Advancing Sexual and Reproductive Health and Rights
 
The Guttmacher Report on Public Policy
February 2001, Volume 4, Number 1
 
Special Analysis

Title X: Three Decades of Accomplishment

Thirty years ago—with data showing that many American women, and especially low-income women, were having more children than they wanted—Congress created Title X, the nation's first federal program dedicated to the provision of family planning services. In the intervening three decades, the Title X program has helped build a national network of family planning clinics, has established the standards used for the delivery of high-quality but low-cost family planning services nationwide and has enabled millions of women to plan their pregnancies and prevent unintended births. Since 1980, Title X has helped women avoid almost 20 million pregnancies, and has provided key reproductive health services to millions of women. The arrival of a new set of players to Washington, many of whom may be unfamiliar with Title X beyond some of the political controversies that have dogged it in recent years, makes it a propitious time to review Title X's history and its record of accomplishment.
By Rachel Benson Gold

In the mid-1960s, many American women, and especially low-income women, had more children than they desired. Important research conducted at that time showed that inequitable access to contraceptives, not a preference for more children, was largely responsible for the difference between lower- and higher-income women's ability to have the number of children they wanted. Other research conducted at the same time began to show that closely spaced pregnancies very early or very late in a woman's reproductive years could lead to adverse health consequences for both the mother and the children. In addition, evidence began to mount that unintended childbearing—particularly among teenagers—increased poverty and reliance on public assistance, and reduced women's ability to participate in the workforce or complete an education. Together, these findings led to the beginning of a consensus that improved access to contraception would further two important social goals—alleviating poverty and improving the health of women and children.

The federal government made its first grants to support the provision of family planning services in 1965 as part of the Johnson administration's War on Poverty, a move that led to a patchwork of widely varying publicly subsidized family planning programs across the country over the next several years. Since states largely controlled the little funding available under these disparate programs, service availability, eligibility criteria and benefit levels varied widely. That uneven landscape changed dramatically in 1970, when Congress enacted Title X of the Public Health Service Act, the only federal program—then and now—devoted solely to the provision of family planning services nationwide. With strong bipartisan support, Title X sought to fulfill President Richard M. Nixon's historical 1969 promise that "no American woman should be denied access to family planning assistance because of her economic condition."

In the years after its inception, Title X was the major source of support for publicly funded family planning services in the United States. More recently, other federal sources—including Medicaid, the social services block grant, the maternal and child health block grant and two newer programs, the State Children's Health Insurance Program and Temporary Assistance for Needy Families—as well as state and local funds have become available to subsidize family planning. Nonetheless, Title X remains central to the national effort. It is still the sole federal program dedicated to family planning. Today, Title X supports the establishment and maintenance of the nationwide network of family planning clinics in a variety of ways, such as paying the salaries of clinic personnel and purchasing contraceptives and other supplies, while also subsidizing the delivery of contraception and other services to clients who lack another source of payment.

Key Role of Title X

Title X is a federal grant program administered by the Office of Family Planning within the federal Department of Health and Human Services. In 1999, 84 Title X grantees spread across all 50 states and the District of Columbia distributed Title X funds to local clinics. Of the roughly 7,000 family planning clinics nationwide, more than 4,500 received Title X funds. Almost 60% of these sites are run by state, county or local health departments; another 14% are operated by Planned Parenthood and the rest are run by a variety of other types of agencies. In fact, one of the hallmarks of the program is that funds go to a diverse set of local grantees that have the flexibility to structure and administer their programs to meet local needs.

Clinics that receive Title X funds can, and do, use funds from other sources as well. These include a variety of other federal programs that may fund family planning, as well as state and local sources. In fact, clinics receiving Title X funding obtain, on average, one-quarter of their revenues from the program.

