Going the Extra Mile: The Difference Title X Makes
It would be hard to overstate the importance of Medicaid in financing the nation’s publicly funded family planning effort. The joint federal-state insurance program for lower-income Americans provides the vast majority of dollars spent on family planning and has been responsible for almost all the growth in public family planning spending over the past two decades (related article, page 7). But for all its size, Medicaid is limited by the very fact that it is an insurance program. As such, it subsidizes care only for those individuals who meet its strict eligibility requirements and are able to successfully enroll. And even then, Medicaid—like any insurance scheme—generally covers only the clinical core of the services many family planning clients need.
Although it cannot parallel Medicaid’s dollars, Title X has the flexibility the behemoth lacks.1 Title X funds go to family planning centers up-front as grants, rather than after-the-fact as reimbursement for services centers have provided to individual enrollees. In addition to their critical role in supporting client-specific clinical services, these grants undergird the infrastructure and general operations of the centers themselves—essentially enabling them to open their doors so that clients can walk through those doors.
But even in their support of client-specific services, Title X dollars are special because they can go where Medicaid cannot. They can be used to provide care to individuals not eligible for Medicaid or otherwise insured. And they can be deployed to provide the intensity of care—beyond that which Medicaid or other insurance plans will cover—that many family planning center clients need to successfully avoid an unintended pregnancy.
Because a center receiving Title X dollars in any amount is subject to Title X regulations and quality-of-care standards for all of its clients, Title X shapes a recipient center’s entire family planning effort. And because 4,000 Title X supported centers serve two in three women obtaining family planning care at publicly funded centers across the country, this comparatively small program has an extraordinary national reach—well beyond the proportion of the overall funding it contributes (see chart).2,3
New findings from a Guttmacher Institute survey of a nationally representative sample of family planning centers—including both those that receive Title X funding and those that do not—show the vital role Title X plays. They particularly show the importance of Title X in three key respects: serving uninsured clients, helping clients easily obtain—and quickly begin using—a contraceptive method best suited to them, and enabling family planning centers to devote extra time and specialized expertise to clients with special needs.4
Serving Uninsured Clients
The Guttmacher survey found that, in general, family planning centers that receive Title X support generally serve more contraceptive clients than centers that do not: Thirty-nine percent of Title X–funded sites serve more than 50 contraceptive clients each week, compared with only 24% of sites that do not receive Title X funds. Moreover, a higher proportion of clients of Title X–funded centers are uninsured: Fully 50% of clients served in sites supported by Title X have no third-party payment for their visit, compared with only 28% of clients served in sites that do not receive Title X funds. This is particularly pronounced with regard to health departments, which care for 40% of clients served by the Title X network:5 Almost six in 10 clients served in centers operated by health departments have no third-party coverage for their care.4
This flexibility to serve uninsured clients is critical now and will continue to be going forward. Even if the Affordable Care Act is fully implemented, there will still be many individuals not eligible for coverage either through Medicaid or an exchange plan, or who will experience gaps in their coverage. Many of these individuals will be immigrants—not only undocumented immigrants, but also legal immigrants in their first five years of residence.
Enabling Women to Get, and Start, a Method
Family planning centers supported by Title X offer clients a wide choice of contraceptive methods. The Guttmacher study found that Title X–funded sites on average offer clients a choice of almost 10 contraceptive methods, and nearly seven in 10 offer at least one long-acting reversible method, such as the IUD or the contraceptive implant.
Along with offering women a broad choice of methods, sites that receive Title X support are more likely than centers not funded through the program to provide contraceptives on-site, rather than giving women a prescription that must be filled at a pharmacy (see chart). Doing so can be critically important. Giving a prescription for oral contraceptives requires a woman to make two trips—one to the family planning center and one to the pharmacy—to get the contraceptives she needs. Giving a woman a prescription for Depo-Provera means that she then has to return to the family planning center for the injection itself—a total of three separate trips. This can be a significant obstacle for a woman who is juggling the demands of school, family or work, as are so many clients, or who is dependent on public transportation or perhaps a borrowed car.
