News and Stories: Indianapolis Star: Did Indiana miss a $7M opportunity?

This article appeared in the Indianapolis Star on November 6, 2011.

Six years ago, Indiana passed a law to provide free birth control to low-income mothers who had recently given birth. The idea had much going for it. Health-care professionals said it would lead to healthier babies. Legislative analysts said it would save the state and taxpayers close to $7 million over five years. It undoubtedly would have led to fewer unwanted pregnancies, fewer children born into families not financially able to take care of them and fewer abortions. And if all that weren't enough, the plan had already been tried -- successfully -- in about 20 other states. The legislature in 2005 voted nearly unanimously to approve the law, which was expected to serve more than 27,000 women per month by the fifth year. But six years later, not a single person has benefited. And none of those millions of dollars has been saved.

WHY? The short answer is that the state's Family and Social Services Administration never completed the process to apply for the federal Medicaid expansion program that would have provided the free birth control.

"When you pass a law, you assume people are going to comply with the law," said Sen. Vi Simpson, D-Ellettsville. "If it had been implemented expediently, we would have saved who knows how many million dollars, who knows how many abortions, who knows how many children who were born with low birth weights and other problems because of too-frequent pregnancies."

Sen. Luke Kenley, R-Noblesville, who co-sponsored the bill with Simpson, said "it seemed like a sensible idea to me."

He was unaware that the law was never implemented until contacted by The Indianapolis Star last month to comment on the issue.

"After it passed," he said, "frankly, I just trusted the administration to follow through on the thing."

The legislation required Gov. Mitch Daniels' Office of Medicaid Policy and Planning -- an office within FSSA -- to apply to federal officials for the Medicaid expansion before Jan. 1, 2006.

It didn't.

The Medicaid office sent its application in a year late, and then -- over the ensuing five years -- withdrew it, resubmitted it, and then withdrew it again.

It's not entirely clear why.

When contacted by The Star, a spokeswoman for Daniels -- who signed the bill -- said the governor declined to comment.

FSSA officials have offered various explanations for the six-year delay at various times.

Most recently, FSSA spokesman Neal Moore told The Star that the application was withdrawn for "clarifications and adjustments."

At an August legislative committee meeting, state Medicaid Director Pat Casanova blamed the delays on federal officials, telling legislators that "there were some people at (Centers for Medicare & Medicaid Services) that didn't like the idea of those (Medicaid expansions) for some reason we could never really identify."

When contacted by The Star, federal officials disagreed with that characterization. According to the federal government, Indiana officials cited budget constraints when they withdrew the application a second time.

That was then-FSSA Secretary Anne Murphy's assertion, as well, in May 2010.

After being questioned by Simpson and a few other lawmakers, she wrote them a letter explaining that "FSSA no longer has the resources to fund the implementation."

The state, in other words, could not pay the start-up costs -- originally estimated at $1.36 million -- for a program the state's own analysts had predicted would yield $8.1 million in savings within five years.

It was a pretty solid prediction. South Carolina adopted Medicaid-covered birth control for women who had recently given birth in 1993. In the ensuing years, the program -- the same one Indiana's legislators intended -- saved South Carolina an estimated $1.86 million annually, according to a study by the Center for Health Economic and Policy Studies at the Medical University of South Carolina.

"All of the best evidence on this topic suggests that spending on family planning should reduce Medicaid costs for hospital births and coverage for kids after they're born," said Martha Bailey, an assistant professor of economics at the University of Michigan who has studied the issue. "I think there's no debate on that."

It's not just that contraception prevents or delays births. The type of births the plan would prevent are disproportionately more risky and carry added health-care costs.

Births that occur within two years of a previous delivery carry health risks to mother and baby, because the mother's body has little time to recover.

Medical research -- including a local study by the Indiana State Department of Health -- finds that babies conceived within 18 months of their siblings' births are more likely to be born prematurely, to have a lower birth weight and to be small for their gestational age.

States that have expanded Medicaid-covered birth control have seen a drop in those kinds of births. In Texas, for example, 18 percent of women who participated in the program had a repeat birth within 24 months, compared with 29 percent of Medicaid-eligible women who did not, according to the 2008 Texas Health and Human Services Commission report.

According to the Indiana Perinatal Network, about half of the births in Indiana are covered by Medicaid -- and 13 percent of those Medicaid mothers become pregnant again within a single year.