One of Title X's biggest contributions to the provision of publicly funded family planning is the set of standards developed under the aegis of the program. These standards apply to all women served at clinics that receive any Title X funds, notwithstanding the source of payment for any individual client. In this way, Title X essentially sets the standards for the provision of publicly funded family planning services and supplies in the United States.

Title X-supported clinics are open to all women, regardless of age, marital status, income or health insurance status. The fee the clinic may charge a woman for services depends on her income: A woman with an income below the federal poverty level ($14,150 for a family of three) is entitled to services free of charge. Women with incomes between 100% and 250% of poverty pay according to a sliding fee schedule; women with incomes above 250% pay the full cost of their care. Significantly, fees for minors are based on their own income, rather than their parents'. As a result, many teens receive services without having to make an out-of-pocket payment, which might be a significant impediment to their receiving care.

All clients at Title X-supported clinics are entitled to confidential care, an essential factor in encouraging some individuals—especially teenagers—to obtain family planning and other reproductive health care. Clinics are required, however, to encourage—to the extent feasible, given the individual family situation—teens to talk to their parents.

Title X services must be completely voluntary; the statute explicitly states that obtaining family planning services may not be made a condition for the receipt of other public benefits. One way that Title X puts into practice the principle of voluntary participation and ensures that a client is not pressured to accept a particular contraceptive method is by requiring that clinics offer clients a range of contraceptive methods and counseling services, including information about natural family planning.

Title X requires that clients visiting clinics for contraceptive care be offered related preventive health services as well. As a result, the program regulations and official guidelines specify a wide range of services to be delivered to clients at Title X-supported clinics, including blood pressure evaluation, breast examinations, pelvic examinations, Pap tests, and sexually transmitted disease (STD) and HIV testing, as indicated.

From its enactment in 1970, the Title X statute has explicitly prohibited using program monies to pay for abortion. However, the program regulations stipulate that a pregnant woman must be offered information and counseling about all of her options, "including prenatal care and delivery; infant care, foster care, or adoption; and pregnancy termination," and referrals upon request. For women facing an unintended pregnancy, such "nondirective counseling" is intended to convey basic facts about all alternatives in a nonjudgmental manner, so that women can explore their options and decide which best suits their circumstances, values and needs.

The Program's Clients

Clinics that receive Title X funding serve over four million women each year, or one-quarter of all U.S. women in need of subsidized family planning services. The vast majority of these women are poor or low-income and are uninsured. In fact, because Title X does not have specific eligibility criteria—instead serving all women and charging them based on their ability to pay—Title X plays an especially vital role in subsidizing services for uninsured women (including women who are poor but not covered by Medicaid because they do not meet that program's rigid eligibility requirements) or for women covered by private insurance that does not include coverage of family planning services and supplies (see chart).

Clients Served

Source: The Alan Guttmacher Institute (AGI), Fulfilling the Promise: Public Policy and U.S. Family Planning Clinics, New York: AGI, 2000, Table 11, p. 46.

Title X-supported clinics are an important source of services for women who need contraceptive care. The clinics serve 15% of all women in the United States who obtain contraceptive prescriptions or supplies or who receive a checkup for birth control each year; they serve one in five women who obtain birth control counseling each year (see chart). In fact, according to an analysis by The Alan Guttmacher Institute of data from the 1995 National Survey of Family Growth, women receiving contraceptive services from Title X- supported clinics are significantly more likely than women who receive such care from private physicians to say that they received counseling about birth control.

Services Provided
A significant proportion of U.S. women rely on Title X-supported clinics for their reproductive health care.

Source: The Alan Guttmacher Institute (AGI), unpublished tabulations of the 1995 National Survey of Family Growth, New York: AGI, 2001.

Women obtaining care from Title X-supported clinics typically receive much more than just contraceptive care. Only 5% of clinic clients, according to the 1995 data, received nothing other than contraceptive services at their visit. Nearly nine in 10 obtained some type of preventive gynecologic care, and more than half received services related to STDs or reproductive tract infections. Eighteen percent of U.S. women who receive testing for STDs each year, and 14% who receive HIV testing, do so at clinics supported by Title X. In addition, almost one in 10 women of reproductive age who receive a Pap test, pelvic exam or testing and treatment for gynecologic infections in the United States obtain these services from Title X-funded clinics.

