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					Family Planning Clinics in Iowa
Impact of the ACA and Health System
Change on the Iowa Safety Net




University of Iowa
Public Policy Center




DRAFT


Last updated: May 7, 2012




                                      1
Family Planning Clinics in Iowa

This report provides background on the financing, provider network and patient characteristics for the
Title X funded family planning clinics in Iowa.

Financing of Family Planning Services in Iowa
        Family planning services in Iowa are federally funded by Title X, Medicaid, Social Security Block
Grants (SSBG), and the Temporary Assistance for Needy Families (TANF) program. As shown in Figure
[_], in FY 2006 Medicaid provided the largest portion of Iowa’s family planning public expenditures with
69.3 percent ($9,339,000). Title X was the second largest public funding source in Iowa with 27 percent
($3,637,000). SSBG and TANF accounted for 3.2 percent of Iowa’s family planning public expenditures
while state appropriations accounted for one-half of one percent.1


                          Public Expenditures for Family Planning
                                  Client Services in Iowa,
                                          FY 2006
                                               $67,000
                                $434,000
             $3,637,000
                                                                         Medicaid
                                               $9,339,000                Title X
                                                                         SSBG and TANF
                                                                         State Appropriations




        Additionally some states receive funding for family planning through the Maternal and Child
Health (MCH) block grant, which accounts for 2 percent of the total $1.8 billion U.S. family planning
public expenditure. 2 For Fiscal Year 2010 in Iowa, expenditures of federally allocated funds totaled
approximately $6 million (thirty-eight percent of Iowa’s total maternal and child health expenditures).3




                                                    2
             Table 1. Total Public Expenditures for Family Planning Client Services (in 000s of constant 2006 dollars)

                                                                                                        % change      % change
                                                                                                            from FY      from FY
                                                                                                        1994 to FY       1980 to
                FY 1980          FY 1987          FY 1994           FY 2001                FY 2006           2006        FY 2006
Iowa          $14,189          $13,125          $8,477           $8,546            $13,477                   59.0         -5.0
U.S.          $1,570,099       $1,067,152       $1,133,067       $1,550,308        $1,846,963                63.0         17.6
                                                                                       1
                                              Source: Sonfield, Alrich, & Gold, 2008

           Table one shows that public expenditures for family planning services have increased from Fiscal
Year 1994 to Fiscal Year 2006 at the national level (63%) and at the state level for Iowa (59%). However,
compared to 1980, state public expenditures have decreased by 5 percent while national totals have
increased at a rate of 17.6 percent.4



IDPH Family Planning Financing
           Federal funding supplied $1.1 million to the Iowa Department of Public Health for family
planning services in 2010. This is a 9.5 percent increase from 2003 funding levels. Additionally,
IDPH’s estimated federal funding for 2011 is $1.3 million, representing an 11.3 percent increase
from 2010.5

                          Figure 1. Federal Financing of Family Planning Services in Iowa through IDPH



                               Iowa Dept. of Public Health
                            Federal Funding for Family Planning
                 $1,300,000

                 $1,200,000

                 $1,100,000

                 $1,000,000

                   $900,000

                   $800,000
                                  2003     2004    2005     2006     2007     2008          2009     2010    2011
                                                                                                              Est




1
    The report is available at: http://www.guttmacher.org/pubs/2008/01/28/or38.pdf

                                                                3
Family Planning Providers
         Title X family planning services in Iowa are administered by two independent organizations: the
Iowa Department of Public Health (IDPH) and the Family Planning Council of Iowa. IDPH’s Family
Planning Program administers Title X funding to eight family planning agencies within the state. These
eight agencies oversee 52 family planning clinics located in 33 counties.6 The Family Planning Council of
Iowa administers Title X funding to a network of six agencies in the state which provide services through
local clinics to 54 Iowa counties.7 One of the Family Planning Council’s agencies, Planned Parenthood of
the Heartland, is often considered three separate agencies (Planned Parenthood of Greater Iowa,
Planned Parenthood of Nebraska & Council Bluffs, and Planned Parenthood of Southeast Iowa) creating
a total of eight agencies.8 There are 28 clinics associated with these eight agencies, creating a total of 80
family planning clinics in the state.9

        Each of the 16 Family Planning agencies in the state of Iowa that receive federal Title X funding
participates in the Iowa Collaborative Safety Net Network. The locations of Iowa’s Title X family planning
agencies and clinics are illustrated in the following map.



