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P4HB® was sanctioned by a broad grant of authority by the Medicaid program, as administered by DCH. As provided by Section 1115 of the Social Security Act, states can

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exercise flexibility in their current Medicaid programs if authorized by the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS). Upon approval from CMS in October 2010, P4HB® was incorporated into the DCH Medicaid regulations as one type of the many Medicaid “classes of assistance” (DCH, 2012). According to this statute’s (2196) policy statement,

Planning for Health Babies (P4HB®) is a Medicaid program that offers family planning services for eligible women in Georgia between the ages of 18 and 44. This program is effective January 1, 2011.

It is important to note that this statement omits any reference to low birth weight or inter- pregnancy care, which as discussed previously, is the impetus for P4HB® and a core focus of the “policy problem.” We do not find specific reference to inter-pregnancy care or the reason for P4HB® until the background information provided in the statute. In this section of the regulation, Planning for Healthy Babies ® is described as:

a five year demonstration waiver (1115) that covers family planning services to women ages 18 through 44 who are at or below 200% FPL, not otherwise covered by insurance (including Medicare), and not receiving coverage under another Medicaid category. P4HB® also covers inter-pregnancy care (IPC) services, including primary care case

management, for eligible women who have delivered a very low birth weight baby (VLBW) AS OF January 1, 2011. The primary goals of the P4HB® program are to reduce Georgia’s low birth weight (less than 2500 grams or 5 lbs. 8 oz) and very low birth weight (less than 1500 grams or 3 lbs. 5 oz) rates; reduce the number of unintended and high risk pregnancies in Georgia; and to reduce Medicaid costs by reducing the number of unintended pregnancies.

It is noteworthy that the program is described as a five year program (it was only authorized for three years), and that there is no mention of resource mother services, although “case management” is listed. Also this statute states that reducing LBW is a

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primary goal, which was later changed via Medicaid policy guidelines due to the high cost of including these women. So, overall, the statute reflects some inaccurate information. We cannot view this legal tool as having precise and clear objectives.

In addition to the statute, the DCH Concept Paper describes the “policy problem” for which P4HB® serves to address. As noted earlier, this paper was written by a

Medicaid official to describe the P4HB® after recommendations were made by the LBW work group to create a strategy to reduce low birth weight rates in Georgia. The Concept Paper, which is 13 pages, was submitted by DCH to CMS before a formal Section 1115 waiver was filed. This paper includes information that defines the problem of low birth weight and very low birth weight in Georgia. According to the first page of this

document, “The Planning for Healthy Babies®

Program (P4HB®) is an 1115

Demonstration Waiver Program borne out of Georgia’s desire to reduce its low birth weight rate (birth weight less than 2500 grams).” The paper also presents information about the planning that occurred with the LBW work group to address low birth weight rates in Georgia, and it also mentions the Grady project that piloted a similar program in the early 2000s. This document provides clear and concisely worded information about the purpose of P4HB® and the problem that it aims to solve. However, there is no mention of family planning or the role that access to such services might play in solving the problem of low birth weight deliveries. Also, as noted earlier, due to concerns by CMS about budget neutrality, DCH narrowed the scope of P4HB® to focus only on very low birth weight deliveries.

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Two additional documents provide information about the nature of the policy problem inherent in the P4HB® program. In December 2010, DCH issued a press release that described P4HB® as

…designed to improve Georgia's very low birth weight (VLBW) and low birth weight (LBW) rates. It is the country's first 1115 Demonstration waiver to place particular focus on reducing LBW rates. According to 2007 birth data, the Kaiser Family Foundation ranked Georgia as 38th in the nation (out of 51 – DC was ranked equivalent to a state) in the number of LBW births. (DCH, 2010)

While this press release is available on the DCH website, (http://dch.georgia.gov/press- releases/2012-11-07/dch-launches-new-family-planning-program), it appears that it was forwarded by the CMOs to their providers in early January 2011, after the program had been implemented. It is not clear how this press release was made available to eligible P4HB® clients. The Concept Paper described above, is also posted on the DCH website.1 A second document created for the marketing of P4HB® also provides information about the “LBW Problem.” In the November 2010 “Plan for Baby” Communications Plan, low birth weight is described as the main reason for the waiver program. “Guided by its mission, in April 2009, DCH identified Georgia’s poor national standing relative to low birth weight (LBW) rates and initiated a collaborative effort to reduce the state’s LBW rate from 9.5% to 8.6% over the next five years.” This document is interesting, because it clearly states the goals for reducing the LBW rates in Georgia as well as timeframe for the program (five years, although CMS only allowed 3 years for the program, due to the onset of health reform in 2014).

1

http://dch.georgia.gov/sites/dch.georgia.gov/files/imported/vgn/images/portal/cit_1210/33/52/156793595PlanningforHe althyBabiesProgram121709Final.pdf).

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These are the only documents we found that explicitly present a public

explanation for the policy problem inherent in the formulation of P4HB®. As described below, however, there are several documents that describe the program’s objectives.