The previous articles in this series argued that the current use of family planning in U.S. welfare policy contradicts the original idealistic purposes of the welfare system. America has always believed that today’s poor could become tomorrow’s productive citizens; welfare assistance to the needy would therefore be an investment to build up what economists call “human capital.” But as the earlier articles argued, federal family planning policy replaces the optimistic premises of welfare with the eugenicist’s pessimistic view that the poor are a net burden on society, that rather than being an investment in human capital, welfare assistance is really just a cost that should be minimized. These assumptions motivated the architects of our current welfare policies, as they found birth control programs particularly attractive because of their racist views about welfare recipients, who in the early 1970s were disproportionately black.

Today, despite the overall decline of racism in American public life, those who wish to increase welfare funding of family planning do not challenge the eugenicist structure of the programs, but instead work within it. While they may not embrace the racist Jim Crow laws, as did the Senators who designed the programs they seek to expand, they do repeat the cynical cost-benefit analyses that those racists used to justify their policies. This final article in the series outlines the recent history of U. S. welfare family planning, showing how it preserves as its central working assumption the eugenicist principle that American society would be better off if poor children are never conceived.

“Averting Births”: The Clinton Era Medicaid Family Planning Expansion

By the early 1990s, Medicaid (the health care program of the welfare system) had become the federal government’s largest source of contraception funding. This was due in part to the growing political clout of the pro-life movement during the 1980s, which was able to slow the growth of direct federal funding for Planned Parenthood clinics through the other major source of federal funding, the Title X program.

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Medicaid’s importance as a source of contraception funding was due mostly to the program’s open-ended structure. Medicaid is not really a health insurance program, but a reimbursement program. If it were a health insurance program, Congress would pay a fixed premium now to reduce future expenses. Instead, Congress promises to reimburse the states for a certain percentage of whatever they spend on eligible health expenses, whether that be $10 million per state or $10 billion. The states decide how much they will spend on Medicaid, and Congress just signs the check. For most medical expenses, the federal government reimburses the states at a little more than half of the state’s expenses, so that if the state makes its health care program too generous (by paying for redundant tests or experimental therapies, for example), it can break the state’s budget.

In the case of family planning funding, however, the states have an incentive to be profligate, because the federal government reimburses the states for 90% of their expenses. Not surprisingly, the states are very creative in finding ways to classify expenses as “related to” contraception. Many states have set up fancy “school-based health clinics” in public middle schools and high schools, complete with an M.D. on staff, and charge the federal government, not just for the contraception they give to the children, but also for the overhead costs of running the clinic. Hospitals and health clinics also have incentives to classify as many expenses as possible as related to “family planning services,” to take advantage of the extra federal money available.

When the states run out of ideas for exploiting this infinite funding stream, abortion providers such as Planned Parenthood are happy to think of some more. Even though Medicaid won’t pay for most abortions, Planned Parenthood clinics can get access to an unlimited amount of money for everything related to contraception, including overhead, secretaries, training, advertising, paperwork, etc. Since the same clinics usually also perform abortions, the money going for “contraception” subsidizes their abortion practice, too. In fact, the Guttmacher Institute frequently conducts symposia and releases special reports on innovative ways states can tap Medicaid’s giant pool of funds for contraception-related services.

Despite these creative efforts, however, there was always the problem that the funding for contraception could not grow unless the demand for contraception among the people eligible for Medicaid also grew. And by the early 1990s, the Medicaid eligible population was so saturated with birth control that demand was in danger of leveling off, threatening the budgets of state Medicaid bureaucracies and the ability of Planned Parenthood to open more clinics. So when Bill Clinton came to Washington, there was a chance to put some of the Guttmacher Institute’s more creative ideas into practice.