                               Figure 2. Family Planning Agencies and Clinics in Iowa




                        Source: http://www.idph.state.ia.us/hpcdp/common/pdf/fp_map.pdf




                                                         4
        The provider mix at Family Planning Council clinics changed from 2009 to 2010; physicians are
more represented (measured by Full Time Equivalents) at clinics in 2010 compared to 2009 in contrast
to physician substitutes who experienced substantial declines in 2010 compared to 2009 (Table 2).

                               Table 2. Provider FTEs in Family Planning Clinics in Iowa

                                 Provider Type                       2010           2009
                                 Physicians                            2            1.45
                                 PAs/NPs/Midwives                    10.8          20.06
                                 Other clinical providers             1.7           28.3
                                         Source: Family Planning Council of Iowa

        For Family Planning Council Clinics, total family planning clinic encounters, encounters with
clinical and non-clinical providers all substantially decreased from 2009 to 2010 (Table 3).

                        Table 3. Unduplicated patient visits at Family Planning Clinics in Iowa

                                 Provider Type               2010           2009       % Change
                         Clinical service                   29,205         78,847          -63
                         providers
                         Non-clinical providers             19,141         53,538          -64
                         Total                              48,306         132,385         -64
                                         Source: Family Planning Council of Iowa




Family Planning Patient Demographics
       In 2010, Iowa family planning agencies in the Safety Net Provider Network reported 82,633
unduplicated patients and 220,942 encounters. Services in those agencies were provided by a total of 6
FTE physicians (either an M.D. or D.O) and 37 FTE mid-level providers (for example, physician assistants
and nurse practitioners).10

        The number of unduplicated patients at family planning agencies in Iowa has increased by
approximately 9 percent (6,657 patients) from 2009, while the number of encounters has decreased by
approximately 9 percent. In 2009 there were 5 FTE physicians and 38 FTE mid-level providers, compared
to previous years when 0.6 FTE physicians and 14.2 FTE mid-level providers served family planning
agencies.2




2
  0.6 FTE physicians and 14.2 FTE mid-level providers served 15 family planning agencies in 2007, according to the
Iowa Collaborative Safety Net Network Calendar Year 2007 Data Report.

                                                            5
                    Table 4. Unduplicated patient and encounters at Family Planning Clinics in Iowa

                                                             2010         2009        % Change
                         Unduplicated patients             82,633        75,976            9
                         Encounters                        220,942      242,550            -9
                                 Source: Iowa Collaborative Safety Net Provider Network



        For 2008, the Alan Guttmacher Institute estimated that 322,207 women in Iowa (103,950
earning less than 250 percent of the Federal poverty level) needed contraceptive services and supplies.11


Patient Race3
        In 2010 eighty-five percent of patients at all family planning agencies were White/Caucasian.
The second largest portion of the patient population was Black/African-American with 7 percent (Figure
4). This proportion is similar to the racial proportions reported for only the Family Planning Council of
Iowa clinics (Table 5). The overall Iowa population in 2010 was 91 percent White/Caucasian and 3
percent Black/African-American.12 Patient race statistics have remained constant in recent years.13
                        Figure 4. Racial demographics for clients at Iowa Family Planning Clinics


                              Race (Unduplicated Patients), 2010
                            1%    2%                                            White/Caucasian
                       0%
                                     1% 4%
                         7%                                                     Black/African-American


                                                                                American Indian/Alaska
                                                                                Native
                                                                                API
                                                    85%

                                                                                Other Race


                                                                                More than One Race




3
 Thirteen out of 16 family planning agencies in the safety net network provided race data for the CY 2010 Data
Report.

                                                           6
                        Table 5. Distribution of family planning patients by sex and race for 2010

                          Race                          Female         Male         Total         Percent
                          American Indian or              64            2            66             0.4
                          Alaska Native
                          Asian                           154           4           158             0.8
                          Black                           969           51         1,020            5.5
                          Native Hawaiian or              21            2           23              0.1
                          other Pacific Islander
                          White                         15,726          499       16,225           87
                          >1 race                        118             7         125             0.7
                          Race Unknown                   955            76        1,031            5.5
                          Total                         18,007          641       18,648           100
                        Source: Family Planning Council of Iowa




Patient Ethnicity4
        In CY 2010 the majority of family planning patients in Iowa were of not of Hispanic/Latino
ethnicity (88%). The proportion of Hispanic/Latino patients has not changed significantly from 2009.14


                                 Figure 5. Ethnicity of clients at Iowa Family Planning Clinics



                             Ethnicity (Unduplicated Patients),
                                           2010
                                            3%
                                                   9%

                                                                                         Hispanic/Latino
                                                                                         Not Hispanic/Latino
                                                                                         Ethnicity Unknown
                                        88%




         Among patients visiting Family Planning Council of Iowa clinics, the number of family planning
clinic patients with limited English proficiency substantially declined from 2009 to 2010 (Table 6).




