The enactment of this year’s budget reconciliation law, the so-called “One Big Beautiful Act” (OBBBA), is already destabilizing the health care ecosystem with its drastic and confusing changes. Almost a trillion dollars will be slashed from Medicaid over the next few years, creating the largest cut in the 60 years of the program’s history. When it comes to sexual and reproductive health care, the blow feels deeper since it is accompanied by the exclusion of an important number of abortion providers from Medicaid along with the Supreme Court decisions in Dobbs and Medina, the Title X funding freeze, and multiple attacks at the state level.
Medicaid is the largest source of federal funding in states’ budgets, financing about one fifth of their total spending. With OBBBA cuts, states will have to be very savvy about how they will make up the difference of the losses at the federal level in order to maintain some level of care for their residents. We will not sugarcoat it; states will have to make some hard decisions from the loss of funding and the uncertainty created by these unprecedented changes. Thankfully, states can tap into prior or existing mechanisms to mitigate the damage. Below we offer examples of the decades-old efforts NHeLP has done in partnership with sexual and reproductive health, rights, and justice advocates to protect and expand this essential care.
Involvement in the Medicaid Advisory Committees (MAC) and Beneficiary Advisory Councils (BAC)
The MACs and BACS are advisory groups that aim to improve Medicaid through beneficiary engagement and other stakeholder feedback. The MACs must include consumer advocacy groups, health care providers, managed care plans, and other state agencies that serve Medicaid beneficiaries. Meanwhile, the BACs can only be composed of past or current Medicaid beneficiaries, family members, and paid or unpaid caregivers of beneficiaries. These committees present an important opportunity to enhance state Medicaid policy development and oversight. Among other things, they advise on issues that impact the provision of services and health outcomes. NHeLP staff have joined these councils and invite other reproductive health advocates and providers to also become involved as well as attend public meetings in order to protect access to this type of care.
Utilizing Abortion Premium Funds
Under Section 1303 of the Affordable Care Act (ACA), insurers offering abortion coverage through the health insurance marketplace must collect and separately account for at least $1 per enrollee per month to cover abortion services that are not eligible for federal funding. The $1 per enrollee per month premium far exceeds the actual cost of providing this coverage to enrollees, meaning that each year insurers have been collecting significant sums of excess premiums. Some states are using these funds to finance the abortion services of individuals. NHeLP spearheaded the legal research and strategy that laid the groundwork for this policy.
Maximizing Use of Telehealth
During the COVID-19 public health emergency, many states moved to ease telehealth requirements like allowing audio-only services to be covered via Medicaid, expanding the types of services and providers that could be reimbursed, and permitting oral consent for purposes of reimbursement. States should maximize these flexibilities to facilitate access to sexual and reproductive health services. The 19 states that currently reimburse for abortions received by Medicaid beneficiaries should extend or implement flexibilities around telehealth – like allowing parity of coverage between telehealth and in-person care, treat synchronous and asynchronous care alike, and permit virtual providers to enroll in Medicaid so that they can serve low-income populations.
Implementing Presumptive Eligibility for Pregnant People
Presumptive Eligibility allows Medicaid-eligible patients to receive services the same day they start the process of enrolling in Medicaid. The ACA required every state to adopt hospital presumptive eligibility and confirmed that states can run their own presumptive eligibility programs like family-planning and pregnancy. In the states that cover abortions for Medicaid beneficiaries and have presumptive eligibility for pregnant people, this path can be used to cover abortions for low-income people.
Allowing Reimbursement of Contraceptives Over-the-Counter and as Prescribed by Pharmacists
The ACA’s contraceptive coverage mandate achieved a massive and historic expansion of contraceptive coverage; however, states moved to further coverage of contraception by enacting Contraceptive Equity Laws. Among other protections, these laws require coverage of all FDA-approved contraceptive drugs, devices, and products without cost-sharing (going beyond the federal mandate), allow pharmacists to prescribe, dispense, or furnish contraceptives, and require coverage of over-the-counter contraceptives at point-of-sale without a prescription and without cost-sharing (including for Medicaid beneficiaries). States that have not enacted these laws should consider doing so and those that have must make sure they are fully implemented by mandating education and enforcement. Enforcement may also involve working to impose Medicaid managed care sanctions when health plans fail to comply with state and federal laws.
