Women need access to comprehensive health and social services in order to thrive as breadwinners, caregivers, and employees. How do we ensure that women have access to a full spectrum of quality, affordable, and women-centered services? In celebration of Women’s History Month, the Health Care Council of Chicago (HC3), in partnership with iCAN! (Illinois Contraceptive Action Now), hosted a virtual discussion on March 27 to address the intersectionality of policies, access, and innovation happening in Illinois to advance women’s health equity.
Moderator:
Katie Thiede, Executive Director, iCAN! (Illinois Contraceptive Action Now)
Panelists:
Amber Kirchhoff, Director, Public Policy + Governmental Affairs, IPHCA (Illinois Primary Health Care Association)
Chi Chi Okwu, MPH, Executive Director, Everthrive
Debra Stulberg, MD, Professor and Chair of Family Medicine, University of Chicago
Kai Tao, ND, MPH, CNM, Co-founder & Principal, Impact and Innovation, iCAN! (Illinois Contraceptive Action Now)
NEWS COVERAGE Health News Illinois. Stakeholders Discuss Barriers to Family Planning. March 29, 2023. Article here
Watch the Recap
Event Recap
Moderator’s Remarks
Katie Thiede (KT): The topic of today's session is a big one, and while there are many critical issues impacting women's health and family planning, the focus of our discussion will be on contraceptive access and quality. Today’s panelists will share their unique perspectives on how family planning services are delivered, accessed, paid for, and much more. That said, women and people who can become pregnant certainly do not experience contraceptive care and family planning needs in a vacuum, and the work to expand access and improve quality is intersectional and multifaceted. Thus, I invite the panelists to draw broadly on their experiences in the field of women's health and family planning.
Panelist Introductions
KT: I would like to invite each panelist to briefly introduce their role and share an example of how they are personally and/or professionally advancing women's health and family planning opportunities within their organization and/or within the greater ecosystem.
Chi Chi Okwu, MPH (CO): Everthrive is a reproductive advocacy organization. Our goal is to ensure that all people have the right to decide when and how to start a family, that they have the right to a safe and healthy birth, and that they can raise their family in a safe and healthy community. We have several initiatives and focus areas. For example, over the past two years we have been working to engage in communities with the highest maternal mortality and morbidity rates to try to understand what challenges and barriers exist. Through surveys and focus groups, Everthrive developed the Gathering Campaign to raise awareness of maternal health disparities in different communities. One of our learnings was that many people, especially in these communities with high disparity rates, still don't know this is even an issue. This is something that really impacts how we think about family planning and what it looks like in our different communities. So, we have been developing a training tool for different community groups and providers to help build bridges for a deeper understanding of the needs we are seeing in communities most impacted by these disparities. We are very proud of this work in Chicago and hope to see more throughout the state to ensure that people are aware of their options and that we can begin to work on more solutions.
Debra Stulberg, MD (DS): I bring a few different perspectives to the conversation, first as a physician – I have been seeing patients at Friend Health for over 15 years on the south side of Chicago; second, I serve as a volunteer on the board of directors at Midwest Access Project, which focuses on training frontline providers in comprehensive reproductive health service; and third, my main role, where I spend the majority of my time, is as a professor and department chair of family medicine at the University of Chicago. Through my faculty position, I conduct research. My focus is improving reproductive health care and outcomes and reducing racial and socioeconomic disparities in reproductive health in the United States.
Kai Tao, ND, MPH, CNM (KT): I’m the principal and co-founder of iCAN! and have practiced as a certified nurse and midwife for the past two decades. Despite living in a blue state with amazing policies that honor bodily autonomy weekly, I am still baffled when I speak to patients who say, “I didn't know where to go, whom to trust, or if I can afford the birth control of my choice.” iCAN! works on improving quality and coverage of contraceptive care while focusing on meeting the needs of patients who have the least to really transform how contraceptive care is valued, accessed, and delivered. Our team likes to think of ourselves as “system orchestrators,” or as I read, it can be called a “field catalyst.” iCAN! is charged with intentionally designing sustainable solutions and ensuring that people with fewer resources are at the center of everything we do.