4
    Fifteen out of 16 safety net family planning agencies provided ethnicity data for the CY 2010 Data Report.

                                                               7
                             Table 6. Number of clinic patients with limited English proficiency 2009-2010

                                                           2010        2009         % Change
                               Number of patients          1,053       1,264          -16.7
                                          Source: Family Planning Council of Iowa




Patient Sex5
       In 2010 approximately 95 percent of unduplicated patients at all family planning agencies in
Iowa were female, compared to 5 percent of patients that were male.15 This proportion is similar to the
proportion reported for only Family Planning Council of Iowa clinics where the majority of patients were
non-Hispanic females (Table 7). Several reasons account for men’s lower utilization of family planning
services. First, Medicaid traditionally does not reimburse for services provided to either single men or
single male parents. Second, men are usually interested in non-clinical contraceptive methods and Title
X focuses on clinical contraceptive methods.16 Finally, family planning experts have not defined a core
set of sexual and reproductive health services that should be provided to men.17

                             Table 7. Distribution of family planning patients by sex and Hispanic ethnicity for 2010

                                                                   Not
                                    Sex          Hispanic        Hispanic     Total      Percent
                               Female             1,772           16,235     18,007        97
                               Male                 85             556         641          3
                               Total              1,857           16,791     18,648        100
                                          Source: Family Planning Council of Iowa




Patient Age6
        In 2010 approximately half of all family planning patients were between the ages of 18-24
(Figure 6). The next largest age categories were 25 to 34 with 28% and 6 to 17 with approximately 12%.
Comparing the data from only Family Planning Council of Iowa clinics to data for all family planning
agencies, the proportions of the age groups are very similar for both males and females (Table 8).




5
    Twelve out of 16 safety net family planning agencies provided gender data in the CY 2010 Data Report.
6
    Twelve out of 16 safety net family planning agencies reported age data in the CY 2010 Data Report.

                                                             8
                                   Figure 6. Age of Clients at Iowa Family Planning Clinics



                                  Age (Unduplicated Patients)

                    40,000

                    30,000

                    20,000

                    10,000

                          0
                               6 to 17 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 and
                                                                                     older

                                                Age (Unduplicated Patients)




                          Table 8. Distribution of family planning patients by sex and age for 2010.

                              Age               Female         Male          Total      Percent
                              <15-17             2,569          53          2,622         14
                              18-24              8,084         322          8,406         45
                              25-34              4,926         190          5,116         27
                              35-44              1,672          40          1,712          9
                              >44                 756           36            792          4
                              Total             18,007         641          18,648        100
                                           Source: Family Planning Council of Iowa

Patient Insurance Status7
         Individuals visiting Iowa’s family planning clinics are most commonly uninsured, self-pay, or
private pay (37%). One third of patients are on Medicaid (33%) compared to less than one third who are
covered by either private or commercial insurance (26%).18 Compared to the insurance distribution for
all family planning clinics, patients visiting Family Planning Council of Iowa clinics are less likely to be
uninsured and more commonly covered by some form of public insurance (Table 9).




7
    Twelve out of 16 safety net family planning agencies reported insurance status data in the CY 2010 Data Report.


                                                              9
                                 Figure 7. Age of Clients at Iowa Family Planning Clinics



                              Insurance Status (Unduplicated
                                         Patients)
                                  0%    3% 1%
                                                                             Private/Commercial
                                                     26%
                                                                             Medicaid
                        37%
                                                                             Uninsured/SelfPay/PrivatePay
                                                                             Medicare
                                                     33%
                                                                             OtherPublicInsurance
                                                                             InsuranceTypeUnknown




        Table 9. Distribution of family planning patients by insurance type covering primary medical care for 2010
                                         Health
                                         Insurance          Total      Percent
                                         Public            9,221         49
                                         Private           4,256         23
                                         Uninsured         4,451         24
                                         Unknown             720          4
                                         Total             18,648        100
                                         Source: Family Planning Council of Iowa.


