One in three women who made a family planning visit in 1988 — the last year for which comprehensive data are available — reported going to a publicly funded family planning clinic. These clinics complement the private health care system in several ways: They serve Medicaid-eligible women when other providers refuse to accept them; provide subsidized services to low-income women who are not eligible for Medicaid; offer more extensive counseling on contraceptive methods; provide confidential services for teenagers and other women who may not be able to discuss reproductive health issues with their regular physicians; and offer contraceptive supplies at a lower cost than is usually available elsewhere.
This Issues in Brief describes the current structure and
funding of the national family planning program, and the reproductive
health and other preventive services it provides. It examines
the impact of the program on the prevention of unintended pregnancies,
births and abortions as well as on the reduction of low birth
weight and infant mortality. It also discusses the central role
that Title X of the Public Health Service Act, the historic core
of the federal effort, plays in determining the shape and substance
of the national family planning service delivery system.
Overview
History. Studies conducted during the 1960s showed that rates of unwanted childbearing among low-income women were at least twice as high as those among the more affluent-a phenomenon that could be traced in large part to inequalities in access to family planning services. By the end of the decade, a sizable, bipartisan consensus had emerged favoring government support of voluntary family planning programs as a means of expanding economic development, alleviating poverty, avoiding welfare dependency and improving the health of women and their families.
In the meantime, Congress had amended a number of federal laws to allow family planning services to be provided under certain existing programs. In 1965, as part of the so-called War on Poverty, federal funds were made available for family planning through the Office of Economic Opportunity. In 1967, Title IV-A of the Social Security Act was amended to require state welfare agencies to offer and provide family planning services to women receiving public assistance.
Then, in 1970, with broad bipartisan support, legislation establishing Title X of the Public Health Service Act was enacted and signed into law by President Richard Nixon, creating for the first time a comprehensive federal program devoted entirely to the provision of family planning services on a national basis. In his Message on Population Growth and the American Future, delivered the preceding year, President Nixon declared that "no American woman should be denied access to family planning assistance because of her economic condition. I believe, therefore, that we should establish as a national goal the provision of family planning services...to all who want but cannot afford them."
Following the enactment of Title X, public expenditures for family planning grew rapidly in the early 1970s, as the clinics Title X helped to create became established across the country. By fiscal year 1983, $340 million in public — federal and state — funds were being spent to provide family planning services to 5 million women at nearly 5200 separate services sites.
A combination of politics and fiscal pressures during the 1980s,
however, forced family planning clinics to confront both budget
cuts and new administrative restrictions. Congress has not formally
reauthorized Title X since 1985. (The authorization process restates
congressional support for a program and sets new funding ceilings.)
Congressional appropriations have continued, but in the absence
of an authorization, funding levels have inevitably been lower.
Despite these struggles, publicly funded agencies have continued
to provide services to increasing numbers of low- and moderate-income
women and teenagers.
Sources of Funding for Family Planning Services. Public funds to provide family planning services come from diverse programs with different focuses (see Figure 1). The single largest source of funding is the federal-state Medicaid program (Title XIX of the Social Security Act). While the large majority of family planning agencies — 83% — derive at least some income from Medicaid reimbursements, few rely heavily on it. Medicaid does not fund family planning clinics or provide services directly. Instead, it is an insurance mechanism whereby federal and state governments reimburse physicians and other health care professionals for the medical services, including family planning, they have provided to eligible individuals.
Many poor women are not eligible for Medicaid coverage. To be eligible for Medicaid in most states, a woman must be single, have already had a child (or be pregnant) and meet income eligibility requirements that are often extremely low; nationwide, the average income eligibility ceiling is only about 50% of poverty, or approximately $6000 a year for a family of three.
Poor and low-income women who do not qualify for Medicaid are dependent on clinics for family planning services. In contrast to Medicaid, Title X is a "categorical" grant program that supports the establishment and operation of clinics. It is the only federal program dedicated solely to funding family planning and related reproductive health care services.
Until 1985,Title X constituted the single largest source of public funds for family planning. In 1992, Title X still helped to support 76% of all family planning agencies, providing more than 20% of the budgets for over half of them. Thus, Title X continues to provide the underpinnings for the entire national family planning effort, enabling clinics established with its funds to take fuller advantage of Medicaid reimbursements and other funding sources.
Clinic services are also partially supported in most states with federal funds from the Maternal and Child Health and Social Services block grants (Titles V and XX of the Social Security Act), but with a few exceptions, family planning services are only a small component of these broad programs. In addition, state contributions to family planning services have grown considerably in recent years. In 1992, only five states did not use any of their own funds for family planning services; 69% of family planning agencies received some support from state appropriations.