Moreover, centers receiving Title X support work hard to make it easy for women to get started on their method quickly. For example, Title X–supported centers are more likely to use the Quick Start protocol, under which women choosing oral contraceptives begin taking them immediately, rather than having to wait until a certain point in their menstrual cycles. And Title X–supported centers are also more likely to prescribe contraceptives without requiring a woman to have a pelvic exam, in line with evidence-based guidelines issued by the World Health Organization, the American College of Obstetricians and Gynecologists and Planned Parenthood Federation of America.6 The need to schedule a pelvic exam may cause a delay in places such as rural areas where workforce shortages limit the availability of providers.7 Also, having to obtain a pelvic exam is widely viewed as a barrier for younger clients who may never have had a gynecological exam before. Finally, centers supported by Title X are more likely than other sites to provide emergency contraception to women in advance, which enables them to have it readily available should they need it and when time is of the essence.4
This emphasis on clearing obstacles to contraceptive use is evident both in the group of centers that focus primarily on providing family planning services and in those that provide contraceptive services in the context of comprehensive primary care (see chart). For example, among specialized family planning centers, those that are supported by Title X are more likely to provide oral contraceptives directly and to allow women to use Quick Start. The differences are even more pronounced among the comprehensive providers: Seventy-six percent of comprehensive primary care agencies that are funded through Title X provide oral contraceptives on-site, compared with only 30% of sites that do not receive Title X funds. Similarly, comprehensive sites supported by Title X are more likely to use Quick Start.
Caring for Clients with Special Needs
Family planning centers are filled with clients who have special needs and who therefore might need specialized outreach or services, or who might benefit by being cared for by specially trained staff. Tailored programs and services may be particularly critical given the sensitive nature of the services provided in family planning centers—and how they might resonate in some communities or raise concerns in others.
The breadth of the effort in Title X–supported centers reflects their commitment to meeting the diverse needs of a highly diverse clientele—ranging from those experiencing intimate partner violence to those who are incarcerated.* According to the Guttmacher study, Title X sites on average have staff trained in serving eight different groups of clients with special needs and operate special programs or outreach efforts aimed at an average of five groups of clients.
For millions of American teenagers, for example, it is a family planning center that makes effective contraceptive use possible in their lives, by giving them access to both affordable and confidential contraceptive services. Serving adolescents has been, and remains, a priority under the Title X statute, and reflecting that priority, Title X sites place more emphasis than other centers on serving teens. Fully 91% have staff trained in meeting adolescents’ special needs, 66% operate special programs specifically tailored to serving adolescents and 76% make special efforts to reach out to adolescents.
The emphasis on serving teens, and serving them well, is also reflected in the amount of time spent with teen clients—an acknowledgement that they may need more counseling and education than adults, and perhaps even more counseling as preparation for a clinical exam. Both in absolute terms and in relation to older clients, staff at Title X–supported centers spend more time with teenagers than do staff at sites not funded by the program (see chart).
Individuals with limited English proficiency also constitute a significant share of clients of many family planning centers. In a quarter of sites supported by Title X, at least one in four clients has limited English skills; in 60%, the client population speaks more than three different languages. Staff of Title X–supported centers spend more time than staff of other centers with clients who have limited English skills; these clients may require both language services and additional counseling. Additionally, almost half of Title X–supported centers report that they make special efforts to reach out to these groups in their communities and have special programs tailored to their needs.
Finally, in more than half of Title X–supported centers, at least 10% of clients are dealing with complex medical or personal issues. Accordingly, more than four in 10 Title X–supported centers report that they have staff trained in working with clients confronting issues of substance abuse, disability or homelessness; more than half have staff trained in serving youth in foster care; and more than eight in 10 have staff trained in providing sexual and reproductive health services to individuals experiencing intimate partner violence. In recognition of the complicated needs of these individuals, staff at Title X centers spend more time meeting the contraceptive needs of these clients than do staff at other sites (see chart).
Real Value Added
Without doubt, Title X makes a special and outsized contribution to the provision of high-quality subsidized family planning services in the United States. In and of itself, applying for Title X funds is evidence of an agency’s commitment not just to providing contraceptive services but to operating an intensive, focused family planning program dedicated to meeting the diverse reproductive and sexual health needs of a wide range of hard-to-reach and difficult-to-serve clients. And the type of funding that Title X provides—dollars that are not tied to reimbursement for a core set of patient-specific clinical services—enables such a program to do just that: to go beyond the provision of bare-bones clinical care to craft a multifaceted effort in which clinicians and counselors with specialized training can take extra time with clients needing extra effort, and resources are invested in community outreach to identify the agency as a source of high-quality, culturally appropriate, affordable and confidential care.
