Title X: An Essential Investment, Now More than Ever
Created in 1970 with broad bipartisan support, Title X of the Public Health Service Act marked a historic step toward making effective contraceptive options just as accessible to low-income women as to women with greater financial resources. Today, Title X remains the backbone of the nation’s publicly supported family planning effort—even as the Affordable Care Act (ACA) goes into full effect.
The ACA’s improvements to insurance coverage—both in terms of expanded eligibility for private and public programs, and the guarantee of contraceptive coverage without copays—are major advances for women’s reproductive health. Now, millions more women can afford the most effective and often the most expensive methods of birth control. Yet, even with insurance, women need a place to go for services. Sustaining—if not strengthening—the Title X network of providers is critical so the newly insured can actually obtain high-quality care. Moreover, Title X sites are particularly well-situated to connect the uninsured to health coverage and to care for the people most likely to fall through the cracks of health reform.
As Title X providers step up to respond to the new demand for services the ACA will likely bring, they continue to deliver family planning and related services to women who are low-income, uninsured or face other obstacles to affordable care. Over the decades, women have sought out Title X service providers because they are reliable and trusted sources of care. Title X has also proven itself one of the government’s most successful and cost-effective public health programs, and new research shows that the case for Title X is stronger now than ever before.
The Impact of Title X
Title X is the only federal program dedicated entirely to family planning and related preventive health care. It is a grant program that supports a diverse network of providers, and its programmatic guidelines effectively set the standards for publicly funded family planning care across the United States.
Title X grants sustain a nationwide network of more than 4,100 family planning provider sites throughout all 50 states and the District of Columbia, most of which specialize in delivering family planning services.1 The program’s grantees include state and local health departments, and nongovernmental organizations such as federally qualified health centers, Planned Parenthood affiliates and other independent agencies.
Title X prioritizes meeting the needs of those who are disadvantaged by their income or age. Centers receiving any Title X funds must deliver voluntary, confidential services to clients regardless of their income. Individuals with incomes below the federal poverty level must be provided care free of charge; others are assessed a fee according to an income-based sliding scale, with those at or above 250% of poverty charged the full cost of care. Because adolescents are often unable to draw on family resources or insurance while obtaining confidential care, they must be assessed fees based on their own income, instead of on their family’s. Additionally, Title X support enables providers to serve clients without insurance coverage and to consistently deliver the full package of services needed to promote effective and consistent contraceptive use—especially among those with specialized needs.
Now, more than 40 years after its inception, Title X continues to prove itself the relatively dollar-small but impact-strong heart of the national family planning effort. Seven in 10 women obtaining contraceptive care at a safety-net center receive those services from a Title X–supported site. The Title X network serves 4.7 million contraceptive clients annually, or one-quarter of women in need of publicly supported contraceptive services.1 Sixty-nine percent of these clients have incomes at or below the federal poverty level, and 64% are uninsured.2 The dramatic impact of Title X can be seen in individual states as well. For example, Title X sites serve nearly half of all women in need of publicly supported family planning services in Delaware and the District of Columbia (see table).
Title X–supported centers are also a major source of critical preventive care related to family planning. In 2011 alone, Title X sites tested 2.5 million clients for chlamydia and provided 2.7 million tests for gonorrhea, 744,000 for syphilis and 1.3 million for HIV.2 Also in that year, 1.4 million clients received Pap tests to detect early signs of cervical cancer, and 1.9 million had breast exams to detect warning signs of breast cancer. In 2010, 18% of all U.S. women aged 15–44 who received STI testing, treatment or counseling did so from Title X sites, as did 14% of all those tested for HIV.3
A new Guttmacher Institute report found that in 2010, the family planning services provided at Title X–supported sites helped women avert 1.2 million unintended pregnancies, which prevented 586,000 unplanned births and 403,000 abortions (see chart).1 In the absence of services provided by Title X–funded providers, the rates of unintended pregnancy and abortion among U.S. women would be 35% higher—42% higher among teens.
Helping women determine for themselves whether and when to have children also generates significant government savings, by averting costs that otherwise would have been borne by Medicaid for prenatal care, delivery, postpartum care and infant care. In 2010, the contraceptive services provided at Title X–funded centers generated $5.3 billion in government savings.1 Put another way, every dollar invested in the publicly funded family planning effort that year saved $5.68. The savings in each state are also substantial: The annual state government savings accrued by services provided at Title X sites in 2010 ranged from $4 million in Vermont to just over $1 billion in California.
