Impact of Publicly Funded Contraceptive Services On Unintended Pregnancies and Implications For Medicaid Expenditures. (ARTICLES).

Of U.S. women who use a reversible method of contraception, 24% each year obtain family planning services from a publicly funded clinic or a private doctor reimbursed by Medicaid. If these subsidized contraceptive services were not available, women who currently use them would have an estimated 1.3 million additional unplanned pregnancies annually, of which 29% would involve women aged 15-19, 67% would involve never-married women and 61% would involve women with a household income below 200% of the federal poverty level. An estimated 632,300 of these pregnancies would end in induced abortion, an increase of 40% over the current national level. Another 533,800 pregnancies would result in unintended births. Some 76,400 of these would be births to families already receiving public assistance, and 64,100 would be to families that would become eligible for public assistance because of the birth; another 197,000 would be to women whose families would not receive public assistance, but would be eligible for Medicaid coverage of pregnancy, delivery and newborn care. In FY 1987, public-sector expenditures for contraceptive services totaled an estimated $412 million. If subsidized services had not been available, the federal and state governments would have spent an additional $1.2 billion through their Medicaid programs for expenses associated with unplanned births and abortions. Thus, for every dollar spent to provide publicly funded contraceptive services, an average of $3.00 was saved in Medicaid costs for pregnancy-related health care and medical care for newborns.

(Family Planning Perspectives, 28:188-195, 1996)

Subsidized contraceptive services are available to U.S. women through family planning clinics funded with federal, state and local monies and through physicians reimbursed by Medicaid. Many of the women who utilize these services would otherwise encounter difficulty obtaining family planning care because of their low income or other circumstances, such as a need for confidentiality. For example, while family practitioners and obstetrician-gynecologists provide 90% of office-based contraceptive services for women in private settings, (1) 35% of them do not provide contraceptives to minors without parental consent, 50% will not accept Medicaid reimbursements for contraceptive visits (2) and 64% do not reduce their fees for women who cannot afford the cost of family planning services. (3) Consequently, women relying on publicly funded contraceptive services are precisely those whose youth or precarious economic circumstances place them at considerable risk both of unintentionally becoming pregnant and of experie ncing health complications and socioeconomic hardships as a result.

For three decades, federal and state programs have sought to redress such inequalities in access to family planning services. In FY 1994, federal and state funding for contraceptive services reached $715 million. (4) Federally funded programs (Title X of the Public Health Service Act and the maternal and child health and social services block grants) contributed 31% of the total; Medicaid (which is jointly funded by the federal and state governments) accounted for 46%; and states directly provided the remaining 23%.

Both Title X and Medicaid (*) contain provisions to reduce socioeconomic obstacles to contraceptive use. For example, Title X guidelines state that clinics must offer their services free to clients with incomes below the federal poverty level and on a sliding fee scale to those with incomes falling between 100% and 250% of the poverty level. Title X legislation also makes family planning services accessible to all women regardless of their marital status or their age. (5) The Medicaid program requires that states pay for family planning services and supplies provided to recipients, and the program reimburses states at a preferential rate, covering 90% of their family planning costs. (6)

During the early 1980s, public-sector support for family planning services in the United States averted about 1.2 million un-planned pregnancies annually, of which an estimated 516,000 each year would have ended in abortion. (7) Moreover, for every dollar the public spent to provide contraceptive services, an average of $4.40 was saved in public costs for medical care, welfare and supplementary nutritional programs during the first two years after a birth and for publicly funded abortions. State-level evaluations have confirmed the significant role played by publicly funded family planning services in reducing the number of unplanned pregnancies and their associated costs. (8) And an analysis of private- and public-sector costs and economic savings associated with contraceptive use shows that regardless of the payment mechanisms or contraceptive method, contraception is highly cost-effective. (9)

In this article, we use updated national-level data to estimate the annual numbers of unplanned pregnancies, births and abortions averted by use of publicly funded family planning services in the United States. Since states fund a considerable portion of family planning services and assume much of the responsibility for clinic administration, we also estimate the number of unplanned pregnancies averted in each state. Additionally, we assess the public-sector benefits of averting unplanned pregnancies in terms of two measures: the number of women who would become eligible for Aid to Families with Dependent Children (AFDC) or Medicaid if they experienced an unplanned pregnancy; and a cost-benefit ratio capturing savings to Medicaid, the program that absorbs the largest share of short-term public costs for unplanned pregnancies. (10)