Strengthening Women’s Health Access: Medicaid and Family Planning

0:05

Good afternoon. I'm Cait Ellis, Director of Research Programs at the National Institute for Health Care Management Foundation. On behalf of NIHCM, thank you for joining us today for this important discussion on strengthening women's health.

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Numerous research studies have shown that access to high quality contraceptive care is critical to both women's health and their economic outcomes.

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Affordable access to contraception, including long acting reversible contraception, or larke. An oral contraceptive pills is proven to result in fewer unintended pregnancies improved health outcomes, and significant cost savings to the health care system.

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Yet ongoing restrictions on access to reproductive health care may reduce contraceptive use, leading to more unplanned births and exacerbating health disparities.

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Today, we will hear from a prestigious panel of experts to learn more about the benefits of contraceptive access, the importance of ensuring contraceptive autonomy, and best practices for implementing policies to expand access.

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Before we hear from them, I want to thank Nancy Chockley, NIHCM's president and CEO and the NIHCMteam who helped to convene today's event.

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You can find biographical speaker information for our speakers on our website.

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Along with today's agenda and copies of slides, We invite you to join the conversation on Twitter using the hashtag women's health.

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I'm now pleased to introduce our first speaker, doctor Jason Lindow, Professor of Economics at Texas A&M University.

1:31

Doctor Linda's Research has examined the impact of access to contraception, including Larks, on women's economic and health outcomes. Under a Nick and Research Grant.

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A few years ago, he published Research Analyzing Expanded LARC Access through Colorados Family Planning Initiative.

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We're honored to have him with us today to share his expertise and perspective, Doctor Linda?

1:56

Thanks so much. I am excited to share.

2:00

Let's move the slide forward. 1, 1 base, if you don't mind.

2:05

Thanks, So, uh, I'm gonna sort of spend time at the beginning of my 15 minute allotment. I'm giving you all a bit of a crash course on how economists typically approach these sorts of issues.

2:22

And then I'll give you an overview of what we know about the effects of family planning access on, primarily, economic and educational outcomes. So if we can get one in four.

2:39

So in terms of economic approaches, I think we can classify them into two groups.

2:46

First, we have economic theory, and that's what probably most immediately comes to mind when people think about economists.

2:55

And this lens through which we typically view of the world, is one in which we consider how incentives, koss, and constraints affect outcomes.

3:05

And, and this is certainly an approach that economists have used to think about how access to reproductive health care. Unintended pregnancy, the timing of pregnancies, and so on and so forth can affect investments in education and careers. And and so on and so forth.

3:30

That being said, I would say an even larger share of economics research generally, but also in this space, is empirical in nature.

3:42

And economists tend to be obsessed with estimating causal effects of choices that people make, of programs and policies, and so on and so forth.

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So I'm going to focus today on this approach to empirical research and the findings from this empirical research.

4:07

So, just to give you a sense of where the findings come from and what sort of research it comes from, when I go through the findings, I do want to mention to you that the methods that economists are typically using to estimate causal effects are the types of methods that are associated with the 2021 Nobel Prize in economics and refinements to those methods. Or maybe you heard about them in recent years. In any case, what we're typically doing is evaluating natural experiments.

4:44

Are circumstances in which institutions, policy makers, or other forces, have generated an experiment of sorts that we can learn from?

4:54

If we can run an experiment, we like to, but it's often difficult, particularly when it concerns reproductive health care, um, in thinking about the empirics in this way, our methods are focusing on trying to identify a counter-factual. In particular, what would have happened if circumstances had been different? And that is what we have in mind when we're thinking about the causal effect of a choice or of a policy change or something.

5:26

So let me let me give you an example of research along these lines from from my own research. This is based on an analysis of the Colorado Family Planning initiative, which was initially at least started as a result of a $23 million investment aimed at expanding access to larks through Title 10 clinics in Colorado.

5:53

And the funds were used to purchase IUD and implants. So they could be stocked at these clinics training for LARC counseling, insertion and removal, and then also technical assistance. So we wanted to evaluate the effect of this initiative on teen childcare.

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And so in this figure, we see the time trend in teen birth rates.

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Now, very clearly, they were steady for some time in the two thousands, and then they fell.

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The question is how much of the fall, if, if any, at all, was due to the Colorado Family Planning Initiative?

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And that's not actually obvious.

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But that's the question we need to answer if we want to know what is the causal effect of this initiative.

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And so what we did is to estimate the counter-factual, or to estimate how outcomes would have evolved in Colorado. In the absence of this initiative, we looked to other similar areas of the country, which also had Title 10 clinics.

7:04

And that's where the black line here demonstrates the teen birthrate, or, excuse me, the the Dash line demonstrates the changes in across the US.

7:17

And the black line demonstrates what happened in Colorado counties with Title 10 clinics. And so that gap that opens up after 2009 is what represents the causal effect of the program. So we found that it reduced teen birth rates by about 6.4% based on that gap that opened up after 2009.