According to this Guttmacher analysis, the cost savings resulting from publicly funded contraceptive services have increased over the last decade, largely because of three factors.1 First, family planning clients are more likely now than clients were in previous years to use more effective contraceptive methods, such as IUDs and contraceptive implants. Second—and likely due to the recession—individuals who are unable to access publicly funded services are now more likely than those in previous years to use either no contraceptive method or a less effective one, such as withdrawal. These first two factors together have contributed to the number of unintended pregnancies prevented by public funding having increased by 15% since 2006. Third, women are increasingly likely to choose childbirth over abortion when faced with an unplanned pregnancy; 4 that increases the cost-savings for every unplanned pregnancy averted, because births are far more costly than abortions.
Certain attributes of the Title X program make it a critical component of generating these significant cost savings. For one, Title X–supported providers are particularly good at providing family planning clients with a range of choices that includes the most effective methods: Nearly seven in 10 Title X sites offer at least one form of long-acting contraceptive, such as IUDs or implants.5 The difference between providers that do and do not receive Title X funding is particularly pronounced among federally qualified health centers. A nationwide survey of these centers’ largest individual sites found that 85% of those supported by Title X offer IUDs and 57% offer implants, whereas just 60% and 38% of sites not supported by Title X offer these methods, respectively.6
Second, in line with the program’s guidelines, providers supported by Title X are particularly able to reach out and provide care to those women who, without access to publicly funded services, are at particularly high risk of using less effective contraceptive methods or no method at all. Clients at Title X sites are nearly twice as likely as those served at other sites to have no third-party payment for their visit.5 Moreover, poor women, women of color and immigrant women are especially reliant on publicly supported health centers, and Title X specifically supports the tailored outreach, staffing and services needed to engage these populations.
Beyond the Numbers
In addition to Title X’s quantifiable and considerable impact, the program occupies a unique niche that is only becoming more indispensable. With the implementation of the ACA, Title X is needed to provide newly insured clients with somewhere to go for high-quality care, to help connect people to health coverage and to care for those who fall through the cracks.
The ACA extends comprehensive health coverage to tens of millions of individuals, including coverage of a full range of family planning and related preventive services without out-of-pocket costs. However, as more people gain coverage and seek that preventive care, they will need somewhere to go for services. Provider shortages are expected to be a real problem, particularly for those who will be newly covered by Medicaid and those living in medically underserved areas— two groups who tend to rely on exactly the kind of safety-net providers Title X supports.
Title X funding will be crucial to addressing these shortages, by helping to keep the nation’s safety net up and running. Because Title X funds go to providers as up-front grants (rather than payment delivered as reimbursement for direct client services, as with Medicaid or private insurance), these funds can be used in a variety of ways to support a health center’s infrastructure. More specifically, Title X funding allows safety-net centers to make improvements to their staff and facilities, such as extending hours; utilizing advanced technologies, electronic health records or online appointment scheduling; tailoring staffing to meet a community’s unique needs; or paying sufficient wages to reduce the high staff turnover that often plagues safety-net providers.7
Furthermore, the Title X program guidelines will continue to help guarantee that people relying on the safety net receive high-quality care, regardless of whether they seek care at a federally qualified health center or a provider specializing in the delivery of family planning services. The basic principles of high-quality care defined through Title X apply even if an individual’s care is paid partially or entirely by another public program, private insurance or the client herself.
First, Title X guarantees that all services will be voluntary, by requiring that clients be offered a broad range of contraceptive methods (see “Going the Extra Mile: The Difference Title X Makes,” Spring 2012). Sites receiving Title X support are much more likely than other sites to offer all forms of contraception, offer them on-site and provide comprehensive contraceptive counseling.5 Moreover, safety-net centers receiving Title X funding must ensure confidentiality of all services for all their clients—a guarantee highly valued by women regardless of age, income or insurance status, but especially by teens.8
The guidelines governing Title X also call for providers to engage their clients in a dialogue that is specifically tailored to the individual’s experiences and needs. In turn, staff of Title X–supported sites invest more time with clients than centers not funded by Title X, especially clients who most need such specialized attention.5 For instance, Title X sites commonly operate programs and employ staff trained to meet the particular needs of adolescents; individuals for whom language is a barrier to quality care; and individuals experiencing intimate partner violence, substance abuse issues and other medical or personal complications. In all cases, staff of Title X–supported centers report spending a significant amount of time meeting the contraceptive needs of these clients—consistently more time than staff at other sites.
