Analysis Race

Health Reform’s Quiet Victory: Pregnancy Assistance Fund Benefits Vulnerable Populations

Sheila Bapat

An under-the-radar provision of the Affordable Care Act, the Pregnancy Assistance Fund, demonstrates the economic justice potential of health reform.

Shauna Humphreys has been leading programs that serve at-risk teens of the Choctaw Nation in Oklahoma for several years. But the impact of her work has increased dramatically over the past two years because of the Pregnancy Assistance Fund (PAF), a provision of the Affordable Care Act supporting a range of services for pregnant teens and young adults.

Humphreys’ program, known as Support for Pregnant and Parenting Teens (SPPT), serves nearly 100 Choctaw mothers under the age of 22 by building their parenting skills, providing sex education to help prevent repeat teen pregnancies, and encouraging young mothers to obtain high school degrees and pursue higher education.

Vastly more robust than the program Humphreys ran prior to receiving a 3-year PAF grant at $900,000 per year, SPPT is staffed with six caseworkers who visit clients’ homes monthly to deliver parenting and life skills training. Caseworkers also serve as a general support network for young women who are experiencing domestic violence.

“These young women need this level of support. They typically don’t have anyone helping them to meet their personal goals,” said Humphreys, herself a mother of twins. “I can’t imagine being pregnant in high school and trying to figure out my life after having a child.”

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While the battle over the ACA rages on in the states, with the Medicaid expansion and the birth control benefit persisting as the most contentious provisions of the law, PAF is an under-the-radar boon of health reform. Needless to say, if the ACA is repealed, PAF will likely be eliminated as well–jeopardizing Humphreys’ program and all PAF-funded programs.

Humphreys’ program is one of 17 PAF-funded programs throughout the country that help young parents and their children overcome hurdles that can limit life opportunities and and perpetuate poverty. States and Native American tribes are eligible to receive PAF funding. PAF was written into the health reform law that passed in 2010, and last year the program was expanded to a $25 million grant program through 2019.

United States rates of teen pregnancy, while declining steadily over the last decade, continue to be high compared with other developed countries. Native American communities consistently see higher teen pregnancy rates than other ethnic groups in the United States.

PAF’s focus is holistic — it funds programs that serve pregnant women who are victims of intimate partner violence and sexual assault. This resource is critical for all communities, and particularly for Native American communities: According to the Center for American Progress, Native Americans are victims of rape or sexual assault at more than twice the rate of other racial groups.

Clients of SPPT who have experienced domestic violence often confide in Humphreys’ caseworkers, who then refer the clients to domestic violence programs that offer shelter and other resources. “Our caseworkers hear about the range of difficulties clients are experiencing and that’s good, we want that, because we want to help in all aspects of their lives,” Humphreys said.

Equally critical is PAF’s focus on education, as children of teen parents are more likely to grow up poor if their parents do not at least make it through high school. For example, the Virginia Department of Health received a $1.5 million PAF grant to aid pregnant and parenting students in colleges and universities, helping them navigate the hurdles to staying in school and obtaining a four-year degree.

Quietly aiding some of the most vulnerable US populations, PAF demonstrates the economic justice potential of the ACA. As long as the ACA is not repealed in full by Congress or a Republican administration, PAF should be intact through 2019. Senator Bob Casey of Pennsylvania sponsored the bill to expand funding for PAF last year — I reached out to Casey’s office for comment about how a repeal of the ACA could impact PAF but haven’t yet heard back.

PAF and the work of its grantees makes the political wrangling over health reform seem completely petty. Writer Sarah Kliff recently pointed out that states’ opposition to the ACA is just as political as it seems, driven primarily by state leaders’ party affiliation. As it happens, none of the 17 states where PAF funding has been disseminated currently plan to oppose the Medicaid expansion.

So while the funding lasts, Humphreys and her team are hard at work. “We hope to hire more caseworkers and serve more women,” said Humphreys. “I don’t want to think about what could happen to these young women if our program loses support.”

Commentary Sexual Health

IUDs Might Be Exciting, But There’s More to Sexual Health Than Preventing Pregnancy

Martha Kempner

I worry that in our excitement to promote long-active reversible contraceptives as an effective way of preventing teen pregnancy, members of the public will overlook the importance of sex education and the need for condoms.