7:39

Again, based on this thought process in which we're thinking about the counter-factual.

7:44

I also want to highlight it would have been.

7:48

Very much exaggerated, the effect of the program if we were to simply evaluate how much teen birth rates fell from 2008 to 20 13 because part of the reason they fell in Colorado was due to the same reasons that it was falling nationwide. It wasn't just the initiative.

8:11

Here's another example of an analysis along these lines.

8:17

And this is a study looking at what happened to teen birth rates in Texas when it cut family planning funding by about two thirds. And here there were Texas Counties with family planning clinics, and those are the counties that were interested in understanding how are they affected?

8:40

And the researcher and Alisa packham used to estimate the counter-factual, or how would they have changed?

8:50

In the absence of this cut to family planning, she is the rest of the United States. And so what we see is, after 20 11, after family planning funding was cut by two thirds, and in Texas, the Teen birth rate in Texas rose dramatically.

9:07

Compared to the rest of the United States, indicating that this family planning funding cuts substantially increased teen birth rates.

9:18

So other researchers have looked at the same policy, and they found significant effects on births to older women as well, and there's similar evidence from the initial rollout of federally funded family planning programs in the 19 sixties and seventies.

9:35

And so, I'll just say, now that there's a huge body of evidence demonstrating the policies, altering access to family planning, effect, tying the timing of childbearing and completed fertility.

9:46

And move forward now to talk about some other other outcomes, economic and educational outcomes. But before getting into those estimates, I do think it's useful to keep in mind, just how costly pregnancy and childbearing can be.

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People forego food and other basic necessities in order to pay for abortions because they view the pregnancy and potential childbearing as being so costly to them personally.

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Economists also highlight that having a child is costly, because not only does it require substantial monetary expenditures, but also because childcare responsibilities mean less time for school and work.

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And so, they can interrupt school and work in a way that really changes someone's life course in a way that means their economic fortunes are our or reduced.

10:46

So in terms of the pile, this, the analyzes, well, actually, I think I'm, my timing is a little, let's, let's skip a little bit. I'll just tell you what folks have have found. So let's skip one more.

11:03

OK, so in terms of studies evaluating the effects of access to contraception on education, researchers have found that early legal access to contraception is associated with increases in education, especially for women from disadvantaged backgrounds. And additionally, half a year, on average, for women from the bottom third of the socio economic status index. And this is based on research from changes in access from the sixties and seventies.

11:33

But I'll talk about more recent research in just a bit.

11:37

Um, in terms of studies looking at childbearing before age 18 versus childbearing after age 18, which, typically, But, of course, monda, pre or post, high school graduation studies, have found that, again, delaying childbearing is advantageous for Education. Avoiding childbearing before age 18 increases GED completion and increases educational attainment in terms of years of schooling.

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It also increases high school graduation and the probability of attending college.

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In terms of labor force participation, We also see effect early legal access to contraception, again, based on the changes taking place in the 19 sixties.

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And seventies showed that, know, having access when women were young increased their labor force participation. Not just when they were young, but as they grew older and increase their economic fortunes in terms of their earnings for many, many years into their adulthood.

12:57

In terms of effects on income and wages, Just to put some numbers on that, folks, who had access to contraception when they were in their teenage years ended up earning 8% higher hourly wages in their late forties. It's also the case that avoiding childbearing before age 18 reduces the likelihood that women are either near the poverty line or below the poverty line. And we see similar effects When we think about unplanned births that could happen at older ages.

13:37

So I would also highlight that there are broader effects because, I mean, this perhaps goes without saying, but sometimes it's lost in the discussions that these people are part of broader families.

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And so if women's economic outcomes are damaged it by L, um, bye their inability to access family planning, that has implications for the resources that are available to the children that they might already have, or the children that they have in the future. And so I do think it's important that we keep those children in mind, as well when we think about the full costs and benefits of access to family planning.

14:30

I want to highlight here that there's also a good amount of research on access to abortion, which points to the same general conclusions bans on abortion from the 19 sixties. Reduced educational attainment, particularly for black women.

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More recent research looking at access to abortion.

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And how it's been hindered by trappe laws has shown that impairing access to abortion reduces educational attainment, particularly for black women.

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Also, folks who are unable to obtain an abortion because they get to an abortion provider just after their gestational age cutoff and, versus just before, they suffer financially, They are at an increased likelihood of being in financial distress, or at least five years, how many years? We don't know, We'll need more research to try to answer that question.

15:32

So, I would, I would really emphasize here that there are, it's not just a literature or a study, but there are many, many studies and many, many literature's which all point in the same direction, which is that women having a greater ability to control their childbearing, both the timing with which they have children and the number of children that they have has important implications for their economic outcomes. And this is not, not an area where there's some research that goes in some direction, some research that goes in the other direction. All of the research points in this direction. And, and as folks who are interested in policy, it's important that we keep in mind that well, pregnancy and childbearing are absolutely outcomes that are affected by policies that have been put in place in the past, and that are being considered moving forward.

