Ed’s Note: Kathy Kneer is the president and CEO of California Planned Parenthood. Capitol Weekly’s Alex Matthews caught up with Kathy recently for a wide-ranging discussion that included health care, family planning, meeting the needs of low-income Californians and the challenges of the Affordable Care Act.
Capitol Weekly: How has the ACA and the Medi-Cal expansion affected Planned Parenthood and other providers of similar services?
Kathy Kneer: The Affordable Care Act provided women, particularly single women, with access to comprehensive health care for the first time, for women who were low income. Low income women — women within above 138 percent of the federal poverty level — are now eligible for full benefits under the Affordable Care Act, and further the Affordable Care Act allows them to have preventive care with no copay, and reproductive healthcare for birth control and annual preventive health exams is now free for that group of women. We have been serving women up to 200 percent of the federal poverty level in the Family PACT program, but the Affordable Care Act gave them coverage, gave some women coverage, with no copays, and access to fuller care.
CW: Has that reduced demand for the low-income services provided by Planned Parenthood and Family PACT?
KK: Looking at the impact of the Affordable Care Act on Planned Parenthood, in general, it’s increased the number of people who are eligible for reproductive health services and we certainly are seeing the influx of new patients as a result of the Affordable Care Act. Demand for reproductive healthcare services has been impacted by two other major factors. One was the change in the screening guidelines. Cervical exams and pap smears went from every year to every three years, so that changed a need for women to come in on an annual basis to get their birth control. Now they don’t have to have a pap smear and it can be done with a middle exam … With the new IUD’s that are available, we have been providing women who have reached their desired family size with an IUD which is long acting, could be to five years, so that’s impacted demand. So we can’t specifically say ACA has decreased demand. It’s increased the number of women we’re seeing, but our overall demand has changed, and we believe long-acting birth control such as an IUD or the change in screening exams is more of the cause for the slight decrease in demand we’ve seen.
CW: For our readers who aren’t familiar with it, how does Family PACT help low-income Californians?
KK: In 1996, Governor Wilson established the Family PACT, which is Family Planning Access Care and Treatment, and he developed a program to make sure that all low-income women up to 200 percent of the federal poverty level have access to free reproductive healthcare. It was not comprehensive services; it was just reproductive health care. He started that program as state-only program, using state General Fund dollars. When Governor Davis became governor, he converted that state-only program into a state plan amendment, which allowed it to grow to its current peak of about 1.8 million women. So it was a major program, not just in California but for the whole country, it expanded access to family planning services. When it became part of the (federal) waiver, it had to be evaluated for cost effectiveness, and that’s when the evaluation of that expansion showed that for every dollar the state spent on family planning it saved four dollars in the first year, and then over four years it saved the state up to nine dollars, in state and federal dollars.
CW: What about Family PACT and the Medi-Cal expansion? Haven’t there been changes?
KK: You’re correct that there have been changes …The Family PACT program provided services for up to 200 percent of the federal poverty level. When the Affordable Care Act began, the women who were up to 138 percent, who we were seeing in Family PACT, were now eligible for Medi-Cal. So one would expect to see those patients migrate over into the Medi-Cal program. One caveat is that the Family PACT program does provide services for undocumented women, and they are not eligible for full scope, so they will remain in the Family PACT program. But by and large, the overwhelming majority of women in Family PACT are eligible now for Medi-Cal, so we have seen that transition happen in our affiliates. We operate about 115 health centers, that transition varies, it’s not uniform, but we have seen in some cases a gradual, in some cases a more accelerated, transition from Family PACT into Medicaid, and they are most likely in Medicaid managed care plans
CW: Some providers who focus exclusively on family planning and reproductive health have had to shut down or merge with others because they have lost Family PACT patients. Has that affected Planned Parenthood?
KK: Yes, none of us are immune to market forces, and how we’ve tried to adapt that depends on the locality and what the needs are of that community. For instance, our Orange County affiliates decided to offer full primary care for women of reproductive age, 18 to 55. So they are seeing full primary care for women, and that transition of women on Family PACT into managed care hasn’t been fully felt because they’re now doing that full primary care. In some areas, we’ve expanded to doing prenatal care because of the shortage of prenatal care providers. In other areas, we’re just seeing a decline in the number of visits, so we’re looking at ways to make sure patients know they can still come to us. At the end of the day, there’s a provider shortage in California, particularly in Medi-Cal managed care, because of the reimbursement rates … We’re still a central component of the managed care system and the delivery system and the safety net system, so our goal is to make sure that we can be there for patients.
CW: What about the issue of low reimbursement rates? It is always a major political/health issue in the Capitol. Are you involved in that?
