (US$39.4 million).
• DONORS ALSO INCREASED FUNDING TO UNFPA. In addition to bilateral disbursements for family planning, donor governments profiled also provided US$373.9 million in core contributions to UNFPA in 2018, an increase of US$29.5 million compared to the 2017 level (US$344.4 million).²  Sweden provided the largest core contribution to UNFPA in 2018 (US$83.0 million), followed by Norway (US$63.8 million), the Netherlands (US$37.5 million), and Denmark (US$37.1 million).For the second year in a row, the U.S. administration invoked the Kemp-Kasten amendment to withhold funding from UNFPA.

Introduction

This report provides the latest data on donor government resources available for family planning activities in low- and middle-income countries. It is part of an effort by the Kaiser Family Foundation that began after the London Summit on Family Planning in 2012 at which the global community pledged to expand contraceptive access to an additional 120 million women and girls by 2020.³  Stakeholders reconvened at The Family Planning Summit for Safer, Healthier and Empowered Futures in 2017 and made new and renewed commitments to global family planning goals.⁴ 

This current report provides data on donor government disbursements in 2018, the most recent year available. It includes data from all 30 members of the Organisation for Economic Co-operation and Development (OECD)’s Development Assistance Committee (DAC), as well as non-DAC members where data are available.⁵  Data are collected directly from donors and supplemented with data from the DAC. Ten donor governments that account for 98% of total disbursements for family planning are profiled in this analysis. Both bilateral assistance and core contributions to UNFPA are included. For more detail, see the below methodology. For information on family planning funding from other sources (e.g. multilateral organizations, foundations, etc.) see Appendix 1.

Findings

Bilateral Disbursements

In 2018, donor governments disbursed US$1.50 billion in bilateral funding for family planning activities (see Figure 1, Table 1 & Appendix 2), an increase of US$237.3 million (19%) compared to the 2017 level (US$1.26 billion) and the highest level of funding since tracking efforts began following the 2012 London Summit (even after adjusting for inflation and currency fluctuation). This was the second year of increases after two years of declines.

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Among the ten donors profiled, seven increased funding in 2018 (Canada, Denmark, Germany, the Netherlands, Norway, the UK, and the US) and three decreased (Australia, France, and Sweden); these trends were the same in currency of origin.

Approximately two-thirds of the overall increase in 2018 was due to an increase in funding from the U.S., the world’s largest donor. In 2018, U.S. disbursements totaled US$630.6 million, an increase of US$155.9 million (33%) compared to 2017 (US$474.7 million). The U.S. increase in 2018 was largely due to the timing of disbursements and does not reflect an actual increase in U.S. appropriations by Congress, which have been flat for several years (see Figure 2 and Box 1). The remaining increase reflects actual increased disbursements from Canada, Denmark, Germany, the Netherlands, Norway, and the U.K.

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The U.S. was the largest donor to family planning, accounting for 42% of donor government disbursements (see Figure 3). The U.K. (19%) was the second largest donor followed by the Netherlands (14%), Sweden (7%), and Canada (5%).

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Since the London Summit in 2012, most donor governments have increased funding for family planning and overall funding has risen by US$405.1 million (37%) (see Figure 4 & Table 1). Eight of the ten donor governments profiled (Canada, Denmark, Germany, the Netherlands, Norway, Sweden, the U.K., and the U.S.) increased funding over the period (see Figure 5). The U.S. was the largest cumulative increase over the period (US$145.6 million), though largely due to fluctuations in disbursement rates. The Netherlands (US$110.2 million) was the second largest cumulative increase, followed by Sweden (US$65.8 million), Canada (US$40.3 million), and the U.K. (US$39.4 million). Five of the donors profiled (Canada, Denmark, the Netherlands, Norway, and Sweden) doubled or more than doubled bilateral family planning funding over the period. It should be noted that the dip in funding in 2015 and 2016 was primarily due to an increase in the value of the U.S. dollar against all other currencies as well as disbursement delays by the U.S.

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Donor Contributions to UNFPA

While the majority of donor government assistance for family planning is provided bilaterally, donors also provide support for family planning activities through contributions to the United Nations Population Fund (UNFPA). Most of UNFPA’s funding is from donor governments, which provide funding in two ways: 1) donor directed or earmarked contributions for specific activities (e.g. donor contributions to the UNFPA Supplies), which are included as part of bilateral funding above; and 2) general contributions to “core” activities that are untied and meant to be used for both programmatic activities (e.g. family planning, population and development, HIV/AIDS, gender, and sexual and reproductive health and rights) and operational support as determined by UNFPA.

In 2018, donor governments profiled provided US$373.9 million in core contributions to UNFPA, an increase of US$29.5 million (9%) compared to the 2017 level (US$344.4 million). Among the donors profiled, two increased funding (Norway and Sweden), five remained flat (Australia, Canada, France, Germany, and the U.K.), and two declined (Denmark and the Netherlands). The U.S. did not provide any funding to UNFPA in 2018 (see Box 2).⁶ 

Sweden provided the largest core contribution to UNFPA in 2018 (US$83.0 million), followed by Norway (US$63.8 million), the Netherlands (US$37.5), and Denmark (US$37.1 million) (see Figure 6 and Table 2). Among the ten donors profiled, one donor – Norway – provided a larger contribution to UNFPA’s core resources than their total bilateral disbursement for family planning.

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Looking Ahead

While donor government funding for family planning reached the highest level since this tracking effort began, a significant share of that increase was due to the timing of disbursements by the U.S. The U.S. increase may be temporary as annual appropriations have been relatively flat in recent years. Family planning funding from most of the remaining nine donors, all of which made new or renewed commitments at the Family Planning Summit in 2017, increased in both 2017 and 2018. These years have also seen funding growth in broader Sexual and Reproductive Health and Rights (SRHR) among a subset of donor governments. Ongoing tracking of whether these trends continue will be important for assessing the post-2020 agenda.

Methodology

Bilateral and multilateral data on donor government assistance for family planning (FP) in low- and middle-income countries were collected from multiple sources. The research team collected the latest bilateral assistance data directly for 10 governments: Australia, Canada, Denmark, Germany, France, the Netherlands, Norway, Sweden, the United Kingdom, and the United States during the first half of 2019. Data represent the fiscal year 2017 period for all governments. Direct data collection from these donors was desirable because they represent the preponderance of donor government assistance for family planning and the latest official statistics – from the Organisation for Economic Co-operation and Development (OECD) Creditor Reporting System (CRS) (see: http://www.oecd.org/dac/stats/data) – which are from 2017 and do not include all forms of international assistance (e.g., funding to countries such as Russia and the Baltic States that are no longer included in the CRS database). In addition, the CRS data may not include certain funding streams provided by donors, such as FP components of mixed-purpose grants to non-governmental organizations. Data for all other OECD DAC member governments – Austria, Belgium, Czech Republic, the European Union, Finland, Greece, Hungary, Iceland, Ireland, Italy, Japan, Korea, Luxembourg, New Zealand, Poland, Portugal, the Slovak Republic, Slovenia, Spain, and Switzerland – which collectively accounted for approximately 2 percent of bilateral family planning disbursements, were obtained from the OECD CRS and are from calendar year 2017.

For purposes of this analysis, funding was counted as family planning if it met the OECD CRS purpose code definition: “Family planning services including counseling; information, education and communication (IEC) activities; delivery of contraceptives; capacity building and training.”⁷  Where it was possible to identify funding amounts, family-planning-related activities funded in the context of other official development assistance sectors (e.g. education, civil society) are included in this analysis. Project-level data were reviewed for Canada, Denmark, France, Germany, the Netherlands, Norway, and Sweden to determine whether all or a portion of the funding could be counted as family planning. Family-planning-specific funding totals for the United States were obtained through direct data downloads and communications with government representatives. Funding attributed to Australia and the United Kingdom is based on a revised Muskoka methodology as agreed upon by donors at the London Summit on Family Planning in 2012. Funding totals presented in this analysis should be considered preliminary estimates based on data provided by representatives of the donor governments who were contacted directly.

It was difficult in some cases to disaggregate bilateral family planning funding from broader population, reproductive and maternal health totals, as the two are sometimes represented as integrated totals. In addition, family-planning-related activities funded in the context of other official development assistance sectors (e.g. education, civil society) have in the past remained largely unidentified. For purposes of this analysis, we worked closely with the largest donors to family planning to identify such family-planning-specific funding where possible. In some cases (e.g. Canada), specific FP percentages were recorded for mixed-purpose projects. In other cases, it was possible to identify FP-specific activities by project titles in languages of origin, notwithstanding less-specific financial coding. In still other cases, detailed project descriptions were analyzed (see Appendix 2 for detailed data table).

Bilateral funding is defined as any earmarked (FP-designated) amount and includes family planning-specific contributions to multilateral organizations (e.g. non-core contributions to UNFPA Supplies). U.S. bilateral data correspond to amounts disbursed for the 2018 fiscal year. UNFPA contributions from all governments correspond to amounts received during the 2018 calendar year, regardless of which contributor’s fiscal year such disbursements pertain to.

With some exceptions, bilateral assistance data were collected for disbursements. A disbursement is the actual release of funds to, or the purchase of goods or services for, a recipient. Disbursements in any given year may include disbursements of funds committed in prior years and in some cases, not all funds committed during a government fiscal year are disbursed in that year. In addition, a disbursement by a government does not necessarily mean that the funds were provided to a country or other intended end-user. Enacted amounts represent budgetary decisions that funding will be provided, regardless of the time at which actual outlays, or disbursements, occur. In recent years, most governments have converted to cash accounting frameworks, and present budgets for legislative approval accordingly; in such cases, disbursements were used as a proxy for enacted amounts.

UNFPA core contributions were obtained from United Nations Executive Board documents. UNFPA estimates of total family planning funding provided from both core and non-core resources were obtained through direct communications with UNFPA representatives. Other than core contributions provided by governments to UNFPA, un-earmarked core contributions to United Nations entities, most of which are membership contributions set by treaty or other formal agreement (e.g., United Nations country membership assessments), are not identified as part of a donor government’s FP assistance even if the multilateral organization in turn directs some of these funds to FP. Rather, these would be considered as FP funding provided by the multilateral organization, and are not considered for purposes of this report.

The fiscal year period varies by country. The U.S. fiscal year runs from October 1-September 30. The Australian fiscal year runs from July 1-June 30. The fiscal years for Canada and the U.K. are April 1-March 31. Denmark, France, Germany, the Netherlands, Norway, and Sweden use the calendar year. The OECD uses the calendar year, so data collected from the CRS for other donor governments reflect January 1-December 31. Most UN agencies use the calendar year and their budgets are biennial.

All data are expressed in US dollars (USD). Where data were provided by governments in their currencies, they were adjusted by average daily exchange rates to obtain a USD equivalent, based on foreign exchange rate historical data available from the U.S. Federal Reserve (see: http://www.federalreserve.gov/) or in some cases from the OECD. Data obtained from UNFPA were already adjusted by UNFPA to represent a USD equivalent based on date of receipts.

1. Totals represent disbursements specifically designated by donor governments for family planning as defined by the OECD DAC (see methodology), and include: standalone family planning projects; family planning-specific contributions to multilateral organizations (e.g., contributions to UNFPA Supplies); and, in some cases, projects that include family planning within broader reproductive health activities. ↩︎
2. Includes core-contributions from members of the OECD DAC only; core contributions from non-DAC donors are not included in this total. ↩︎
3. FP2020, London Summit on Family Planning: Summaries of Commitments, December 2013, available at: http://www.familyplanning2020.org/about-us. ↩︎
4. FP2020, The Family Planning Summit for Safer, Healthier and Empowered Futures, July 2017, available at: http://summit2017.familyplanning2020.org/. ↩︎
5. Includes funding from 29 DAC member countries and the European Union (EU). ↩︎
6. In FY17 and FY18, the U.S. administration invoked the Kemp-Kasten amendment to withhold funding – both core and non-core contributions – to UNFPA. In FY16, U.S. contributions to UNFPA had totaled $69 million, including $30.7 million in core resources and an additional $38.3 million in non-core resources for other project activities (see KFF “UNFPA Funding & Kemp-Kasten: An Explainer”). ↩︎
7. OECD, The List of CRS Purpose Codes and Voluntary Budget Identifier Codes, June 2018. ↩︎
8. UNFPA, Direct communication, September, 2019. ↩︎
9. Bill & Melinda Gates Foundation, Direct communication, October, 2019. ↩︎

Blue Wall Voices Project

A Collaboration Between KFF and The Cook POlitical Report

The Kaiser Family Foundation and Cook Political Report have embarked on a new project examining the attitudes and experiences of voters in several key battleground states leading up the 2020 presidential election. The Blue Wall Voices Project is a unique state-based polling project that relies on an innovative probability-based approach to conducting public opinion polls using a combination of telephone and online methodologies. Drawing from voter registration lists, KFF and Cook Political Report have conducted interviews with 3,222 voters in the four states constituting the “Democratic Blue Wall” – the area in the Upper Midwest that was previously considered a Democratic stronghold, and where state polls performed poorly in 2016 and underestimated support for President Trump. The data analyzed is from 767 voters in Michigan, 958 voters in Minnesota, 752 voters in Pennsylvania, and 745 voters in Wisconsin. For more details, please see the methodology section of this report.   

• There are many undecided voters and a few persuadable swing voters. One year out from the 2020 presidential election and without a clear frontrunner in the Democratic primaries, a large share of voters – about four in ten (41%) – say they have not yet made up their minds about who they plan to vote for in November 2020. These “swing voters” either report being undecided about their vote in 2020 or are leaning towards a candidate but haven’t made up their minds yet. With a substantial number of votes still up for grabs, this analysis looks in-depth at this group of voters to explore the policy issues that could swing these voters to vote for either President Trump or the Democratic nominee.
• President Trump himself is the defining factor for voters – both positive and negative. When asked to offer in their own words what one thing will motivate them to vote in the 2020 presidential election, nearly three times as many voters offer responses related to defeating President Trump (21%) as offer responses related to re-electing him or not wanting a Democrat to be elected (8%). Defeating President Trump was offered as the top motivation to vote in 2020 by four in ten Democratic voters (39%) while responses related to re-electing President Trump/not wanting a Democrat were offered by 21% of Republican voters. One-fifth of independent voters offered responses related to defeating President Trump while fewer (7%) of independent voters offered responses related to re-electing President Trump. Overall, one-fourth (23%) of voters offer issues such as health care, the economy, and immigration, as their motivation for voting in the 2020 presidential election.
• The 2020 election may be a lot about health care and the economy, two issues that voters judge President Trump’s actions on very differently. Health care and the economy are the top issues for voters leading up to the 2020 presidential election but they are also two issues on which voters give President Trump very different marks. Overall, voters are somewhat positive in their views of how President Trump is handling the economy (-1 percentage points net approval) while a larger share of voters “disapprove” than “approve” of the way President Trump is handling health care (-21 percentage points net approval). Health care is one of the only issues in which President Trump’s approval is lower than his overall job approval (-18 percentage points). President Trump also has low approval ratings (-20 percentage points) on the way he is handling foreign policy– an issue of increasing importance among voters in these states.
• Democrats have a slight edge in enthusiasm in three of the four states heading into the 2020 presidential election. Over six in ten Democratic voters in Pennsylvania (66%), Michigan (65%), and Wisconsin (62%) say they are more motivated to vote in next year’s 2020 presidential election than they were in 2016. This is at least 10 percentage points higher than the share of Republican voters in each state saying the same (54% in Pennsylvania, 53% in Michigan, and 46% in Wisconsin). Republican voters in Minnesota are as motivated as their Democratic counterparts. To see more on Republican voters in Minnesota, check out the Minnesota-specific report.
• President Trump still has solid support among his base in this region. Most Republican voters approve of the way Donald Trump is handling his job as president and large majorities approve of his approach on key national issues including more than nine in ten who approve of the way he is handling the nation’s economy. Most Republican and Republican-leaning voters (73%) also say they want President Trump to be the Republican Party’s nominee for the 2020 election while small shares of Trump voters (28%) can imagine a scenario in which he enacts a policy, or fails to enact a policy, that would result in them changing their vote choice.
• Few Democratic voters see progressive positions as deal breakers in their 2020 vote. The Blue Wall Voices Project also sought to find out whether the progressive positions being discussed by the Democratic nominees for president on the campaign trail are deal breaker issues for voters. Overall, a majority of voters in the Blue Wall who plan to vote for the Democratic nominee view the progressive platforms asked about in this survey as “good ideas,” including majorities of voters in each of the four states. None of these issues are deal breakers, with most voters saying that if a candidate disagrees with them on this issue then there would still be a chance that they would vote for them.
• Most swing voters in these states see bans on fracking, stopping detainments at the U.S. border, and Medicare-for-all as bad ideas. The poll also consistently finds that while Medicare-for-all has played a significant role in the 2020 Democratic primary debates, it is not the top health care issue for Democratic voters. Large shares of swing voters in Michigan, Minnesota, Pennsylvania, and Wisconsin say stopping detainments at the U.S. border for people cross into the country illegally and a national Medicare-for-all plan are “bad ideas.” Swing voters are slightly more divided in their views of a ban on fracking with large shares of Pennsylvania and Wisconsin swing voters saying such a ban is a “bad idea” as do a slim majority in Michigan and half of Minnesota swing voters.
• As the Democratic presidential primary heats up, this poll finds Senator Elizabeth Warren and Vice President Joe Biden as the front-runners among Democratic primary voters in the Blue Wall region. One-fourth of Democratic primary voters in Michigan and Minnesota say they plan to support Sen. Warren during the Democratic primary as do 22% of Wisconsin Democratic primary voters. Former Vice President Joe Biden garners 27% of support from Pennsylvania Democratic primary voters. Minnesota Senator Amy Klobuchar also garners support from 15% of Minnesota Democratic primary voters.

