Washington State’s TAKE CHARGE program, which began July 2001,
expands Medicaid coverage for family planning services to men and women with
family incomes at or below 200% of the federal poverty level (FPL). Program
goals are to improve the health of women, children and families in Washington by
reducing unintended pregnancies and lengthening intervals between births and to
reduce state and federal Medicaid expenditures for births from unintended
pregnancies and their associated costs. The Health and Recovery Services
Administration (HRSA), formerly the Medical Assistance Administration (MAA), of
the Department of Social and Health Services administers this program.
This final evaluation report describes the first five years of program
implementation, from July 1, 2001, to June 30, 2006. Data sources include client
surveys, Medicaid claims data and eligibility history, and birth certificates
from the First Steps Database.
FINDINGS
PROGRAM
PARTICIPATION
Washington’s TAKE CHARGE program
enrolled more than 335,000 clients in the first five years of the
demonstration. While 94% (N=314,626) of the enrolled clients were female,
21,131 were male.
The number of newly enrolled
clients (Program G) (N=248,669) was nearly twice the number of clients who
were automatically enrolled in the post-pregnancy extension (Program S)
(N=116,139).
Over two-thirds (67.3%) of female
clients enrolled in the first five years were between the ages of 18 and 29.
The same age group accounted for 74% of Medicaid-paid births in 2004.
PROVIDER ENROLLMENT
As of January 2005, TAKE CHARGE providers offered services in
199 clinics throughout the state.
PROGRAM OBJECTIVES Four of five program objectives described in the initial
application (December 1998) have been achieved, or exceeded. The fifth objective
about raising provider awareness of unintended pregnancy prevention represents a
long-term goal and a number of initial steps to facilitate this objective have
been completed.
An estimated 22% of the women
eligible under the waiver, who would have had an unintended pregnancy,
remained pregnancy free.
The proportion of clients using a
more effective family planning method increased from 53.0% at enrollment to
70.6% one year later. The proportion that reported using abstinence in the
prior two months remained steady at 11.3%.
The number of Medicaid women
(including TAKE CHARGE clients) who received services from family planning
clinics increased from 22,850 during the baseline year to 85,607 in year one,
108,253 in year two, and 121,997 in year three.
The number of Medicaid men
(including TAKE CHARGE clients) receiving family planning services increased
from 850 during the baseline year to 3548 in year one, 4384 in year two, and
5018 in year three.
FERTILITY RATES
For the first three years, fertility rates for participants were
very similar to birth rates for Washington women overall, 61 – 63 births per
1000 women 15-44. After the first three years, fertility rates for demonstration
participants decreased, reaching a level well below the statewide fertility rate
in years four and five (41 – 42 per 1000). Restricting the fertility rate
computation to births occurring after enrollment in TAKE CHARGE resulted in much
lower rates (5 – 7 per 1000), comparable to failure rates for more effective
contraceptive methods.
CHARACTERISTICS OF FEMALE CLIENTS
Women with a history of a birth were older (mean 26.3 years)
than clients without a history of a prior birth (mean 22.9 years). Overall, half
the clients with a birth (50.1%) were married at their most recent birth. Asian
women (62.0%)
and women of Hispanic ethnicity (56.7%) demonstrated the highest proportion of
those married at their most recent birth. The lowest proportion was among Native
American women (27.3%). Clients married at their most recent birth were older
(mean 26.9 years) than clients who were not married (mean 23.0 years). The
average total number of births was higher for married clients (mean 2.4) than
for unmarried clients (mean 1.7).
CLIENT SERVICES Of the total enrolled clients in years one through four
(N=289,187), 80% received one or more covered medical family planning service.
How clients were enrolled in the program was strongly related to differences in
service use. Nearly 95% of newly enrolled female clients received one or more
medical family planning services, compared to 47.9% of recently pregnant women
who were automatically enrolled. Among program participants, however, the
proportions who used oral contraceptives and hormone injections were similar,
and recently pregnant women had higher rates of use for the transdermal patch
and IUDs.
CLIENT SELF-EFFICACY
Client survey questions about contraceptive self-efficacy
indicated slight increases in this measure one year after program enrollment;
questions in other self-efficacy domains showed non-significant changes, or
changes that reflected reduced self-efficacy, or perhaps more realistic
expectations on the part of the clients. It had been hoped that client-centered
practice would result in overall improvements in client self-efficacy; however,
only contraceptive self efficacy showed slight increases.
CONCLUSION: TAKE CHARGE has demonstrated a remarkable
impact on access to and provision of family planning services in Washington
State. Concepts of client-centered Education, Counseling, and Risk Reduction are
beginning to diffuse throughout the state and establish a new standard of care
for family planning practice. Demographic profiles of female clients suggest
that the program is helping younger, unmarried women avoid unintended pregnancy
until they are older and potentially married. While the proportion of female
clients using more effective family planning methods increased more at
Intensive Follow-up Services (IFS) sites compared to controls, the high cost of
IFS precluded statewide expansion. Client centered practice and individualized
follow-up will receive greater emphasis in future program activities and
trainings. Women with automatic extension of eligibility for family planning
services in the post-pregnancy period were modest users of family planning
services. How TAKE CHARGE can be more effective in reaching this group
remains to be explored.
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report: "Take Charge: Final Evaluation, First Five Years: July
2001-June 2006."
Publication Date: 9/2006. Report Number: 9.83, (752 KB)
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Copyright 2004 Washington State Department of Social and Health Services.
TAKE CHARGE