Texas Policy Evaluation Project
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Letter to Texas Health and Human Services Commission Regarding the Healthy Texas Women 1115 Waiver

[Download a copy of the PDF here]

June 12, 2017

To: Jami Snyder Associate Commissioner,
Medicaid and CHIP Services Texas Health and Human Services Commission

Sent via email to: TX_Medicaid_Waivers@hhsc.state.tx.us
Re: Healthy Texas Women 1115 Demonstration Waiver

Dear Ms. Snyder:

As a group of academic researchers with the Texas Policy Evaluation Project (TxPEP), we appreciate the opportunity to comment on the Texas Health and Human Services Commission’s (HHSC) Section 1115 family planning waiver application. Based at The University of Texas at Austin Population Research Center, TxPEP’s mission is to conduct methodologically principled research that evaluates the impact of reproductive health policies and programs in the state of Texas and to communicate the results to a broad audience.

According to HHSC materials about the 1115 family planning waiver application, also known as the Healthy Texas Women (HTW) Demonstration, its first goal is to: “Increase access to women's health and family planning services.” This letter discusses the recommendation that the waiver application request permission to cover men’s vasectomy services. We also outline two additional recommendations that will enhance services through the use state funds that are already allocated for the program. All three recommendations will improve the HTW program and help HHSC achieve its goal of increasing access to family planning services.

Recommendation #1: Cover vasectomy services for men. Although vasectomy poses fewer surgical risks and is more cost effective than tubal sterilization, few family planning organizations in Texas offer vasectomy. Through interviews we conducted with program administrators at 54 family planning organizations across Texas, we found that two-thirds did not offer vasectomy on-site or pay for referrals with family planning funding; only 9 organizations frequently provided vasectomy.1 Lack of funding was one of the main reasons that organizations did not offer vasectomy: low-income men are not eligible for services through many of the state’s family planning programs, and some program administrators viewed the procedure as too costly to make it widely available through the other grant funding they received. Our study, and other research we have conducted in Texas,2 also indicate that men are interested in vasectomy, particularly when they have access to accurate information about the procedure and know where to obtain affordable services.

Currently, there are 20 states that include men in their family planning expansion programs, including five states that continue to operate these programs as waivers.3 By including vasectomy as a covered service in the HTW Demonstration, Texas would expand contraceptive options available to low-income men and couples in the state.

Recommendation #2: Provide technical assistance and continuing education on evidence-based practice for new providers. With the exclusion of Planned Parenthood from state family planning programs, Texas has increasingly relied on primary care providers to deliver family planning services. Our research demonstrates that many of these providers lack the necessary capacity to provide evidence-based family planning services.4 One year after the creation of the Expanded Primary Health Care (EPHC) program, we interviewed program administrators at 30 of the 52 EPHC-funded organizations, two-thirds of which were primary care contractors (e.g. community health centers, public health departments). Clinicians at primary care sites often lacked training and proficiency to provide intrauterine devices and contraceptive implants, limiting the availability of these long-acting contraceptive (LARC) methods. They also described contraceptive provision protocols that required women to make multiple visits for medically unnecessary services or denied LARC methods to teens or women without children, contrary to medical guidelines.5

Because many primary care organizations in the provider network lacked necessary capacity to provide evidence-based services, we recommend that the state use some of the savings generated should the wavier application be successful to provide technical assistance and continuing education for new providers in the HTW network. This could include training on insertion and removal of LARC methods and continuing education on evidence-based family planning practices through webcasts and practice alerts. The state also could consider requiring documentation of continuing education about the provision of contraception. This will ensure that all providers in the HTW network have the training necessary to provide the full range of methods to all eligible women so that they have timely access to the methods they would like to use to prevent pregnancy.

Recommendation #3: Provide HTW and postpartum benefits to undocumented women meeting the income criteria. The current set of family planning programs for low-income Texans provide limited support to women who do not meet the residency/citizenship requirements of both Health Texas Women and pregnancy Medicaid. While Title X sub-recipients and HHSC Family Planning Program contractors are not bound by this constraint, together these programs do not provide coverage wide enough to permit broad access for this important population group. This, in turn, constitutes a major challenge for providers, including those providing immediate postpartum contraception, who want to provide equivalent services to all of their low-income patients. Recognizing that federal funds could not be used for this purpose, we recommend that some of the funds the state would save with the waiver be used to expand coverage to undocumented women of reproductive age who meet the HTW income criteria. Moreover, we recommend that family planning coverage be extended to undocumented women in the postpartum period, similar to that recently implemented in Michigan.6

We are grateful for the opportunity to submit comments on the Healthy Texas Women waiver application. We hope that HHSC will consider our suggestions to expand the scope of the waiver application, which will greatly increase the ability of low-income Texans to achieve their family planning goals.


Joseph E. Potter, PhD Professor University of Texas at Austin Principal Investigator, TxPEP
Kari White, PhD, MPH Assistant Professor University of Alabama at Birmingham Investigator, TxPEP
Kristine Hopkins, PhD Research Assistant Professor University of Texas at Austin Investigator, TxPEP
Daniel Grossman, MD Professor University of California, San Francisco Investigator, TxPEP

1 White, Kari, Anthony Campbell, Kristine Hopkins, Daniel Grossman, and Joseph E. Potter. 2017. “Barriers to offering vasectomy at publicly funded family planning organizations in Texas.” American Journal of Men’s Health http://journals.sagepub.com/doi/10.1177/1557988317694296
2 Hubert, Celia, Kari White, Kristine Hopkins, Daniel Grossman, and Joseph Potter. Forthcoming 2016. “Perceived interest in vasectomy among Latina women and their partners in a community with limited access to female sterilization.” Journal of Health Care for the Poor and Underserved 27(2):762-777.
3 https://www.guttmacher.org/state-policy/explore/medicaid-family-planning-eligibility-expansions
4 White, Kari, Kristine Hopkins, Daniel Grossman, and Joseph E. Potter. “Integrating family planning and primary care at publicly funded organizations in Texas to repair the reproductive health safety net” Contraception 2015; 92(4): 369-370.
5 U.S. Medical Eligibility Criteria for Contraceptive Use, 2016; https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6503.pdf
6 http://www.michigan.gov/documents/mdhhs/MSA_16-47_547266_7.pdf 

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