Center for American Progress

Fact Sheet: Challenges and Solutions to Improve Access to Contraception Through Section 1115 Medicaid Waivers and SPAs
Fact Sheet

Fact Sheet: Challenges and Solutions to Improve Access to Contraception Through Section 1115 Medicaid Waivers and SPAs

This fact sheet accompanies a new Center for American Progress report on best practices to expand and improve access to contraception at the state level, covering common implementation challenges and offering recommendations to states pursuing family planning expansions through Section 1115 Medicaid waivers and state plan amendments (SPAs).

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A woman has her vitals checked at a family planning center.
A woman has her vitals checked at a family planning center in Jacksonville, Florida, on July 20, 2022. (Getty/AFP/Chandan Khanna)

Medicaid is a jointly funded federal and state partnership that provides health coverage to individuals and families who meet certain eligibility criteria.1 It is the largest payer of reproductive health services in the United States and is an essential provider of contraceptive care and other family planning and preventive services.2 More than 19 million women in the United States live in contraceptive deserts—areas with insufficient access to the full range of birth control methods.3 This burden disproportionately affects women of color,4 who also tend to report more negative health care experiences overall.5 To help address this crisis, states can explore a family planning expansion option through Section 1115 Medicaid waivers and state plan amendments.

However, there are common challenges to implementation that policymakers must be aware of and work to address. This is not an exhaustive list and is meant to create an informative foundation that states can build on to plan and create new programs and improve existing programs.

Challenge: Patient awareness and outreach

To reach out to new patients as well as inform existing ones of changes to Medicaid programs, state agencies must consider what options are practicable, accessible, and effective. In particular, they should pursue the following strategies:

  • Directly reach out to people who are currently enrolled or have previously been enrolled in publicly funded insurance programs and resources. For instance, some states have opted to work with family planning centers to engage existing clients who meet the specified eligibility criteria, which can also be beneficial for patient retention and enrollment.6
  • Adequately fund and staff hotlines and establish an easily accessible program website for people to get more information. While these are more passive forms of outreach activities, they are still useful for people seeking information.

Challenge: Ease of enrollment

A common barrier to expanding family planning access is lack of awareness regarding services and eligibility. States can avoid this by making enrollment as accessible as possible. Facilitating a smooth enrollment process is crucial to robust take-up and ensuring that patients are not discouraged by or forced to go through unnecessary hurdles. Additionally, more accessible application and enrollment processes can better reach populations that are disproportionately uninsured or underinsured for a variety of reasons.

Specifically, states can take the following steps:

  • Use automatic enrollment to help facilitate a smooth transition for people who are losing full Medicaid coverage but are still eligible for coverage under a Family Planning Only program, which most often happens during a small postpartum window.
  • Utilize providers as a point of outreach for enrollment. Some patients may prefer to apply for benefits in person with an available provider. In doing so, patients can apply for the program and receive services at the same time through a provider outreach and enrollment strategy.
  • Use presumptive eligibility in Medicaid enrollment. This process allows health care providers to determine that a patient is temporarily eligible for coverage, with applications for ongoing coverage processed later by the state.

Challenge: Compliance with the freedom-of-choice provision

Under the freedom-of-choice provision, Medicaid enrollees have the right to receive family planning services from any qualified provider.7 However, studies have found that this provision is generally not well understood by enrollees and sometimes ignored by states, and thus patients are unable to take full advantage of their options.8 Furthermore, some states have excluded providers that offer abortion services from participating in Medicaid, even though these are sometimes the main providers of comprehensive family planning services.9 Moving forward, states should be careful that they:

  • Don’t carve out or restrict certain family planning providers from care through waivers or SPAs.
See also

Challenge: Robust data collection and evaluation

The impact of comprehensive data cannot be understated, as they can encourage family planning expansion programs and uptake in other states. There is a need for more consistent, up-to-date, reliable, and comprehensive data on Medicaid and family planning. Accordingly, states must:

  • Conduct data collection and evaluation measures through state departments of health or other social services agencies. States might also find it worthwhile to contract with outside organizations, such as local universities and research institutions, to be independent evaluators.


As the largest payer for reproductive health services, Medicaid is a necessary and vital public program for pregnant and postpartum women, low-income women, uninsured or underinsured women, women of color, and disabled women. States that have expanded family planning benefits under Medicaid have seen benefits such as increased cost-effectiveness and decreases in unintended pregnancies. While Section 1115 waivers and SPAs both have their benefits and drawbacks, each offers a way to make meaningful change for not only access to birth control but other crucial preventive services. Policymakers can look to some of the states mentioned in the full report10 as models on how to initiate and design a program that is tailored properly to their respective state’s needs.


  1. U.S. Department of Health and Human Services, “What is the Medicaid program?”, available at (last accessed December 2022).
  2. Ivette Gomez and others, “Medicaid Coverage for Women,” Kaiser Family Foundation, February 17, 2022, available at
  3. Power to Decide, “Contraceptive Deserts,” available at (last accessed December 2022).
  4. Rebecca J. Kreitzer and others, “Affordable but Inaccessible? Contraception Deserts in the US States,” Journal of Health Politics, Policy and Law 46 (2) (2021): 277–304, available at
  5. Molly R. Altman and others, “Information and power: Women of color’s experiences interacting with health care providers in pregnancy and birth,” Social Science & Medicine 238 (2019), available at
  6. Ibid.
  7. Omnibus Budget Reconciliation Act of 1981, Public Law 35, 97th Cong., 1st sess. (August 13, 1981), available at
  8. Jocelyn Guyer and others, “Medicaid Family Planning Programs: Case Studies of Six States After ACA Implementation” (San Francisco: Kaiser Family Foundation, 2017), available at
  9. Julian Polaris and Cindy Mann, “Restoring Women’s Access to Medicaid Family Planning Services,” The Commonwealth Fund, July 21, 2021, available at (last accessed February 2023).
  10. Kierra B. Jones, “Advancing Contraception Access in States Through Medicaid 1115 Waivers and State Plan Amendments” (Washington: Center for American Progress, forthcoming 2023).

The positions of American Progress, and our policy experts, are independent, and the findings and conclusions presented are those of American Progress alone. A full list of supporters is available here. American Progress would like to acknowledge the many generous supporters who make our work possible.


Kierra B. Jones

Senior Policy Analyst


Women’s Initiative

The Women’s Initiative develops robust, progressive policies and solutions to ensure all women can participate in the economy and live healthy, productive lives.

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