By Jennifer Salcedo, MD, MPH and Andrea Sorensen, BA

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Approximately half of all pregnancies in the United States are unintended, and over forty percent of these pregnancies end in abortion. Low-income women have higher rates of unintended pregnancy and are consequently disproportionately represented among women seeking abortion. The provision of contraception at the time of abortion is within the medical standard of care and is desired by a high percentage of women. Additionally, provision of contraception at the time of abortion has been demonstrated to decrease rates of subsequent abortions compared to the planned provision of contraception at abortion follow-up. Despite these facts, as a result of the fragmentation of abortion and contraception services and policies that restrict federal funds from being used for abortions, less than one-third of high-volume abortion providers in the U.S. are able to offer placement of intrauterine devices (IUDs), a form of long-acting reversible contraception, at the time of abortion.

In California, one of a minority of states to fund both abortion and contraception for low-income women, confusion over how healthcare providers may seek reimbursement for concurrently provided abortion and contraception services serves as a major barrier to women’s access to immediate postabortal contraception. This is particularly true for women with incomes between 100% and 200% of the Federal Poverty Line (FPL) who receive abortion coverage under Presumptive Eligibility or Limited-Scope Medi-Cal, and contraception care under the separate Family PACT program. In 2007 this population of women represented 30,500 of the 80,069 publiclyfunded abortions performed in the state.

In this report, we analyze current barriers to the provision of immediate postabortal contraception for low-income women in California. Additionally, we create a decision analytic model to evaluate the potential cost-savings to public programs if immediate postabortal contraception was made available to low-income women undergoing abortion, compared to planned provision of contraception at abortion followup. Through these evaluations, we aim to provide recommendations to the UCSF Bixby Center for Global Reproductive Health (Bixby Center) regarding how California can best provide postabortal contraception to its low-income women in a way that: (1) is consistent with the medical standard of care, (2) reduces the number of unintended pregnancies and abortions, and (3) minimizes public program costs. The Bixby Center’s mission is to advance women’s health worldwide through research, training, policy analysis and services. Consistent with these goals, the Bixby Center provides ongoing evaluation of California’s Family PACT program to ensure its continued positive impact on health outcomes and cost-savings.

FINDINGS

•  In California, barriers to the provision of immediate postabortal contraception forlow-income women persist despite lack of specific legal prohibitions that disallowconcurrent billing for contraception funded by Family PACT and abortionservices funded by Medi-Cal.

• When considering only the future costs of contraception and pregnancy-relatedcare for each woman undergoing a Medi-Cal funded abortion and desiring an IUD, California’s public programs would save $111 over one year if the IUD was provided at the time of the abortion, compared to planned placement at abortionfollow-up. After five years, California’s public programs would be expected tosave $4296 per woman, when considering direct medical costs of contraceptionand pregnancy, and additional public health insurance and social program costs ofthe woman and her children. This would result in a public program cost savingsof $98 million, when accounting only for women with incomes 100 and 200% ofthe FPL.

• Provision of immediate postabortal IUDs, compared to planned placement atabortion follow-up, is anticipated to result in at least 2,294 fewer abortions annually for women with incomes 100 and 200% of the FPL in California.

RECOMMENDATIONS

• To decrease confusion among clinicians, office managers, and billing staff aboutthe ability to obtain reimbursement from Family PACT for contraception servicesprovided at the time of a Presumptive Eligibility or Limited-Scope Medi-Calfundedabortion procedure, we recommend that Family PACT amend its Policy &Procedures Manual to clarify the specific process by which to securereimbursement for these services. We additionally advise that the Family PACT program expand its current legislatively-mandated training sessions to educate all Family PACT-participating clinicians and office managers about the current medical standard of care for the provision of immediate postabortal contraception and the appropriate mechanisms for seeking reimbursement for these concurrently provided services.

• As a temporary mechanism, we recommend that the Family PACT program educate family planning clinic personnel about its new retroactive reimbursement provisions for contraceptive services provided to eligible women for the three months prior to their Family PACT enrollment. Additionally, we recommend that the Family PACT program establish a mechanism through which providers can seek retroactive reimbursement for eligible services billed to, but not yet paid for, by these women.

•  As a longer-term goal, we recommend expanding Medi-Cal programs and formularies such that all versions of Medi-Cal provide coverage for the full range of FDA-approved methods of contraception so as to eliminate the fragmentation that surrounds family planning services in California. This change will require action from and support on the part of the California State Legislature.