Not all of those pregnancies are planned or wanted. From 2003 to 2005, the Perinatal Network polled about 500 new mothers, predominately Medicaid clients, at Indianapolis-area hospitals. Of those, 73 percent indicated they would have preferred to be pregnant "later or not at all."

The situation is especially acute among the poor.

A 2006 study by the Guttmacher Institute, which tracks federal and state reproductive policy, found that poor women were four times as likely as more affluent women to have an unintended pregnancy and three times as likely to have an abortion.

The plan lawmakers approved in 2005 specifically targeted poor women. Currently, many women poor enough to qualify for Medicaid during pregnancy do not qualify for Medicaid-covered birth control after the baby is born. Today in Indiana, a pregnant single woman who makes up to $29,420 -- 200 percent of poverty -- can receive Medicaid.

But those benefits end abruptly. The state estimated in 2005 that 70 percent of those women lose their Medicaid coverage shortly after they give birth. The reason is that to continue qualifying for Medicaid beyond two months after birth, the new mother must earn less than $3,383 a year -- 23 percent of poverty level.

The 2005 law would have allowed mothers to remain eligible for Medicaid -- but just for free birth control -- until two years after their baby's birth.

Maiesha Guyton, 19, said she would gladly take advantage of such a benefit. Her son Mack was born in December, and the pregnancy was covered by Medicaid.

But after Mack's birth, Guyton, a restaurant cashier who earns $7.50 an hour, was no longer eligible for coverage or for the prescription birth control Medicaid had provided. She tried to use protection, she said, but in August she showed up at a Wishard Health Services clinic, terrified that she was pregnant. It was a false alarm.

"I don't have the finances right now to take care of two kids," said Guyton, who plans to start nursing school at Ivy Tech in January. "I'm trying to get my college together."

Linda Spaulding, who heads the Learning Center, an Indianapolis Public Schools alternative high school program for teen girls who are pregnant or parenting, said it's a common problem.

"There are very high statistics for repeating of having a child within two years," said Spaulding, who has worked with pregnant teens and young mothers for 30 years. Students learn that abstinence is an option, she said, but once they are already sexually active, it's a hard sell.

"If we want to prevent another pregnancy," she said, "we need to offer birth control to those that wish to obtain it."

The government generally agrees. State-subsidized birth control goes back to the 1960s, when family planning grants were created by Presidents Lyndon B. Johnson and Richard M. Nixon, who declared that "no American woman should be denied access to family planning assistance because of her economic condition."

Today, many states have gone further than the plan Indiana made -- but never followed through on -- in 2005. Of the 28 states with Medicaid expansion programs, 22 extend Medicaid-covered birth control not just to new mothers but to all poor women -- usually up to 200 percent of poverty level -- according to the Guttmacher Institute. Eleven even extend the benefit to men, who can receive Medicaid-covered vasectomies.

Indiana still could reap some of the savings and health benefits of providing poor mothers with birth control.

But not through the legislation Hoosier lawmakers passed in 2005. That law expired in January.

In 2014 (unless it is overturned) President Barack Obama's health-care overhaul will require that every state provide everyone up to 133 percent of poverty level access to free birth control.

That will cover fewer new mothers than the 200-percent-of-poverty-level threshold in Indiana's 2005 bill, but it will provide coverage to qualified men for vasectomies and to women who have never been pregnant.

This spring, lawmakers approved a measure allowing Indiana to implement the Obama plan early.

But there are reasons to suspect the early implementation could run into some roadblocks.

First, the new family planning expansion -- while again estimated to save the state millions -- also carries start-up costs, which are estimated at more than $1 million. And start-up expenses were one of the reasons the Daniels administration has cited for shelving the original program.

Second, the law approved this spring requires the Indiana Medicaid office to submit its application to federal officials by the end of the year. It has not yet done so.

It does not always take so long for Daniels' Medicaid office to apply to amend its Medicaid plan. When a state law cutting off Medicaid funding to Planned Parenthood went into effect May 10, the state submitted its application to the Centers for Medicare & Medicaid Services -- within five days.

The state's Medicaid Office said it will act promptly to expand Medicaid birth control coverage. This time.

Not everyone is entirely convinced.

Sen. Jean Breaux, D-Indianapolis, who has long supported expanding access to birth control, won't go so far as to say she's lost faith in the agency.

"But if you just go by the history of what has occurred up to this point," she said, "you're not optimistic."