More than half of voters in Michigan, Minnesota, Pennsylvania, and Wisconsin say they have already made up their minds about which candidate they plan to vote for. One-third of voters say they are “definitely going to vote for the Democratic nominee” while one-fifth (22%) say they are “definitely going to vote for President Trump.” The share who say they are “definitely going to vote for President Trump” in these states is slightly lower than the share of voters nationally who reported the same in our national KFF Health Tracking Poll analysis earlier this year. It is important to note that while there are currently a larger share of voters in each state who say they are “definitely going to vote for the Democratic nominee” than “definitely going to vote for President Trump,” it is unclear how this could change once the Democrats choose a nominee and President Trump and other Republicans start attacking a single candidate rather than the entire field of candidates.

This leaves four in ten voters (41%) as the crucial voting block known throughout this report as “swing voters.” This group of voters either say they are “probably going to vote for President Trump” (11%), “probably going to vote for the Democratic nominee” (8%), or say they are “undecided” about how they will vote (23%).

There are not significant differences across the states, with similar shares of voters in Michigan (43%), Minnesota (41%), Pennsylvania (39%), and Wisconsin (43%) saying they are either “probably” going to vote for a candidate or are “undecided.”

It is important to note that not all “swing voters” could potentially change their vote to support the other party’s candidate. While nearly half of those who say they are probably going to vote for President Trump say there is “a chance” they will vote for the Democratic nominee (4% of all voters), on the other side of the ballot almost none of those who say they are probably going to vote for the Democratic nominee say that there is “a chance” they will vote for President Trump (less than 1%).

This is similar to what we found in our national analysis earlier this year, with few voters who say they are probably going to vote for either President Trump or the Democratic nominee saying there is “a chance” they will vote for the other party’s candidate. This is also similar across the four states included in this analysis with few voters saying there is “a chance” they would vote for the other party’s candidate.

A majority of Democratic voters and Republican voters in each state say they aren’t going to cast a vote for the other party’s candidate. About seven in ten (72%) Democratic and Democratic-leaning independent voters in Michigan say they are definitely going to vote for the Democratic nominee as do two-thirds of Democratic voters in Minnesota (68%), Wisconsin (66%), and Pennsylvania (65%).

A smaller share, but still a majority, of Republican and Republican-leaning independent voters say they are definitely going to vote for President Trump (58% in Minnesota, 53% in Wisconsin and Pennsylvania, and 52% in Michigan). Nearly twice as many Republican and Republican-leaning voters in Michigan and Wisconsin are undecided about their 2020 presidential vote choice as the Democratic counterparts in the states.¹ 

On most demographics, swing voters look very similar to their counterparts (voters who say they have already decided who they are going to vote for in the 2020 election), but they differ on three key variables: age, party identification, and ideology. Swing voters generally are more likely to say they are moderate in terms of their ideology (58%) and a larger share identify as political independents (29%) than their decided counterparts (5%). In addition, swing voters are slightly younger as a whole with about half (51%) under the age of 50 compared to 42% of decided voters.

During the 2016 election, President Trump ran as an unconventional candidate who was going to work to implement bold changes in this country and deliver a shock to business as usual in Washington, D.C. One year out from the 2020 election, a slightly larger share of voters – including a majority of Republican voters – still prefer to vote for a candidate who wants to make bold changes rather than moderate changes. A slightly larger share of voters in Michigan, Minnesota, Pennsylvania, and Wisconsin say they prefer to vote for a candidate in 2020 who wants to make bold changes (54%) rather than a candidate who works to make moderate changes (45%).

Six in ten Republican voters (62%) say they prefer a candidate who works to make bold changes rather than a candidate who works to make moderate changes (37%). Democratic voters are more divided on their preference with half (52%) preferring a candidate who works to make bold changes and a similar share preferring a candidate who works to make moderate changes (48%). A majority of independent voters (55%) prefer a candidate who works to make moderate changes.

Democratic voters appear to have the edge in motivation one year out from the 2020 general election with a larger share of Democratic voters (64%) saying they are “more motivated” about voting in next year’s presidential election than either independent voters (55%) and Republican voters (53%).

About two-thirds of Democratic voters in Pennsylvania (66%) and Michigan (65%) and six in ten Democratic voters in Wisconsin (62%) say they are “more motivated” to vote in next year’s election. This is compared to less than half of Republican voters in Wisconsin (46%) and slightly more than half of Republican voters in Pennsylvania (54%) Michigan (53%) who say they are more motivated to vote than in the previous presidential election. Partisan voters in Minnesota are both “more motivated” to vote in next year’s election. To see more on this, check out the individual state reports.

When asked to offer in their own words what one thing will motivate them to vote in the 2020 presidential election, one-fifth of all Blue Wall voters offer responses related to defeating President Trump (21%). This is followed by those who say voting is their civic duty (9%), health care (8%), re-electing President Trump or not wanting to elect a Democrat (8%), and the economy (4%) is their top motivation. Overall, one-fourth (23%) of voters offer issues such as health care, the economy, and immigration, as their motivation for voting in the 2020 presidential election.

Defeating President Trump is offered as the top motivation to vote in 2020 by four in ten Democratic voters (39%) and one-fifth of independent voters, while responses related to re-electing President Trump or not wanting to elect a Democrat was offered by 21% of Republican voters – followed by those who say that their civic duty is their top motivation to vote in 2020 (12%).

Most Republican and Republican-leaning independent voters (73%) also say they prefer President Trump to be the Republican Party’s nominee for the 2020 election with about one-fourth (26%) saying they prefer another candidate to be the Republican Party’s nominee. Those who self-identify as Republicans are more tied to President Trump with nearly eight in ten (78%) saying they prefer President Trump be the nominee compared to about six in ten (62%) independents who lean Republican in their views.

Most voters who say they are going to vote for President Trump in 2020 do not see a scenario in which he would no longer have their vote. Seven in ten Trump voters say there is not a policy he could enact or fail to enact that would make them no longer vote for him while three in ten (28%) say they can think of a scenario that would make them no longer vote for President Trump.

When asked to offer in their own words what policy President Trump could enact, or fail to enact, that would make them no longer vote for him, one-fifth (6% of all 2020 Trump voters) say that if he no longer continued to support gun rights they would no longer vote for him. This is followed by one in six (4% of all 2020 Trump voters) who offered that if he changed his position on immigration, they would no longer vote for him. Other issues that were offered include supporting Medicare-for-all (2%), supporting access to abortions (2%), or if foreign relations worsened (2%). Few Trump voters said they would not vote for President Trump if he endangered the constitution (1%).² 

Democratic voters in the Blue Wall are divided in what is most important to them when selecting a candidate for president. Four in ten voters (42%) say it is more important that the Democrats select a candidate who “has the best chance to defeat President Trump” while a similar share (40%) say it is more important to select a candidate who “comes closest to their views on the issues.” Fewer (13%) voters say it is more important to select a candidate who “is the most authentic” and even fewer (4%) say it is most important to select a candidate who “can most disrupt the current system.”

A larger share of Democratic and Democratic-leaning independent voters in Minnesota say it is more important that the eventual nominee be able to defeat President Trump (48%) than come closest to their views on the issues (33%).

Yet, despite this, significant shares of Democratic voters in each of the states say they do not plan to vote in the Democratic primary in their state and instead plan to wait to vote until the 2020 general election. One-third of Democratic and Democratic-leaning voters in Minnesota say they plan to wait to vote until the 2020 general election as do one-fourth of Democratic voters in Michigan, one-fifth of Democratic voters in Wisconsin, and 17% of Democratic voters in Pennsylvania.

Senator Warren and Vice President Biden Top List Of Democratic Primary Candidates

Among those primary election voters, Senator Elizabeth Warren and former Vice President Joe Biden have the edge over the other major Democratic presidential candidates. One-fifth of Democratic primary voters say Sen. Warren (22%) is the candidate they plan to support which is similar to the share who say Vice President Biden is the candidate they plan to support (21%). While Senator Warren and Vice President Biden garner similar shares of top choice votes among Democratic primary voters across the Blue Wall, four in ten Democratic primary voters choose Sen. Warren as either their first or second choice in the Democratic primary. This is followed by 29% who choose Vice President Biden, one-fourth who choose Sen. Sanders, and 14% who choose Mayor Pete Buttigieg. Most of the shift over to Sen. Warren is from Sen. Sanders supporters with half of Sen. Sanders supporters choosing Sen. Warren as their second choice of candidates. For more information about how voters in each of the states rank the candidates, check out the individual state reports.

Are Progressive Platforms Deal Breakers For Voters?

The Blue Wall Voices Project also seeks to find out how voters view many of the progressive positions being discussed by some of the Democratic nominees for president. Overall, a majority of voters in the Blue Wall who say they are either “definitely” or “probably” going to vote for the Democratic nominee view the progressive platforms asked about in this survey as “good ideas.” This includes majorities of these self-reported likely 2020 Democratic voters in each of the four states.

Nine in ten self-reported 2020 Democratic voters (92%) say the Green New Deal, the plan to address climate change through new regulations and increases in government spending on green jobs and energy-efficient infrastructure is a “good idea.” This is closely followed by large majorities who say a pathway to citizenship for immigrants in the U.S. illegally (91%), a ban on the future sale of assault weapons (88%), and a ban on the ownership of assault weapons and military-style rifles like the AR-15 including a mandatory buyback program for current owners (83%) are “good ideas.” Fewer, but still a majority (62%), say a national health plan in which all Americans would get their health coverage through a single government plan, Medicare-for-all, is a “good idea.” Slightly more than half of self-reported 2020 Democratic voters say stopping U.S. detainments for people crossing the border illegally or a ban on fracking are “good ideas” (56% and 54%, respectively). These three issues rank at the bottom of progressive platforms for self-reported 2020 Democratic voters in each of the four states.

Yet, none of these issues are “deal breakers” with small shares of voters saying there is no chance they would vote for a candidate who disagreed with them on the issue. The positions that solicit that largest share of voters saying there is “no chance” they would vote for them are if a candidate was against a ban on future sales of assault weapons (20%), against a ban on ownership of assault weapons (15%), or against the Green New Deal (13%).

Few self-reported 2020 Democratic voters view any of the progressive ideas as deal breakers with less than 10% of Democratic voters saying the platforms are “bad ideas” and if a Democratic candidate disagreed with them on this, there is no chance they would vote for them.

Some 2020 Democratic voters see Conservative gun Control Stance As A Possible Deal breaker

Many likely 2020 Democratic voters see more moderate positions on assault weapon bans as possible deal breakers. One-fifth of self-reported 2020 Democratic voters say there is “no chance” they would vote for a candidate who was against a ban on the future sales of assault weapons and about one in eight (15%) 2020 Democratic voters say there is “no chance” they would vote for a Democratic nominee who was against a ban on owning assault weapons, including a mandatory buyback program.

Swing Voters And Progressive Platforms

Majorities of swing voters, a crucial voting block in 2020, view a pathway to citizenship for immigrants in this country illegally (70%), the Green New Deal (67%), a ban on the future sale of assault weapons (66%), and a ban on the ownership of assault weapons including a mandatory buyback program (54%) as good ideas. Yet, many of these voters see three progressive platforms as “bad ideas.” Majorities of these voters view a ban on fracking (54%), a national Medicare-for-all plan (62%), and stopping border detainments of people coming into the country illegally (71%) as bad ideas.

Health care and the economy are the top issues for voters in these states leading up to the 2020 presidential election but they are also two issues on which voters give President Trump very different marks. Voters give President Trump a somewhat positive rating (-1 percentage points) on the way he is handling the economy while a larger share of voters disapprove than approve of the way President Trump is handling health care (-21 percentage points net approval). Health care is one of the only issues in which President Trump’s approval is lower than his overall job approval (-18 percentage points). This report also examines the role of other key issues in the 2020 election such as immigration and international trade.

President Trump Job Approval

President Trump’s approval in each of the states as well as the Blue Wall overall is similar to what we see in national polls with about four in ten voters (41%) in the Blue Wall saying they either “strongly approve” or “somewhat approve” of the way Donald Trump is handling his job as president, while six in ten (59%) disapprove. If we look at the strongest opinions, twice as many voters “strongly disapprove” of the job President Trump is doing than “strongly approve” (50% v. 25%). About half of voters in each of the four states strongly disapprove of the way Donald Trump is handling his job as president.

Support for President Trump runs highest among his base including voters who voted for him in 2016 (89%), conservative voters (78%), and rural voters (57%).

On the other hand, vast majorities of 2016 Clinton voters (97%) and liberal voters (95%) disapprove of his job performance. As do non-white voters across education groups, urban voters, voters earning less than $40,000 annually, moderate voters, and many more.

Voters in the Blue Wall states rank President Trump’s job performance most positively on the economy with about half of voters (49%) approving of the way Donald Trump is handling the economy. About four in ten voters approve of the job he is doing on the other issues including trade with other countries (43%), immigration (43%), foreign policy (40%), and health care (39%). There are no differences across the four states with similar shares of voters in Michigan, Minnesota, Pennsylvania, and Wisconsin approving of President Trump’s job on each of these key issues.

There are, however, unsurprisingly strong partisan differences. Large majorities of Republican voters approve of the job President Trump is doing on all of the issues while independent voters lean more negative in their assessments of President Trump’s job performance. Few Democratic voters approve of his job performance on any of the national issues included in the survey. Across the issues, President Trump ranks best in his handling of the economy with 94% of Republicans approving of the way he is handling the nation’s economy, as do half of independent voters and 11% of Democratic voters.

Voters Say Health Care and Economy Are Top Issues

One year out from the 2020 general election, health care and the economy are the top two issues for voters. About one-fifth of voters say health care (21%) or the economy (21%) will be the most important issue in deciding their vote for president next year. These are followed by climate change (14%), gun policy (13%), foreign policy (9%), immigration (9%), taxes (6%), and international trade and tariffs (1%).

Health care and the economy are the top issues across the Blue Wall states with Minnesota voters also selecting climate change as one of their top issues (17%). To see more about how partisans rank these issues in each state, check out the individual state reports.

The ranking of issues is largely driven by partisanship. Twice as many Republican voters say the economy will be the most important issue in deciding their vote for President next year than any other issue. Republicans rank the economy (30%), gun policy (15%), and immigration (15%) as the top issues in the presidential election. Democrats rank health care (27%) and climate change (25%) as the top issues. Independent voters choose health care (23%) and the economy (21%) as their top two issues.

Health Care

Lowering prescription drug costs and making sure the ACA’s protections for people with pre-existing health conditions continue are the top health care priorities that voters want to see Congress take on next year. About two-thirds of voters (across states) say lowering prescription drug costs for as many Americans as possible should be a top priority for Congress which is similar to the share who say making sure the ACA’s protections for people with pre-existing conditions should be a top priority. These are the top health care priorities across voters in Michigan, Minnesota, Pennsylvania, and Wisconsin.

Lowering prescription drug costs ranks at the top of the list of health care priorities among all partisans (74% of Democratic voters, 69% of independent voters, and 62% of Republican voters). Making sure the ACA’s protections for people with pre-existing conditions continue is a top priority for both Democrats (83%) and independent voters (65%) while more than half of Republican voters (54%) say repealing and replacing the ACA is a top priority for Congress.

