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States increasingly trying to facilitate LARC access

November 1, 2016 — State Medicaid programs increasingly are implementing a policy that allows women to receive long-acting reversible contraception (LARC) immediately after giving birth, the New York Times reports.

Background

According to the Times, nearly 50 percent of births in the United States are unintended, and the rate of unintended pregnancy is higher among low-income women (Tavernise, New York Times, 10/28). LARC, including intrauterine devices (IUD) and hormonal implants, are seen as ways to reduce the country's rate of unintended pregnancies and associated costs. LARC devices are more effective than other forms of contraception and can last between three and 10 years after insertion.

State Medicaid programs are required to cover family planning services at no out-of-pocket cost. In the past, most state Medicaid programs did not include the option for IUDs in the payment set for labor and delivery (Women's Health Policy Report, 10/19). As a result, women frequently had to wait until a post-birth checkup, typically around six weeks after delivery, to discuss contraceptive options with their provider. However, the majority of women covered through Medicaid do not return for a follow up visit after birth (New York Times, 10/28).

The Centers for Disease Control and Prevention has identified the provision of LARC immediately post-partum as key to reducing unintended pregnancy, and the Centers for Medicare and Medicaid Services this spring urged states to cover the procedure. The American College of Obstetricians and Gynecologists and the Association for State and Territorial Health Officers have also supported the practice (Women's Health Policy Report, 10/19).

States increasingly ease LARC access via Medicaid programs

About 19 state Medicaid programs have implemented the policy, including Georgia, Iowa, Maryland, Massachusetts, South Carolina and Texas, the Times reports.

According to the Times, the policy shift enables providers to offer women LARC at a time when they are likely to be interacting with the health care system and likely to be insured, as uninsured, low-income women who are pregnant can obtain temporary Medicaid coverage. Judith Burgis, the chair of the department of obstetrics and gynecology at Palmetto Health University of South Carolina Medical Group, praised the efficacy of the policy shift. "[Offering LARC is] easier to do right then and there, before [the woman] gets home and has a newborn to take care of," Burgis said.

States that have implemented the policy have seen success: South Carolina, for instance, reported a 6 percent decline in the unintended pregnancy rate since implementing the policy in 2012, while the state's Medicaid program has reported $1.7 million in savings. Spurred by those results, Blue Cross Blue Shield -- South Carolina's largest private insurer -- has implemented the same policy. Meanwhile, the state's Medicaid program also has eased access for women who are not pregnant by enabling them to get LARC "almost immediately after asking for one" from a provider, rather than waiting several weeks, the Times reports.

In addition, several states -- including California, Illinois, Maryland and Vermont -- have enacted policies mandating that insurers include LARC in their contraceptive coverage. Meanwhile, advocates are helping train providers on how to administer and bill for LARC methods.

Greta Klingler, a public health official in Colorado, said, "Things have shifted so dramatically ... Every single state is really making efforts to increase access. I'm hopeful we've hit the tipping point."

Advocates respond

According to the Times, many women's health advocates have praised easing access to LARC as a means of empowering women by enabling them to choose when and with whom to get pregnant. In addition, Isabel Sawhill, a senior fellow at the Brookings Institution, said LARC access can help women avoid single parenthood, if they do not want to be single parents, which in turn can enable them to avoid poverty.

Separately, two advocacy groups -- SisterSong and the National Women's Health Network -- advised providers to be cautious when offering LARC to women. "Many of the same communities now aggressively targeted by public health officials for LARC also have been subjected to a long history of sterilization abuse," the organizations said.

According to the Times, public health officials are working to address such concerns. In South Carolina, for instance, officials say that providers aim to discuss contraception with women during prenatal visits and leave the decision regarding which, if any, contraceptive method up to the woman.

Lisa Waddell -- chief program officer of community health and prevention at the Association of State and Territorial Health Officials, an organization that discusses LARC policy with states -- said, "The words voluntary and reversible are very important." She continued, "It's important that women don't feel coerced into something" (New York Times, 10/28).