16:44

Great. Thank you so much, doctor Linda, for helping to set the stage for this conversation on women's access to contraception and their economic and health outcomes.

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Next, we'll hear from doctor Jessica Cohen, The Bruce ..., Robert ..., Alexander ..., Associate Professor of Global Health at Harvard TH Chan School of Public Health, and co-director of Harvard's Lead Fellowship for Women Global Health Leaders.

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She is a Health Economist well-known for her research on maternal and child health policies and programs in the United States and East Africa.

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Under a recent Netcom grant, doctor Cohen and Colleagues published new research on the impact of Medicaid reimbursement on immediate post-partum LARC Use. We're so grateful. She is with us today to share her perspective and research doctor Cohen.

17:30

Great. Thank you so much for inviting me. And I'm very glad to be here, with this esteemed panel.

17:38

Just like to mention, my co-authors on this research, Maria Sunland at Brown University ..., who's an MD PHD student at Harvard, with me, Lydia paste, who's at Brigham and Women's Hospital and Harvard Medical School in Anniston Eco, who's also at the Harvard Chan School of Public Health. And thanks, Cindy, for funding and to ...

17:58

and the Harvard Chan School. So let's get started.

18:02

Could do turn the slide, please. Thank you. So there's still a very high rate of unintended pregnancy in the US. Although the, the data is a little out of date. Something like 45% of pregnancies were unwanted or wanted at a different time in the US.

18:18

And these rates are highest among adolescents: racial ethnic minorities, and lower income populations.

18:25

And unintended pregnancies has already been mentioned are associated with adverse, maternal and newborn health outcomes, for example, pre-term birth and also with lower educational attainment and earnings.

18:40

Next slide, please, Thank you. So the great majority of post-partum pregnancies are unintended, fully, 80% of pregnancies that happen within six months of a prior pregnancy are unintended.

18:54

And even if you go up to six months to 11 months after a prior pregnancy, 70% of those pregnancies are unintended, Next slide, please.

19:05

Thank you.

19:06

So these short interval pregnancies, pregnancies that happened within a short interval of the prior one, are also associated with a range of adverse, maternal, and newborn outcomes.

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So the American College of Obstetrics and Gynecology Guidelines recommend avoiding enter pregnancy intervals that are shorter than six months.

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The World Health Organization actually recommends inter pregnancy intervals of two years or more.

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So ensuring that post-partum people have access to freely choose, among the full range of contraceptive methods is really key to preventing these unintended short interval pregnancies that occur throughout the post-partum year.

19:47

Next slide, please.

19:50

The problem is that in the US as in many other places, post-partum people face what we refer to as post-partum cliffs.

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In other words, they have quite a lot of health system scaffolding to ensure their access to health care during pregnancy and delivery but that support falls off abruptly in the post-partum period. Next slide.

20:19

So in particular, people bringing people have a strong connection to the healthcare provider and system that develops during pregnancy and delivery, but this often feeds or even plummets, post-partum and so many people within the United States received no post-partum visit at all.

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And even those that do often don't get comprehensive, post-partum care, or appropriate transitions to primary care contraceptive.

20:45

So contraceptive options that are available during the delivery admission that is immediate post-partum contraception can really offer a tremendous opportunity for unintended pregnancy prevention for people who may lose access to affordable or high quality care in the post-partum period.

21:05

Next slide please.

21:08

Until about 10 years ago, the only options for immediate post-partum contraception, or tubal ligation, progestin only pills or injectables. So these are either permanent methods or short acting methods only.

21:23

But IUD and implants or long acting reversible contraception, often referred to as Larks, which are the most effective forms of reversible contraception were not really widely available.

21:39

So until about 10 years ago, immediate post-partum larks weren't offered.

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Why was that?

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Well the device the IUD or Implant and the Procedure or the Insertion costly, but these would only be covered as part of the global fee for labor and delivery or childbirth.

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In other words, if health care providers decided to offer immediate post-partum LARC to delivery patients, they would all be doing that on their own dime and their their payment. Reimbursement rate wouldn't go up.

22:13

And so, uh, momentum grew from clinicians and policy experts, women's health advocates and researchers to unbundle the reimbursement for immediate post-partum LARC from this global payment, in other words, separately reimburse for the insertion or the device.

22:33

Next slide, please.

22:36

So South Carolina, Medicaid was the first state to adopt this policy of unbundling, the immediate post-partum LARC from the global delivery payment, but the majority of states have adopted this. Unbundling of state Medicaid programs have adopted this in some form since then. Next slide, please.

23:00

And so my research along with this research group, started with a focus on South Carolina, since that was the first state to implement this policy of the most, the most data on these phones.

23:14

So in this paper, what did we do?