Because they are often their clients’ entry point to the health care system, providers supported by Title X are also uniquely positioned to connect people to health insurance. Six in 10 women who seek contraceptive care at a Title X site consider it their usual source of medical care.3 Yet, when they walk in the door, a large proportion of Title X clients are often eligible for coverage for which they have not yet enrolled; two-thirds are uninsured, and in line with the program’s priorities, the vast majority are also low-income and are therefore often eligible for Medicaid. Yet, roughly four in 10 people eligible for public coverage are not enrolled, often because they do not realize they are eligible or because they have had a difficult time navigating the application process.9 Eligibility for public coverage will only become more commonplace as the ACA’s Medicaid expansions go into effect in some states, and open enrollment begins for the new insurance marketplaces nationwide (intended for individuals with incomes just over the Medicaid eligibility threshold).
Title X providers should be counted on as qualified partners in connecting their eligible clients to coverage options newly available under health reform (see “The Role of Family Planning Centers as Gateways to Health Coverage and Care,” Spring 2011). And Title X sites should embrace this responsibility. Many Title X–supported centers are already adept in guiding their clients to Medicaid and other forms of public coverage, especially those in states with Medicaid family planning expansions.5 Since the mid-1990s, more than half the states have opted to expand Medicaid eligibility specifically for family planning services; these programs are different from the broad Medicaid expansions provided for under the ACA and have reshaped the terrain of the national family planning effort over the past 20 years, including giving providers valuable xperience in helping low-income clients to enroll in newly available insurance coverage.
Going forward, these centers may well be able to help clients to learn about and enroll in private insurance options newly available to them, and to apply for and obtain federal subsidies to make that coverage affordable. Title X providers are also a natural fit to provide brochures to their clients; refer people to state hotlines and to other groups providing enrollment assistance; set up computer kiosks in their waiting rooms for clients to use to learn about their options; and work with states to station government enrollment staff on site.
The flexibility Title X funds give providers to serve uninsured clients, or clients who cannot use their insurance, will be critical going forward. This is in part because, even with the coverage advances of the ACA, many people will still be ineligible for public or private coverage. This includes individuals in the currently 22 states not planning to expand Medicaid eligibility (another four states have not yet committed one way or the other)10 who have income too low to qualify for subsidies and tax credits to help make coverage on the state marketplaces affordable (see “Affordable Care Act Survives Supreme Court Test, But Medicaid Expansion Placed in Peril,” Summer 2012). In addition, millions of immigrants will remain unable to gain health insurance because of their immigration status—not only those who are undocumented, but also lawfully present immigrants barred from Medicaid during their first five years of residency, as well as young people brought to the United States as children and given legal status under the Deferred Action for Childhood Arrivals program (see “Toward Equity and Access: Removing Legal Barriers to Health Insurance Coverage for Immigrants,” Winter 2013). In addition, many people will gain and lose eligibility for coverage as their income and other life circumstances fluctuate, leaving them uninsured for weeks or months at a time. Finally, some individuals with insurance coverage may be afraid to use it because of concerns about confidentiality. This issue is most often encountered by those insured as dependents—often women and teens, which are populations for whom Title X is specifically designed.8,11
Under Unfounded Attack
Despite Title X’s proven contributions, the program and the safety net it supports have been under siege recently like never before. In certain states controlled by social conservatives, policymakers insist that the program and the providers it supports are merely a front for promoting abortion—despite the fact that the national family planning program, with Title X at its core, most certainly does more to reduce the need for abortion than any of the extreme antiabortion measures these same political factions are pushing. Where these policymakers’ campaigns against access to contraception have succeeded, the clear results have been to undermine the health of women in their communities and to increase costs in their state budgets. A prime example are the recent events in Texas: Drastic family planning budget cuts and restrictions on providers’ eligibility for public funds enacted in 2011 have resulted in closed health centers, reduced access to affordable and confidential care, government savings from family planning services being cut by more than half, and an estimated 30,000 additional unintended pregnancies in 2012.12,13
At the federal level, the U.S. House of Representatives voted to kill the Title X program outright in 2011 for the first time in the program’s history. After a showdown with the Senate and President Obama, the social conservatives who control the House finally relented. However, the political reality and programmatic case that Title X is and should be here to stay has not deterred House conservatives from going through the motions to eliminate the program again in 2012, and they will most assuredly try to do so once again this year. The Obama administration and the Senate, by contrast, have stuck to the facts and to their positions, and have repeatedly affirmed their commitment to the Title X program and the U.S. family planning effort. Indeed, for FY 2014, the administration urged an increase in Title X funding, and Senate appropriators assented.