Immigration

Overall, majorities of voters in each of the four states have positive views of immigrants in this country. Most say it is generally true that “immigrants strengthen our country because of their hard work and talents” (72%) and that it is generally not true that “immigrants are a burden on our country because they take their jobs” (81%) or “increase rates of violent crimes in this country” (75%).

While most Republican voters in Michigan, Minnesota, Pennsylvania, and Wisconsin say that it is generally not true that “immigrants are a burden because they take our jobs,” they are more divided on whether they think “immigrants increase rates of violent crime in this country.” Half of Republican voters say this is generally not true which is similar to the share who say it is generally true (47%).

The U.S. Economy

While the economies of each of the states included in the Blue Wall Voices Project are distinct, the views of the economic outlook for the next year as well as views towards the fairness of the economic system are largely similar. The major differences in voters’ perceptions of the U.S. economy are mostly driven by party identification.

Voters are divided along party lines in their economic outlook for the next year with three-fourths (77%) of Democratic voters (across states) saying they expect that during the next 12 months the U.S. will have “bad times” while eight in ten Republicans (81%) say they expect the U.S. will have “good times.” Independent voters are split with similar shares saying they expect that during the next 12 months the U.S. will have good times financially (47%) as bad times (51%).

Views of the fairness current economic system are also largely partisan with larger shares of Democratic voters saying it is more often that “needy people go without government help in American today” (68%) than say it is more often that “irresponsible people get government help they don’t deserve” (30%). Republican voters view the system differently with the vast majority saying it is more often that “irresponsible people get government help they don’t deserve” (84%). A larger share of independent voters also say “irresponsible people getting government help they don’t deserve” happens more often in America today (55%).

Six in ten voters (62%) say that “unfairness in the economy that favors the wealthy” is a bigger problem in this country while one-third of voters (36%) say “over-regulation that interferes with growth and prosperity” is a bigger problem. Nine in ten Democratic voters (93%) say unfairness in the economy is a bigger problem while seven in ten Republican voters (72%) say over-regulation is a bigger problem. Six in ten (63%) independent voters say unfairness in the economy is a bigger problem while 36% say over-regulation is a bigger problem.

International Trade and Tariffs

With the U.S. engaged in a trade dispute with China and other countries, the Blue Wall Voices project sought to examine voters’ opinions of the possible impacts of the tariffs in Michigan, Minnesota, Pennsylvania, and Wisconsin.

More than half of voters in the Blue Wall say the recent import taxes on certain goods brought into the U.S. from China and other countries will hurt both the national economy (55%) and workers in their state (55%). While these views are largely partisan, about one-fourth of Republican voters say the recent tariffs will hurt both the national economy (23%) and workers in their state (25%).

Overall, a larger share of voters in the Blue Wall say the recent tariffs will hurt rather than help them and their families, but a considerable share also say they expect the import taxes to have no effect. More than four in ten voters say the recent tariffs will hurt them and their family including roughly half of voters in Pennsylvania and Wisconsin.

Partisanship plays a large role in views of recent tariffs with seven in ten Democrats (69%) saying the tariffs will hurt them and their families compared to 46% of independent voters and 21% of Republican voters. 

President Trump Currently Has Support Among Rural Voters, But The Economy Matters A Lot To This Group And Many Worry About The Effect Of Recent Tariffs

One key group that President Trump needs to retain support from in 2020 are rural voters. The poll indicates that currently President Trump has the support of rural voters in Michigan, Minnesota, Pennsylvania, and Wisconsin with larger shares of rural voters in each of the states saying they are either “definitely” or “probably” going to vote for President Trump than the Democratic nominee.

A key issue for this group is the economy with large shares of rural voters in each of the states saying the economy is among the most important issues when deciding their vote next year. And most rural voters approve of the way President Trump is handling the economy with about two-thirds of rural voters in Michigan (66%), Minnesota (65%), Pennsylvania (66%), and Wisconsin (61%) saying they either “strongly approve” or “somewhat approve.” In addition, majorities of rural voters in each state say they expect the U.S. will have good times financially during the next 12 months.

Rural voters are currently less negative in their assessment of how the recent tariffs will hurt workers in their state, the national economy, or their family than suburban and urban voters. But still about half of rural voters say the recent tariffs will hurt workers in their state (47%) and the national economy (45%), while about four in ten (39%) say the recent tariffs will hurt them and their families.

The Blue Wall Voices Project examines voters in the state of Michigan to get their perspectives on key issues and aspects of the 2020 election, including the role that health care and the economy may play in voters’ decisions. In addition, it gauges enthusiasm and vote choice leading up to the 2020 presidential election.

Overall, a larger share of Michigan voters say health care and the economy are the most important issues in deciding their vote for president in 2020. About one in five Michigan voters say health care (22%) and the economy (22%) are the most important issues to their vote, with smaller shares saying issues like climate change (13%), foreign policy and national security (11%), gun policy (10%), immigration (9%), taxes (6%), and international trade and tariffs (1%). Partisans are divided in their priorities, with one in four Democrats and independents choosing health care as their top issue, and one-third of Republicans choosing the economy as the most important issue.

With health care and the economy ranking above all other issues for Michigan voters, it is important to note that Michigan voters give President Trump very different marks on both of these issues. Half (51%) of Michigan voters approve of the way President Trump is handling the economy compared to four in ten (41%) who approve of the way he is handling health care.

International Trade and Recent Tariffs

While voters do not rank international trade as one of the most important issues in deciding their vote next year, Michigan is a state expected to be most affected by the ongoing trade disputes with China and other countries. Overall, about half of voters – including majorities of Democrats and independents – say they think the recent tariffs will hurt both the national economy (54%) and workers in Michigan (53%). However, this opinion is only shared by about one-fourth of Republican voters (21% and 26%, respectively) compared to majorities of Democrats (80% and 78%, respectively) and independent voters (58% and 57%, respectively). Six in ten Republican voters in Michigan (61%) say the recent tariffs will “help” the national economy and about four in ten (41%) say the tariffs will “help” Michigan workers.

Partisans also differ in how they perceive the recent tariffs will impact them and their families. More than six in ten Democratic voters in Michigan (63%) say the recent tariffs will hurt them and their families while about half of independent voters (47%) and a majority of Republican voters (57%) in the state say they will “have no effect.” Overall, few voters (14%) say the recent tariffs will help them and their families.

Health Care Priorities among Michigan Voters

When asked specifically about health care priorities that Congress should work on next year, over six in ten say that lowering prescription drug costs (69%) and maintaining protections for people with pre-existing conditions (64%) should be the top priority for Congress. These priorities substantially outrank other policy proposals such as repealing and replacing the ACA, expanding government aid for people who buy their own health insurance, and implementing a public option or national Medicare-for-all plan. These top two priorities persist across partisans, with large shares of Democratic voters, independent voters, and Republican voters naming lowering prescription drug costs and maintaining pre-existing condition protections as top priorities. However, over half of Republican voters (56%) also say that repealing and replacing the ACA should be a top priority. Implementing a national Medicare-for-all plan, a topic that has dominated health care discussions in the 2020 Democratic primary, is not a top issue for all voters or for Democratic voters, specifically.

Michigan Voters’ Economic Outlook

Turning to the economy, the other top issue for voters during the 2020 election, voters in Michigan are split about what they think the economic forecast will be like for the next 12 months. Similar shares of Michigan voters say that during the next 12 months, the U.S. will have bad times (50%) and good times (48%). Views on the economic outlook are largely partisan with roughly eight in ten Democrats (78%) saying bad times are ahead and roughly eight in ten Republicans saying good times are ahead (83%). Independent voters are more divided, with four in ten saying the U.S. will experience “good times”  while 54% say they expect “bad times” ahead.

The Democratic Primary in Michigan and Preview of the General Election

More than half of Michigan voters say they are more motivated (55%) to vote in next year’s election than in the previous presidential election. This includes a majority of Democrats (65%), independents (61%) and Republicans (53%) saying they feel more motivated than they did in 2016. Yet, similar to other states included in this analysis, a larger share of Democratic voters say they are “more motivated” than the share of Republican voters who said the same.

Given the high levels of motivation as the next presidential election approaches, the Blue Wall Voices survey explored what could be motivating voters. When asked specifically what the one thing is that will motivate them to vote in the 2020 election, voters offer an array of open-ended responses, with the most frequently volunteered response relating to defeating President Trump (21%), followed by those who offered responses related to civic duty (10%) and health care (8%). Small shares of voters cited reasons such as wanting to re-elect Trump and not wanting to elect a Democrat (6%), or the economy (5%).

With more than four months before the 2020 Michigan Democratic primary, Senator Elizabeth Warren garners the most support among likely Democratic primary voters followed by Vice President Joe Biden and Senator Bernie Sanders. One-fourth of Michigan Democratic primary voters say Senator Warren is their first choice for the 2020 Democratic ticket and a combined 43% of voters say she is their first choice or second choice.

Overall, many voters (43%) in the state remain uncertain about who they will support in the 2020 election. One-third of Michigan voters say they are definitely voting for the Democratic nominee and about one-fifth (21%) say they are definitely voting for President Trump. In contrast, one-fourth of voters say they are undecided, and few voters say they are either probably voting for the Democratic nominee (6%) or for President Trump (11%). This poll finds there are few persuadable Michigan voters meaning that, while they currently support one candidate, they could be convinced to support the other party’s candidate.

Michigan swing voters (those who are either undecided voters or say they are probable but not definite Trump or Democratic voters) are supportive of three progressive platforms: the Green New Deal, a pathway to citizenship for immigrants, and a ban on future sales of assault weapons. But, on the other progressive platforms included in this project, Michigan voters are either split or a majority say they are a bad idea. This includes two-thirds of Michigan swing voters (65%) who say a national Medicare-for-all plan is a “bad idea.”

The Blue Wall Voices Project examines voters in the state of Minnesota to get their perspectives on key issues and aspects of the 2020 election, including the role that health care and the economy may play in voters’ decisions. In addition, it gauges enthusiasm and vote choice leading up to the 2020 presidential election.

Overall, Minnesota voters say that a number of issues will be the most important in deciding their vote for president in 2020, with health care, the economy, and climate change emerging as the top issues. About one in five Minnesota voters say health care (20%), climate change (17%), and the economy (16%), are the most important issues to their vote, with smaller shares naming issues like gun policy (11%), immigration (11%), foreign policy and national security (9%), taxes (8%), and international trade and tariffs (1%). Partisans are divided in their priorities with three in ten Democrats ranking health care and climate change as their top issues, about two in ten independents ranking health care and the economy as their top issues, and one-fourth of Republicans ranking the economy as the most important issue and one in five saying immigration will be the most important issue in deciding their 2020 vote choice.

Overall, a majority of Minnesota voters disapprove of President Trump’s job performance (58%) while four in ten voters approve (42%). In addition, most Minnesota voters also disapprove of the way he is handling foreign policy (58%), health care (57%), immigration (56%), and trade with other countries (55%). Minnesota voters are more divided in their views of how President Trump is handling the economy with 49% of voters saying they approve compared to 51% who disapprove.

Minnesota Voters on Health Care Priorities

When asked specifically about health care priorities that Congress could work on next year, over six in ten say lowering prescription drug costs (64%) and maintaining protections for people with pre-existing conditions (62%) should be the top priority for Congress. These priorities substantially outrank other policy proposals such as repealing and replacing the Affordable Care Act (28%), expanding government financial help for people who buy their own health insurance coverage on the ACA marketplace to include more people (21%), and implementing a public option (23%) or national Medicare-for-all plan (20%). These top two priorities persist across partisans, with large shares of Democratic, independent, and Republican voters naming lowering prescription drug costs and maintaining pre-existing condition protections as top priorities. However, over half of Republican voters (53%) also say that repealing and replacing the ACA should be a top priority. Implementing a national Medicare-for-all plan, a topic that has dominated health care discussions in the 2020 Democratic primary, is not a top priority for a majority of voters or for Democratic voters, specifically.

Minnesota Voters’ Views of the U.S. Economy

Turning to the economy, the other top issue for voters during the 2020 election, Minnesota voters are optimistic about the U.S. economic forecast over the next 12 months. About half of Minnesota voters say that during the next 12 months, the U.S. will have “good times” (53%), compared to a slightly smaller share who say the U.S. will experience “bad times” (44%). Views towards the U.S. economy are largely partisan with two-thirds of Democrats (68%) saying bad times are ahead, while over eight in ten Republicans (84%) say the U.S. will experience “good times” financially. Independent voters are more divided, but lean positive with 54% saying they expect “good times,” while 44% say the U.S. economy will experience “bad times” over the next year.

The Democratic Primary in Minnesota and Preview of the General Election

Slightly over half of Minnesota voters say they are more motivated (52%) to vote in next year’s election than in the previous presidential election. This includes majorities of Democrats (57%) and Republicans (59%) and nearly half of independents (47%) saying they feel more motivated than they did in 2016.

Given the high levels of motivation as the next presidential election approaches, the Blue Wall Voices survey explored what could be motivating voters. When asked specifically what the one thing is that will motivate them to vote in the 2020 election, voters offer an array of responses, with the most frequently volunteered response related to defeating Trump (18%), followed by those who offered responses related to civic duty (11%). Smaller shares cite reasons such as to re-elect Trump or not wanting a Democrat (9%), health care (6%), a candidate with good ethics (4%), and the environment or climate change (4%).

With more than four months left before the 2020 Minnesota Democratic primary, Senator Elizabeth Warren garners the most support among likely Democratic primary voters followed by Minnesota Senator Amy Klobuchar, Vice President Joe Biden, and Senator Bernie Sanders. One-fourth of Minnesota Democratic primary voters say Senator Warren is their first choice for the 2020 Democratic ticket and a combined 43% of voters say she is their first choice or second choice.

About one-third of Minnesota voters say they are “definitely voting for the Democratic nominee” (32%) and about one-fourth (24%) say they are “definitely voting for President Trump.” Many voters (41%) in the state remain uncertain about who they will support in the 2020 general election. Of that 41%, two in ten voters say they are “undecided” (21%), and about one in ten say they are either “probably voting for the Democratic nominee” (10%) or “probably voting for President Trump” (10%). This poll finds few persuadable Minnesota voters, meaning that, while they currently support one candidate, they could be convinced to support the other party’s candidate. Three percent of all Minnesota voters say that they are probably going to vote for President Trump, but there is “a chance” they will vote for the Democratic nominee. On the other side, 1% of Minnesota voters say that they are probably voting for the Democratic nominee, but there is “a chance” they will vote for President Trump.

Minnesota swing voters (those who are undecided or say they are probably going to vote for either President Trump or the Democratic nominee) have very different views on two key immigration issues. While three-fourths of Minnesota swing voters (76%) think a pathway to citizenship for immigrants who are in the country illegally is a “good idea,” two-thirds think stopping detainments at the U.S. border for people who are coming into the country illegally is a “bad idea.”

On other progressive platforms, Minnesota swing voters have positive views towards a ban on future sales of assault weapons (68%) and a Green New Deal that would address climate change through new regulations and increases in government spending on green jobs and energy-efficient infrastructure (64%), but say a national Medicare-for all plan is a “bad idea” (63%). Minnesota swing voters are more divided in their views towards a ban on owning assault weapons including a mandatory buyback program (54% say it is a “good idea,” while 46% say it is a “bad idea”) and a ban on fracking (42% say it is a “good idea,” while 50% say it is a “bad idea”).

The Blue Wall Voices Project examines voters in Pennsylvania, a state that President Trump won by less than one percentage point (approximately 44,000 votes) over Democratic candidate Hillary Clinton in 2016. This poll finds that health care is among the top issues for voters more than one year out from the general election and examines enthusiasm and vote choice leading up to the 2020 presidential election.

Health care ranks among the top issues for voters leading up to the 2020 presidential election along with the economy, gun policy, and climate change. Health care is the top issue for Democratic voters (28%) and ranks among the top issue for independent voters (25%), but ranks lower among Republican voters.  In fact, among Republican voters, health care ranks below the economy (31%), gun policy (16%), and immigration (14%), and alongside foreign policy or national security (9%) and taxes (9%), with one in ten Republican voters saying health care will be the most important issue in deciding their vote next year.