23:15

We looked at the impact of the Medicaid payment for immediate post-partum Larks on LARC Use in South Carolina. So what these graphs are showing?

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So this data was linked inpatient, hospital inpatient, hospital discharge data with birth certificate data from all of the Medicaid Berths in South Carolina.

23:37

And this was an interrupted time series analysis, looking at the impact of the introduction of this policy on trends in immediate post-partum LARC use.

23:46

So what you're looking at here is time on the on the horizontal axis. And the horizontal line is the introduction of the Medicaid policy in each dot here is a month.

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So this is showing you the fraction of deliveries paid for by Medicaid in South Carolina, in which an immediate post-partum LARC was placed.

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What you can see is that after the introduction of the policy, the trend in IPP LARC placement goes up dramatically. On the left is adults. That's people 20 years and older. And on the right was adolescence.

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The increase by the end of this study period 2018 was a 5% point increase in immediate post-partum LARC placements, and an 8.3% point increase for adolescents.

24:31

Next slide.

24:34

So then with in further analysis, we looked at the impact of this on five other early adopting states.

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So those were Georgia, Iowa, Maryland, New York, and Rhode Island, which implemented the policy in 20 14 or 2015.

24:54

And for this, we used state inpatient database, the state inpatient database provided by ..., linked to American Hospital Association surveys and other datasets.

25:06

And again, we used an interrupted time series to look at the trend in immediate post-partum LARC placement, Change after the introduction of the policy.

25:16

So again, the way to look at these is the Dash line is the introduction of the policy.

25:20

The line the blue line shows you that in most states, other than Iowa and Maryland, that trend an immediate post-partum LARC placement was pretty flat prior to the introduction of the policy and then increased quite a bit.

25:35

You can see there's quite a lot of heterogeneity across states so that the biggest effects were in New York, Georgia, and Rhode Island.

25:44

Smaller effects in Iowa and Maryland. Next slide, please.

25:49

So what we found across the board, both in our earlier work in South Carolina and in this later work in the other states was that adoption of this. The offer of this method was not adopted evenly across facilities at all. So the offer of immediate post-partum LARC, even after the introduction of this Medicaid policy was really only offered in a handful of health facilities.

26:15

So on the graph on the left, you can see is that across Georgia, Iowa, Maryland, New York, and Rhode Island.

26:21

Even after the introduction of the Medicaid payment, 73% of facilities were not we're not inserting immediate post-partum LARC in any deliveries and then another 17% were doing it and only, you know, less than 1% of deliveries.

26:37

So really, you know, sort of 1% to 20% of deliveries, getting immediate post-partum LARC was only happening in 10% of facilities.

26:47

The graph on the right, basically shows the same thing in South Carolina.

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Next slide, please.

26:54

We also looked at characteristics of facilities that adopt immediate post-partum LARC.

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What we found was that the handful of facilities that were offering them were overwhelmingly likely to be urban, non catholic, high level teaching hospitals.

27:11

Next slide, please.

27:15

Another thing that we found that was quite interesting is that the introduction of the Medicaid reimbursement for immediate post-partum larks spilled over into commercially paid births. So if you look at the graph, for example, on the bottom left in New York, you these are these are the fraction of deliveries, commercially paid burst, in which an immediate post-partum LARC was pleased. You can see that after the policy, there's an increase for commercially paid for us in some of these states as well in New York, Rhode Island.

27:47

And a bit in Georgia.

27:49

Next slide, please.

27:52

So again, since we've had longer to look at South Carolina was the first one. We've dug in a little bit deeper into the impact of this this policy change.

28:03

So one of the first things that we saw that I think was really interesting was that along with the big increase in immediate post-partum LARC use in South Carolina was a sizeable decline in Tubal ligation for adult women. In other words, we we seem to observe a sort of switching from permanent sterilization forward toward LARC.

28:26

On the other hand, for adolescents, breathing people under 20, we did not see that, which, not surprisingly, since many of them are not getting Tubal ligation, but actually saw an overall increase in the use of effective contraception for adolescence.

28:41

Next slide, please.

28:46

We also, in South Carolina, looked at the impact of the policy on short interval burst, which I mentioned before, are often unintended and which are associated with adverse maternal and newborn outcomes.

28:58

We didn't see an overall change in the likelihood of short interval births, but we did see a significant decrease in short interval burse among adolescents in South Carolina, and also a significant increase in birth spacing for adult non hispanic blacks.

29:20

Next slide, please.

29:23

So this is just showing you the Interrupted Time series results for short interval burst for adolescents. It's a pretty sizable. You saw that there was a big increase in immediate post-partum LARC use. For adolescence, this seems to have translated into a reduction in short interval burse a 5.3% points.

29:41

Next slide, please.

29:45

We also in South Carolina, see evidence that the Medicaid payment for immediate post-partum LARC led to reductions in pre-term and low birth weight birth, exactly's.

29:58

So the effects were somewhat modest.