The Program's Impact

Clinics receiving Title X funds have been at the forefront of the ongoing effort to reduce rates of unintended pregnancy and abortion, and their impact has been enormous. Each year, Title X-supported clinics enable one million women to avoid unintended pregnancy, and women served at Title X-supported clinics have prevented almost 20 million pregnancies over the last two decades. Nine million of these pregnancies would have ended in abortion (see chart). The program has played a particularly important role in reducing pregnancies to teenagers. By helping to prevent 5.5 million adolescent pregnancies, Title X funded clinics have helped young women avoid more than two million births and a similar number of abortions over the last two decades. Without Title X, the number of teenage pregnancies would have been 20% higher than it was for this period.

Dramatic Results
Women getting contraceptives from Title X-supported clinics avoided almost 20 million unintended pregnancies over the last two decades.

Source: The Alan Guttmacher Institute (AGI), Fulfilling the Promise: Public Policy and U.S. Family Planning Clinics, New York: AGI, 2000, Table 13, p. 46.

The program's accomplishments are all the more remarkable because they have the net effect of saving, rather than costing, public dollars in the long run. For every dollar that the federal and state governments spend on family planning services, three dollars are saved in Medicaid costs for pregnancy-related and newborn care.

In addition, Title X-supported clinics have helped numerous women detect and obtain early treatment for a range of dangerous, and even life-threatening, medical conditions. Between 1995 and 1998, Title X clinics performed 19 million tests for STDs, including 1.4 million for HIV. Over the past 20 years, an estimated 54.4 million breast examinations have been conducted at Title X-supported clinics; providers funded by the program have taken an estimated 57.3 million Pap tests, which resulted in the early detection of as many as 55,000 cases of invasive cervical cancer.

Looking Ahead

Subsidized family planning services enjoy the support of nine in 10 Americans, yet Title X has been politically controversial for much of its life. Unfounded charges that the program promotes teenage sexual activity and abortion have translated into legislative and administrative attacks, in which opponents of the program have sought either to eliminate it completely or to impose restrictions that have the potential to cripple service delivery. These controversies have left a political cloud hanging over the program.

While the legislative and administrative attacks on Title X have met with varying degrees of success over time, the political opposition has undeniably resulted in a depressed funding level for the program. During the 1980s, the program suffered steep funding cuts, and despite fairly steady increases in appropriations since then, it has never fully recovered. Taking inflation into account, the program's funding level in 1999 was 60% lower than it had been 20 years ago (see chart).

Funding Gap
Despite recent increases, Title X funding has decreased 60% since 1980, when inflation is taken into account.

*Constant 1980 dollars, calculated by deflating annual appropriations using the Consumer Price Index for Medical Care. Source: The Alan Guttmacher Institute (AGI), Fulfilling the Promise: Public Policy and U.S. Family Planning Clinics, New York: AGI, 2000, Table 14, p. 47.

As a new administration—one that some program advocates worry may not be as friendly to the provision of publicly funded family planning services as was its predecessor—and Congress arrive in Washington, the program's three decades of accomplishments underscore its vital role in reducing abortion and unintended pregnancy and in improving the health of women and teens by providing them with a range of key reproductive health services, in sharp contrast to the claims of many of its opponents.

This article is adapted from The Alan Guttmacher Institute (AGI) report, Fulfilling the Promise: Public Policy and U.S. Family Planning Clinics. Research for the report was supported in part by the US. Department of Health and Human Services under grant FPR000072-01. The report and its distribution were also supported by a grant from the Open Society Institute. The conclusions and opinions expressed in this article are those of the author and AGI.