Similar to the overall Blue Wall, Pennsylvania voters are most positive in their views of the way President Trump has handled the economy with nearly half (48%) of Pennsylvania voters saying they approve of his job performance on this issue. On the other hand, more than six in ten Pennsylvania voters (63%) say they disapprove of the way he has handled health care. Both of these issues appear to be key issues leading up to the 2020 presidential race.

Pennsylvania Voters on Health Care

While Medicare-for-all has dominated most of the health care discussions on the 2020 Democratic campaign trail, it ranks low among the priorities that the public has for Congress next year. One-fourth (26%) of Pennsylvania voters say implementing a national Medicare-for-all plan is a “top priority” for Congress compared to nearly seven in ten who say the same about lowering prescription drug costs for as many Americans as possible (68%) as well as maintaining the Affordable Care Act’s protections for people with pre-existing medical conditions (68%). Implementing a national Medicare-for-all plan is not even a top priority among Democratic voters (36%).

The Economy

The economy is another top issue for Pennsylvania voters but views of how the economy will fare over the next 12 months are largely driven by partisanship. Overall, voters in Pennsylvania are divided with similar shares saying they think that the U.S. will experience “good times” (47%) and “bad times” (51%) over the next 12 months. Eight in ten (78%) Democratic voters say the U.S. will have bad times financially over the next year while 80% of Republicans say the U.S. will have good times. Independents are evenly divided (49% v. 49%).

The Democratic Primary in Pennsylvania and Preview of the General Election

Two-thirds of Democratic voters say they are more motivated to vote in next year’s 2020 presidential election than they were in 2016 compared to slightly more than half of independent voters (54%) and Republican voters (54%). This is similar to the overall Blue Wall findings, which finds the Democratic Party has a slight enthusiasm edge over their Republican counterparts.

When asked to say in their own words what will be the one thing that will motivate them to vote in the 2020 presidential election, a larger share of voters offer responses related to defeating President Trump than any other thing. One-fifth of voters say defeating President Trump (22%) is the one thing that will motivate them to vote next year, followed by those who say they are motivated by re-electing President Trump or not wanting to elect a Democrat (10%), the issue of health care (8%), or their civic duty (7%).

With more than six months before the Pennsylvania Democratic primary, Vice President Joe Biden, a Pennsylvania native, is the first choice among Democratic primary voters. One-fourth (27%) of Democratic primary voters chose Vice President Biden as their first choice of 2020 Democratic candidates followed by 18% of Democratic primary voters who chose Senator Elizabeth Warren and 14% who chose Senator Bernie Sanders. Senator Warren and Vice President Biden have a relatively similar share of first choice and second choice votes with more than one-third of voters selecting either candidate as their first or second choice.

Nearly four in ten (39%) Pennsylvania voters are still either undecided (22%) about their 2020 vote choice, or say they are “probably” voting for either President Trump (10%) or the Democratic nominee (7%) but have not made up their minds yet. This is compared to one-third of voters who say they are “definitely voting” for the Democratic nominee and one-fourth who are “definitely voting” for President Trump (23%).

With four in ten Pennsylvania votes still up for grabs, the poll finds that majorities of Pennsylvania swing voters (those who either say are still undecided or are either probable but not definite Trump or Democratic voters) say many of the progressive platforms currently being discussed in the Democratic primary are good ideas, but these voters are less positive in their views of three important policy positions, including Medicare-for-all. More than half of Pennsylvania swing voters say a pathway to citizenship for immigrants in the country illegally (72%), the Green New Deal (69%), a ban on future sales of assault weapons (67%), and a ban on owning assault weapons (57%) are good ideas. On the other hand, Pennsylvania swing voters are more negative in views of a national Medicare-for-all plan, fracking, and no longer detaining people for crossing the U.S. border illegally. Majorities of Pennsylvania swing voters say all three of these progressive platforms, a national Medicare-for-all plan (56%), a ban on fracking (57%), and stopping U.S. border detainments (72%), are “bad ideas.”

The Blue Wall Voices Project examines voters in Wisconsin, a state that President Trump won by less than one percentage point over Democratic candidate Hillary Clinton in 2016. This poll finds the economy and health care are among the top issues for voters more than one year out from the general election and examines enthusiasm and vote choice leading up to the 2020 presidential election.

With approximately one year before the 2020 presidential election, the economy (22%) and health care (20%) emerge as the top issues for Wisconsin voters. Smaller shares name climate change (16%), gun policy (11%), foreign policy or national security (11%) and immigration (9%) as the issue which will be most important in deciding their vote. However, there are notable partisan differences on which issues are most important in deciding their vote. Among Democrats, climate change emerges as a top issue with nearly three in ten (29%) saying it will be the most important issue in deciding their vote, while among Republicans, only 2% say climate change is the most important issue. Nearly three in ten Republicans (29%) say the economy is the most important issue, compared to 22% of independents and 12% of Democrats. Larger shares of Democratic voters and independent voters say health care is the most important issue in deciding their vote (25% and 21%, respectively) than Republican voters (13%).

While Wisconsin voters are evenly divided in their views of how President Trump is handling the economy (50% v. 50%), a larger share of Wisconsin voters give President Trump negative marks on all other issues included in this poll including foreign policy (60%), health care (58%), immigration (58%), and international trade (57%).

Wisconsin Voters’ Views of Health Care Priorities

When asked about specific health care priorities for Congress to work on next year, nearly seven in ten Wisconsin voters say lowering prescription drug costs (69%) and maintaining protections for people with pre-existing conditions (66%) should be “a top priority.” Majorities of Democrats (79%), independents (70%), and Republicans (59%) say lowering prescription drug costs should be a top priority for Congress. A majority of Republicans (57%) say repealing and replacing the ACA should be a top priority while a smaller share (46%) say maintaining protections for people with pre-existing conditions should be a top priority for Congress. With discussions about Medicare-for-all dominating the health care conversation in the recent Democratic primary debates, equal shares of Wisconsin Democratic voters say implementing a national Medicare-for-all plan and implementing a public option should be a top priority for Congress next year (43% each), mirroring the policy divide on this issue among the leading Democratic candidates.

The Economy

Wisconsin voters are divided in their economic outlook for the country in the next 12 months. About half (51%) think the U.S. will have “bad times” financially in the next year while 47% expect “good times.” There is a stark partisan divide with eight in ten Democrats expecting bad economic times in the next year, whereas three in four Republicans (77%) expect good times financially for the country. Similar shares of independent voters expect bad economic times (52%) and good times financially (46%).

The Democratic Primary in Wisconsin and Preview of the General Election

About half of Wisconsin voters (51%) say they are more motivated to vote in 2020 than they were in the 2016 presidential election. Democrats seem to have the edge when it comes to motivation with more than six in ten Democrats (62%) saying they are “more motivated” to vote in 2020 than they were last election compared to less than half of Republicans (46%) who say they are more motivated.

When asked specifically what one thing will motivate them to vote in the 2020 election, the most frequently volunteered response was defeating President Trump (19%). Smaller shares cited reasons such as a sense of civic duty (9%), re-electing President Trump or not wanting to elect a Democrat (8%), health care (6%), the economy (5%), and to vote for the best candidate (4%) or a candidate with good ethics (4%).

With about five months before Wisconsin’s 2020 primary election, about one in five Democratic voters say Senator Warren (22%) and Vice President Biden (17%) are who they plan to support during the Democratic primary. Vermont Senator Bernie Sanders, who won the Wisconsin primary in 2016 when he challenged former Senator Hillary Clinton for the nomination, is currently garnering 10%. Notably, about four in ten (41%) Wisconsin Democratic primary voters select Senator Warren as their first or second choice compared to one in four Democratic primary voters who select Vice President Joe Biden as their first or second choice while one in five (21%) say Senator Sanders is their first or second choice.

About four in ten (43%) Wisconsin voters are either undecided (21%) about their 2020 vote choice or say they are “probably” voting for either President Trump (11%) or the Democratic nominee (10%) but have not made up their minds yet. About three in ten voters say they are “definitely voting” for the Democratic nominee (31%) and about one in five say they are “definitely voting” for President Trump (22%).

Majorities of Wisconsin swing voters (those who are either undecided or say they are probably going to vote for either president Trump or the Democratic nominee) say many of the progressive platforms are “good ideas” including a pathway to citizenship for immigrants in the U.S. illegally (75%), a Green New Deal (65%), and a ban on future sales of assault weapons (65%). But most Wisconsin swing voters say a ban on fracking (55%), a national Medicare-for-all plan (63%), and stopping detainments at the U.S. border (66%) are bad ideas.

The Blue Wall Voices Project was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF) in collaboration with the Cook Political Report. The survey was conducted September 23^rd – October 15^th, 2019, among a representative random sample of 3,222 registered voters in four states (767 in Michigan, 958 in Minnesota, 752 in Pennsylvania, and 745 in Wisconsin) constituting the “Democratic Blue Wall” – the area in the Upper Midwest that were previously considered Democratic strongholds, and where state polls performed poorly in 2016 and underestimated support for President Trump. All registered voters included in the sample were sent an invitation letter including a link to complete the survey online, a toll-free number that respondents could call to complete the survey with a telephone interviewer, and $2 pre-incentive. Respondents who were living in Census block-groups identified as low-education and respondents identified as likely Hispanic were offered $10 post-incentive if they completed the survey. A random half of respondents received a QR code on their invitation letters. All respondents were then sent a reminder postcard, which included a QR code for all respondents. Respondents who were flagged in the voter file as both a) speaking Spanish and b) speaking either primarily or only their native language, received bilingual mailings, including text in both English and Spanish.

The sample was designed to reach respondents less likely to complete surveys online, by oversampling areas with a relatively low percentage of college graduates. Sample that could be matched to telephone numbers and that had not yet completed the survey online or by inbound computer-assisted telephone interview (CATI) were called by CATI interviewers to attempt to convert this sample to completed interviews. A total of 2,763 respondents completed the questionnaire online, 255 by calling in to complete, and 204 were completed as outbound CATI interviews. Data collection was carried out in English and Spanish by SSRS of Glen Mills, PA. The registered voter sample was provided by Aristotle. KFF paid for all costs associated with the survey.

A series of data quality checks were run on the final data, which resulted in 40 completes being removed from the data. Weighting involved multiple stages: First, each state sample was weighted to account for the sampling methodology including the oversampling of low-educational attainment areas and to the proportions of the voter file reachable or unreachable by outbound phone-call. Second, each state’s sample was weighted to match the voter file distribution of 2016 voter status, party identification, gender, race/ethnicity, home-ownership, Metropolitan status, state region, as well as the 2018 CPS Voter Supplement for age-by-gender, educational attainment and race. To address non-response among partisans not accounted for by demographics, the weight was adjusted so that the self-reported 2016 vote in each state matched the actual state outcome.  The final weight combined each state’s weight and balanced the combined total sample to state distributions. All statistical tests of significance account for the effect of weighting.

The margin of sampling error including the design effect for the full sample is plus or minus 2 percentage points. Numbers of respondents and margins of sampling error for each state are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Note that sampling error is only one of many potential sources of error in this or any other public opinion poll. Kaiser Family Foundation public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

1. In the wake of the 2016 election there was some speculation that voters who were planning to support President Trump were reluctant to express this to interviewers during public opinion polls. This “shy Trump voter” hypothesis was not found to be a meaningful contribution to the polling errors in 2016. By examining whether voters were less willing to express support for President Trump during a live interview compared to an online response, we found no evidence of any voters, regardless of party identification, being less willing to express support for President Trump during live interview surveys. It is also important to note that while we did not find evidence of shy Trump voters, this may be a result of respondents being able to self-select into their various modes. ↩︎
2. The Blue Wall Voices Project began on September 23rd, 2019, one day before House Speaker Nancy Pelosi announced a formal impeachment inquiry into Trump on September 24th as a result of President Trump’s phone call with the Ukrainian President. As the field period continued into October, we did see an increase in the share of voters who mentioned President Trump’s commitment to constitution in their responses to this question. ↩︎

Since Medicaid’s inception, federal law has generally prohibited states from using Medicaid funds for services provided to nonelderly adults in “institutions for mental disease” (IMDs).¹  The IMD payment exclusion was intended to leave states with the primary responsibility for financing inpatient behavioral health services.²  However, the lack of federal funding may limit access to needed inpatient services and contribute to high levels of unmet need. In recent years, the federal government has provided new mechanisms for states to finance IMD services for nonelderly adults through Medicaid in certain situations. There are now four options for states to cover these services: Section 1115 demonstration waivers, managed care “in lieu of” authority, disproportionate share hospital payments, and the SUPPORT Act state plan option.

This report provides new data to understand current patterns of Medicaid enrollees’ use of inpatient and outpatient substance use disorder (SUD) and mental health treatment services; explains the options for states to access federal Medicaid funds for enrollees receiving IMD services; analyzes current waiver activity; and draws on interviews with policymakers in two states and one county using IMD waivers to examine successes and challenges. Appendix Tables contain state-level data. Key findings include:

• Many nonelderly Medicaid adults with a behavioral health condition report unmet treatment needs. Though Medicaid adults with behavioral health needs are more likely than those privately insured to have used services in the past year, treatment rates are low across all payers, including payers not subject to the IMD payment exclusion. Most Medicaid adults who receive behavioral health treatment do so as outpatients.
• Twenty-six states have a Section 1115 waiver to use Medicaid funds for IMD SUD services, as of November 2019. Vermont is the only state with an IMD mental health waiver to date.
• Interviews with policymakers in two states and one county using IMD waivers reveal that all devoted substantial time and resources to expanding and strengthening available community-based SUD treatment services in addition to IMD services. All three report overall positive experiences with their waivers, along with some implementation challenges that had to be resolved.
• Early waiver evaluation results in the case study areas show more Medicaid enrollees using SUD services and increased provider participation since allowing IMD payment. Policymakers also described some constraints of the IMD waivers, particularly around the length of stay limits.

As states continue to seek Medicaid IMD payments, key issues to watch include capacity and utilization of treatment services across the care continuum, IMD day limits, discharge planning and care transitions, and the continued evolution of evidence-based best practices for SUD and mental health treatment.

What Behavioral Health Services Does Medicaid Cover?

Medicaid covers many behavioral health services, though there is not a specifically defined category of Medicaid benefits dedicated to behavioral health. Some behavioral health services fall under mandatory Medicaid benefit categories that all states must cover. For example, psychiatrist services are covered under the required “physician services” category. States also cover behavioral health services through optional benefit categories that states may choose to include in their Medicaid programs, such as case management or prescription drugs (which all states do). One important benefit category for behavioral health is the rehabilitative services option, through which states commonly cover non-clinical behavioral health services such as peer support and community residential services. In addition, under waiver or state plan authority, states can provide home and community-based long-term care behavioral health services that support independent community living, such as day treatment and psychosocial rehabilitation services. While all states that participate in Medicaid must cover inpatient services, federal law prohibits payment for services provided in IMDs, as further described below. Box 1 provides examples of behavioral health services that may be covered by Medicaid. A glossary defining key Medicaid behavioral terms is included in the Appendix.

Medicaid coverage of behavioral health services is sometimes more comprehensive than private insurance coverage. While many private insurance plans cover psychiatric hospital visits, in some states, Medicaid is more likely to cover additional services, such as case management, individual and group therapy, detoxification, and medication management. Medicaid is the primary payer for long-term services and supports on which many people with disabilities, including those with mental health needs, rely to live independently in the community.

What Are the Patterns of Behavioral Health Treatment Among Nonelderly Medicaid Adults?

Most nonelderly Medicaid adults receiving behavioral health treatment do so in an outpatient setting, without any inpatient services. In 2017, inpatient services were used by just under half (46%) of nonelderly Medicaid adults with SUD who received drug or alcohol treatment in the past year (Figure 1). A smaller share (17%) of Medicaid enrollees with mental illness who received treatment used inpatient services. The data do not distinguish services provided in IMDs from those provided in other inpatient settings such as a general inpatient hospital.

Though nonelderly Medicaid adults with behavioral health needs are significantly more likely than those who are privately insured to have used inpatient and outpatient treatment services in the past year, treatment rates are low across all payers. Among nonelderly adults with SUD, those with Medicaid are more likely have used inpatient treatment services compared to those with private insurance (8% vs. 3%, Figure 2). Similarly, among nonelderly adults with any mental illness, those with Medicaid are more likely to have used inpatient treatment, compared to those with private insurance (6% vs. 2%). Nevertheless, treatment utilization rates (use of treatment services in past year by those with a behavioral health diagnosis), particularly for inpatient treatment, remain low across payers. Inpatient treatment rates are low even for private insurers who, unlike Medicaid, are not subject to the IMD payment exclusion.