30:00

But we start, but we we did see a significant reduction following the introductions policy in rates of pre-term birth, low birth, weight birth, and in particular, the moderate pre-term births, the not the very, very pre-term or very low birth weight.

30:17

Next slide, please.

30:20

So just in some State Medicaid policies to unbundle immediate post-partum LARC reimbursement from the global fee have increased use of this method across a range of states, although the effects vary.

30:34

The adoption, however, of the offer of immediate post-partum LARC across facilities is very uneven with only a handful of facilities offering it, meaning that access to this method is definitely not uniform for reading.

30:49

There is some evidence of declines in short interval births and adverse birth outcomes, although not across the board and for all groups. And this is something we continue to look at in our research.

31:01

The policy, of course of reimbursing for immediate post-partum LARC is meant to increase patient choice, right? To increase the options that are available to post-partum people.

31:12

What evidence is needed about whether patients are receiving patient centered, complete and unbiased counseling regarding immediate post-partum LARC, to ensure that the policy is actually increasing choice.

31:26

And finally, I think we need more information on the modifiable factors that are influencing adoption of immediate post-partum, LARC, at facilities in order to ensure that this method is more widely available to patients. Next slide, please.

31:47

So just would like to thank you very much and welcome your feedback and suggestions.

31:53

And again, thank my collaborators and Nick for the intro for the invitation to speak today.

32:03

Great, thank you so much, doctor Cohen for sharing your research and giving us a foundational understanding of the role that Medicaid reimbursement can play in contraceptive access and use.

32:13

Next, we'll hear from Kate Daniel, the New Mexico Title 10 Director and Family Planning Program Manager, and doctor Wen Nneka, Baraka, Medical Director for the New Mexico Title 10 Family Planning Program. We are grateful to have you both with us today to share your work to expand contraceptive access, especially in rural limited provider settings.

32:37

Thank you very much for providing us with this opportunity to give our perspective, as New Mexico's Title 10 State Office staff. Who have worked to expand access to family Planning Services. In our own Title 10 Funded Clinics, as well as collaborated with other agencies, particularly in New Mexico, Medicaid, to expand family planning services beyond Title 10 clinics. It's important to note that the conclusions and opinions, provided here are mine and doctor ... alone and may not be those of the New Mexico Department of Health, the New Mexico Human Service department, or the Federal Office of Population Affairs. Title 10 much of this data comes from our June 20 22 American Journal of Public Health article titled Impacts of a Statewide Effort To Expand Contraceptive Access in New Mexico 2014 to 20 20. Next, please.

33:27

New Mexico is the fifth largest state with over 121,000 square miles, but has just over two point one million residents. Ranking us 36 10 population, approximately 43% of New Mexico's population resides in the center of the state. or the the Turquoise and Mint Green section in the Center which is the Albuquerque Metro area burned Leo, Sandoval Torrance, and Valencia Counties, New Mexico. Does share borders with Arizona.

33:57

Utah, Colorado, Oklahoma, Texas, and the country of Mexico.

34:02

This slide shows two New Mexico maps that we included in our needs assessment for the most recent Title 10 grant application, On the left, you'll see that most New Mexico counties were identified by this federal Centers for Disease Control Prevention as areas with high social vulnerability index. On the right, you'll see the Title 10 service sites, or satellite sites, with at least one located in almost all of the 33 counties in New Mexico. With the exception of Katherine and Harding counties, which have very sparse populations. The majority of New Mexico, Title 10 clinics are New Mexico Department of Health Public Health offices, indicated by a Blue Star, which are run by the New Mexico Department of Health Public Health Division, in a centralized health care system.

34:46

New Mexico Family Planning program has been piloting telehealth family planning services across the state, which is for the most part, rural and frontier.

34:54

In the first few months of this year, over one thousand clients and 61 providers have benefited from Telehealth, Family Planning Services. Next, please.

35:08

As the Title 10 Grantee for the State of New Mexico, we have played a critical role in ensuring access to a broad range of family planning and preventive health services, as well as overseeing client centered care delivery in the state.

35:21

All of our services funded through Title 10 are client centered and decisions about a client's reproductive health services are made by the client in conjunction with the clinician.

35:32

In 20 21 New Mexico Title 10 clinical services prevented almost 2000 unintended pregnancies based on Guttmacher calculator. Next please.

35:46

We impact family planning and reproductive health services in a mulch and a multi-pronged approach with clinical services and educational programming. Pregnancy and birth are significant contributors to the high school dropout rates among girls.

36:00

In 20 18 nineteen's, four year, graduation cohort, 79% of all female ninth graders in New Mexico graduated from high school for years later, which is significantly lower than the national rate of 86%.

36:14

During those same years, the teen birth rate was 25.3 per thousand and 24.4 per thousand, respectively.

36:23

And the 2018, 19 school year, our adjusted cohort graduation rate for all genders, was the lowest in the nation at 75%.