Who Provides Publicly Funded Family Planning Services. In 1992, a total of 2610 agencies provided organized family planning services — 1430 health departments, 170 Planned Parenthood affiliates, 260 hospitals and 750 other types of agencies. Together, these agencies operated more than 5400 individual clinic sites. Of these, 52% were operated by state health departments, 15% by Planned Parenthood affiliates, 6% by hospitals and 27% by other agencies. Over the last 10 years, there has been a decrease in the proportion of clinics run by health departments and an increase in those operated by other agencies, such as independent family planning councils and community and migrant health centers.
The average number of clients served at each clinic site in 1992 was 1010. Planned Parenthood affiliates had both more clinic sites and larger caseloads, serving 4-8 times as many clients per agency as the other types of agencies. While Planned Parenthood affiliates reported an average of 2040 clients per clinic site, health department clinics, many of which are located in rural or sparsely populated areas, served an average of 760 clients annually.
Who Receives Services at Publicly Funded Family Planning Clinics. Data from the 1988 National Survey of Family Growth (NSFG), conducted periodically by the National Center for Health Statistics (NCHS) of the federal Centers for Disease Control and Prevention, show that the number of women who received their most recent family planning services at a publicly subsidized clinic rose from 6.1 million in 1982 to 7.1 million in 1988.
The trend toward greater use of family planning clinics is promising. Nonetheless, gaps in the provision of services remain. According to the 1988 NSFG, only 84% of women in households with incomes below 200% of poverty who were at risk of unintended pregnancy were using contraception. In contrast, 92% of women with higher incomes were using some form of contraception.
Another indicator of the continuing need is a 1995 NCHS report
indicating that, overall, U.S. women have an average of 3.3 pregnancies
over their lifetime, of which only 1.8 are wanted births. White
women average 2.8 pregnancies, 1.6 of which are wanted births;
black women average 5.1 pregnancies, of which 1.8 are wanted births;
and Hispanic women average 4.7 pregnancies, of which 2.6 are wanted
births.
Services Provided in Publicly Funded Family Planning Clinics. Besides providing contraceptive methods and related counseling, family planning clinics conduct many related tests and examinations (see Table 1). In fact, one study found that women who had obtained family planning services from a clinic during the previous 12 months were much more likely than women who had not to have received a pelvic exam and other essential health screening, regardless of the number of visits or source of payment for the visit.
The large majority of agencies also provide contraceptive and
STD/HIV services to men and have special programs targeted at
teenagers. Over half of the agencies conduct educational programs
emphasizing the postponement of sexual activity, and three-quarters
report that their counselors spend extra time with teenage clients,
particularly to provide information and counseling on sexually
transmitted diseases.
The Impact of Publicly Funded Family Planning Services
Publicly funded family planning services have been responsible for preventing large numbers of unintended pregnancies, abortions and births to low-income women, and especially to unmarried women and teens.
The data also show that public funding of family planning services prevents poor birth outcomes and improves women's overall health.
The benefits of publicly funded family planning services in the
United States have long been recognized. Leading authorities in
public health have agreed on its demonstrated effectiveness, not
just in preventing pregnancy, but in improving the health of women
and their children (see Table 2).
The Key Role of Title X
While no longer its largest funder, the Title X program continues to be the glue that holds the national family planning service delivery system together, largely determining both its structure — through its nationwide network of clinics — and the substance of the services that are provided to low- and moderate-income women and teenagers. In 1990, 5.3 million family planning clients were served by clinics administered by Title X-supported agencies.
Women who received services at Title X-supported clinics in 1990 were predominantly young, poor and had never had a child. Black women, who are more likely than others to be poor, were disproportionately represented among the clinic population. At the same time, when all clinic clients are taken into account, about 42% of the women using Title X-funded clinics were married; 69% were 20 years or older; and 63% were non-Hispanic whites.
Title X is administered by the Department of Health and Human Services (DHHS), which is responsible for allocating the funds appropriated annually by Congress among the 10 federal health regions. In each region, the health administrator receives applications from, and awards grants on a competitive basis to, public and nonprofit private agencies that provide contraceptive services as well as training, technical assistance and other support.
In 1991, there were a total of 85 primary Title X grantees, ranging from 1-4 per state. Fifty Title X grantees were state and local health departments; 12 were independent family planning councils; eight were Planned Parenthood affiliates; 15 grantees were other types of agencies.