Patient Income
        The National Family Planning and Reproductive Health Association estimated that in 2010, 62
percent of patients visiting Iowa’s family planning agencies had incomes either equal to or below 100
percent of the federal poverty level (FPL). An additional 18 percent of all family planning clinic patients
had incomes between 100 percent and 250 percent of the FPL.19 Examining data from only Family
Planning Council of Iowa clinic patients reveals similar proportions: seventy percent of patients earned
less than 100 percent of the FPL; however, ninety-six percent of patients earned less than 250 percent of
the FPL (Table 10).




                                                           10
                     Table 10. Distribution of family planning patients by income level for 2010
                                         Income
                                        (% of FPL)        Total      Percent
                                       ≤100              13,011        70
                                       101-150           3,048         16
                                       151-200           1,249          7
                                       201-250             547          3
                                       >250                793          4
                                       Total             18,648        100
                                       Source: Family Planning Council of Iowa.


IDPH Patient Information
      The number of unduplicated patients served by IDPH family planning agencies increased from
16,854 patients in 2005 to 18,648 in 2009 (a 11 percent increase).

        Among the clients utilizing IDPH family planning services in 2009: 16,059 were low-income (a
32% increase from 2000); 5,337 were adolescents (a 1.3% increase from 2001); 1,020 were African-
American (a 37% increase from 2001); 1,857 were Hispanic (a 108% increase from 2001); and 641 were
males (a 91% increase from 2004).20




                              Iowa Dept. of Public Health
                                   Patients Served
         20,000


         15,000


         10,000


          5,000


              -
                       2005               2006                2007                2008             2009

                      Total Patients               Patients < 150% FPL            Adolescents
                      African-American             Hispanic                       Male




                                                         11
Patient Utilization of Family Planning Services

         Testing for sexually transmitted diseases is one service provided by family planning clinics. As
demonstrated in the following tables, from 2009 to 2010 most screening tests showed a substantial
decline in the number of patients receiving those tests at Family Planning Council of Iowa clinics (Tables
11, 12, 13, and 14). One exception to the general decline was an increase in the number of women
receiving syphilis tests (Table 13).

                 Table 11. Number of unduplicated female patients and cervical cancer screening tests
                                                                Number of
                                                              Patients/Tests
                                                            2010       2009           % Change
                   Patients obtaining Pap smear             7,093     21,343             -67
                   Pap tests performed                      7,390     22,305             -67
                   Pap tests with ASC or higher             1,066      3,222             -67
                   Pap tests with HSIL or higher             234        138               70
                                       Source: Family Planning Council of Iowa.




                      Table 12. Unduplicated number of patients receiving a clinical breast exam

                                                            Number of
                                                             Patients
                                                          2010      2009          % Change
                        Received breast exam             10,261    28,589            -64
                        Referred based on exam            262      1,065             -75
                                       Source: Family Planning Council of Iowa.




                        Table13. Number of unduplicated patients tested for Chlamydia by sex

                                                                          %
                                                2010        2009       Change
                                    Female      8,161      24,069        -66
                                    Male         472       2,067         -77
                                       Source: Family Planning Council of Iowa.




                                                         12
                    Table 14. Number of clinic patients tested for gonorrhea, syphilis, and HIV by sex

                                                   Number of Patients
                                                    2010        2009           % Change
                                                       Gonorrhea
                                       Female       8,974     26,783               -66
                                         Male        502       2,311               -78
                                                        Syphilis
                                       Female        311         215                45
                                         Male         1          155               -99
                                                          HIV
                                       Female        584       5,969               -90
                                         Male        128         859               -85
                                        Source: Family Planning Council of Iowa.

          Counseling and providing contraception to males and females are additional services provided
by family planning clinics. Oral contraceptives are the most popular birth control method for females
visiting family planning clinics; next most popular are the three-month implant and the male condom
(Table 15). Additionally, the male condom is the most common contraceptive method reported by males
visiting family planning clinics in 2010 (Table 15). Among males not utilizing a contraceptive method
themselves, a medical reason was the most common explanation for not using contraception (Table 16).