Many people with behavioral health diagnoses report unmet treatment needs. Substantial shares of nonelderly adults with SUD and any mental illness report an unmet need for drug or alcohol treatment, with those with private insurance significantly more likely to have an unmet SUD treatment need compared to those with Medicaid (91% vs. 80%, Figure 3). The share of nonelderly Medicaid adults with SUD and any mental illness reporting an unmet need for mental health treatment is similar to those with private insurance (36% vs. 34%).

Administrative data shows wide state variation in use of inpatient services among nonelderly Medicaid adults who receive mental health or substance use disorder services. In FY 2013, the share of nonelderly Medicaid adults receiving any behavioral health treatment who received any inpatient SUD services ranged from 10% in Alaska to 57% in West Virginia. The share of those receiving any inpatient mental health services ranged from 9% in Alaska to 31% in Alabama and New York (Appendix Table 1). Like the national data discussed above, the state-level data do not separately identify IMD services from other inpatient services. In addition, this data – which is the most recently publicly available – predates the Affordable Care Act’s Medicaid expansion and the opioid epidemic’s impact over the last six years, and consequently may understate the number of enrollees now utilizing these services in states that have implemented the expansion since 2014.³ 

What is the IMD Payment Exclusion and Its Exceptions?

Federal law generally bars states from receiving “any [Medicaid] payments with respect to care or services for any individual who has not attained 65 years of age and who is a patient in an [IMD].”⁴  The payment exclusion applies to services provided within an IMD as well as to services provided outside an IMD to nonelderly adult IMD patients. An IMD is a “hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases [sic], including medical attention, nursing care, and related services” (Figure 4).⁵  Whether a particular facility is an IMD is determined by the state. Figure 4 lists factors considered in this determination. While all states that choose to participate in the Medicaid program must cover inpatient hospital services, those services specifically exclude care provided in IMDs.⁶  The IMD payment exclusion applies to Medicaid enrollees ages 21 through 64. States have the option to cover inpatient psychiatric hospital services for those under age 21⁷  and IMD inpatient hospital and nursing facility services for those age 65 and older.⁸ 

There are four ways that states can receive federal Medicaid funds for IMD services for nonelderly adults. These include Section 1115 demonstration waivers, Medicaid managed care “in lieu of” authority, disproportionate share hospital (DSH) payments, and the SUPPORT Act⁹  state plan option (beginning in October 2019) (Figure 5). Box 2 discusses considerations for providing institutional services under the Americans with Disabilities Act, separate from Medicaid.

Section 1115 waivers

With the opioid epidemic increasing, CMS has been inviting states to apply for Section 1115 IMD SUD waivers,¹³  with guidance released in 2015,¹⁴  and revised in 2017.¹⁵  These waivers allow states to test using federal Medicaid funds to provide short-term inpatient and residential SUD treatment services in IMDs. Some of the requirements for these waivers have evolved over time (Figure 6). For example, unlike waivers approved under the 2015 guidance,¹⁶  waivers approved under the 2017 guidance do not explicitly limit the length of individual IMD stay.¹⁷  In addition, waivers under the 2015 guidance were contingent on states covering community-based SUD treatment services at the time of approval,¹⁸  while the 2017 guidance allows states up to two years after waiver approval to cover “critical levels of care.”¹⁹  As discussed in more detail below, more than half of states have an approved or pending IMD SUD payment waiver as of November 2019.

In addition to covering certain levels of care, the 2017 guidance incorporates other milestones that states must achieve during the term of an IMD SUD waiver (Figure 7).²⁰  These include using evidence-based patient placement criteria; applying nationally recognized provider qualification standards; implementing prescribing guidelines and other strategies to address opioid abuse; and improving care coordination and transitions between levels of care.²¹  CMS’s 2019 IMD SUD waiver evaluation design guidance identifies SUD treatment access and utilization,²²  health outcomes,²³  and opioid-related overdose deaths as three key areas to assess.²⁴ 

CMS also reversed long-standing policy and issued new guidance inviting states to apply for Section 1115 IMD payment waivers for mental health services in November 2018 (Figure 6).²⁵  Until this point, CMS had not approved IMD mental health waiver requests in Illinois,²⁶  Massachusetts,²⁷  or North Carolina,²⁸  citing its former policy not to allow Medicaid payments for individuals who receive only mental health treatment in IMDs.²⁹  Under the new guidance, states will have to achieve a set of milestones over the term of these waivers, including ensuring institutional care quality, improving coordination and community transitions, increasing access to crisis stabilization, and earlier identification and engagement in treatment. States that previously had IMD mental health waiver requests that were not approved, as well as states with new requests, can apply for waivers under the 2018 guidance. As of November 2019, only one state (Vermont) has an approved Section 1115 IMD mental health waiver.

Managed care “in lieu of” authority

States with capitated managed care delivery systems can use “in lieu of” authority to cover IMD SUD and mental health services for up to 15 days per month.³⁰  Specifically, states can use federal Medicaid funds for capitation payments to managed care plans that cover IMD inpatient or crisis residential services for nonelderly adults instead of providing other services, such as non-IMD inpatient or outpatient services, that are covered in the state plan benefit package.³¹  The IMD services must be medically appropriate and cost-effective, and enrollees cannot be required to accept IMD services instead of state plan services. This regulation took effect in July 2016,³²  although it codified pre-existing long-standing federal sub-regulatory guidance that allowed federal Medicaid payments for IMD services. However, unlike the regulation, the former guidance did not subject IMD services covered under “in lieu of” authority to a day limit. Of the 41 states using comprehensive risk-based managed care organizations, 31 use Medicaid managed care “in lieu of” authority to cover IMD SUD and/or mental health services in both FY 2019 and FY 2020, and two (MS and NC) report plans to begin doing so in FY 2020.³³  Two states reported using the authority in FY 2019 only (Appendix Table 3).³⁴ 

Disproportionate Share Hospital payments

States can spend a portion of their Medicaid DSH funds on IMD services.³⁵  States must make these payments to offset uncompensated care costs incurred by hospitals that serve a disproportionate number of low-income patients. In FY 2018, 33 states made DSH payments totaling $2.9 billion to mental health treatment facilities including IMDs. These payments ranged from 0.0003% of total DSH payments to mental health facilities in Minnesota to 18% in New York (Appendix Table 4).

Support Act state plan option

The SUPPORT Act partially lifts the IMD payment exclusion by allowing states to use federal Medicaid funds for nonelderly adults receiving IMD SUD services up to 30 days a year,³⁶  from October 2019 through September 2023.³⁷  IMD coverage under the SUPPORT Act option is in addition to IMD services covered under managed care in lieu of authority³⁸  and Section 1115 waivers.³⁹  To receive Medicaid payments under the SUPPORT Act option, IMDs must follow “reliable, evidence-based practices” and offer at least two forms of medication-assisted treatment (MAT) on-site⁴⁰  for opioid use disorder. Separately, the SUPPORT Act also authorizes Medicaid payments for services provided outside IMDs for pregnant and post-partum women receiving IMD SUD services, as of October 2018.⁴¹ 

States must satisfy five criteria to qualify for Medicaid funds under the SUPPORT Act option (Figure 8). First, states have to maintain annual state and local funding levels⁴²  for both IMD services and a specific list of community-based outpatient services⁴³  provided to nonelderly adults who become eligible for Medicaid-funded IMD services under the new option. Additionally, states must ensure that nonelderly adults receive “appropriate evidence-based clinical screening” prior to receiving IMD SUD services.⁴⁴  States also must confirm that IMDs receiving Medicaid payments can provide outpatient services, either themselves or through an established relationship with another facility or provider accepting Medicaid patients, to allow for successful community transitions.⁴⁵  Finally, states electing the SUPPORT Act option must cover Medicaid SUD treatment services at four outpatient levels of care⁴⁶  and at least two of five inpatient levels of care⁴⁷  (Figure 9).

According to a KFF survey, five states report plans to pursue the SUPPORT Act option in FY 2020.⁴⁸  These states include Idaho, Indiana, New Hampshire, South Dakota, and Tennessee.⁴⁹  Twenty-one states report that they have not yet determined if they will pursue the SUPPORT Act option,⁵⁰  and 24 states indicate that they do not plan to pursue this option.⁵¹  In explaining the rationale for not pursuing this option, many states noted that they already had a Section 1115 waiver in place or were pursuing such a waiver to allow IMD funding.⁵²  Several states also felt that their Section 1115 waiver would provide more flexible limits on length of IMD stays compared to the 30-day cap on IMD services under the SUPPORT Act option.⁵³  Table 1 compares key elements of Section 1115 IMD waivers with the SUPPORT Act.

How Are States Using Medicaid IMD Waivers?

The number of Section 1115 IMD SUD waiver approvals has markedly increased since January 2017. Four states had IMD SUD waivers approved by CMS as of December 31, 2016, and another 22 states have had IMD SUD payment waivers approved since then. Three more states have these waiver requests pending with CMS as of November 2019 (Figure 10 and Appendix Table 2).⁵⁴  To date, Vermont remains the only state with an existing IMD mental health waiver, the current terms of which require those payments to phase out between 2021 and 2025.⁵⁵  Vermont recently submitted a request to transition its existing mental health authority to the terms of the new guidance. Additionally, DC and Indiana have submitted pending waiver requests for IMD mental health services under the new guidance, with more states expected to follow. Idaho, Massachusetts, New Hampshire, New Jersey, North Carolina, and Rhode Island report plans to pursue an IMD mental health waiver in FY 2020, while Alaska, Connecticut, Virginia, and Washington report plans to do so after FY 2020.⁵⁶ 

While waiver evaluations are still underway, news reports, interim evaluations, and feedback directly from states can inform the ongoing implementation of IMD waivers. While some waiver evaluation results are emerging, most are not expected until 2024 or 2025 (Appendix Table 2).⁵⁷  Given the attention to state efforts to combat the opioid epidemic and emerging focus on mental health, states are moving forward with waiver implementation. State experience with these initiatives can help inform policy choices and design as other states consider similar waivers. To make some of this information available in advance of formal waiver evaluations, we conducted case studies in two states and one county. Table 2 summarizes the waivers in the three case study areas, and Box 3 describes the case study methodology.

Role of Community-Based Services

Interviews with case study areas implementing IMD waivers reveal that some expanded community-based treatment services in addition to IMD services. Notably, Virginia used state funds that previously went to IMD services to finance additional community-based SUD services to complement the IMD SUD services authorized by its waiver. Specifically, Virginia used state plan authority to add recovery supports and expanded medication-assisted treatment to the intensive outpatient, partial hospitalization, and residential levels of care. In addition to IMD residential services, California’s waiver adds enhanced SUD community-based services in the participating counties, including case management, withdrawal management, recovery services, physician consultation, and at county option, additional MAT drugs and partial hospitalization. Without the waiver, the California Medicaid state plan benefit package is limited to outpatient, intensive outpatient, perinatal residential (non-IMD), and opioid treatment program services. Other states not included as case studies for this report similarly expanded community-based services either under or in conjunction with their waivers authorizing payment for IMD services, such as West Virginia,⁶³  Kansas,⁶⁴  Illinois,⁶⁵  Alaska,⁶⁶  Indiana,⁶⁷  and Wisconsin.⁶⁸  However, at least one state (Kentucky) has restricted access to some community-based services (methadone) while funding IMD services under its waiver.⁶⁹ 

While states believe that newly added community-based services are essential to achieving their waiver goals, utilization of some of the new services during initial implementation has not been as high as expected. Respondents noted that use of recovery supports (Virginia and California)⁷⁰  and case management (California)⁷¹  has been low. As waiver implementation continues, these states are focused on additional provider training to increase new service utilization and improve treatment continuity as enrollees transition among care settings.

States are making efforts to address transitions between inpatient and outpatient care settings. California’s managed care external quality review report recommends that SUD providers at both residential and outpatient levels of care be allowed to bill for services provided to an individual on the same day to align with evidence-based best practices that call for introducing a patient to new treatment staff at least twice before residential discharge.⁷²  This practice is intended to smooth care transitions and increase the rate of community-based treatment engagement after residential discharge. Having implemented bundled payments for episodes of care in 2019, Vermont is transitioning to value-based payments for IMD SUD services by January 2021, seeking to eliminate incentives for longer residential stays resulting in higher provider payments. The model is designed to encourage providers to engage in effective discharge planning, with payment disincentives for rapid readmissions. Virginia requires providers to include comprehensive transition plans and coordination of current care and post-discharge plans related to community services in their treatment plan to ensure continuity of care upon discharge with the individual’s family, school and community.

Provider Networks and Service Delivery Changes

In addition to covering new services, states took steps to expand or maintain IMD residential provider networks for SUD services. San Diego County has worked to develop its residential provider network, while Vermont is focused on maintaining its long-standing network. One challenge in San Diego and other California counties has been helping residential providers establish the record keeping and quality improvement initiatives needed to successfully bill for Medicaid services.⁷³  San Diego’s initiatives in this area include “gentle” reimbursement withholding incentives, in which a portion of provider payment is delayed until certain performance standards are met. San Diego also has spent substantial county staff time offering technical assistance to providers and introduced advance payments so that providers had funding available upfront to establish the needed administrative infrastructure.

States also worked to expand their community-based provider networks and increase payment rates. Virginia has been able to use state funds to fund “significant” provider rate increases for intensive outpatient and partial hospitalization services intended to build the Medicaid provider network. California’s waiver broadens the range of approved SUD treatment providers and allows counties to pay providers at higher than state plan rates to account for geographic differences and encourage providers to add capacity.⁷⁴ 

All three areas also have initiatives to improve care coordination across providers to help ensure that enrollees remain connected to care as required under waiver guidance and milestones.  For example, Virginia added a new office-based treatment program benefit, which co-locates a buprenorphine waivered provider and a licensed mental health provider, and includes reimbursement for care coordination. Virginia also changed its policy to allow both medical and SUD providers to bill for services for the same patient on the same day. This change was identified as a lesson learned to incentivize engaging patients in SUD treatment when they come in for other needed care. For example, a pregnant woman may see both an obstetrician and an MAT provider on the same day. San Diego County is including peer advocates and social work staff alongside doctors in emergency departments to help connect patients to community-based treatment after discharge.

Utilization and Participation

Evaluation results in all three areas show increased treatment service utilization and provider participation. Results from the first year (April 2017 to March 2018) of waiver implementation in Virginia found that the number of outpatient providers billing for ARTS services increased by 173%;⁷⁵  the number of Medicaid enrollees who used SUD treatment services increased by 57%;⁷⁶  and more than 40% of enrollees with SUD received treatment, up from 24% in the prior year.⁷⁷  In the seven counties that began service delivery in 2017, California’s waiver evaluation found that the number of people accessing treatment increased by about 7%.⁷⁸  In the three counties included in the California waiver’s managed care external quality review report, the number of enrollees receiving SUD services nearly tripled in the first year of waiver implementation, compared to pre-waiver baseline claims data.⁷⁹  While not yet included in California’s waiver evaluation findings, San Diego County anecdotally reports a 40 to 50% increase in the number of patients receiving SUD treatment services on both an inpatient and outpatient basis since waiver implementation in July 2018, compared to the corresponding month in the prior year. Vermont’s evaluation for 2013 to 2016 found that rates of initiation and engagement in community-based treatment post inpatient discharge for enrollees who had received IMD services exceeded both the general Vermont Medicaid rate and the national rate for both SUD and psychiatric services.⁸⁰ 

California’s waiver evaluation found notable gains in access to residential treatment that could not have been financed by Medicaid without the waiver.⁸¹  Additionally, the California waiver’s managed care external quality review report notes that without the IMD payment authority, “[a]pproximately 80 percent of the residential facilities in California would not have qualified for [Medicaid] reimbursement, thus severely limiting treatment options.”⁸²  As of March 2019, San Diego County reported adding 67 IMD beds, which has reduced the number of patients waiting for services.⁸³ 

Evaluation results also have found decreases in emergency room visits and inpatient hospitalizations. From 2013 through 2016, Vermont’s interim waiver evaluation found that emergency room use within 30-days post-IMD discharge declined compared to emergency room use prior to the IMD admission for both mental health services (with declines ranging from 23 to 44%)⁸⁴  and SUD services (with declines ranging from 39 to 56%).⁸⁵  Psychiatric IMD readmission rates averaged 8% after 30 days over the four years, while SUD readmission rates were under 15% across settings (general hospital detox, IMD detox, and IMD residential) during this period.⁸⁶  During the first 10 months of waiver implementation in Virginia, the number of emergency department visits related to SUD decreased by 14%, and the number of Medicaid enrollees with an acute inpatient admission related to SUD decreased by 4%.⁸⁷ 

Implementation Limitations and Challenges

States report that existing IMD authority and policy may limit their efforts to address unique needs of special populations, such as pregnant women and individuals in the criminal justice system. With Vermont’s transition from its older waiver authority to waivers under the more recent CMS guidance, the state will no longer be able to use federal Medicaid funds for a specialized residential treatment facility that serves pregnant women and new mothers and infants. That care delivery model is based on a length of stay of 12 to 18 months, with an average length of stay of six months from 2013 through 2016.⁸⁸  As a result, including this one program would cause the statewide average length of stay to exceed the 30 days approved in Vermont’s waiver. San Diego County and Virginia both reported unexpected challenges where the courts were ordering defendants to residential SUD treatment instead of incarceration, without regard to the evidence-based placement criteria adopted under the waiver that instead called for outpatient treatment.⁸⁹  In both cases, Medicaid staff had to educate the courts about the need to order a medical evaluation to determine the appropriate level of care instead mandating residential care in all circumstances.