KK: We’ve done a couple things: We’ve tried to adjust the provider rates, working with a coalition, trying to get the governor to expand reimbursement rates. One example was after the Affordable Care Act, the federal government recognized the provider shortage, recognized low participation in Medicaid, and they provided a rate increase for primary care providers for the first three years of the Affordable Care Act. When that was in place a lot of doctors in private practice started accepting Medicare and Medicaid patients because the federal government paid 100 percent of that. When that portion of the Affordable Care Act expired, some states elected to continue because they saw that rates were essential to having adequate networks of providers, but Governor Brown has not done that. With the loss of that rate increase for primary care, providers dropped out. So that’s really one thing we lobbied hard to get the governor to continue that provider rate increase, but he did not do it. Another thing, which is what we’re working on today and dedicating time energy and resources, is the passage of Prop. 56, the tobacco tax initiative, because that program is going to provide new money into the Medi-Cal system … So it’s absolutely essential for the networks of providers of Medi-Cal that Prop. 56 is passed, so that we can maintain access for patients to a provider and have them not rely on the emergency room as their provider.
CW: Can you tell me a little bit about the populations that Planned Parenthood serves in California?
KK: … Overall the majority of our patients are eligible for Medi-Cal; we have very few that are over Medi-Cal eligibility. Even though Medi-Cal is 138 percent and Family PACT goes up to 200 percent, I still think our patients are below even the 138 percent base. Our practice, if you will, is overwhelmingly Medi-Cal patients. In terms of geographic distribution, we do have 115 health centers that are throughout the state that we try to provide the best we can geographic access, but it’s a big state, so there’s still communities we believe are underserved, but we don’t have the capacity to serve them. Even in areas that have primary care providers, what’s interesting with our expansion into primary care in Orange County, I was talking with our local CEO, and what we find is that all these new patients who are coming to us and getting into primary care for the first time, it’s somewhere around 60 to 70 percent of the women who were coming to us for our primary care were not on a method of birth control, it’s actually higher than that. We have to re-crunch some numbers, but it’s like 80 percent of the patients coming are not on a birth control method when they come for their first visit, but like 60 to 70 percent of them leave with a birth control method.
CW: You already mentioned Prop. 56, but are there any other issues you are targeting?
KK: I would say from a California perspective, Prop. 56 is our number one priority, hands down. Overall, from a national perspective, our biggest concern is that if Donald Trump becomes president he would take action to defund our Planned Parenthood affiliates across the country … The Medicaid program under federal rules must be open to any provider who meets Medi-Cal standards, and of course we do. Donald Trump would follow other Republican predecessors by saying ‘Well if you do abortion you can’t be in the Medi-Cal program.’ The president would have the power working with Congress to strip Planned Parenthood of participation in the Medi-Cal program. It’s not really just defunding us, it’s defunding access for the patients because oftentimes we are their provider of choice, or we’re their only choice, so we have to make sure at a national level that that doesn’t happen. We will do everything we can to make sure that Donald Trump is not the President of the United States.
CW: California’s political landscape differs from the rest of the country. Are the challenges here different those facing Planned Parenthood in other states?
KK: There are some things that are similar, but it’s true that if you live what we call one of the red states where the Legislature and the governor’s office are controlled by anti-choice Republicans, and it’s important to put ‘anti-choice in front of the word Republican. These days there are very few moderate Republicans who support reproductive healthcare. There are a handful at the state and national level, but by and large the Republican party and Republican party platform is now completely anti-choice. In those states, they’re not just putting restrictions on Planned Parenthood, they’re also practicing medicine and making changes on ultrasounds for abortion, and they’re putting all sorts of restrictions on that are not medically necessary and are meant to deter women from making a free informed decision, forcing women to hear biased counseling. It’s things like that we’re able to stop here … If you heard about the fetal tissue video, three of the doctors that were in those first videos were in California. Those videos were illegal … California has a right to privacy, and it is illegal to tape a conversation without consent in California. What’s not illegal is to distribute your illegal recording. So if you currently make an illegal recording, you might get a $2,500 fine, but that’s it, there’s a possibility of jail sentence, but it’s very minimal. And the reality is if you distribute it, there’s no harm done, but the harm to us and to our doctors is enormous, and we need the law (AB 1671) to protect our doctors, so they’ll stop the distribution of these illegal videos.
CW: You’ve developed apps to help women get STD tests and track other health issues. Can you tell me more about using technology at Planned Parenthood?
KK: I don’t know if you’ve seen, but the national office developed an app called ‘Spot On,’ it’s a period tracker app. It’s not relevant for me personally, but some of our younger staff use it, I hear quite good things about the app, and it looks like it was the number one app in Apple or Android, I don’t know which, but it’s very, very popular. We have some technical challenges. We have developed an app called PP Direct, which is only available here in California. That’s to do STD testing: where you download the app, you pay a fee of $129, you fill out your medical history, and we send you then a test kit to give us a urine sample, you mail it to our lab, and our lab can then generate your results. We’ve been modestly successful with that, but it’s only right now geared for patients who can self-pay, so you can imagine $129 is prohibitive for someone on Medi-Cal. We also want to expand the app to do birth control and Urinary Tract Infection, and again, we have to do it first as a self-pay model. We really want to make it available for family planning services for Medi-Cal women and Family PACT women, but the State of California is not interested unless it saves them money … If we can’t make cheaper than the cost of an office visit, they won’t approve us to use it, which is nonsensical, because expanding access to contraception saves them more money. So we’ve been very disappointed in their response to using this app as a way to expand access to the places we can’t build a clinic.