Mitigating the Harm of Work Requirements for SRH Patients
By mandating nationwide work requirements for Medicaid expansion beneficiaries ages 19–64, OBBBA puts at risk the coverage of individuals of reproductive age with SRH needs. Advocates must intervene early, beginning now, to successfully mitigate the damage to come. Opportunities include optimizing redetermination and verification policies and procedures (including allowing self-determination), developing systems for monitoring and evaluating work requirement outcomes and related inequities, notice advocacy, and community outreach. More suggestions on how to prepare for Medicaid work requirements can be found on this webinar.
Expanding Medicaid Coverage of Pregnancy Care, Including Doula Services
People with low incomes in the United States are at a higher risk of poor birth outcomes, and pregnant and birthing people of color, especially Black and Indigenous/Native American pregnant and birthing people, are especially vulnerable. Medicaid coverage of doula services as well as the expansion of Medicaid postpregnancy coverage to one year have been effective tools to counter maternal mortality and morbidity; and both policies have gained support of policymakers across the aisle. If states have already enacted Medicaid coverage of doula services and one-year postpregnancy coverage, they should make sure these are being fully implemented.
Adopting Medicaid State Plan Amendments for Family Planning
States still have the opportunity to offer limited-scope family planning coverage to individuals whose income is too high for full scope Medicaid. These services, irrespective of gender, are still reimbursable at a 90% federal match and must include family planning services and supplies, screening and treatment for STIs, contraceptive counseling, lab tests, and other services that take place during a family planning visit. Our recommendation is to prioritize the use of State Plan Amendments rather than section 1115 waivers because the latter are time-limited and family planning coverage has been shown to already improve the wellbeing of Medicaid beneficiaries.
Making it as easy as possible for people to access sexual and reproductive health
In addition to abortion coverage mandates, states can prohibit cost-sharing (e.g. deductibles, copayments, coinsurance) for abortion services. Even when abortions may be covered by health plans, many patients must still meet high deductibles which essentially means they have to pay for the abortions. These laws make abortion truly accessible by removing economic burdens. Furthermore, studies demonstrate that abortion coverage mandates have no impact on insurance premiums. In addition, states can prohibit health plans from imposing prior authorization and other limitations that delay care, which is crucial for the time-sensitive nature of abortion care.
Utilizing Special Funding Mechanisms
States will have to look into innovative financing mechanisms to make up for OBBBA’s requirement to reduce provider taxes and state directed payments. While these have been critical in increasing Medicaid reimbursement rates, including for reproductive health providers, nothing prevents a state from passing through state funds to providers that serve low-income populations. Money can come from tobacco taxes or substance use settlements. As we enter an unprecedented era of Medicaid and budget shortfalls, this is also the time that states may have to consider emergency reserves.
Although not an adequate way to solve the gap that OBBBA has left in Medicaid, the Rural Health Program will provide $50 billion in funding over a five-year period to improve access to health for rural communities. This might be an interesting mechanism that could help increase access to providers of reproductive health care like maternity wards, doulas, and pharmacists that serve rural areas.
One Last Thought
In order to fully resist all the harms and attacks that the movement is experiencing, advocates must leverage the power of coalitions to collectively strategize and mobilize. Diverse coalitions are needed to advocate before Medicaid agencies, managed care plans, insurance commissioners, as well as the state legislative and executive branches. As an example, state advocates may consider forming abortion-focused councils to maximize impact and strengthen relationships with various stakeholders. Researchers, advocates, beneficiaries, and providers should also document the harms that OBBBA will make over the next several years like publishing op-eds, collecting stories, tracking coverage losses and provider closures, as well as submitting comments to build an administrative report. And while it will not fully solve this public health crisis, litigation strategies will be crucial to slowing or halting the damage and ensuring that due process rights are protected.
If you have any questions about these policy ideas, please contact [email protected]