Some Title X grantees operate family planning clinics directly, distributing grant funds among their various facilities. Others allocate the money to "delegate agencies," which administer the operation of individual clinics. Agencies providing family planning services, whether primary Title X grantees or their delegates, are diverse, community-based organizations. Recipients of Title X funds (in addition to those listed above) include: university medical centers, community action organizations, community health centers, nursing service organizations and a wide variety of nonprofit agencies, many of which are located in places where little or no other reproductive health care is available.
In 1991, 814 separate delegate agencies received Title X funds; Title X grantees and delegate agencies together administered approximately 4100 clinics that year. Clinics administered by Title X agencies were located in each state and in at least two-thirds of all counties. Over half of these clinics (58%) were administered by state and local health departments; 17% by Planned Parenthood affiliates; and the remaining 25% by hospitals, regional or local family planning councils, Indian nations and community organizations.
Title X also determines the substance of the services offered to individuals. Each grantee is ultimately responsible for ensuring that its delegate agencies and the clinics they run meet the program's requirements. The Title X statute requires that a grantee provide "a broad range of acceptable and effective methods and services." Both the Title X regulations and official program guidelines outline in greater detail protocols for the provision of family planning services that comport with nationally recognized medical standards, including a mandate to offer the full range of contraceptive methods and related counseling as well as to provide confidential services.
Any woman, regardless of age or whether she has had a child, may go to a Title X-funded clinic for family planning services. However, the amount each individual pays for the services she receives depends upon her income. If her income level is at or below 100% of the federal poverty level, by law she should receive completely subsidized services, including the contraceptive method she chooses. She will be charged on a sliding fee scale if her income is between 100-250% of poverty; and she will pay full fees if her income is above 250%.
The Title X regulations and guidelines serve to ensure that eligible
women receive subsidized services based appropriately on their
incomes; low-income women tend to be charged higher fees in family
planning clinics that do not receive Title X funds.
Title X and Politics. As the one federal program devoted to the provision of family planning services, Title X has also been the focal point for much of the political wrangling over reproductive health issues.
Title X and Teens. From the beginning, Title X has required that services be made available without regard to age or marital status. Consequently, Title X-supported clinics have always served adolescents confidentially and without regard for their ability to pay.
In 1981, Congress amended Title X to require that "to the extent practicable, [Title X-funded] entities... shall encourage family participation." Shortly thereafter, the Reagan administration proposed new regulations — better known as the "squeal rule" — requiring that all parents whose adolescents visited a family planning clinic be notified by registered mail.
Although over 40,000 letters of protest against the proposals were filed with DHHS from medical, health and civic groups, the regulations were finalized. Most comments made the argument that the regulations were trying to mandate open family communication which, although everyone agreed is desirable, is not always possible.
Two federal appeals court judges eventually barred the regulations' enforcement on constitutional grounds, and they were withdrawn without ever going into effect. Since that time, Congress has repeatedly rejected mandatory notification or consent for contraception, and Title X-supported clinics have maintained the policy of encouraging, but not requiring, parental involvement in minors' reproductive health decisions.
Title X and Abortion. Since its inception in 1970, the Title X statute has prohibited use of the program's funds for "abortion as a method of family planning." Repeated, congressionally requested investigations during the 1980s found that all Title X-funded clinics were operating in full compliance with the law. Of the more than 4000 Title X-funded clinics nationwide, approximately 80 provide abortions, all with other than Title X funds. More than half of these clinics are in hospitals.
However, problem pregnancy counseling, and requested referrals for medical and social services that are not offered under Title X, have been standard practice and are required by Title X guidelines. Even so, DHHS in 1988 promulgated new regulations (ordered the previous year by President Ronald Reagan) that, among other changes, would have prohibited doctors and other health professionals in Title X-funded clinics from providing any abortion-related information or referrals on the grounds that Title X funds were to be spent only on "pre-pregnancy related services."
The regulations generated more than 75,000 comments. Thirty-six state governments, a host of national health, medical and civic groups, and all 25 deans of the nation's schools of public health wrote in opposition, expressing concern that withholding this information would violate their medical ethics and standards; moreover, they pointed out, many of the women who depend on Title X services often have no other place to go for the information.
The legality of the so-called gag rule was upheld by the U.S.
Supreme Court in 1991. Subsequently, however, it was roundly rejected
in Congress. In 1992, both houses of Congress passed legislation
both to reauthorize Title X and overturn the gag rule. The legislation
was vetoed by President George Bush. The Senate overrode the veto
by a vote of 73-26. The House vote was 266-148, only 10 votes
short of the necessary two-thirds. A series of last-minute court
orders blocked actual enforcement of the regulations, and they
were ultimately withdrawn in 1993 at the direction of President
Bill Clinton.