Title X is smart government at its best. It represents a sound investment of taxpayer dollars, especially important in an era of shrinking government spending. And for decades, women by the millions have been voting with their feet in support of the national family planning program; more are likely to want to join their ranks soon. As health reform takes hold, women must be able to rely on a strengthened network of Title X–supported providers for the family planning services they need and the guidance that can help them obtain health insurance they can use.
1. Frost JJ, Zolna MR and Frohwirth L, Contraceptive Needs and Services, 2010, New York: Guttmacher Institute, 2013, <http://www. guttmacher.org/pubs/win/contraceptive-needs-2010.pdf>, accessed Aug. 12, 2013.
2. Fowler CI et al., Family Planning Annual Report: 2011 National Summary, Research Triangle Park, NC: RTI International, 2012, <http:// www.hhs.gov/opa/pdfs/fpar-2011-national-summary.pdf>, accessed Aug. 12, 2013.
3. Frost JJ, U.S. Women’s Use of Sexual and Reproductive Health Services: Trends, Sources of Care and Factors Associated with Use, 1995–2010, New York: Guttmacher Institute, 2013, <http://www. guttmacher.org/pubs/sources-of-care-2013.pdf>, accessed Aug. 12, 2013.
4. Finer LB and Zolna MR, Shifts in intended and unintended pregnancies in the United States, 2001–2008, American Journal of Public Health, 2013, forthcoming.
5. 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 Aug. 23, 2013.
6. Wood S et al., Health Centers and Family Planning: Results of a Nationwide Study, Washington, DC: George Washington University, 2013 <http://sphhs.gwu.edu/departments/healthpolicy/publications/ health_centers_and_family_planning.pdf>, accessed Aug. 12, 2013.
7. Gold RB, Stronger together: Medicaid, Title X bring different strengths to family planning effort, Guttmacher Policy Review, 2007, 10(2):13–18, <http://www.guttmacher.org/pubs/gpr/10/2/gpr100213. pdf>, accessed Aug. 26, 2013.
8. Frost JJ, Gold RB and Bucek A, Specialized family planning clinics in the United States: Why women choose them and their role in meeting women’s health care needs, Women’s Health Issues, 2012, 22(6):e519–e525, <http://www.guttmacher.org/pubs/journals/ j.whi.2012.09.002.pdf>, accessed Aug. 12, 2013.
9. Sommers BD and Epstein AM, Medicaid expansion—the soft underbelly of health care reform? New England Journal of Medicine, 2010, 363(22):2085–2087, <http://www.nejm.org/doi/full/10.1056/ NEJMp1010866>, accessed Aug. 12, 2013.
10. Kaiser Family Foundation, Status of state action on the Medicaid expansion decision, as of Sept. 3, 2013, <http://kff.org/medicaid/state-indicator/state-activity-around-expanding-medicaid-under-theaffordable-care-act/>, accessed Sept. 6, 2013.
11. English A et al., Confidentiality for Individuals Insured as Dependents: A Review of State Laws and Policies, New York: Guttmacher Institute, 2012, <http://www.guttmacher.org/pubs/ confidentiality-review.pdf>, accessed Aug. 4, 2013.
12. Aaronson B, Legislature restores some family planning cuts, New York Times, Aug. 8, 2013, <http://www.nytimes.com/ 2013/08/09/us/legislature-restores-some-family-planning-cuts. html?partner=rss&emc=rss>, accessed Aug. 26, 2013.
13. University of Texas Population Research Center, TXPEP Family Planning Data Finder, no date, <http://www.prc.utexas.edu/ txpep/#state>, accessed Aug. 26, 2013.
14. 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 Sept. 6, 2013.