36:33

The New Mexico grads program, which works with pregnant and parenting teens on 10 unique topic areas, reports that 84% of teen mothers in New Mexico are enrolled in in the program, in 20 22, compared to 53% nationwide.

36:47

In addition, the repeat, teen pregnancy, sorry, And the repeat, pregnancy rate among New Mexico grad students is 2.4%, compared to 14% statewide.

36:57

New Mexico has very progressive Health education, and comprehensive *** education standards promulgated by the New Mexico Public Education Department.

37:05

That being said, individual school boards determine what, if any health or comprehensive *** ed lessons are offered in their school district next, please.

37:19

A broad range of FDA approved contraceptives are available in 44 public health offices, and two outreach sites, and 15 community or school based health centers across the state.

37:29

The use of IUD and implants increased from 50% in 20 16 to 66% in 20 21 and all ages, and from 23% in 20 16 to 28% in 2021, and teens aged 15 to 19, As you would, as you would just do, assume, as the use of most effective methods increased, the reliance on moderately effective methods decreased in all age groups. Next, please.

37:59

Now that Kate has provided background about State of New Mexico in our program, I am going to walk us through the journey that Kate and I had travel through, after our implementation of IPP black, from the Medicaid side in 20 13. So it jewelry call, doctor Cohen's presentation. Not The Lion, was the first state in in 20 12. And New Mexico was one of the very first few.

38:29

I think ours is implemented in, in April of 2013.

38:37

So this slide is the poster that was presented in 20 16, Title 10 conference, And it's summarized the timeline of the outcome of IPP luck and bundling them medicated in 20 13. And our collaborator is at the top.

38:56

So, this is, the poster was supported, know, by the learning community group that Association of State and Territorial Health Officials, or ..., recruited us to join as one of the first state cohort.

39:14

And, ah, it listed the collaborator here, which are us and New Mexico, Medicaid, and University of New Mexico State.

39:26

Unlike the other states that doctor Cohen presented in her presentation, University Hospital located in Bernalillo County. He represented the majority, the IPP lack claims, which were almost 250 claims in 20 14, The year after the unbundling of lack of IPP like was implemented when I went up to 300 approximately in 20 15.

39:59

And interestingly, also, that the majority of claims that was file was from implant.

40:09

Next, please.

40:15

So the slide, I would just like to mention that between 2014 to 20 18, as those supported multiple cohorts, learning community and, um, the IPP lac learning community has expanded to include the development of policy and programs to increase access to the full range of reversible contraceptives through this logic model.

40:45

Next, please.

40:50

Next slide. Is the data that I did to query when I served as a New Mexico, Medicaid Medical Director.

41:00

Slightly BC Graph, because it's kind of like help me put things in perspective before we was exploring to do the publication.

41:09

The X axis is the time axis by year between 2010 to 20 18.

41:18

And it was not very obvious where 2010 starred because I know, label the timeline of the many New Mexico Medicaid policy implementation beginning in 2013, by.

41:37

In 20 Sorry, I'm sorry, On the, in the beginning, Well, like 20 12, I believe, is the expansion of the lower age limit for female, New Mexico, Medicaid, beneficiary, to be eligible for family planning Medicaid. In the meantime, they also eliminate gender limitation to include men as the family planning, Medicaid beneficiaries as well.

42:05

So April 2013, Medicaid unbundle IPP lag in 2014.

42:14

The third box in the X axis is when Medicaid adopted Affordable Care Act, and expand Medicaid to, y'know, to higher income beneficiaries. And the last significant landmark of Medicaid policy change is the unbundling or lack from FQHCs, bundle, encounter rate.

42:40

And so, in this graph, I have two data presented. The bar graphs represent.

42:48

The number of black claims, which I kind of color coded and numbers on top, is the number of black claims total.

42:58

Which went up from 727 in Green Fon on on the left-hand side of the first backup to over 400 18 on this graph.

43:12

And the tip off the bar graph, that orange tip, which, you know, you can see in the middle, like the Year 20 13, that it represents the IPP lack, number of IPP Lak claims.

43:28

13, IP lack ahtisaari, the teen lack claims, not IPP represented in purple, black graphs in this graph.

43:39

And as you can see, the widening of that, you know, the purple graph, and the meantime, the green, green bar bar, graphs also increasing in height over time. So I simply impose the bar graph of the number of black claims.

43:56

Not to imply any association, OK? Just kind of exploring the data number of Medicaid birds.

44:03

It went down from almost 20,000 in the year 2010, 2, just above 600,000 in 20 18.

44:16

And then I fraction needed this lie graph into how many of those were teen births and represented in the red line like just across the lower part of the biograph.

44:32

And how many of these in general answers in in the total? for ...

44:37

County level, I told you the university hospital is located in Bernalillo County and I can kind of chair that the majority of decline or medicate birds come from Bernardino County and to a minor degree from teen birds.

44:57

OK, next slide, please.