States report that waiver terms about IMD lengths of stay may not align with current evidence-based or state practices. California’s external quality review report found that the waiver’s limit of two IMD stays per year may be too restrictive because patients often do not complete their initial residential treatment visits, instead leaving in the first week to 10 days, but then later return when they are ready to commit to treatment.⁹⁰  The report notes that current clinical criteria call for residential treatment to stabilize SUD issues, followed by partial hospitalization or intensive outpatient services, but do not limit residential treatment to two stays per year. In contrast, Virginia’s waiver initially included a 90-day maximum IMD stay, but CMS subsequently removed that provision, recognizing that stays tend to be longer at the lower levels of residential care where the focus is more on supportive services and less on clinical care. While Vermont finds that a 30-day average statewide length of stay is appropriate for SUD treatment, it believes that this limit will be too limiting for mental health treatment, especially with CMS’s newly cited position that federal Medicaid funds will be limited to individual IMD stays that do not exceed 60 days. Vermont’s state hospital serves patients with the most severe needs that can take “substantially longer to stabilize;” the average length of stay there is 120 days. Vermont will be able to meet CMS’s 30-day statewide average requirement by averaging that facility’s stays with another IMD that has more beds and serves patients with less acute needs. However, Vermont is concerned that its ability to use federal Medicaid funds for most of its state hospital patients will be limited because CMS has newly proposed that Medicaid cannot fund individual IMD stays that exceed than 60 days.

States are considering non-waiver exemptions to the IMD waivers, in part due to the time limited nature of waivers. For example, while Vermont reports that its IMD SUD waiver is working well, it also is considering pursuing the SUPPORT Act state plan option. While “largely redundant” of its existing waiver, the state sees the state plan option as more of a “long-term assurance” to have IMD payment authority in place. Virginia noted that it decided to add SUD community-based services using state plan rather than waiver authority as a way of “securing” those services as waivers are not permanent.

States are drawing on their experience with IMD SUD waivers to inform their consideration of whether to pursue and how to design an IMD mental health waiver. Before applying for an IMD SUD waiver, Virginia reviewed its existing Medicaid SUD benefits to determine what was working well and whether there were other evidence-based services that could be added to the benefit package to establish a robust community-based continuum of care. Now, Virginia is similarly assessing its Medicaid-covered mental health services. The state plans to establish a solid community-based services foundation first and then pursue a future IMD mental health waiver. After largely deinstitutionalizing its mental health services over the past 30 years,⁹¹  Vermont is working to retain a minimum capacity for patients with the most acute needs.⁹²  The state is concerned that losing its current IMD mental health capacity under the existing federal funding phase-out plan will strain its community-based providers, who would be challenged by having to serve patients with more severe needs and as a result have less capacity to serve those with less severe needs. In Vermont’s experience, providing institutional care for the most acute patients reserves community-based services for those who do not need institutional care.

Looking Ahead

Many people with behavioral health diagnoses report unmet treatment needs, with substantial shares of nonelderly adults with SUD and any mental illness reporting an unmet need for drug or alcohol treatment. Though treatment utilization among nonelderly Medicaid adults with behavioral health needs is greater than the privately insured, treatment rates are low across all payers. Enabling states to access federal Medicaid funds for inpatient SUD and mental health treatment could help to address some of this unmet need and help states to cover services that reflect current evidence-based treatment standards. Additionally, providing federal matching funds for IMD services can free up state dollars previously spent on inpatient treatment to instead fund corresponding expansions in community-based services across the behavioral health care continuum. By law, state initiatives to expand behavioral health services cannot solely focus on inpatient services and instead also must consider community-based services, given states’ community integration obligations under the Americans with Disabilities Act. Thus, state expansion of behavioral health services under efforts to fund IMDs may also address demonstrated unmet treatment needs for outpatient behavioral health services.

The number of states with Section 1115 IMD SUD payment waivers has increased dramatically since 2017, now comprising over half the states. DC, Indiana, and Vermont have submitted applications seeking an IMD mental health payment waiver under the new guidance to date, other states have expressed interest, and more applications are likely to follow. In addition, the SUPPORT Act option for IMD SUD services is newly available to states in October 2019, with a few states expressing interest to date. All three case study areas in this report reported overall positive experiences with their waivers, supported by early evaluation findings, along with some implementation challenges that had to be resolved. Notably, all three areas had devoted substantial time and resources to expanding and strengthening a robust network of community-based SUD treatment services in addition to IMD services. Policymakers reported that receiving federal Medicaid funds for IMD services under the waivers can allow state and local funds to be used to expand community-based service options, increase provider payment rates, and develop other necessary program features that Medicaid does not fund, such as housing.

Given the widespread use of SUD waivers, and the notable policy change now allowing mental health waivers, states, health plans, providers, and enrollees will be interested in evaluation results assessing the waivers’ impact. Key questions include how allowing states to use federal Medicaid funds for IMD services affects access to and utilization of inpatient and outpatient care, health outcomes, care quality, costs, IMD day limits, discharge planning and care transitions, and the continued evolution of evidence-based best practices for SUD and mental health treatment. States may draw on their IMD SUD waiver experience to inform their design and implementation of IMD mental health waivers, and many enrollees have co-occurring SUD and mental health conditions. Still, it is not entirely clear how states’ IMD SUD experience will translate to IMD mental health waivers, given differences in providers and different requirements in CMS guidance. CMS and states may implement policy changes that represent lessons learned based on states’ mid-point assessments toward their waiver milestones. While some waiver evaluation results are emerging, most are not expected until 2024 or 2025. In the meantime, states’ quarterly and annual waiver reports to CMS and interim evaluation findings can provide important information about the waivers’ impact to inform whether CMS makes further Medicaid IMD policy changes and/or whether Congress acts to amend the statute.

• Medicaid Behavioral Health Glossary:  Key Terms and Concepts
• Appendix Table 1:  Medicaid Beneficiaries Aged 21-64 Receiving SUD and/or Mental Health Services – Inpatient vs. Outpatient Care, FY2013
• Appendix Table 2: Key Components of Approved Section 1115 Waivers for the IMD Payment Exclusion as of Oct. 2019
• Appendix Table 3: States Using Medicaid Managed Care “in lieu of” Authority to Fund IMD Services in FY2019 and/or FY2020
• Appendix Table 4: Disproportionate Share Hospital (DSH) Payments to Mental Health Treatment Facilities in FY 2018

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Medicaid Behavioral Health Glossary: Key Terms and Concepts

Care Continuum: An integrated system of care that guides and tracks patients over time through a comprehensive array of health services spanning all levels of care.⁹³ 

Community-based care: Healthcare provided in the home or another community setting and that typically allows the person to stay in their home rather than moving them to a facility to receive care. Examples include home health aides, case management services, and personal care services.⁹⁴ 

Disproportionate Share Hospital (DSH) payments: Payments required by federal law from state Medicaid programs to qualifying hospitals that serve a large number of Medicaid and uninsured individuals.⁹⁵ 

Inpatient Treatment: Healthcare provided upon admission to a facility, such as a hospital. Typically treats more severe diagnoses, provides 24-hour medical and emotional support, and involves the patient staying in the facility for an extended period of time.

Institution of Mental Disease: Hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services.⁹⁶ 

Institutional Care: Healthcare provided in an institutional setting such as a nursing facility, mental health institution, or an intermediate care facility for individuals with intellectual disability.

Medicaid Managed Care: Delivery system for Medicaid covered services by health plans that accept a set capitated payment for these services through a contract with the state Medicaid agency.⁹⁷ 

Olmstead case: 1999 Supreme Court decision that found that the unjustified institutionalization of people with disabilities is illegal discrimination. Requires states to eliminate unnecessary segregation and ensure that persons with disabilities receive services in the most integrated setting appropriate to their needs.⁹⁸ 

Outpatient Treatment: Healthcare provided in a part-time setting that allows the patient to continue their day-to-day activities outside of treatment. Typically allows the patient to maintain a more normal daily routine and relies more heavily on social circle support.

Section 1115 Demonstration Waiver: Authority by which HHS Secretary can allow states to test new approaches in Medicaid that differ from what is required by federal statute.⁹⁹ 

Serious Emotional Disturbance: Someone under the age of 18 with a diagnosable mental, behavioral, or emotional disorder in the past year, which resulted in functional impairment that substantially interferes with or limits their role or functioning in family, school, or community activities.¹⁰⁰ 

Serious Mental Illness: Someone over the age of 18 with a diagnosable mental, behavior, or emotional disorder that causes serious functional impairment that substantially interferes with or limits one or more major life activities.¹⁰¹ 

Substance Use Disorder: Recurring use of alcohol or drugs that causes significant clinical and functional impairment.¹⁰² 

SUPPORT Act: Federal law partially lifting the IMD payment exclusion by allowing states to use federal Medicaid funds for nonelderly adults receiving IMD SUD services up to 30 days a year, from October 2019 through September 2023.¹⁰³ 