Just as clearly, that contribution will be no less important even if the Affordable Care Act is fully implemented, Medicaid is expanded as projected and the nation over time approaches something close to universal health insurance coverage. But the ability of Title X to play its special role is in jeopardy. Although the program managed to survive the very clear threat of extinction in 2011, when the House of Representatives moved to defund it entirely, funding is and has long been far below the need. At $296.8 million, it is more than $20 million below what it was just two years ago. In inflation-adjusted dollars, it is 65% below what it was in 1980.8
As a result, maintaining the ability to go the extra mile to help clients to achieve control over their childbearing—often despite their special needs and the complex circumstances of their lives—is already a heavy lift for Title X–supported centers. As just one example of the challenges they face, although they strive to give clients access to the full array of contraceptive methods, many family planning centers are not able to do so; six in 10 Title X–supported sites say that they are unable to stock some methods because of the cost, according to the Guttmacher survey.4 Most distressingly, among the methods centers are least likely to be able to make available are long-acting methods, such as the IUD and implant. These are the most effective reversible methods on the market, but they require special expertise and training. And although they are highly cost-effective over time, they carry high up-front costs to centers.
To ameliorate these stresses and many others on the system, the unique value added of the Title X program needs to be fully assessed and appreciated. Currently, the overwhelmingly dominant impact-indicator is the total number of clients served in Title X–funded centers, which leads to national and state-level estimates of the number of unintended pregnancies, births and abortions the program averts. This is largely how program’s value is demonstrated both within the Department of Health and Human Services to officials who are responsible for requesting funding levels and to members of Congress who ultimately control the purse strings. Obviously, this is a critical barometer of impact, and it clearly must continue.
But focusing on the total number of clients served assesses only the program’s breadth, and not its depth. That depth—the ability to spend extra time with clients who need it, training staff to meet clients’ special or complex needs and operating special programs or outreach efforts tailored to their communities—is a critical part of the program’s unique contribution and key to its impact. It is this depth that, in large measure, allows centers to reach and serve those most likely to have an unintended pregnancy, and for whom unintended pregnancy, if it occurs, is most likely to lead to abortion or to have serious consequences for themselves and their existing families. To assess the full significance and impact of Title X, program stakeholders both in and out of government would be well-served to seek and advocate for new ways to assess performance that value the depth of the effort along with its breadth in meeting the needs of the communities and individuals it serves.
1. Gold RB et al., Next Steps for America’s Family Planning Program: Leveraging the Potential of Medicaid and Title X in an Evolving Health Care System, New York: Guttmacher Institute, 2009, <http://www.guttmacher.org/pubs/NextSteps.pdf>, accessed May 1, 2012.
2. Frost JJ, Henshaw SK and Sonfield A, Contraceptive Needs and Services, National and State Data, 2008 Update, New York: Guttmacher Institute, 2010, <http://www.guttmacher.org/pubs/win/contraceptive-needs-2008.pdf>, accessed May 1, 2012.
3. Sonfield A and Gold RB, Public Funding for Family Planning, Sterilization and Abortion Services, FY 1980–2010, New York: Guttmacher Institute, 2012, <http://www.guttmacher.org/pubs/Public-Funding-FP-2010.pdf>, accessed May 1, 2012.
4. Frost JJ et al., Variation in Service Delivery Practices Among Clinics Providing Publicly Funded Family Planning Services in 2010, New York: Guttmacher Institute, 2012, <http://www.guttmacher.org/pubs/clinic-survey-2010.pdf> accessed May 23, 2012.
5. Cohen S, The numbers tell the story: the reach and impact of Title X, Guttmacher Policy Review, 2011, 14(2):20–23, <http://www.guttmacher.org/pubs/gpr/14/2/gpr140220.pdf>, accessed May 1, 2012.
6. Association of Reproductive Health Professionals, Breaking the contraceptive barrier: techniques for effective contraceptive consultations, 2008, <http://www.arhp.org/Publications-and-Resources/Clinical-Proceedings/Breaking-the-Contraceptive-Barrier/System-Barriers>, accessed May 1, 2012.
7. RB Gold, The National Health Service Corps: an answer to family planning centers’ workforce woes? Guttmacher Policy Review, 2011, 14(1):11–15, <http://www.guttmacher.org/pubs/gpr/14/1/gpr140111.pdf>, accessed May 1, 2012.
8. Sonfield A, Title X funding chart, unpublished memo, Washington, DC: Guttmacher Institute, 2012.