  Table 15. Number of unduplicated female clinic patients by most common primary female contraception methods, male
                                       contraception methods, and age for 2010

                                                         Number of Females by Age
                                                <15-      18-   25-   35-
                            Method               17       24    34     44 >44                Total
                     Oral pill                  943      3,392 1,659 445 154                 6,593
                     3-month implant            482       963   742 324 109                  2,620
                     Male condom                176       700   504 202 97                   1,679
                     Hormonal implant           347       824   374    78    12              1,635
                     Intrauterine device         33       506   656 190 31                   1,416
                     Vaginal ring               174       703   297    36     2              1,212
                     Sterilization               0        17    187 201 134                   539
                     Patch                       85       188   128    23     0               424
                     Abstinence                  84       111   55     27    22               299
                     Other method                3         6    25     27    88               149
                     Vasectomy                   0         1    25     17     7               50
                                        Source: Family Planning Council of Iowa.




                                                           13
        Table 16. Number of unduplicated male clinic patients by primary contraception method and age for 2010

                                                               Number of Males by Age
                                                                        25-    35-
                      Method                     <15-17        18-24     34     44 >44          Total
              Male condom                          27           164      59     9    8           267
              Other method                         0              0      2      0    0            2
              Vasectomy                            0              0      0      2    0            2
              Abstinence                           0              1      0      0    0            1
                                                               No Contraceptive Method
              Other medical                         8            14      5      1    2            30
              Rely on partner’s method              0             1      0      1    1            3
              Partner pregnant                      0             0      0      1    0            1
                                       Source: Family Planning Council of Iowa.


Title X Information
         Established in 1970 as Title X of the Public Health Service Act (Pub.L. 91-572), the National
Family Planning program funds family planning education, counseling, and medical services. The
program is administered by the Department of Health and Human Services’s Office of Family Planning.
Title X allows individuals to access contraceptive services, supplies, and family planning information. By
law, a minimum of 90 percent of Title X funding must be used for clinical family planning services.21

Relationship Between Title X and Medicaid
        Recently, Medicaid became the primary funding source for family planning as Title X funding
decreased.22 However, Title X funding can cover services not covered by Medicaid in addition to services
for individuals who are ineligible for Medicaid—essentially wrapping around the “core” services covered
by Medicaid. According to the National Family Planning & Reproductive Health Association:

                 Title X-funded health centers in Iowa deliver a wide range of services,
                 including: abstinence education; hormonal contraceptives; long-acting,
                 reversible contraceptives; vasectomy and female sterilization; cervical
                 and breast cancer screening; management of abnormal Pap smears;
                 vaccination services; domestic violence screening/referrals; depression
                 screening/referrals; assessment and assistance with substance use; STD
                 and HIV screening, education and referral for management of positive
                 HIV tests; pregnancy testing with referrals, and WIC enrollment when
                 possible; prenatal vitamins for women with positive pregnancy tests;
                 and reproductive life counseling.23
        Utilizing a Medicaid waiver from CMS, Iowa family planning clinics can provide the emergency
contraceptive pill; tubal ligation and vasectomy; and provide HPV vaccine for adults aged 21-26.24
Eligibility for family planning Medicaid coverage in Iowa requires an income less than, or equal to, 200
percent of the Federal Poverty Level, United States citizenship, and Iowa residence.25



                                                          14
        Family planning centers often rely on the federal 340B Drug Pricing Program, which allows
clinics to procure contraceptives at reduced prices. However, studies during the previous 10 years
document an increase in the cost for contraceptives and supplies purchased by family planning clinics
due to changing pharmaceutical business models and new contraceptive methods.26


        A provision in the Patient Protection and Affordable Care Act (Pub.L. 111-148) allows states an
alternate option for covering family planning services under Medicaid: states can expand Medicaid
coverage without obtaining a waiver by modifying the State Medicaid Plan to create parity between the
SPA eligibility level and the poverty percentage utilized for calculating pregnancy-related care eligibility;
or the state can offer true parity by establishing an SPA eligibility procedure equivalent to the process
for pregnancy-related care eligibility.27 However, if the State alters the State Medicaid Plan, the State
must cover men and adolescents, which is not required by the current Medicaid waivers.28