One exciting and new opportunity to support our advocacy efforts is Illinois’ family planning program supported by Health Care & Family Services’ (HFS) Illinois Medicaid program. HFS’ family planning program has drastically eliminated financial barriers for anyone seeking the birth control of their choice, including vasectomies and tubal ligation. It also covers a wide array of related services such as sexually transmitted infection (STI) screening and treatment, screening for cervical and breast cancer, vaccines related to HPV and or hepatitis A and B, vaccines, and much more. HFS’ family planning program was created to be as patient-centered as possible so that cost is never a burden for anyone who wants to access birth control voluntarily. Anyone that lives in Illinois and who has some initial coverage – which is called presumptive eligibility – is eligible for this program. For those that do not have citizenship, the initial access is currently temporary, but at least they can get their birth control choice and/or any other initial needs met. Another component of eligibility is that it is based on individual income. Many programs are based on household, but this only applies to the individual. So, if the individual’s income is less than $3,250 a month, they qualify for this program. And, if a patient has some insurance coverage but high out-of-pocket costs or their plan does not cover birth control, they can still apply for the program with no questions asked.
Amber Kirchhoff (AK): I am the director of public policy and government affairs with the Illinois Primary Health Care Association (IPHCA), Illinois’ statewide nonprofit association representing the 53 community health centers or Federally Qualified Health Centers (FQHCs) across the state. IPHCA serves hundreds of thousands of women and girls across the state. Community health centers provide family planning services and prenatal care, support patients during labor and delivery and post-partum care, and offer well-child visits.
Moderated Q&A
Q: Considering the landscape of maternal health and family planning in Illinois and across the country and the existing issues and barriers, why does this work matter so much?
CO: Many of the issues and barriers are related to social determinants of health (SDoH). For example, do people have access to childcare or transportation? Do they have sick leave or affordable housing? These socioeconomic challenges make it difficult to be able to focus on one’s health needs as it relates to family planning. Additionally, many women feel that they are not being fully heard at the doctor's offices and providers. When an individual has a negative interaction with their doctor, they seek out alternative resources and solutions. And when it comes to discussing contraception access, it must be a patient-centered experience built on trust.
DS: In some of the research I am doing, my focus and goal is to improve reproductive health service delivery and improve outcomes, specifically at the structural and systemic level. Although I focus on state and federal public policy, I think we sometimes forget to think about the next level down with our institutional policies. In an ideal world, health care is about the relationship between a patient or a family and their provider, but the reality is that we are receiving and giving care in the context of institutions and organizations. Additional factors that affect care in the context of women’s reproductive health including whether or not their insurance policy covers the full scope of contraceptive options in their insurance plan. On the provider side, those facility-level policies may or may not align with some of the options a patient has available to them in their insurance plan.
In my residency program earlier in my career, I worked at a community-based hospital that was acquired by a faith-based catholic system. One of the most common practice policy changes was the transition to no longer provide abortion access; however, there were other procedures or medical interventions (e.g., getting your tubes tied after birth) that suddenly were not able to be applied as well. These new limitations were reflective of the power of institutional policies in action.
The other system-level issue that I spend a lot of time thinking about is around providers’ skills, knowledge, and capacity to provide high-quality, comprehensive reproductive health care as it intersects with any institutional issues. As we continuously look for ways to adequately train providers for various settings with different policies in play, how are we ensuring the patient’s voice is heard? And for clinicians to be able to provide a high-quality visit, we offer them a supportive environment with a low administrative burden that allows them to prioritize and focus on patients.
Q: What steps are you taking to deliver high-quality reproductive health care services?
KT: Debbie shared that we need to create space and time for providers to listen. iCAN!’s goal is to de-silo and destigmatize birth control, and one way to accomplish this is through working with medical providers, primarily at FQHCs, to implement screenings for people of reproductive age for their contraception needs and desires. Routinely screening with a simple question such as, “Do you think you would like to have children or more children at some point?” reduces stigma and raises awareness of contraceptive options as a starting point for a broader conversation.
Q: What barriers are you seeing at the health system level related to policy?
DS: Policies can advance opportunities for more time, space, and flexibility for providers to listen and facilitate additional screening questions. This could be applied through changes in payment models and reimbursements so that there is less emphasis on volume. Policies can support other sites of care as well. For example, doulas could be educating patients so that they are prepared and empowered to ask the right questions when they see their doctor, or pharmacists can be trained to dispense contraception, a policy implemented and happening in the state of Illinois.
