Bixby Center for Reproductive Health Research & Policy University of California, San Francisco Eliminating Health Disparities by Increasing Access to Family Planning Services: California’s Family PACT Program Claire Brindis, DrPH, Antonia Biggs PhD, Gorette Amaral, MHS, Diana Foster PhD, & Heike Thiel de Bocanegra, Ph.D.

Family PACT (Planning, Access, Care, and Treatment) Program Established by the California legislature in 1996 Purpose: to provide family planning and reproductive health services at no cost to California’s low income residents of reproductive age. Goal: Prevent unintended pregnancies and sexually transmitted infections (STIs)

Family PACT Program Eligibility At or below 200% of the Federal Poverty Level Women, men and teens of reproductive age (women up to age 55, men up to age 60) At risk of childbearing (excludes pregnant or sterilized men and women or those not of reproductive age) Uninsured 3

Reduced Barriers in Family PACT (as of June 1, 2007) Personal, Confidential, No Cost, FPRH Services On site client enrollment by health care provider Teens qualify as their own family of one and are encouraged to seek services prior to the onset of sexual activity. Undocumented immigrants are eligible (paid by state only funds) Public and private sector providers throughout State Telephone system for Referrals

Family PACT Services All FDA approved birth control methods, including new ring, patch and Implanon EC available in advance of need Pregnancy testing and counseling Basic health assessments including expected adolescent changes STI testing & treatment HIV testing Limited female and male cancer screening Client-centered FPRH education and counseling Linkages with TPP programs 5

Family PACT’s Centers for Medicaid and Medicare Services (CMS) Waiver 12/ /2004 (plus extensions) Demonstration Project and Purpose:  “Reach the Hard to Reach and Keep the Hard to Keep” Goals Focus on These Special Populations:  Adolescents  Males  Women in high unmet need areas 6 Years of the Waiver have resulted in $1.5 billion Federal Funds to California  $3 out of $4 spent on FPACT derived from federal funds

Growth in Number of Clients Served by Family PACT

Clients Served by Age and Gender, FY The client population is 89% female, 11% male 1 in 5 clients are teens Nearly two-thirds (63%) are between the ages of

Clients Served by Race/Ethnicity, Primary Language and Income, FY 05-06

5-Year Growth Rates in Clients Served by Ethnicity

Trend in the Number of Enrolled Clinician Providers Delivering Family PACT Services by Provider Type In FY 05-06, 2,100 enrolled clinician providers delivered Family PACT services.

Profile of Family PACT Clients Served by Provider Sector, FY 05-06

Percent of Female Clients Served by Method Provided and Race/Ethnicity, FY 05-06

Patterns of Birth Control Use by Race/Ethnicity Latina women were provided with highly effective, long-acting methods slightly more frequently than women of other groups (13% vs. 7-11%). Latina and African American women received contraceptive injections at the highest rate (11% and 10% respectively), while Asian/Filipino/Pacific Islander women received injections at the lowest rate (6%).

Patterns of Birth Control Use among Latinas, FY African American women received OCs (26% vs. 29% - 50%) and IUCs (0.5% vs %) less often than any other group. White women received barrier methods at the highest rate (51%) and Latina women at the lowest (42%). White women were dispensed OCs (50% vs %), the vaginal ring (6% compared to 2 - 5%) and ECPs most frequently (35% vs %).

Provision of Contraceptive Methods to Family PACT clients resulted in: 204,950 unintended pregnancies averted to female clients 8,300 unintended pregnancies averted to males

Pregnancies Averted The 204,950 pregnancies averted to female clients in CY 2002 would have led to: Sources: Hatcher R, Trussell J, Stewart F, Cates W, Stewart G, Guest F, Kowal D. Contraceptive Technology. New York, NY: Ardent Media; Trussell J, Koenig J, Stewart F and Darroch J. Medical care cost-savings from adolescent contraceptive use. Fam Plann Perspect. 1997;29(6):248-55,295. Henshaw S. Unintended pregnancy in the United States. Fam Plann Perspect. 1998;30(1):24-29,46. Saraiya Mm, Berg CJ, Shulman H, Green CA, Atrash HK. Estimates of the annual number of clinically recognized pregnancies in the United States, Am J Epidemiol. 1999;149(11):

Each Pregnancy Draws on Health & Social Programs Medical costs: Medi-Cal Healthy Families Children with special needs: California Children’s Services Early Start Supplemental Security Income (SSI) Income support programs: Cal-WORKs cash grants, employment services, and special pregnancy payment Food Stamps WIC Other social service programs: Cal-WORKs Stage 1 child care California Department of Education’s child care and development programs Foster care Head Start/Early Head Start Pregnant or parenting teens: Cal-Learn Cal-SAFE Adolescent Family Life Program

Cost Benefit Ratio For every dollar spent, Family PACT saved $2.76 up to two years after pregnancy and $5.33 up to five years after pregnancy Total costs averted Family PACT expenditures Ratio 2 yrs after pregnancy $1.1 billion÷$403.8 million=$ yrs after pregnancy $2.2 billion÷$403.8 million=$5.33

Conclusions The Family PACT program serves a large and diverse population, while gaining significant public cost savings. Clients’ ability to choose the type of provider, point of service enrollment and reproductive health services have been key factors in its wide acceptability. As nearly 60% of Latinos are uninsured (vs 23% whites) and 1/3 of women (ages 18-64) live at or below 200% of poverty, the program has made significant inroads in serving the under-served.

Implications for Policy, Delivery or Practice Cost-effective programs are feasible, while diminishing traditional barriers to care. Creating programs that respond to the multitude of needs of different client sub-groups, including ethnic/racial, age and gender, is doable. Eliminating barriers to care for fundamental services as symbolized by family planning care should be considered in eliminating health disparities.

Bixby Center for Reproductive Health Research and Policy, University of California, San Francisco Claire Brindis,