Looking Ahead
The proportion of public funding for family planning services from different sources has shifted greatly over the last period. In 1992, Medicaid expended $319 million — 50% of all public funding-for contraceptive services, up 81% from its 1981 level. In contrast, Title X, at $110 million, accounted for only 17%. After adjustment for inflation, Title X expenditures for contraceptive services decreased by 72% between 1980 and 1992. Total public expenditures for contraceptive services dropped by 27% during that period.
At the same time, the cost of providing family planning services appears to have risen in several areas, such as contraceptive supplies and related laboratory expenses (between 1991 and 1992, the average price for oral contraceptives to publicly funded family planning clinics rose 42%) and STD and HIV counseling, testing and treatment. In 1993, among the agencies that do offer and provide them, these services constitute, on average, 26% of the agency's contraceptive services budget.
Furthermore, family planning clinics are being called upon to provide care to people with other health problems. In recent years, for example, the proportion of patients coming to family planning clinics in need of screening or treatment for STDs has increased dramatically. Forty percent of all medical visits to one Title X grantee in 1990 involved testing or treatment for STDs, compared with only 10% of visits in 1980. Some providers cannot absorb these additional costs; they are forced to forgo testing and to treat patients based on their examinations alone.
Moreover, since these clients frequently have no other source of care, Title X-assisted clinics must address their health needs more comprehensively, by offering such corollary health services as screening for diabetes or cholesterol levels, prenatal care, programs on smoking cessation and counseling on substance abuse. All of these efforts consume additional resources, in both staff time and money, usually without extra funding.
Despite evidence that, in sheer numbers, family planning clinics served more people in 1991 than in 1981, many family planning providers have been forced to cut or change the nature of their services, a development likely to have an increasingly serious impact on the accessibility of services to their clients. Some providers report that new clients have to wait longer for an appointment, or that they have been compelled to require higher fees for their services or to take a higher proportion of clients who can afford to pay. For poor women seeking to prevent an unintended pregnancy, these changes could present insurmountable obstacles.
According to a report recently issued by the Institute of Medicine, during the 1980s — when real (inflation adjusted) spending on publicly subsidized family planning services dropped and Title X went unauthorized — unintended pregnancy in the United States began to increase, reversing the downward trend of previous years. Ironically, this situation has led some critics to argue that Title X should be defunded entirely on the grounds that it has failed to solve our national problems of unintended teenage pregnancy and out-of-wedlock births. Some critics go so far as to argue that contraception itself is a failure, and that the provision of family planning services has made these problems worse.
Incontrovertibly, contraception works: While no contraceptive,
or contraceptive user, is perfect, the fact remains that the 10%
of American women at risk of unintended pregnancy who do not use
contraception at all account for 53% of all unintended pregnancies.
Public support for family planning works, too. Even its strongest
supporters readily admit that the national family planning program
will never, by itself, reduce the nation's unintended pregnancy
rate to zero. At the same time, they point out that the availability
of affordable, voluntary family planning services remains the
only major programmatic intervention that — in a cost-effective
manner — has been demonstrated to reduce unintended pregnancy, avert
the need for abortion and improve birth outcomes and the overall
reproductive health of the women in the United States.
Table 1
Family planning agencies provide a broad range of services
…
In the course of a contraceptive visit . . . And beyond
Percentage of family planning agencies routinely providing
Pelvic exam 98
Percentage of family planning agencies offering various
Female Clients
Male Clients
________________________________________________________________________
various services in the course of a woman's contraceptive visit:
Breast exam
(including selfbreast exam) 98
Blood pressure measurement 98
Pap smear 98
Anemia screening 90
Gonorrhea screening 70
Cardiovascular problems 59
Syphilis screening 49
Chlamydia screening 46
Diabetes 45
Urinary tract infection screening 34
Pregnancy tests 30
Herpes screening 10
reproductive health and other services beyond contraception:
HIV testing 82
Wellbaby care 71
Postpartum care 70
WIC program 69
Prenatal care 66
Infertility counseling 57
Social services 49
Sports/work physicals 42
Primary health care 40
Colposcopy 32
Genetic counseling 31
Cryotherapy 30
Midlife health program 29
Mental health services 21
Mammography 15
Infertility treatment 11
Abortion 8
Day care 7
Condom distribution 93
STD treatment 86
STD screening 84
HIV testing 79
Sports/work physicals 36
Social services 35
Primary health care 33
Infertility counseling 32
Testicular cancer screening 30
Mental health services 21
Infertility treatment 5