In 1993, the Clinton Administration approved a plan whereby states could expand Medicaid’s free family planning services to those who were too rich to be eligible for Medicaid. There was a catch, however—a state could have access to Medicaid’s contraception money only if it could promise that it would save the government money in the long run by “averting births” of children who were likely to be a drain on the welfare system. The Guttmacher Institute had been publishing papers since the 1970s arguing that averting the births of the poor would save money set aside for helping the poor; now the federal government was demanding that the states adopt this perverse argument in order to have access to more of Medicaid’s millions.

South Carolina was the first to be admitted under this program, and other states have followed suit—by March 2008, 26 states had adopted such programs, and several others were in the process of establishing them. To demonstrate that the extra spending saves money, all used some variation of the Guttmacher Institute’s figure purporting to show that every $1 spent on contraception would save the welfare system $4 in births averted. Medicaid even developed a model worksheet to guide the state bureaucrats in making this calculation. (This method has serious weaknesses, as detailed here).

The results have been an enormous success for the program’s designers. Overall Medicaid funding of family planning services more than doubled since the Clinton expansion program was started, driven by nearly 500% increases in the states that were the first to sign up. As of 2006, Medicaid was spending over $1.3 billion on family planning services, up from $536 million in 1994 (in constant dollars). Medicaid pays for 97% of the nation’s publicly funded sterilizations.

But the program cannot transcend its eugenicist structure. To the bureaucrats in charge, “averting births” of low-income children is all in a day’s work. They are ruthlessly utilitarian as they weigh the high costs of a new poor person against the few benefits his life is likely to bring to society, and they conclude that it is cheaper to invest in methods likely to avert his too expensive life. (For an example of this sort of calculation, see here).

The 2009 Stimulus Package

When Pelosi told George Stephanopoulos that “family planning services reduce costs,” she was defending a provision that would have made the Clinton Medicaid family planning expansions permanent. The Clinton-era family planning expansion program was effective but cumbersome. Because of the laws that govern the program, the states have to apply for a renewal every five years, and they had to conduct research showing the programs’ effectiveness. The Democrats saw the stimulus package as a way to make these programs permanent, so that any state could offer Medicaid-funded family planning to those earning up to double the federal poverty line (i.e., up to $39,000 for a family of four).

The original stimulus bill would have changed current law in other ways as well, according to Dennis Smith, the policy analyst at the Heritage Foundation whose paper first called attention to the contraceptive funding in the stimulus package. The provision would have provided discount contraceptives to college students in university health clinics, eliminated the parents’ role in contraception decisions for their children and allowed all children to have free government-funded birth control, given family planning to illegal immigrants, and denied the states the flexibility to accommodate religious objections to aspects of the program.

Not of all of these ideas are eugenicist. Pushing contraception on immigrants might be, but giving contraceptives to college girls at a discount has another motivation entirely. Yet all of these policies were designed to tap into Medicaid because of its extraordinarily favorable rules toward contraception, especially the 90% federal reimbursement rate for family planning costs and the rules giving Planned Parenthood and others access to children without their parents’ knowledge or consent. And as shown above, those policies were enacted as part of a desperate political compromise to avoid an alternative policy—mandatory contraception for welfare recipients—that the NAACP regarded as a racist and eugenicist nightmare.

A Simple, Substantive Fix

As long as Medicaid is structured this way, Pelosi’s eugenicist statements will accurately describe the intellectual justification for U.S. contraception policy. Congress could fix that with three modest changes: reimburse family planning services at the same rate as other services in Medicaid, make contraception an optional part of a state’s Medicaid plan (like most other services in Medicaid), and defer to the states’ policies on parental notification and consent. In other words, it could stop giving contraception special treatment, so that promoting the health of the poor would become at least as important a national priority as preventing them from having children. In that case, federal policy would treat contraception as an individual’s choice for which the state provides moderate financial assistance, rather than as a government priority with which the person on welfare is pressured to cooperate. There are stronger measures that could be taken, and many would dispute that Medicaid should pay for contraception at all, but these three steps would be enough to distance the federal government from an unsavory policy with a dark history.