Q: What types of solutions are really needed at the policy level to overcome barriers?
KT: We live in a state where the policies are amazing, but how policies are implemented is key. We must prioritize and consider the three Ps: Providers, Patients, and Payers. How do providers learn about and activate policies in their work? Do patients understand their rights in the context of these policies? How do we optimize coverage and payment? In Illinois, pharmacists can be trained to dispense hormonal contraception, but the implementation piece has not been thought about thoroughly, so many people don’t know this is an option.
What policies are Everthrive and IPHCA working on to advance opportunities?
CO: As Kai shared, the implementation piece is so important. Everthrive has a focus on community education and awareness. One bill Everthrive is trying to support is expanding the health benefits for undocumented people of reproductive age.
AK: IPHCA is interested in and focused on how the policy landscape shapes care delivery to create additional opportunities for value-based care. Currently, providers at FQHCs can only be reimbursed for certain services, and this creates constraints. Through the state’s health care transformation program, there is a pilot program focused on maternal health care to create more flexibility in care design.
One of IPHCA’s priority legislation goals this year is to increase investment in community health centers, which would broaden access and allow for innovation and partnerships that better serve communities, including maternal health and family planning.
KT: iCAN! has been working to advance House bill 3293, which would provide coverage for one’s birth control of choice to anyone, regardless of citizenship status. The bill would allow for reimbursement of vasectomy services as part of a carve-out and mandate that, under Medicaid, there would be performance measures related to quality and access relating to family planning.
What are the perspectives of IPHCA and its members around opportunities for improvement in maternal and reproductive health access and care delivery?
AK: We still see many disparities in maternal health outcomes, which correspond with racial and socio-economic lines. Screening for SDoH is important to incorporate into health centers for a more holistic care approach. In Illinois, mental health and substance use challenges are one of the leading causes of maternal mortality in the first year postpartum; therefore, strengthening integrated behavioral health care and supportive addiction-based services and interventions in community health centers is another opportunity to improve maternal health outcomes.
To improve the overall quality of care, Illinois should also continue to focus on supporting a more diverse workforce representative of the populations served. IPHCA and our partners are working with the state Medicaid agency to implement the Health and Human Services pillar of the Illinois Legislative Black Caucus legislation, which passed a couple of years ago. This would allow for Medicaid to cover a broader number of paraprofessionals and support workers who make a big difference in ensuring outreach and enrollment to marginalized communities and ensuring that there is access to culturally and linguistically appropriate services.
I also want to add-on to a point made earlier that a carve-out for Medicaid vasectomy services would really make it much more financially viable for community health centers to offer equitable access to reproductive health services regardless of gender.
What has the overturning of Roe vs. Wade meant for reproductive rights in Illinois?
DS: I actually want to put a positive spin on this, which is to say that I have been really amazed to see local clinicians and others really wanting to step up. We know that Illinois protects the right to an abortion while many of our surrounding states do not. We have seen an influx of patients coming to Illinois to seek abortion care. However, we have also seen increased interest in nurses, medical residents in all fields, and other providers that can provide medication-assisted abortion in primary care settings, stepping up to receive the necessary training to be able to provide those services. Clinicians want to meet the comprehensive needs of their patients, and by adding this training, we are meeting the need in a holistic way.
CO: Despite some of the protections and policies we have in place, it can be confusing at times, as there are people that are getting their news with national perspectives in the headlines. So how people get their information can leave them confused about what services are available here and how to navigate the system. Robust communications and helping people understand their rights is an important effort as we move forward.
Audience Q&A
Are there any policies in the works to increase access, such as IVF (in vitro fertilization) for people who are having infertility issues and would like to be pregnant?
KT: Illinois requires group insurance and Health Maintenance Organization (HMO) plans to cover the diagnosis and treatment of infertility which includes many reproductive technologies. At this point, Medicaid does cover basic infertility services but not IVF.
Learn more about iCAN! (Illinois Contraceptive Access Now) and access more resources for family planning and contraceptive access here: https://ican4all.org/
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