Legal Review of the Impact of the ACA on Family Planning Clinics
        The Patient Protection and Affordable Care Act (“ACA”) expands the coverage of family planning
services to individuals of childbearing age who are not pregnant and earn an income equal to, or less
than, the Medicaid income limits for pregnant women.29 When determining income for family planning
service eligibility, states can consider only the applicant’s income.30 Additionally, states can offer family
planning services to individuals who would be covered under a Section 1115 waiver.31
        The primary care services for expanded eligibility that the ACA allows are evaluation and
management services and the ACA limits benefits to the expanded eligibility group are family planning
supplies and services provided as part of a family planning service in a family planning setting.32
        Entities furnishing services and supplies covered by Medicaid and deemed capable of making
presumptive eligibility determinations by the State agency may presumptively consider individuals
covered based on preliminary information.33 After determining presumptive eligibility, an eligible entity
may provide family planning services to the presumptively eligible individual.
        However, presumptively eligible individuals must apply for medical assistance in order to
continue—if deemed eligible—family planning services after the application deadline.34 Until the state
Medicaid agency determines that an individual is not eligible for Medicaid, the presumptively eligible
individual can continue receiving family planning services.35
        Finally, certain primary care physicians are guaranteed by the Health Care and Education
Reconciliation Act (“HCRA”) at least 100 percent of the Medicare payment rate through Medicaid for
providing evaluation and management and immunization administration-related services.36
        For the Actual Statutory text, please refer to Appendix A.




                                                      15
Sites for Additional Information
The following web sites provide additional information for anyone interested in learning more about
family planning clinics, services, funding, and patients:
Organization                                          Web Site
The Iowa Department of Public Health
                                                      http://www.idph.state.ia.us/hpcdp/family_planning.asp
(family planning)
National Family Planning and Reproductive
                                                      http://www.nfprha.org
Health
Kaiser Family Foundation (Women’s Health)             http://www.statehealthfacts.org
Office of Population Affairs, Department of
                                                      http://www.hhs.gov/opa/title-x-family-planning/
Health and Human Services
The Alan Guttmacher Institute                         http://www.guttmacher.org


1
  Sonfield et al. Public Funding for Family Planning, Sterilization and Abortion Services, FY 1980–2006; Accessed
from http://www.guttmacher.org/pubs/2008/01/28/or38.pdf on 7/28/11
2
  Sonfield et al. Public Funding for Family Planning, Sterilization and Abortion Services, FY 1980–2006; Accessed
from http://www.guttmacher.org/pubs/2008/01/28/or38.pdf on 7/28/11
3
  Health Resources and Services Administration, Title V Information System. Available at:
https://mchdata.hrsa.gov/TVISReports/Snapshot/SnapShot.aspx?statecode=IA [accessed 30 January 2012].
4
  Sonfield et al. Public Funding for Family Planning, Sterilization and Abortion Services, FY 1980–2006; Accessed
from http://www.guttmacher.org/pubs/2008/01/28/or38.pdf on 7/28/11
5
 Iowa Department of Public Health Annual Reports for 2004-2010. Accessed on 10/13/11 from
http://www.idph.state.ia.us/adper/annual_reports.asp.
6
 Family Planning Grantees, Delegates, and Clinics: Office of Population Clearinghouse Family Planning Database,
Region VII. Accessed from http://www.opaclearinghouse.org/pdf/dynamic/region.cfm?regionID=7&pdf=1 on
10/3/11;
Family Planning; Iowa Department of Public Health. Accessed on 10/3/11 from:
http://www.idph.state.ia.us/hpcdp/family_planning.asp
7
 Mission and Vision – Family Planning Council of Iowa. Accessed from
http://www.fpcouncil.com/about/view/57/About+-+Mission+%26+Vision.html on 10/3/11
Family Planning; Iowa Department of Public Health. Accessed from
http://www.idph.state.ia.us/hpcdp/family_planning.asp on 10/3/11
8
 Family Planning Grantees, Delegates, and Clinics: Office of Population Clearinghouse Family Planning Database,
Region VII. Accessed from http://www.opaclearinghouse.org/pdf/dynamic/region.cfm?regionID=7&pdf=1 on
10/3/11
9
 Family Planning Grantees, Delegates, and Clinics: Office of Population Clearinghouse Family Planning Database,
Region VII. Accessed from http://www.opaclearinghouse.org/pdf/dynamic/region.cfm?regionID=7&pdf=1 on
10/3/11


