Wisconsin family planning advocates, providers, and citizens of reproductive age received another gift to be thankful for during the holiday season. Wisconsin became the first state in the nation to win approval of a Medicaid (MA) State Plan Amendment (SPA) — making our very successful MA Family Planning Waiver a permanent part of our MA plan.  Helping women and men protect their sexual health and future fertility; helping them take charge of timing their childbearing; helping them get testing and treatment for STDs; helping them complete their education and/or get the job training they need; these are perfect gifts in these tough economic times.

At the beginning of the year, Speaker-to-be John Boehner denounced inclusion of the plan in the American Recovery and Reinvestment Act to make it easier for states to expand their MA family planning programs saying it would not stimulate the economy. Speaker Nancy Pelosi seemed unprepared to make the economic argument for family planning services and President Obama pulled the language with a promise to bring it back later.

President Obama kept his promise. The Patient Protection and Affordable Care Act included language empowering states and the District of Columbia to have much easier access to federally-funded family planning services. In April, the Wisconsin Family Planning and Reproductive Health Association began working diligently with the Wisconsin Department of Health Services and the state MA program to enable and encourage an early application for an effective program.  Using blogs, letters-to-the-editor, web video interviews, and even a professional lobbyist, we tried to inform legislators and advocates from Wisconsin as well as from other states and the District of Columbia about the opportunity. We hoped to establish a context where legislative leaders and state employees would feel they had a solid basis to proceed with an MA State Plan Amendment in Family Planning.

Faced with an end-of-year expiration of our existing Family Planning Waiver and armed with convincing evidence of cost-efficiency, our pro-family planning administration in Wisconsin submitted a request to make our family planning program larger and permanent.  Wisconsin submitted a request before the Centers for Medicaid and Medicare Services even established the criteria. In an April 2010 RHRealitycheck.org blog, advocates set out our “recipe” for success:

• Presumptive eligibility for immediate contraceptives and STD services.
• Full eligibility must be processed quickly.
• Income eligibility must be broad.
• Covered comprehensive services must include most contraceptive methods and Emergency Contraception.
• Eligibility for students and minors must be based on their own income.

On December 22^nd Wisconsin’s application was approved.  Although there were a few points of negotiation and compromise on structural points, all of the ingredients in our “recipe” were included.  California and South Carolina have also applied for SPAs and are in the queue for approval.

The celebration is justified and the victory is truly monumental.  However, there is no time to be self-satisfied. In Wisconsin, a new anti-choice administration and an anti-choice legislature is almost certain to test the federal maintenance of effort requirements for the family planning program.  Although the program has established its cost-efficiency, ideologues are likely to try to use the budget pressures of a tough state economy as cover for efforts to dismantle the program.  Because they have repeated it so often, the opposition believes that access to family planning and sexual health care undermines parental authority and encourages promiscuity.

Although the political battles are formidable, I don’t think the ideologues at the gates are the greatest challenge ahead to family planning and reproductive health access.  I think our greatest challenge is our own vision for change in the new environment of primary preventive health care.  How will we make the transition to electronic health records? How will we collaborate with other primary care providers? Will we see ourselves or be seen as competitors and be marginalized by our unwillingness or inability to be a part of the emerging systems?  Even though Medicaid patients have a choice of provider for reproductive health care, how will we be their provider of choice? Are we ready to negotiate contracts with Health Maintenance Organizations (including state Medicaid plans) and to participate in the new Health Exchanges? 

These challenges cannot be trusted to fortune. While the opponents of sexual health care must be vigorously resisted, we must simultaneously articulate and achieve a new complementary role for family planning programs and clinics in the reformed health care world.  If we fail, the fault will not be our opponents or in our stars, it will be our own.