Women's Health Waiver Program: A Case Study of Arkansas' Medicaid Family Planning Expansion

Nationally, 27 states have received federal approval to implement Medicaid Section 1115 waiver programs to expand family planning services to low-income, uninsured women and in some states, men. Arkansas was one of the first to implement a Medicaid family planning waiver program, known as the Women's Health Waiver (WHW), in 1997. WHW now serves over 60,000 women ages 14 to 44 who have incomes at or below 200% of the federal poverty line. We conducted a mixed-methods study to test the effects of WHW on women's access, service usage, and intended pregnancy. Qualitative methods included informant interviews with Medicaid and Title X officials as well as family planning providers. Focus groups were conducted in June 2009 with WHW clients in two county clinics. Findings from the qualitative study indicate that WHW clients are satisfied with the program and encounter few barriers to enrollment and access to family planning and other primary care services, most of which is provided through public health departments. More recently, barriers to participation include the annual redetermination and citizenship verification. Providers reported mixed experiences, with some describing it as an important source of reimbursement while others felt it has had little financial impact. State officials hope to enroll more private providers in WHW, as participation to date has been low. With the introduction of the waiver, Arkansas's Medicaid and Title X family planning spending per poor woman increased from $8 to almost $41. To examine the effects of this expansion we used treatment and control groups pre and post the waiver and difference-in-differences analysis. The main treatment groups were women under 133% of the Federal Poverty Level (FPL), especially nulliparous women, and teens. We found that the Arkansas Medicaid family planning waiver decreased the percentage of births that were unwanted among the nulliparous and teen treatment groups in the range of 4 to 6%. There was also a positive effect on teens' use of birth control post partum which may indicate reductions in repeat teen pregnancies or increases in inter-partum birth intervals related to the waiver that we are unable to observe. While these findings suggest positive effects, we found unexpected increases in reports of mistimed teen pregnancies associated with the waiver. Also, research suggests that family planning service use is low among waiver participants in Arkansas, and our data indicate that rates of unintended pregnancy among Medicaid insured remain high.