45:00

Next slide. So we're gonna go into the publication that we did as. A part of the supplement issue of ....

45:12

New Mexico capture 2014 to 20 20, with four major strategies that were implemented in the state.

45:20

one is provision of low or no cost contraception, which Kate provide an overview of, mainly provided by statewide Title 10 Clinics. Second, is to provide, training 10 training and technical assistance, and in two different format.

45:38

one is, mainly face to face.

45:42

Training via lack mentoring program.

45:45

This is before Colgate, because Optical during cold lack mentoring program also move into virtual type of training and an LMP ProVis hand on skill training as well as billing training.

46:00

And a second platform is through virtual maintenance type of you know every other week type of training with the expert via the ... program.

46:14

Both of the programs were launched in December of 2016 the third train. The third strategy is public awareness campaigns, which will run, kid would know more about this, but it brand in quarter.

46:28

And every time we brand this public awareness campaign, we'll see the increase in the number of clients entitled 10 Clinics that opted for implants in the following quarter.

46:40

Last but not least was the various policy change that I, you know, highlighted in the previous slide of Medicaid.

46:49

So next slide, next slide, will show the outcome of this study that was published.

46:56

And, and so bear with me, I'm going to walk you guys through this.

47:02

So this data, well from New Mexico, Medicaid claims data.

47:08

And they are presented here in quarterly section, so every quarter, the numbers.

47:15

You know, all off the clients who utilize the services, and have claimed a unique within quarto, but they are not unique across the quarter.

47:27

So she's only quarterly unique, and that July station data were presented in bar graph, in this, you know, picture, and the black bar represented black claims, and the orange bar represents the moderately effective load, control method claim which including by hormonal contraceptives, such as pills, patch, bring in injectable and as well as diaphragm, OK.

48:03

So I simply impose in this graph with the number of Medicaid providers who rendering this claim with the DAC Bar Graph Doc, Like, line graph is Medicaid, Medicaid provider who provided services to teens.

48:20

And the dash line, will, Medicaid providers, will provide a service, two young, female Klein, young women, from the age of 19 to 24 24.

48:33

So as you can see, the biograph do not fractionate out the age group.

48:39

However, I'm going to describe that between 20 14 to 20 20, the number of black user in adolescent went up about 33 falls. And number of adolescent moderately effective use of wind up about 42 falls. This effect was less upset in younger women. Between the age of 19 to 24, we only saw 14 full full full increase for each lack and moderately effective juicer.

49:12

As far as the number of Medicaid rendering providers to teens, as well as too young women, they went up in the same fashion, more in teen provider, 20 falls, and only four falls for young women providers. Next slide, please.

49:34

The teen birth rate in New Mexico decreased by just over 60% from 20 11 to 20 21, and by over 36%, from 20 16 to 20 21. While the US, teen birth rates decreased by 55.6%, and 31.5% in the same years.

49:55

The second graph shows the other states within our Title 10, Regions six, and Arizona, which is a state that is very similar to us, and many demographic measures. New Mexico started out as one of the highest rates, and you'll see are the yellow line is New Mexico, and is now the state, in our title 10, Region six, with the lowest rate, while the trend is decreasing across all represented states, New Mexico's rate is falling at a faster rate.

50:21

In 20 21. New Mexico was ranked 10th highest in the nation, with the teen birth rate of 19 per one thousand. Compared to 13.9 per thousand for the U S, next please.

50:35

So, the next either hail statistic that we would like to present at time, personally very excited, is the New Mexico Pregnancy Risk Assessment and monitoring system survey from the year 20 12 to 20 19.

50:51

If you remember, in the previous slides that I presented, the data was from 20 14 or so, that the into N interventions, you know, that we capture begin began.

51:04

So this graph began in 20 12, As you are similar to the graphs that doctor Cohen kind of presented, The lie was kind of flat prior to 20 14. And if the line on top, which is blue line, darker blue line, is the line for intended pregnancy reporting by the survey participants.

51:32

And we saw the increase in trend and parallel with the light on the bottom, that the women reported, unintended or miss time pregnancy that are going down.

51:45

Then last, I would like to end this presentation by thanking both estel our collaborators as well as the coalition to expand contraceptive access to provide support and technical assistance.

52:04

Great, Thank you. OK, and doctor ..., for sharing your experience in New Mexico, and some of the outcomes that you are seeing in the population. We will like to use the remaining time to engage in a Q&A session with our audience. So please continue to submit your questions in the Q and A tab, and I will ask all of our panelists to come off mute, and you can come back onto video.

52:27

Great, and I will start working our way through some of the questions that have come in. Doctor Cohen, a question came in for you. And then we can open it up to the other panelists as well, if they would like to add anything.

52:38

Has research told us anything about the ways to incentivize the ... to offer a medium immediate post-partum larks?

52:51

Sorry, I was muted. That's a great question. And one that I would love to know the answer to, also.

52:59

I think incentives are only one part of the issue.

