In Informed Deliberations, Patients Call for Revision of the Federally-Mandated Medicaid Sterilization Policy.

Document Type

Conference Proceeding

Publication Date

6-2025

Abstract

Research Objective: Sterilization is the most common way pregnancy is prevented in the US. The current consent and waiting period policy for Medicaid enrollees stems from a history of forced sterilization but poses barriers for those who want permanent contraception. We aimed to understand whether and how potential patients think the policy should change.

Study Design: We conducted 10 deliberations in 2024 (7 virtually, 3 in-person), with low-income individuals of reproductive age. Deliberations included learning about the policy, asking questions, and discussing policy options. Participants completed pre- and post-surveys. Deliberations were recorded and transcribed verbatim. Survey items and scales were analyzed descriptively; comparison of pre vs. post scores used Wilcoxon signed rank tests. To analyze deliberations we developed a codebook based on the literature and our deliberation guide. We first coded synchronously then transitioned to asynchronous double coding once reliable application of the codebook was demonstrated, meeting weekly to compare coding and resolve discrepancies.

Population Studied: We recruited participants in Michigan whose household income was at or below 350% of the federal poverty level at the time of screening, to reflect those who might be covered by Medicaid for pregnancy. We intentionally included one deliberation group with only Middle Eastern/North African (MENA) women, another with only African American women, and one group of couples. Overall, participants self-identified as 52.9% White, 24.7% Black/African American, 11.8% Asian, 5.9% American Indian/Alaska Native, 11.8% 2 or more races, 10.6% MENA, 5.9% Hispanic/Latinx, and 4.7% other. Our sample included mostly women (87.1%).

Principal Findings: None of the 10 groups nor any of the 27 breakout groups recommended keeping the current policy. Most (23) recommended replacing it completely; others recommended decreasing or eliminating the waiting period. Deliberators often were not aware of the policy and considered it violating the right to control one’s body: "One of those policies that was made to control baby, birth, and bodies." While most supported having a national policy, they found having different policies based on health insurance inherently discriminatory. They did not agree on a specific waiting period; some advocated none at all while some thought a shorter period might avoid regret. Knowledge about contraception and the policy increased after deliberations (Mean correct = 4.30 of 7 before, 6.24, p< 0.001) as did agreement that there should be a national policy regarding sterilization rather than a separate policy for Medicaid enrollees (3.28 vs. 4.18, p< .001).

Conclusions: In informed group deliberations about Medicaid policy related to sterilization, low-income Michiganders agreed that the current policy should be replaced, and that such a policy restricting access for people with Medicaid is inequitable.

Implications for Policy or Practice: The Medicaid sterilization policy must be revised to better facilitate access to autonomously-desired permanent contraception. Centering the voices of underrepresented and most affected communities remains essential in the process of policy revision to ensure that future policies are patient-centered, equitable, and properly balance protection from coercion with access to care.

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AcademyHealth Annual Research Meeting, June 7-10, 2025, Minneapolis, MN

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