Advancing Reproductive Health Equity Through a New Contraceptive Access Initiative

Illinois has been a national leader in adopting progressive reproductive health policies that have expanded Medicaid coverage, reduced Medicaid abortion coverage restrictions, and protected minors’ rights to many sexual and reproductive health services. Although these strides are significant, inequality in contraceptive access persists. Nearly one third of contraceptive users lack coverage for contraceptive services and supplies.¹ An estimated 800 000 women live in counties without health centers offering the full range of contraceptive methods.² One in three health care delivery networks in Illinois are religiously affiliated, with an even higher proportion among Medicaid recipients in Cook County, limiting patients’ options for family-planning services.³

Where contraceptive care is accessible, quality varies widely and depends on the individual provider’s training and biases and the health center’s infrastructure.⁴ Many Medicaid providers report offering birth control, but often the services are limited to birth control pills or Depo-Provera.⁵ Among patients seeking contraceptive care at Illinois community health centers, only one in five receives contraceptive counseling.¹

By training community health care providers to deliver patient-centered contraceptive care, by empowering patients to seize their right to the highest-quality care, and by removing financial barriers through innovative policy reform, Illinois Contraceptive Access Now (ICAN!) seeks to create an Illinois where every person can decide whether, when, and under what circumstances to become pregnant and parent. Lessons from this five-year initiative (2021–2025) will help to establish a new standard for contraceptive care in preventive and primary care.

TOWARD A NEW STANDARD OF CARE

ICAN! has adopted a three-pronged, systems-change approach to achieving our goals of (1) establishing screening for contraceptive needs and desires as a routine and essential component of preventive and primary care, (2) decreasing the number of people without health coverage for contraceptive care, and (3) expanding points of access to contraceptive care and education. Informed by the reproductive justice framework and guided by a 15-member community advisory board, ICAN! aims to center the specific lived experiences of Black women and women of color who may experience distrust of the health care system because of discrimination, racism, or contraceptive coercion.^6,7 Community advisory board members represent the communities served by our health center partners and guide all facets of ICAN! program development.

Partnering

In the United States, women of reproductive age (15–44 years) comprise the vast majority of federally qualified health center (FQHC) patients (63%) and adult Medicaid enrollees (65%).⁸ They do not experience their contraceptive need in a vacuum but rather as an integrated part of their overall well-being. ICAN! partners with FQHC networks to build their capacity as contraceptive care quality hubs that provide same-day access to the full range of US Food and Drug Administration (FDA)–approved birth control methods at low or no cost. Through clinical training and technical assistance, we support health centers to screen all patients of reproductive age for contraceptive needs and desires, provide patient-centered contraceptive counseling, ensure accurate coding and billing for capturing maximum revenue, stock and prescribe all methods on the day of request, and enhance benefits enrollment procedures. ICAN! trainings promote a TRUER (Trauma-informed, Respectful, Unconscious bias aware, Evidence-based, and Reproductive well-being centered) care approach that places the individual and their unique life realities at the center of the provider–patient relationship. This model affirms the viewpoint that with education and unbiased information about the full spectrum of contraceptive options, people can be empowered to become experts on their own reproductive and sexual lives.

By contrast to many other statewide contraceptive access initiatives, ICAN! does not serve as a payer of last resort. Although we provide limited capacity-building funds for general operations, we are focused on achieving long-term sustainability by shifting payer practices to reward contraceptive care provision, expanding coverage for individuals with few resources, and supporting health centers in maximizing revenue from contraceptive care services through accurate billing and coding practices.

During ICAN!’s 2021 demonstration year, we partnered with three of the largest FQHCs operating in underserved communities throughout the greater Chicago area—Erie Family Health Centers, Near North Health, and PCC Community Wellness—for them to become contraceptive care quality hubs. More than 500 of their providers and staff participated in ICAN! trainings, and together they served 15 204 contraceptive patients, a 17% increase over the previous year. In coming years, ICAN! will expand its reach to FQHCs serving Central Illinois and rural Southwestern Illinois—regions with profound racial and economic inequities in reproductive health outcomes and great unmet contraceptive need.