Earlier this month, the Centers for Disease Control and Prevention (CDC) released a study that found more people ages 15-to-19 are using long acting reversible contraceptive (LARC) methods than in the past. That rate among young people, however, is still relatively low. The authors of the report join a chorus of public health experts in suggesting that further efforts be taken to increase access to and use of these methods throughout the country.

I worry that in our excitement to promote LARCs as an effective means of preventing teen pregnancy, we will overlook the importance of sex education and the need for condoms—both as an alternative, short-term form of contraception and to prevent sexually transmitted infections.

Contraceptive methods that are safe and highly effective are vital for preventing unwanted pregnancies, but there is more to sexual health than that.

The Methods

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IUDs are small, T-shaped devices that are inserted into the uterus by a physician. They prevent pregnancy primarily by interfering with the path of the sperm toward the egg. Two of the IUDs on the market—Mirena and Skyla—release hormones similar to those in some birth control pills, which create a barrier to sperm by thickening the cervical mucus and may also prevent ovulation. The other type of IUD, called ParaGard, releases copper, which is thought to create an environment that is toxic to sperm. ParaGard lasts for ten years, Mirena for five, and Skyla (which is smaller and was introduced with young women in mind) for three, but any of them can be removed sooner if a user wishes to become pregnant or switch methods.

Contraceptive implants, sold under the brand name Nexplanon, are flexible plastic devices about the size of a matchstick that are inserted under the skin on a woman’s upper arm. Nexplanon releases hormones similar to those in birth control pills, which prevent ovulation and thicken cervical mucus. Nexplanon also lasts three years but can be removed earlier.

LARC methods have the highest efficacy rates against pregnancy, in large part because users can “set them and forget them,” so to speak. Unlike the birth control pill, which a woman has to take every day regardless of whether she has sex, or a condom, which couples must use each time they have sex, these methods work with no effort on the part of the user. This means that the typical-use efficacy rate (the one that shows how well the method usually works for a couple during the first year of use) is very similar to the perfect-use efficacy rate (the one that shows how well the method can work if used consistently and correctly).

IUDs have a failure rate of less than 1 percent; implants have a failure rate of 0.05 percent. In other words, out of 100 couples who use these methods as their primary form of birth control, fewer than one will experience an unintended pregnancy in the first year of use. In comparison, typical use rates for the pill suggest that nine couples out of 100 will experience an unintended pregnancy that first year.

Though IUDs were once thought to be safe only for older women or women who had already had children, research in the past decade has found that they are safe for women of all ages, including adolescents. Implants have also been found to be safe for women of all ages.

The Excitement

Given the safety and efficacy of these devices, it’s easy to see why so many experts feel that LARCs may help prevent teen pregnancy in the United States. After all, if a 16-year-old gets an IUD, there’s almost a guarantee that she won’t get pregnant until she’s 19 at the least.

As Rewire has reported, both the American Congress of Obstetricians and Gynecologists (ACOG) and the American Pediatric Association (APA) have suggested that LARC methods should be a first choice for young women.

ACOG writes:

When choosing contraceptive methods, adolescents should be encouraged to consider LARC methods. Intrauterine devices and the contraceptive implant are the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion in young women.

The APA recommendations are similar:

Pediatricians should be able to educate adolescent patients about LARC methods including progestin implants and IUDs. Given the efficacy, safety, and ease of use, LARC methods should be considered first-line contraceptive choices for adolescents. Some pediatricians will choose to acquire the skills to provide these methods to adolescents. Those who do not should identify health care providers in their communities to whom patients can be referred.

And, this month’s CDC report will likely add to that excitement. The report looked at IUD and implant use among 15-to-19-year-old women who receive health care through Title X clinics. The Title X program provides family planning and related preventive health services for low-income individuals; it serves approximately one million teens nationwide each year.

The report found that among teens who sought contraceptive services at Title X sites, use of LARCs increased from less than 1 percent in 2005 to more than 7 percent in 2013. In 2013, roughly 3 percent of teens who sought contraceptive services used an IUD and 4 percent an implant. Teens older than 18 were more likely than 15-to-17-year-olds to use these methods.