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1. Nonelderly adults are ages 21-64. “Mental disease” is an antiquated term used in the statute. It comprises “diseases listed as mental disorders in the International Classification of Diseases with the exception of mental retardation [sic], senility, and organic brain syndrome,” including the Diagnostic and Statistical Manual of Mental Disorders, and encompasses alcoholism and other chemical dependency syndromes. CMS State Medicaid Manual § 4309 (D), (E), https://www.cms.gov/Regulations-and-Guidance/guidance/Manuals/Paper-Based-Manuals-Items/CMS021927.html. ↩︎
2. David G. Smith and Judith D. Moore, Medicaid Politics and Policy, at 188-89 (2008); see also CMS State Medicaid Manual § 4309 (A)(2), https://www.cms.gov/Regulations-and-Guidance/guidance/Manuals/Paper-Based-Manuals-Items/CMS021927.html. ↩︎
3. See Kaiser Family Foundation, Status of State Medicaid Expansion Decisions:  Interactive Map (Sept. 20, 2019), https://modern.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/. ↩︎
4. 42 U.S.C. § 1396d (a)(29)(B). ↩︎
5. 42 U.S.C. § 1396d (i). “Whether an institution is an [IMD] is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases [sic], whether or not it is licensed as such.” 42 C.F.R. § 435.1010. IMDs do not include institutions for people with intellectual disabilities. Id. Whether a particular facility is considered an IMD is based on an assessment of various factors, such as licensure or accreditation as a psychiatric facility; falling under the state’s mental health authority jurisdiction if the facility serves people with mental illness; specializing in providing psychiatric or psychological care and treatment (based on “thorough review” of patient records, an “unusually large” proportion of staff with specialized psychiatric/psychological training, or a large proportion of patients receiving psychopharmacological drugs); and the need for institutionalization resulting from “mental diseases [sic]” for more than 50% of the facility’s patients. CMS State Medicaid Manual § 4309 (C), https://www.cms.gov/Regulations-and-Guidance/guidance/Manuals/Paper-Based-Manuals-Items/CMS021927.html. Other relevant factors also may be considered, such as whether the average age of patients in a nursing facility is significantly lower than a typical nursing facility. Id. Components of entities that are certified as different provider types, such as nursing facilities and hospitals, are considered independent from each other and assessed separately. Id. § 4309 (B). ↩︎
6. 42 U.S.C. § 1396d (a)(1); 42 C.F.R. § 440.10. ↩︎
7. 42 U.S.C. § 1396d (a)(16)(A). ↩︎
8. 42 U.S.C. § 1396d (a)(14). ↩︎
9. Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, H.R. 6, 115th Congress (2018); see also Kaiser Family Foundation, Federal Legislation to Address the Opioid Crisis:  Medicaid Provisions in the SUPPORT Act (Oct. 2018), https://modern.kff.org/medicaid/issue-brief/federal-legislation-to-address-the-opioid-crisis-medicaid-provisions-in-the-support-act/. ↩︎
10. Kaiser Family Foundation, Olmstead’s Role in Community Integration for People with Disabilities Under Medicaid:  15 Years After the Supreme Court’s Olmstead Decision (June, 2014), https://modern.kff.org/medicaid/issue-brief/olmsteads-role-in-community-integration-for-people-with-disabilities-under-medicaid-15-years-after-the-supreme-courts-olmstead-decision/. Although the ADA’s anti-discrimination provisions do not apply to individuals who are currently using illegal drugs, the ADA does protect people who previously used illegal drugs and people with mental health disabilities.  ADA Title II Technical Assistance Manual, § II-2.3000, https://www.ada.gov/taman2.html. ↩︎
11. Kaiser Family Foundation, Medicaid Home and Community-Based Services Enrollment and Spending (April 2019), https://modern.kff.org/report-section/medicaid-home-and-community-based-services-enrollment-and-spending-issue-brief/. ↩︎
12. Kaiser Family Foundation, Medicaid’s Role in Financing Behavioral Health Services for Low-Income Individuals (June 2017), https://modern.kff.org/medicaid/issue-brief/medicaids-role-in-financing-behavioral-health-services-for-low-income-individuals/. ↩︎
13. Section 1115 of the Social Security Act allows the Health and Human Services Secretary to waive certain provisions of federal Medicaid law for an “experimental, pilot, or demonstration project” that “is likely to assist in promoting the objectives of” the program. 42 U.S.C. § 1315 (a). Section 1115 waiver authority is limited to provisions contained in 42 U.S.C. § 1396a, while the IMD payment exclusion is contained in 42 U.S.C. § 1396d. However, the Secretary has approved IMD payment waivers under Section 1115 expenditure authority, which has been interpreted to independently permit the “costs of such [demonstration] project[s] which would not otherwise be included as [federal Medicaid] expenditures. . . [to] be regarded as expenditures under the State [Medicaid] plan. . . .”  42 U.S.C. § 1315 (a)(2). ↩︎
14. CMS, New Service Delivery Opportunities for Individuals with a Substance Use Disorder, SMD #15-003, (July 27, 2015), https://www.medicaid.gov/federal-policy-guidance/downloads/smd15003.pdf. ↩︎
15. CMS, Strategies to Address the Opioid Epidemic, SMD #17-003 (Nov. 1, 2017), https://www.medicaid.gov/federal-policy-guidance/downloads/smd17003.pdf. ↩︎
16. Waivers issued under the 2015 guidance included specific day limits on IMD stays eligible for federal Medicaid funds:  Maryland’s waiver allows two 30-day stays, while California has approval for two 90-day stays for adults and two 30-day stays for adolescents. California allows a one-time 30-day extension if medically necessary, and peri-natal patients may stay for the duration of pregnancy and 60 days post-partum. California’s waiver notes that the average length of stay is 30 days. ↩︎
17. Some waivers approved under the 2017 guidance (e.g., KY, LA, UT) do not have an explicit day limit. More recent waivers approved or renewed under the 2017 guidance (e.g. NH, NJ, IL, VT, WA) note that the state “will aim for a statewide average length of stay of 30 days. . . to ensure short-term residential treatment stays.” See, e.g., CMS Special Terms and Conditions, Illinois Behavioral Health Transformation Demonstration, at p.8, section V., ¶ 20 (July 1, 2018-June 30, 2023), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/il/il-behave-health-transform-ca.pdf; CMS Special Terms and Conditions, Vermont Global Commitment to Health Demonstration at p. 53-54, section XV., ¶ 92 (Jan. 1, 2017-Dec. 31, 2021, amended June 6, 2017), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/vt/vt-global-commitment-to-health-ca.pdf. Virginia and West Virginia’s waivers note that the average length of stay is 30 days. ↩︎
18. Medicaid community-based behavioral health services can be covered under state plan or waiver authority. The 2015 guidance required states to cover community-based services along with short-term institutional services that “supplement and coordinate with, but do not supplant, community-based services. CMS, New Service Delivery Opportunities for Individuals with a Substance Use Disorder, SMD #15-003, (July 27, 2015), https://www.medicaid.gov/federal-policy-guidance/downloads/smd15003.pdf. ↩︎
19. CMS, Strategies to Address the Opioid Epidemic, SMD #17-003 (Nov. 1, 2017), https://www.medicaid.gov/federal-policy-guidance/downloads/smd17003.pdf. The 2017 milestones specify that states must cover outpatient, intensive outpatient, MAT, intensive residential/inpatient, and medically supervised withdrawal management within 12-24 months of waiver approval. Section 1115 SUD Demonstration Guide for Developing Implementation Plan Protocols, https://www.medicaid.gov/medicaid/section-1115-demo/downloads/evaluation-reports/sud-implementation-plan-template.pdf. The 2017 guidance notes that “states should indicate how inpatient and residential care will supplement and coordinate with community-based care in a robust continuum of care in the state” and directs states to “demonstrate how they are implementing evidence-based treatment guidelines.” CMS, Strategies to Address the Opioid Epidemic, SMD #17-003 (Nov. 1, 2017), https://www.medicaid.gov/federal-policy-guidance/downloads/smd17003.pdf. ↩︎
20. See also Section 1115 SUD Demonstration Guide for Developing Implementation Plan Protocols, https://www.medicaid.gov/medicaid/section-1115-demo/downloads/evaluation-reports/sud-implementation-plan-template.pdf. ↩︎
21. CMS also released a set of 24 required and 12 recommended monitoring metrics for IMD SUD waivers based on Medicaid administrative data that align with the waiver milestones. Monitoring Metrics for Section 1115 Demonstrations with SUD Policies, https://www.medicaid.gov/medicaid/section-1115-demo/downloads/evaluation-reports/sud-monitoring-metrics.pdf; see also Medicaid Section 1115 SUD Demonstration Monitoring Report Template, https://www.medicaid.gov/medicaid/section-1115-demo/downloads/evaluation-reports/sud-monitoring-report-template.pdf; Medicaid Section 1115 SUD Demonstration Monitoring Protocol Template, https://www.medicaid.gov/medicaid/section-1115-demo/evaluation-reports/evaluation-designs-and-reports/index.html. Additionally, states may report on state-identified metrics. ↩︎
22. These include increased referrals to and engagement in treatment, increased adherence to treatment, and reduced preventable or medically inappropriate emergency department and inpatient treatment. ↩︎
23. These include improved access to care for physical health conditions and fewer preventable or medically inappropriate SUD readmissions. ↩︎
24. SUD Section 1115 Demonstration Evaluation Design Technical Assistance (March 6, 2019), https://www.medicaid.gov/medicaid/section-1115-demo/downloads/evaluation-reports/sud-evaluation-design-tech-assistance.pdf. ↩︎
25. CMS, SMD #18-011, Opportunities to Design Innovate Service Delivery Systems for Adults with a Serious Mental Illness or Children with a Serious Emotional Disturbance (Nov. 13, 2018), https://www.medicaid.gov/federal-policy-guidance/downloads/smd18011.pdf; see also CMS SMI and SED Demonstration Opportunity Technical Assistance Questions and Answers (May 17, 2019), https://www.medicaid.gov/federal-policy-guidance/downloads/faq051719.pdf. ↩︎
26. Letter from CMS Administrator Seema Verma to Illinois Healthcare and Family Services Director Felicia Norwood at 1 (May 7, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/il/il-behave-health-transform-ca.pdf. ↩︎
27. Letter from CMS CMCS Acting Director Tim Hill to MassHealth Assistance [sic] Secretary Daniel Tsai at 3 (June 27, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ma/ma-masshealth-ca.pdf. Massachusetts’ approved waiver includes IMD payments as part of the safety net care pool (authorizing payments according to the waiver’s uncompensated cost limit protocol for otherwise covered services for IMD patients at inpatient psychiatric hospitals and community-based detoxification centers as part of the DSH-like Pool) (¶ ¶ 21, 54(a)(i)(3); see also Attachment E, Charts A and B and Attachment H Safety Net Care Pool Uncompensated Care Cost Limit Protocol); for diversionary behavioral health services including those provided by IMDs as part of the managed care benefit package (including acute substance abuse treatment services and substance abuse clinical support services in 24-hour facilities for nonelderly adults) (¶ 40, Table C); and for additional IMD SUD services (clinically managed population-specific high-intensity residential services (specialized treatment services to meet more complex needs) and clinically managed low-intensity residential services (24-hour transitional support services and 24-hour residential rehabilitation services and community-based family SUD treatment services) in 24-hour facilities) (¶ 41, Table D). CMS, MassHealth Medicaid Section 1115 Demonstration Special Terms and Conditions, No. 11-W-00030/1 (approved July 1, 2017-June 30, 2022, amended June 27, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ma/ma-masshealth-ca.pdf. In September, 2017, Massachusetts sought an amendment that would have waived all federal payment restrictions on IMD mental health and SUD services for nonelderly adults, including the 15-day managed care limit and the safety net care pool expenditure caps. Commonwealth of Mass. Exec. Office of Health and Human Servs., Office of Medicaid.  MassHealth Section 1115 Demonstration Amendment Request (Sept. 8, 2017), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ma/ma-masshealth-pa3.pdf. In June, 2018, CMS denied the state’s request to expand the IMD payment waiver beyond the terms already approved. ↩︎
28. Letter from CMS Administrator Seema Verma to NC Dep’t of Health & Human Servs. Deputy Sec’y for Med’l Assistance Dave Richard at 5 (Oct. 19, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/nc/nc-medicaid-reform-ca.pdf. ↩︎
29. Another state (Maryland) indicated that CMS denied its request for IMD mental health payment waiver authority, while approving its request for IMD SUD payment authority. GAO, States Fund Services for Adults in Institutions for Mental Disease Using a Variety of Strategies, GAO-17-652 at 34 (Aug. 2017), https://www.gao.gov/assets/690/686456.pdf. ↩︎
30. States can effectively receive federal matching funds for capitation payments made for enrollees with IMD stays up to 30 days if the stay does not exceed 15 days in a single month. Kaiser Family Foundation, CMS’s Final Rule on Medicaid Managed Care:  A Summary of Major Provisions (June 2016), https://modern.kff.org/medicaid/issue-brief/cmss-final-rule-on-medicaid-managed-care-a-summary-of-major-provisions/. ↩︎
31. Id. ↩︎
32. The SUPPORT Act incorporates the regulatory provisions into the statute. H.R. 6, § 1013; see also Kaiser Family Foundation, Federal Legislation to Address the Opioid Crisis:  Medicaid Provisions in the SUPPORT Act (Oct. 2018), https://modern.kff.org/medicaid/issue-brief/federal-legislation-to-address-the-opioid-crisis-medicaid-provisions-in-the-support-act/. ↩︎
33. NC did not have managed care in FY 2019. ↩︎
34. NM and WV may have discontinued use of managed care in lieu of authority in FY 2020 due to approval/implementation of Section 1115 IMD SUD waivers. Four states (CA, MD, ND, and PA) reported that they do not use this authority, and two states (GA and KS) did not respond to this question. Kaiser Family Foundation, A View from the States:  Key Medicaid Policy Changes, Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2019 and 2020 at 55 (Oct. 2019), https://modern.kff.org/medicaid/report/a-view-from-the-states-key-medicaid-policy-changes-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2019-and-2020/. ↩︎
35. DSH payments to IMDs are limited to the lesser of the state’s FY 1995 DSH payment to IMDs and other mental health facilities or one-third of the state’s FY 1995 DSH allotment. 42 U.S.C. § 1396r-4 (h); GAO, States Fund Services for Adults in Institutions for Mental Disease Using a Variety of Strategies, GAO-17-652 at 34 (Aug. 2017), https://www.gao.gov/assets/690/686456.pdf. ↩︎
36. The 30 days do not need to be consecutive.  H.R. 6, § 5052 (a)(2) (creating new Social Security Act § 1915 (l)(2)). ↩︎
37. H.R. 6, § § 5051-5052; see also Kaiser Family Foundation, Federal Legislation to Address the Opioid Crisis:  Medicaid Provisions in the SUPPORT Act (Oct. 2018), https://modern.kff.org/medicaid/issue-brief/federal-legislation-to-address-the-opioid-crisis-medicaid-provisions-in-the-support-act/. The new state plan option authorizes Medicaid funding for 30 days of services provided in IMDs as well as for other medically necessary services provided outside IMDs to IMD patients. H.R. 6, § 5052 (a)(2) (creating new Social Security Act § 1915 (l)(6)). ↩︎
38. H.R. 6, § 5052 (a)(2) (creating new Social Security Act § 1915 (l)(5)). ↩︎
39. H.R. 6, § 5052 (b) (noting that the new state plan option is not be to be construed as preventing states from conducting Section 1115 demonstration waivers to improve access to and quality of SUD treatment for nonelderly adults). ↩︎
40. H.R. 6, § 5052 (a)(2) (creating new Social Security Act § 1915 (l)(7)(C)). MAT must include at least one antagonist (e.g., naltrexone) and one partial agonist (e.g., buprenorphine). Methadone is a full agonist. SAMHSA, Medications for Opioid Use Disorder for Healthcare and Addiction Professionals, Policymakers, Patients, and Families Treatment Improvement Protocol 63  at Exhibit 1-1 (2018), https://store.samhsa.gov/shin/content/SMA18-5063FULLDOC/SMA18-5063FULLDOC.pdf. ↩︎
41. H.R. 6, § 1012; see also CMCS Informational Bulletin, State Guidance for the New Limited Exception to the IMD Exclusion for Certain Pregnant and Postpartum Women included in Section 1012 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (Pub. L. 115-271), entitled Help for Moms and Babies (July 26, 2019), https://www.medicaid.gov/federal-policy-guidance/downloads/cib072619-1012.pdf. ↩︎
42. State and local funding must remain at the level for the most recent fiscal year prior to SUPPORT Act enactment or the most recently ended fiscal year as of the date the state submits a state plan amendment to elect the new option, if higher. H.R. 6, § 5052 (a)(2) (creating new Social Security Act § 1915 (l)(3)(A)). States must verify compliance with the maintenance of effort requirement before a SUPPORT Act SPA can be approved. Id. The Secretary is to establish a process for state reporting within 8 months of enactment.  Id. ↩︎
43. The maintenance of effort provision applies to outpatient and community-based SUD treatment services; evidence-based recovery and support services; clinically directed therapeutic treatment to facilitate recovery skills, relapse prevention, and emotional coping strategies; outpatient MAT, related therapies, and pharmacology; counseling and clinical monitoring; outpatient withdrawal management and related treatment designed to alleviate acute emotional, behavioral, cognitive, or biomedical distress resulting from or occurring with alcohol or drug use; routine monitoring of medication adherence; and other outpatient and community-based SUD treatment services designated by the HHS Secretary. Id. ↩︎
44. The screening must include “initial and periodic assessment to determine the appropriate level of care, length of stay, and setting of care for each individual.” H.R. 6, § 5052 (a)(2) (creating new Social Security Act § 1915 (l)(4)(B)). Additionally, the SUPPORT Act IMD option shall not be construed as encouraging states to place individuals in inpatient or residential settings when home or community-based services would be more appropriate. H.R. 6, § 5052 (b). ↩︎
45. H.R. 6, § 5052 (a)(2) (creating new Social Security Act § 1915 (l)(4)(D)(ii)). The state must consider the proximity to an individual’s support network, such as family members, employment, counseling, and other services near an individual’s residence. H.R. 6, § 5052 (a)(2) (creating new Social Security Act § 1915 (l)(4)(D)(i)). ↩︎