Community Engagement

ICAN! empowers patients to seize their right to the highest-quality contraceptive care through digital innovation, community outreach, and youth education. ICAN!’s Web site, www.ican4all.org, provides accurate, unbiased birth control information and connects users to care at their local quality hub. Interactive features include a quiz to assess which methods might fit users’ needs and preferences and a “phone-a-friend” option to speak directly with a trusted expert. Because of the social, financial, and practical barriers that people with limited access to care, such as Black women, women of color, and women with few resources, may face in accessing care at a health center, ICAN! has prioritized building out our digital platform to increase points of access through telehealth and to support users in understanding their coverage through an eligibility assistance function.

ICAN! partners with Chicago Public Schools, the Chicago Department of Public Health, the Illinois Department of Human Services, and local youth-serving organizations to provide birth control education and resources. Through training and educational resources, we also equip trusted, community-based maternal and child health providers—including case managers, home visiting nurses, and nutritionists—as well as staff of community-based organizations to screen clients for contraceptive needs and desires and make referrals to quality hubs. ICAN!’s foundational trainings will be adopted in the suite of professional development requirements for the state.

State Policy Research and Development

ICAN! pursues data-driven solutions to fundamentally transform the way contraceptive care is delivered, covered, and accessed by people with few resources. Our focus is not on new legislation but rather on optimizing existing policies by testing best practices for implementation to ensure maximum benefit. The cornerstone of this largely administrative agenda is a model family-planning state plan amendment, described in Figure 1, through which more than 70 000 individuals will become eligible for coverage.

FIGURE 1—

ICAN! Proposed Model Family-Planning SPA Inclusions: Illinois

Note. FPL = federal poverty level (as established by the US Department of Health and Human Services and adopted by the Centers for Medicare and Medicaid Services); ICAN! = Illinois Contraceptive Access Now; SPA= state plan amendment.

To increase points of access, ICAN! is supporting the implementation of Illinois’ new pharmacy prescribing law by drafting a state plan amendment that establishes high-quality care and referral protocols and by influencing pharmacist training standards. Furthermore, ICAN! is working with state Medicaid to enforce managed care organization member transparency and ensure adequate network coverage of family-planning services. Currently, there is no mechanism in place for informing patients that their care options may be restricted by religiously affiliated health providers, and payors are not held accountable for educating patients about the Centers for Medicare & Medicaid Services freedom of choice provision or for making timely referrals to contraceptive care. Together, ICAN!’s efforts have the potential to drive expansive and meaningful impact in removing barriers to high-quality contraceptive care for the people of Illinois.

MEASURING ACCESS AND QUALITY

The dominant outcome measures used by the field—sexually transmitted infection rates, unintended pregnancy rates, and adolescent pregnancy rates—fail to measure the extent to which individuals are able to exercise reproductive autonomy and achieve reproductive well-being. Rather than make assumptions about patients’ reproductive goals (e.g., avoiding pregnancy), ICAN! measures the extent to which patients feel respected, supported, and informed enough to make decisions about whether, when, and under what circumstances to become pregnant or parent. Our leading measure of care quality is patient-reported experience metric data, as collected via the National Quality Forum–endorsed Person-Centered Contraceptive Counseling survey.⁹ Our leading measures of access include the number of contraceptive encounters and method mix (which should reflect all FDA-approved birth control methods) at each health center.

Through our own evaluation process—which began in our 2021 demonstration year and will continue through 2026—we will work at the state and federal levels to define the core contraceptive access and quality metrics that will drive transformation at the health center level, exploring the merits and limitations of various data in upholding patient autonomy. We will use our relationships with our FQHC quality hubs, pharmacy allies, and managed care organization partners to glean patient feedback, method mix, and utilization patterns that will deepen the field’s understanding of what it means to provide high-quality contraceptive care.

FIVE-YEAR IMPACT

By 2025, ICAN! aims to have developed 20 quality hubs in urban and rural communities statewide that have the ability, demand, and capacity to meet patient need for high-quality contraceptive care. An estimated 500 000 patients will have access to person-centered contraceptive counseling, and 250 000 individuals previously uninsured for contraceptive care will gain coverage. As Illinois democratizes access to high-quality contraceptive care, our hope is to serve as a replicable model for advancing reproductive health equity nationwide, paving the way for real and lasting culture change and new standards for reproductive health delivery in primary care.