The study also found that the use of LARCs varied widely across states. In Mississippi, for example, less than 1 percent of women ages 15-to-19 used LARCs, but in Colorado that percentage was up to over 28 percent. This finding is not surprising, as Colorado has implemented an initiative designed to improve LARC use among Title X clients.

The authors of the CDC study suggest that more programs like this are needed:

Given the estimated 4.4 million sexually experienced female teens in the United States, and the high effectiveness, safety and ease of using LARC, continued efforts are needed to increase access and availability of these methods for teens.

This month, the CDC also released a Vital Signs document about the key role that the government, health-care providers, and parents can take in helping teens prevent pregnancy. The document points out that about 43 percent of teens ages 15-to-19 have had sex and that four out of five used birth control the last time they had sex—but only 5 percent used “the most effective methods.” (This differs from the CDC study mentioned earlier because that study was limited to teens who sought contraceptive services through Title X providers.) The CDC suggests adults encourage teens to be abstinent, but also encourage the use of LARC methods when they become sexually active. It also suggests the government can help by funding programs, such as Colorado’s, to make such methods affordable and accessible.

The Concerns

While this push toward LARCs is indeed exciting, many public health experts and sexuality educators, myself included, worry that in our rush to promote them we will forget to discuss condoms—or worse, suggest that condoms are not good at preventing pregnancy. We have seen the manufacturers of other birth control methods, such as emergency contraception, throw condoms under the bus by suggesting they break easily. Similarly, the infographics accompanying the Vital Signs document depict the efficacy of various methods—LARC methods are at one end, with few pregnancies, and condoms are at the other, with many.

Though the information is not inaccurate, it does not contain the nuance needed to remind young people that condoms can work very well to prevent pregnancy but have a low typical use efficacy rate because people often make mistakes using condoms: Most notably, they don’t use one every time.

We know that young people often use condoms as their first method of birth control and that those who use them the first time are more likely to do so going forward. We also know that many people rely on condoms when they are in between relationships or in between other methods. This is encouraging for individual and public health reasons, and emphasizing condom failure runs counter to the goal.

And perhaps most importantly, condoms are the only birth control method that provide protection from STIs, for which we know adolescents are at high risk. Adults concerned about teens’ health need to stress dual use for young people: “Even if you or your girlfriend has a LARC, you should still be using condoms.” This will not only protect them from STIs now; it will help ensure their future fertility, as untreated STIs can compromise the ability to become pregnant later in life.

Deborah Arrindell of the American Sexual Health Association (ASHA) explained to Rewire:

LARC are a fantastic addition to the pregnancy prevention [resources]. But unless we are very intentional about promoting dual use of condoms and LARC, we leave young people at risk for HIV and other STIs. In fact, what young women do to prevent pregnancy now, may leave them exposed to complications from STIs that may prevent pregnancy when they want it. Maintaining good sexual health can be challenging, and we need to do everything we can to promote comprehensive messages.

As a sexuality educator, I must also say that I fear LARCs will be seen as a substitute for teaching young people about sex. Sexuality education is already controversial and undervalued. Even educators, advocates, and elected officials who support contraceptive-inclusive sexuality education often sell it primarily as a way to prevent teen pregnancy, because that is more politically expedient than arguing for knowledge for the sake of knowledge. But programs that start and stop with pregnancy prevention—or even STI prevention—don’t help teens understand the characteristics of healthy interactions, examine their own values around sexuality, and think critically about issues such as consent, gender roles, and sexual orientation. 

As Debra Hauser, president of Advocates for Youth, told Rewire:

There are no magic bullets. Young people who wish to use LARC should have confidential, low or no cost access. But LARC will not help reduce sexual assault or young people’s risk for STDs. Nor will LARC, in and of itself, promote healthy relationships. Enthusiasm for the effectiveness of LARC and its ability to prevent unplanned pregnancy should not usurp the importance of helping young people acquire the information and skills they need to develop agency and take personal responsibility for their sexual health and well-being.

Knowledge for the sake of knowledge is important if we want young people to grow up sexually healthy—to understand how their bodies work, have the skills they need to create and sustain good relationships, and make responsible decision about pregnancy and disease prevention. LARC methods can prevent pregnancy, but they can’t do anything else.