46. These include (1) early intervention for those who are at known risk of developing substance-related problems and those for whom there is not yet sufficient information to document a diagnosable SUD; (2) outpatient recovery or motivational enhancement therapies and strategies at less than 9 hours per week for adults and less than 6 hours per week for adolescents; (3) intensive outpatient to treat multidimensional instability at 9 hours or more per week for adults and 6 hours or more per week for adolescents; and (4) partial hospitalization to treat multidimensional instability that does not require 24-hour care at 20 hours or more per week for adults and adolescents. H.R. 6, § 5052 (a)(2) (creating new Social Security Act § 1915 (l)(4)(C)). ↩︎
47. These include: (1) clinically managed low-intensity residential services for adults and adolescents, including 24-hour living support with trained personnel and at least 5 hours of clinical services per week per individual; (2) clinically managed population-specific high intensity residential services to stabilize multidimensional imminent danger and provide less intense milieu and group treatment for those with cognitive or other impairments unable to use full active milieu or therapeutic community for adults, including 24-hour care with trained counselors and less intensive treatment for those with cognitive or other impairments; (3) clinically managed high intensity residential services intended to stabilize multi-dimensional imminent danger and prepare for outpatient treatment for adults and clinically managed medium-intensity residential services for adolescents, including 24-hour care with trained counselors; (4) medically monitored intensive inpatient withdrawal management for adults and medically monitored high-intensity inpatient services for adolescents, including 24-hour nursing care, physician availability for significant problems, and 16 hours per day of counseling services; and (5) medically managed intensive inpatient services targeted to individuals with severe unstable problems in acute intoxication and/or withdrawal potential, biomedical conditions and complications, and emotional, behavioral or cognitive conditions and complications for adults and adolescents, including 24-hour nursing care and daily physician care. H.R. 6, § 5052 (a)(2) (creating new Social Security Act § 1915 (l)(4)(C)(ii) and (7)(A)). The SUPPORT Act requires physician availability for significant problems in ASAM Dimensions 1, 2, and 3. Id. These include significant problems in acute intoxication and/or withdrawal potential, biomedical conditions and complications, and emotional, behavioral or cognitive conditions and complications. Amer. Soc’y of Addiction Med., At A Glance:  The Six Dimensions of Multidimensional Assessment, last accessed Oct. 24, 2019, https://www.asam.org/resources/the-asam-criteria/about. ↩︎
48. Kaiser Family Foundation, A View from the States:  Key Medicaid Policy Changes, Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2019 and 2020 at 55 (Oct. 2019), https://modern.kff.org/medicaid/report/a-view-from-the-states-key-medicaid-policy-changes-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2019-and-2020/. ↩︎
49. Id. at Table 9. ↩︎
50. These states include AL, AK, AZ, AR, FL, GA, HI, KS, KY, MA, MN, MT, NV, NM, NY, OK, UT, VT, WV, WI, and WY. Id. ↩︎
51. These states include CA, CO, CT, DE, DC, IL, IA, LA, ME, MI, MS, MO, NE, NJ, NC, ND, OH, OR, PA, RI, SC, TX, UT, and WA. In addition, MD did not respond to this survey question. Id. ↩︎
52. Id. at 55. ↩︎
53. Id. ↩︎
54. Kaiser Family Foundation, Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State (Oct. 9, 2019), https://modern.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-by-state/. ↩︎
55. Vermont had sought expanded waiver authority for IMD mental health services along with new SUD authority, but CMS approved only the SUD authority. Letter from CMS, CMCS Acting Director Timothy B. Hill to Vermont Agency of Human Services Secretary Al Gobeille, at 1 (June 6, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/vt/vt-global-commitment-to-health-ca.pdf. ↩︎
56. Other states’ plans were undetermined at the time of this survey, with the exception of MD, which did not respond to this question. Kaiser Family Foundation, A View from the States:  Key Medicaid Policy Changes, Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2019 and 2020 at 55 and Table 9 (Oct. 2019), https://modern.kff.org/medicaid/report/a-view-from-the-states-key-medicaid-policy-changes-results-from-a-50-state-medicaid-budget-survey-for-state-fiscal-years-2019-and-2020/. ↩︎
57. Additionally, the SUPPORT Act directs MACPAC to study Medicaid payments to IMDs in a representative sample of at least two states by January 2020. The study must include the number of IMDs, facility type, and any coverage limits; services provided and clinical assessment, reassessment, and discharge processes; any federal waivers and other Medicaid funding sources such as supplemental payments; state certification, licensure, and accreditation requirements; state quality, clinical, and facility standards; and recommendations for Congress and CMS to improve care, standards, and data collection. H.R. 6, § 5011-5012. ↩︎
58. “As part of its original 1115 Demonstration for the Vermont Health Access Plan (VHAP) Medicaid Expansion, Vermont received a waiver of the IMD exclusion. This waiver, effective January 1, 1996, permitted Vermont to reimburse IMDs for individuals enrolled under the 1115 Demonstration. At that time, the rationale behind this waiver was to permit the use of IMDs as alternatives to potentially more costly, general acute hospital services. . . The IMD waiver was completely phased out January 1, 2006. . . Since 2005 Vermont has used its “in lieu of” authority under [the] Global Commitment [to Health Section 1115 Demonstration to fund IMD services.]” The Pacific Health Policy Group, Vermont Global Commitment to Health Section 1115 (a) Medicaid Demonstration 11-W-00194/1, Interim Evaluation Report #1, including Evaluation of IMD Expenditures at 39-40 (March 30, 2018), https://dvha.vermont.gov/administration/vt-gc-1115-demo-interim-eval-report-final-apr2-18.pdf. ↩︎
59. See id. ↩︎
60. Vermont Agency of Human Servs., Global Commitment to Health Section 1115 Medicaid Demonstration, 11-W-00194/1, Final Evaluation Design Extension Period Jan. 1, 2017-Dec. 31, 2018, Amended June 6, 2018, Effective July 1, 2018, at 11 (approved by CMS June 19, 2019), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/vt/Global-Commitment-to-Health/vt-global-commitment-to-health-eval-dsgn-appvl-20190609.pdf. ↩︎
61. CMS Special Terms and Conditions, California Medi-Cal 2020 Demonstration, #11-W-00193/9 (approved Dec. 30, 2015-Dec. 31, 2020, amended June 7, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ca/ca-medi-cal-2020-ca.pdf . The counties serve as managed care plans, overseeing provider qualifications and training, network adequacy, quality assurance and performance improvement, beneficiary rights and protections, program integrity, and service delivery. California Health Care Foundation, Medi-Cal Moves Addiction Treatment into the Mainstream:  Early Lessons from the Drug Medi-Cal Organized Delivery System Pilots at 4, 5 (Aug. 2018), https://www.chcf.org/wp-content/uploads/2018/08/MediCalMovesAddictionTreatmentToMainstream.pdf. ↩︎
62. CMS Special Terms and Conditions, Virginia Governor’s Access Plan for the Seriously Mentally Ill (GAP) and Addiction and Recovery Treatment Services (ARTS) Delivery System Transformation Demonstration, #11-W-00297/3 (approved Jan. 12, 2015-Dec. 31, 2019, amended Sept. 22, 2017), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/va/va-gov-access-plan-gap-ca.pdf. ↩︎
63. WV added methadone and peer recovery supports. CMS Special Terms and Conditions, West Virginia Continuum of Care for Medicaid Enrollees with Substance Use Disorders, #11-W-00307/3 (approved Jan. 1, 2018-Dec. 31, 2022), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/wv/wv-creating-continuum-care-medicaid-enrollees-substance-ca.pdf. ↩︎
64. Kansas’ waiver added SUD rehabilitation services intended to avoid preventable inpatient hospitalizations and also includes a pilot program to provide supported employment services to 500 enrollees with a behavioral health diagnosis, including those with co-occurring SUD, who receive SSI or SSDI benefits. CMS Special Terms and Conditions, KanCare, No. 11-W-00238/7 (Jan. 1, 2019-Dec. 31, 2023), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ks/ks-kancare-ca.pdf. ↩︎
65. Illinois is piloting case management, peer recovery supports, and supported employment services. CMS Special Terms and Conditions, Illinois Behavioral Health Transformation Section 1115 (a) Demonstration, #11W00316/5 (approved July 1, 2018-June 30, 2023), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/il/il-behave-health-transform-ca.pdf. ↩︎
66. Alaska expanded some HCBS under state plan authority and is using the waiver to pilot case management, peer recovery supports, and supported employment services. CMS Special Terms and Conditions, Alaska Substance Use Disorder and Behavioral Health Program, No. 11-W-00318/0 (Jan. 1, 2019-Dec. 31, 2023), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ak/ak-behavioral-health-demo-ca.pdf. ↩︎
67. IN expanded HCBS using state plan authority. CMS Special Terms and Conditions, Healthy Indiana Plan (HIP), #11-W-00296/5 (approved Feb. 1, 2018-Dec. 31, 2020), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/in-healthy-indiana-plan-support-20-ca.pdf. ↩︎
68. WI expanded HCBS using state plan authority. CMS Special Terms and Conditions, Wisconsin BadgerCare Reform, #11-W-00293/5 (approved Oct. 31, 2018-Dec. 31, 2023), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/wi/wi-badgercare-reform-ca.pdf. ↩︎
69. KY added methadone using state plan authority contingent on waiver authority that eliminates the requirement for the state to provide non-emergency medical transportation for enrollees to access those services. CMS Special Terms and Conditions, KY HEALTH 1115 Demonstration, #11-W-00306/4 and 21-W-00067/4 (approved Jan. 12, 2018-Sept. 30, 2018, amended Nov. 20, 2018), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ky/ky-health-ca.pdf. ↩︎
70. UCLA Integrated Substance Abuse Programs, California’s Drug Medi-Cal Organized Delivery System 2018 Evaluation Report at 4 (revised Oct. 19, 2018), http://www.uclaisap.org/dmc-ods-eval/assets/documents/2017-2018%20UCLA%20DMC-ODS%20Evaluation%20Report%2011192018.pdf; VCU Health Behavior and Pol’y School of Medicine, An Evaluation Report Prepared for the Va. Dep’t of Med’l Assist. Servs., Addiction and Recovery Treatment Servs. Access and Utilization during the First Year (April 2017-March 2018) at 15, 24 (Aug. 2018), https://hbp.vcu.edu/media/hbp/policybriefs/pdfs/ARTSone-yearreport_8.9.18_Final.pdf. ↩︎
71. Behavioral Health Concepts, Drug Medi-Cal Organized Delivery System External Quality Review Report FY 2017-2018 (Nov. 19, 2018), https://www.caleqro.com/data/DMC/County%20&%20Annual%20DMC%20Reports/FY%202017-2018%20Reports/Annual%20Report/CalEQRO%20DMC-ODS%20Statewide%20Annual%20Report%20FY17-18%20.pdf; UCLA Integrated Substance Abuse Programs, California’s Drug Medi-Cal Organized Delivery System 2018 Evaluation Report (revised Oct. 19, 2018), http://www.uclaisap.org/dmc-ods-eval/assets/documents/2017-2018%20UCLA%20DMC-ODS%20Evaluation%20Report%2011192018.pdf. ↩︎
72. Behavioral Health Concepts, Drug Medi-Cal Organized Delivery System External Quality Review Report FY 2017-2018 at xii (Nov. 19, 2018), https://www.caleqro.com/data/DMC/County%20&%20Annual%20DMC%20Reports/FY%202017-2018%20Reports/Annual%20Report/CalEQRO%20DMC-ODS%20Statewide%20Annual%20Report%20FY17-18%20.pdf. ↩︎
73. See also California Health Care Foundation, How Medi-Cal is Improving Treatment for Substance Use Disorder in California at 2 Dec. 2018), https://www.chcf.org/wp-content/uploads/2018/11/HowMediCalImprovingTreatmentSUD.pdf; California Health Care Foundation, Medi-Cal Moves Addiction Treatment into the Mainstream:  Early Lessons from the Drug Medi-Cal Organized Delivery System Pilots at 8-9 (Aug. 2018), https://www.chcf.org/wp-content/uploads/2018/08/MediCalMovesAddictionTreatmentToMainstream.pdf; UCLA Integrated Substance Abuse Programs, California’s Drug Medi-Cal Organized Delivery System 2018 Evaluation Report at 4 (revised Oct. 19, 2018), http://www.uclaisap.org/dmc-ods-eval/assets/documents/2017-2018%20UCLA%20DMC-ODS%20Evaluation%20Report%2011192018.pdf. ↩︎
74. California Health Care Foundation, Medi-Cal Moves Addiction Treatment into the Mainstream:  Early Lessons from the Drug Medi-Cal Organized Delivery System Pilots at 4, 5, 6 (Aug. 2018), https://www.chcf.org/wp-content/uploads/2018/08/MediCalMovesAddictionTreatmentToMainstream.pdf. ↩︎
75. VCU Health Behavior and Pol’y School of Medicine, An Evaluation Report Prepared for the Va. Dep’t of Med’l Assist. Servs., Addiction and Recovery Treatment Servs. Access and Utilization during the First Year (April 2017-March 2018) at 7 (Aug. 2018), https://hbp.vcu.edu/media/hbp/policybriefs/pdfs/ARTSone-yearreport_8.9.18_Final.pdf. ↩︎
76. Id. at 10. ↩︎
77. Id. at 11. ↩︎
78. UCLA Integrated Substance Abuse Programs, California’s Drug Medi-Cal Organized Delivery System 2018 Evaluation Report at 2 (revised Oct. 19, 2018), http://www.uclaisap.org/dmc-ods-eval/assets/documents/2017-2018%20UCLA%20DMC-ODS%20Evaluation%20Report%2011192018.pdf. ↩︎
79. Behavioral Health Concepts, Drug Medi-Cal Organized Delivery System External Quality Review Report FY 2017-2018 at 48 (Nov. 19, 2018), https://www.caleqro.com/data/DMC/County%20&%20Annual%20DMC%20Reports/FY%202017-2018%20Reports/Annual%20Report/CalEQRO%20DMC-ODS%20Statewide%20Annual%20Report%20FY17-18%20.pdf. ↩︎
80. Vermont uses HEDIS measures. The Pacific Health Policy Group, Vermont Global Commitment to Health Section 1115 (a) Medicaid Demonstration 11-W-00194/1, Interim Evaluation Report #1, including Evaluation of IMD Expenditures at 82-83 (March 30, 2018), https://dvha.vermont.gov/administration/vt-gc-1115-demo-interim-eval-report-final-apr2-18.pdf. ↩︎
81. UCLA Integrated Substance Abuse Programs, California’s Drug Medi-Cal Organized Delivery System 2018 Evaluation Report at 2 (revised Oct. 19, 2018), http://www.uclaisap.org/dmc-ods-eval/assets/documents/2017-2018%20UCLA%20DMC-ODS%20Evaluation%20Report%2011192018.pdf. ↩︎
82. Behavioral Health Concepts, Drug Medi-Cal Organized Delivery System External Quality Review Report FY 2017-2018 at v (Nov. 19, 2018), LINK. ↩︎
83. Dr. Luke Bergmann, Director Behavioral Health Services and Christian Jones, Public Consulting Group, Update on Advancing the Behavioral Health Continuum of Care Through Regional Collaboration and Innovation, Board Conference First Quarterly Update at 9 (March 26, 2019), on file with authors. ↩︎
84. The Pacific Health Policy Group, Vermont Global Commitment to Health Section 1115 (a) Medicaid Demonstration 11-W-00194/1, Interim Evaluation Report #1, including Evaluation of IMD Expenditures at 50, 81 (March 30, 2018), https://dvha.vermont.gov/administration/vt-gc-1115-demo-interim-eval-report-final-apr2-18.pdf ↩︎
85. Id. at 67, 81. ↩︎
86. Id. at 83. ↩︎
87. VCU Health Behavior and Pol’y School of Medicine, An Evaluation Report Prepared for the Va. Dep’t of Med’l Assist. Servs., Addiction and Recovery Treatment Servs. Access and Utilization during the First Year (April 2017-March 2018) at 19-21 (Aug. 2018), https://hbp.vcu.edu/media/hbp/policybriefs/pdfs/ARTSone-yearreport_8.9.18_Final.pdf. The evaluation notes “[a]lthough the report did not specifically identify ARTS as the casual mechanism for the decrease in emergency department visits and inpatient admissions, it is consistent with the expectation that increased access to treatment should result in fewer overdoses and other addiction-related health emergencies and hospitalization.” Id. at 24. ↩︎
88. The Pacific Health Policy Group, Vermont Global Commitment to Health Section 1115 (a) Medicaid Demonstration 11-W-00194/1, Interim Evaluation Report #1, including Evaluation of IMD Expenditures at 71 (March 30, 2018), https://dvha.vermont.gov/administration/vt-gc-1115-demo-interim-eval-report-final-apr2-18.pdf. Vermont may be able to achieve an average statewide 30-day length of state looking across all IMD SUD and mental health facilities, but CMS policy requires that length of stay be determined separately for SUD vs. mental health services. ↩︎
89. See also California Health Care Foundation, How Medi-Cal is Improving Treatment for Substance Use Disorder in California at 2 Dec. 2018), https://www.chcf.org/wp-content/uploads/2018/11/HowMediCalImprovingTreatmentSUD.pdf; California Health Care Foundation, Medi-Cal Moves Addiction Treatment into the Mainstream:  Early Lessons from the Drug Medi-Cal Organized Delivery System Pilots at 8 (Aug. 2018), https://www.chcf.org/wp-content/uploads/2018/08/MediCalMovesAddictionTreatmentToMainstream.pdf; Behavioral Health Concepts, Drug Medi-Cal Organized Delivery System External Quality Review Report FY 2017-2018 at x (Nov. 19, 2018), https://www.caleqro.com/data/DMC/County%20&%20Annual%20DMC%20Reports/FY%202017-2018%20Reports/Annual%20Report/CalEQRO%20DMC-ODS%20Statewide%20Annual%20Report%20FY17-18%20.pdf. ↩︎
90. Behavioral Health Concepts, Drug Medi-Cal Organized Delivery System External Quality Review Report FY 2017-2018 at xiii (Nov. 19, 2018), https://www.caleqro.com/data/DMC/County%20&%20Annual%20DMC%20Reports/FY%202017-2018%20Reports/Annual%20Report/CalEQRO%20DMC-ODS%20Statewide%20Annual%20Report%20FY17-18%20.pdf. ↩︎
91. The Pacific Health Policy Group, Vermont Global Commitment to Health Section 1115 (a) Medicaid Demonstration 11-W-00194/1, Interim Evaluation Report #1, including Evaluation of IMD Expenditures at 40 (March 30, 2018), https://dvha.vermont.gov/administration/vt-gc-1115-demo-interim-eval-report-final-apr2-18.pdf. ↩︎
92. Vermont’s existing inpatient mental health capacity may be inadequate to meet patient needs, given reports of psychiatric boarding in emergency rooms due to high occupancy rates and based on nationally recognized level of care placement criteria. Id. at 84. ↩︎
93. Connie J. Evashwick, “Creating the continuum of care.” Health matrix (1989), https://www.ncbi.nlm.nih.gov/pubmed/10293297. ↩︎
94. Kaiser Family Foundation, Key State Policy Choices About Medicaid Home and Community-Based Services (April 2019), https://modern.kff.org/medicaid/issue-brief/key-state-policy-choices-about-medicaid-home-and-community-based-services/. ↩︎
95. CMS, Medicaid Disproportionate Share Hospital (DSH) Payments, https://www.medicaid.gov/medicaid/finance/dsh/index.html. ↩︎
96. 42 U.S.C. § 1396d (a)(29)(B). ↩︎
97. CMS, Managed Care, https://www.medicaid.gov/medicaid/managed-care/index.html. ↩︎
98. Kaiser Family Foundation, Olmstead’s Role in Community Integration for People with Disabilities Under Medicaid:  15 Years After the Supreme Court’s Olmstead Decision (June, 2014), https://modern.kff.org/medicaid/issue-brief/olmsteads-role-in-community-integration-for-people-with-disabilities-under-medicaid-15-years-after-the-supreme-courts-olmstead-decision/. ↩︎
99. Kaiser Family Foundation, Section 1115 Medicaid Demonstration Waivers: The Current Landscape of Approved and Pending Waivers (February 2019), https://modern.kff.org/medicaid/issue-brief/section-1115-medicaid-demonstration-waivers-the-current-landscape-of-approved-and-pending-waivers/. ↩︎
100. SAMHSA, Mental Health and Substance Use Disorders (April 13, 2019) https://www.samhsa.gov/find-help/disorders. ↩︎
101. Id. ↩︎
102. Id. ↩︎
103. H.R. 6, § 5052 (a)(2) (creating new Social Security Act § 1915 (l)(6)). ↩︎