53:05

I think one of the things that I infer from the fact that we saw an impact of this policy on commercially insured burse, is that there are sort of what economists call startup costs are fixed cost, fixed cost starting to offer this method.

53:22

In hospitals, one just basic thing is stocking the devices in the hospital, pharmacy itself, training providers on a large placement, updating billing systems and that kind of thing.

53:37

And so I think, I think incentives are important, and the states vary in how strong the incentive is to offer it.

53:48

But I think there are some real bread and butter, sort of logistical things that need to be put in place in order to speed up adoption outside of these sort of, you know, in these sort of teaching hospitals and higher level hospitals that are almost, you know, are often the first ones to adopt these files.

54:10

I want to echo doctor Colin's comment out this Alex experience as well the stocking cost is what prohibit most hospitals birthing hospitals Great. Thank you.

54:25

We had another question come in how will the implementation of 12 months of post-partum Medicaid coverage affect family planning benefits and Medicaid doctor ...?

54:36

Kate, would you like to take that one?

54:40

So I think that in font not too complicated.

54:45

The, you know, the Medicaid structure is practically expansion from six weeks to 12 months.

54:56

So, women that are eligible for pregnant, pregnant categories of eligibilities, which in New Mexico, there, two of them did have two different type of income, No requirement would stay in that benefit longer, with full Medicaid benefit for 12 months Is a good thing in other words, and it doesn't jeopardize their their chance to if after 12 months they still qualify for family planning medicate afterwards, because the 12 month period that they cover They have HIO benefit, broader benefit. And can I maybe take this time to chair?

55:42

That it is very important, because majority of the issues that women encounter at the post-partum, even though it is pregnancy all or not related, it can manifest itself later because some of them are kind of like, behavioral health related, and, and the issue takes longer to, to be able to, you know, addressed.

56:11

So six weakest is not, it's not adequate.

56:17

Great, thank you. We also had some questions come in around contraceptive autonomy and building trust in the community. And I was wondering if anyone can speak to addressing mistrust in the community specifically around some of the more targeted birth control policies and programs.

56:41

OK, I can try, I'm sorry. Our state is rural and frontier.

56:48

So, when you see somebody's car parked in front of the Health Department, they tend to kind of know that you're getting reproductive health services, either STI testing treatments or family planning.

57:04

So the and some of our counties border the Southern border.

57:11

So, we have immigrant population, as well. Though, what amount for us is, is very important. When, when your friends and family or enable, it tells you that they went there, they got to services. And, you know, nothing bad happened to them.

57:32

It is very important for us. And these days and age, we augment with the in person, type of visit, with the telehealth that they don't have to step foot outside. They update their home at all, and they can get services.

57:48

And we starting to males, mail order pharmacy that we can mail contraceptive up to one year supply as well as emergency contraceptive pills to, to declines. And, you know, we encourage or incentivize wortham out via social platform. And this is the first year. We are doing this. So, it yet, to be remain to be seen. How that make an impact?

58:19

Can I just add, that I think when talking about reproductive health care and policies, we're usually thinking about access and expanding options and opportunities to people.

58:35

And, and, generally, there are economists lens that that should make them better off, as opposed to coercive methods, or approaches where you might restrict people's options, and we would expect that to make them them worse off. But most of these policies that we're talking about are certainly the types that expand pupils options, and it's all about access, as opposed to, necessarily, you know.

59:05

Crushed any, any pressure about what, what someone's should be using.

59:11

Great, thank you. And I will, just, we have time for, I think, one more questions. If anyone would like to answer this before we wrap up.

59:19

How are approaches changing regarding women and mortality and morbidity issues and prevention?

59:31

The big question, I think, but I'll give it a shot.

59:36

I think, you know, since we only have a short amount of time left, I'll just summarize by saying, I think that there is a growing understanding that morbidity and mortality especially around delivery in the post-partum period are about more than sort of the basic inputs of health care.

59:55

You know, so there are very few things we measure right now.

59:59

Well, with regard to, um, prenatal health care quality and delivery quality, we have very few HEDIS measures, for example, on quality of care, and I think we are starting to realize that it's not just how early you start natal care. How many prenatal care visits You get. That kind of thing that determine these outcomes, but that have a lot to do with your health coming into pregnancy.

1:00:25

Have a lot to do with structural racism and bias, and the health care system have a lot to do with the quality of care that you get in pregnancy and delivery and post-partum. In ways that we haven't gotten. We haven't done a great job measuring yet, but we'll need to in order to you.

1:00:46

Great. Thank you. Well, unfortunately, we are out of time. I would like to thank our excellent panel of speakers for being with us, today, and sharing their valuable work and perspectives, and thank you to our audience for joining this discussion.

1:00:58

Your feedback is important, and there is a brief survey that will pop up after the event and appreciate your feedback. Please also check out the other resources available on our website, including additional work on Maternal Health. Thank you all for joining us today.