We can and should be enthusiastic about LARCs for teenagers. They are safe and highly effective and can help our young people prevent pregnancy in their teen years and beyond. But as we promote these methods and increase access to them, we have to remember to look at the whole picture of sexual health and make sure we do not sell our young people short.

News Law and Policy

President Obama’s 2016 Budget Draws Praise, Criticism From Women’s Health Advocates

Emily Crockett

Including the Hyde Amendment in the president's budget isn't new. But advocates, and even some members of Congress, are working to make it news.

President Obama’s 2016 budget was praised by women’s health advocates for investing in health and economic security for families, but drew criticism for failing to take a stand on reversing a decades-old abortion funding restriction.

The budget includes a number of ambitious policy proposals that would benefit women and families in particular, and that reflect Democratic messaging about how women’s economic fates affect the entire country.

“The president’s budget contains a strong vision to improve the health and economic wellbeing of our families,” said Jessica González-Rojas, executive director of the National Latina Institute for Reproductive Health. “However, we remain concerned that low-income women and immigrant communities are left behind by many of the proposals.”

The budget triples the current child care tax credit, makes big investments in affordable child care, and expands paid sick and maternity leave. It proposes free community college for two years, and it gives tax breaks to families with two breadwinners. It would fund these policy priorities at the expense of the wealthy, with new taxes on inheritances, large banks, and overseas profits, as well as a higher capital gains tax and a limit on corporate tax deductions.

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But the White House’s budget also neglects one key factor in women’s equality and economic success: affordable access to abortion care.

“It is deeply disappointing to see this nation, year after year, renew the vast financial roadblocks that stand between millions of women in the U.S. and the health care they need,” Nancy Northup, president of the Center for Reproductive Rights, said in a statement.

The inclusion in the president’s budget of the Hyde Amendment—which has prohibited federal funds from covering abortion care except in cases of rape, incest, or life endangerment since 1976—isn’t new. But advocates, and even some members of Congress, are working to make it news, pointing out that the act discriminates against poor women of color in particular.

The ban includes women covered under Medicaid—who by definition can’t afford to pay for an abortion out of pocket—as well as Native American women, federal employees, women in prisons or immigration detention centers, and women in the District of Columbia.

In a letter to Office of Management and Budget Director Shaun Donovan late last month, 20 pro-choice House members on the Budget and Appropriations committees called for President Obama to take a bold stance against the Hyde Amendment by not including it in his budget.

The president’s annual budget request to Congress is a statement of policy priorities more than anything else, since Congress can choose to ignore anything it dislikes in the request.

“Withholding coverage for abortion care creates profound hardships for millions of women and families,” the letter reads, pointing to data showing that a woman is three times more likely to fall into poverty if she is denied the abortion care she seeks, and that a majority of women of color live in states that don’t use their own funds to pay for broader Medicaid abortion care.

“Given the continued assaults against women’s personal decision-making—including the ban on insurance coverage for abortion that recently passed the House—it is more important than ever that policymakers, including the President, oppose efforts by politicians to make abortion care more costly and out of reach,” González-Rojas said.

Obama’s budget lifts the ban on Washington, D.C., using its own funds to pay for abortion coverage through Medicaid—which it has year after year despite annual Republican moves to put the ban back into place.

Advocacy groups praised that move, and spoke approvingly of the president’s proposal to increase funding for Title X family planning programs and fund evidence-based teen sex education.

“Thanks to these programs, we have made tremendous progress in public health outcomes as a country,” Cecile Richards, president of Planned Parenthood Federation of America, said in a statement.

The budget calls for $300 million for Title X, the only federal program devoted to helping low-income people access family planning services. That’s a $13.5 million increase over fiscal year 2015, but 2015’s funding level was already low by historical standards.

Family planning has been one of many programs to suffer from the drastic, indiscriminate spending cuts under the federal government’s overwhelmingly unpopular sequestration.

President Obama has no interest in a budget that continues the sequestration cuts, he said Monday, and Congress should work with him to “replace mindless austerity with smart investments that strengthen America.”

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