                                                         16
10
     Iowa Collaborative Safety Net Provider Network CY 2010 Data Report
11
  Frost, Henshaw, and Sonfield (2008), Contraceptive Needs and Services, National and State Data, 2008 Update;
available at: http://www.guttmacher.org/pubs/win/contraceptive-needs-2008.pdf [accessed 10 October 2011].
12
  Iowa Quickfacts from the U.S. Census Bureau. 2010. Accessed on 10/6/11 from
http://quickfacts.census.gov/qfd/states/19000.html
13
     Iowa Collaborative Safety Net Provider Network CY 2008-2010 Data Reports
14
     Iowa Collaborative Safety Net Provider Network CY 2009-2010 Data Reports
15
     Iowa Collaborative Safety Net Provider Network CY 2009-2010 Data Reports
16
  R. Gold, A. Sonfield, C. Richards, J. Frost. (2011). Next Steps for America’s Family Planning Program: leveraging
the potential of Medicaid and Title X in an evolving health care system. Guttmacher Institute: available online
[accessed 25 July 2011].
17
  R. Gold, A. Sonfield, C. Richards, J. Frost. (2011). Next Steps for America’s Family Planning Program: leveraging
the potential of Medicaid and Title X in an evolving health care system. Guttmacher Institute: available online
[accessed 25 July 2011].
18
     Iowa Collaborative Safety Net Provider Network CY 2009-2010 Data Reports
19
  Title X in Iowa: Improving Public Health and Saving Taxpayer Dollars – February 2011. Accessed on 10/6/11 from
the National Family Planning and Reproductive Health Association at
http://www.nfprha.org/images/insert/Title_X_IA.pdf

2010 Poverty Guidelines. Accessed on 10/6/11from
https://www.cms.gov/medicaideligibility/downloads/POV10Combo.pdf
20
  Iowa Department of Public Health Annual Reports for 2004-2010. Accessed on 10/13/11 from
http://www.idph.state.ia.us/adper/annual_reports.asp.
21
  Title X Family Planning: Office of Population Affairs. Accessed from http://www.hhs.gov/opa/title-x-family-
planning/ on 10/3/11.
22
  R. Gold, A. Sonfield, C. Richards, J. Frost. (2011). Next Steps for America’s Family Planning Program: leveraging
the potential of Medicaid and Title X in an evolving health care system. Guttmacher Institute: available at:
http://www.guttmacher.org/pubs/NextSteps.pdf [accessed 10 October 2011].
23
  National Family Planning & Reproduction Health Association (February 2011), Title X in Iowa: improving public
health and saving taxpayer dollars, available at: http://www.nfprha.org/images/insert/Title_X_IA.pdf [accessed 10
October 2011].
24
     From the Kaiser Family Foundation, available at: statehealthfacts.org [accessed 4 August 2011].
25
     Kaiser Family Foundation, available at: statehealthfacts.org [accessed 4 August 2011].
26
  A. Sonfield. (2006). Summer Price Spike: a case study about publicly funded clinics and the cost of
contraceptive supplies. Guttmacher Policy Review, 9(4), available at:


                                                           17
http://www.guttmacher.org/pubs/gpr/09/4/gpr090402.html [accessed 10 October 2011]; R.B. Gold. (2002).
Nowhere but Up: Rising Costs for Title X Clinics. The Guttmacher Report on Public Policy, 5 (5), available at:
http://www.guttmacher.org/pubs/tgr/05/5/gr050506.html [accessed 10 October 2011].
27
  A. Sonfield, J.J. Frost, & R.B. Gold. (2011). Estimating the Impact of Expanding Medicaid Eligibility for Family
Planning Services: 2011 Update. Guttmacher Institute; available at: http://www.guttmacher.org/pubs/Medicaid-
Family-Planning-2011.pdf [accessed 2 February 2012].
28
  A. Sonfield, J.J. Frost, & R.B. Gold. (2011). Estimating the Impact of Expanding Medicaid Eligibility for Family
Planning Services: 2011 Update. Guttmacher Institute; available at: http://www.guttmacher.org/pubs/Medicaid-
Family-Planning-2011.pdf [accessed 2 February 2012].
29
   ACA Section 2303(a)(2).
30
   ACA Section 2303(a)(2).
31
   ACA Section 2303(a)(2).
32
   ACA Sections 2303(a)(2),(3).
33
   ACA Section 2303(b)(1).
34
   ACA Section 2303(b)(1).
35
   ACA Section 2303(b)(1).
36
   HCRA Section 1202(a)(1).




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