Fulfilling the Promise: Public Policy and U.S. Family Planning Clinics

Publicly funded family planning services empower millions of Americans to decide whether and when to have children, and help women avoid 1.3 million unintended pregnancies every year. Family planning clinics offer contraceptive counseling, services and supplies, as well as other important preventive health measures, including Pap smears, breast and pelvic examinations, and screening and treatment for sexually transmitted diseases (STDs). The widespread availability of confidential, affordable services to those in need has enriched the lives of American women, children and families and has improved public health. It also has resulted in a substantial cost savings for the government: For every public dollar spent on family planning services, three dollars are saved in Medicaid costs for pregnancy-related and newborn care.

Despite the successes of the U.S. family planning clinic system, political controversy has plagued it since its inception. Social and religious conservatives claim that the availability of confidential contraceptive services encourages sexual activity among teenagers, and that family planning clinics promote abortion. While confronting these ongoing assaults, the family planning clinic system must rise to meet new challenges, including cost increases associated with new medical technologies, changes in health care delivery and financing, and a growing uninsured population.

Fulfilling the Promise: Public Policy and U.S. Family Planning Clinics brings together more than five years of research and analysis on publicly funded family planning services. The report is based upon data from the National Survey of Family Growth and surveys conducted by The Alan Guttmacher Institute among publicly funded family planning clinics, the agencies that run them and state funding agencies. This executive summary highlights some of the report's key findings.

Origins of the U.S. Family Planning Clinic Network

To have no more than two children - the goal of most Americans - a woman must spend about three-quarters of her reproductive life trying to avoid unintended pregnancy. Yet women who are marginalized within society because of their income, age, race or ethnicity have historically had difficulty accessing or affording family planning care. Indeed, groundbreaking research conducted in the 1960s demonstrated that unequal access to contraceptives, not a preference for more children, was largely responsible for existing differences between lower- and higher-income women's family sizes.

To close this gap, the federal government in 1970 enacted Title X of the Public Health Service Act, which was intended to make contraceptive services and supplies available to anyone in need. Title X is the only federal program devoted solely to the provision of family planning services on a nationwide basis, but additional public support for family planning comes from Medicaid, the maternal and child health block grant, the social services block grant and state contributions.

The Role of Family Planning Clinics Today

The national family planning clinic system is a loose network of agencies that together run more than 7,000 clinics. Each year, about a quarter of all women who obtain family planning services from a medical provider do so at a publicly funded clinic. Almost all of these women are poor or low-income, and most are younger than 30.

The clinics' impact is evident in a wide variety of measures. Examples include the following:

• Publicly funded family planning clinics serve approximately 6.5 million women each year.

• One in four women who obtain a contraceptive method do so at a clinic.

• Clinics serve one in seven women of reproductive age who receive Pap smears, pelvic examinations and testing or treatment for gynecologic infections.

• One in four women of reproductive age seeking HIV tests each year, and one in three obtaining other STD services, get these services at a clinic.

The Key Role of Title X

Title X is the centerpiece of the national family planning program. It provides funding to pay the salaries of clinic personnel, purchase contraceptives and other medical supplies, and subsidize services to clients who lack another source of payment. Clients with incomes below the federal poverty line - three out of five of those attending Title X-supported clinics - receive services free of charge, and those with incomes above the poverty line are charged according to their ability to pay.

The Title X regulations also contain a set of ethical principles governing the delivery of contraceptive services. All services must be provided on a voluntary and confidential basis; clients visiting clinics for contraceptive care must be offered related preventive health services; and pregnant women must be offered "nondirective counseling" about all of their options and must be given referrals on request.

The program's accomplishments have been nothing short of remarkable. For example:

•Over the last two decades, Title X-supported clinics have helped prevent almost 20 million unwanted pregnancies, nine million of which would have ended in abortion.

• From 1979 to 1998, Title X- supported clinics took an estimated 57.3 million Pap smears (resulting in the early detection of as many as 55,000 cases of invasive cervical cancer) and conducted an estimated 54.4 million breast examinations.

• Title X-supported clinics performed an estimated 19 million tests for STDs, including 1.4 million for HIV, between 1995 and 1998.

Nevertheless, ongoing political opposition to Title X threatens its funding. Taking inflation into account, Title X funding in 1999 was 60% lower than it had been 20 years earlier. Yet the major objections to the program - that it promotes sexual activity among teenagers and abortion - are unfounded. The availability of contraceptives at clinics does not encourage teenagers to have sex; in fact, the average teenager does not visit a family planning provider until 14 months after she has become sexually active. And by enabling women to prevent unintended pregnancies, Title X funding has prevented millions of abortions. (By law, Title X funds may not be used to pay for abortions.)

Challenges and Opportunities

Publicly funded family planning clinics face new challenges in ensuring that all Americans can meet their childbearing goals. Clinics must find ways to pay for extremely effective, but also expensive, new contraceptive methods and technologies for detecting cervical cancer and STDs. They must recruit trained personnel who are familiar with the languages and customs of local communities. And they must serve increasing numbers of Americans without any health insurance - public or private - while coping with the rapid growth of managed care, which draws away clients who have insurance and, therefore, potential revenue.

While confronting these challenges, clinics are looking for new ways to eliminate unintended pregnancies and improve the public health. They are reaching out to women who are at high risk of unintended pregnancy yet do not visit family planning providers or use contraceptives, and they are attempting to better serve men. Some clinics are integrating specialized gynecologic care, routine primary care and comprehensive STD services into their family planning services, in order to deliver coordinated, comprehensive and convenient care.

The family planning clinic network has nearly eliminated historic differences in access to and use of contraceptives. Between 1982 and 1995, the proportion of women at risk of unintended pregnancy who were using a contraceptive method rose from 68% to 92% among poor women, from 73% to 90% among black women and from 78% to 91% among Hispanic women - levels comparable to those among higher-income and white women. Yet the need for family planning clinics remains strong: Each year, half of all pregnancies in the United States are unintended, and half of unintended pregnancies end in abortion.

A renewal of the political and financial commitment to family planning that spurred the government's involvement 30 years ago - and of the commitment to social justice that lay at the heart of that effort - is crucial to fulfilling the promise to give all Americans the ability to achieve their childbearing goals and enhance their reproductive health.

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