On May 7, President Obama sent Congress his proposed 2010 budget recommendations. For programs and policies relating to sexual and reproductive health at home and abroad, the proposed budget contains some good news, some bad news and some news that is only okay. The most welcome development is the abolition of “abstinence-only-until-marriage” programs. The most disappointing is the failure of leadership the president displayed by sanctioning the continuation of federal bans on subsidized abortion services for U.S. women who depend on the federal government for their health care or health insurance. In reviewing the budget, it is important to remember it is just a starting point: Congress gets a crack at whether to accept, reject or modify the president’s recommendations.

Abstinence-Only Out; Evidence In. In a clear victory for evidence-based policies, the proposed budget ends funding for abstinence-only-until-marriage programs that ignore or actively denigrate the effectiveness of contraceptives and safer-sex behaviors. Instead, the president recommends shifting these funds, plus an additional $15 million—a total of $178 million—to support a new teen pregnancy prevention initiative that includes a grants-to-states program and a separate community-based grant program. Seventy-five percent of the community-based funds would support “comprehensive, evidence-based programs,” which have been proven to delay sexual activity, increase contraceptive use or reduce teenage pregnancy, and 25% of funds would support demonstration and research grants to test new models and approaches. Abstinence-only programs could continue to receive funding under the latter category so long as they have promise, but they would have to compete with other initiatives.

Access to Abortion: Absence of Leadership. The president had the option to assert his prochoice credentials and propose in his budget that the many abortion funding restrictions that exist throughout a range of federal health programs be deleted. The most infamous of these, the Hyde Amendment, prohibits Medicaid from paying for abortions for poor women. The president chose politics over principle on this set of issues. His budget proposal leaves almost all the abortion funding restrictions intact. The one restriction his budget does recommend changing, as a matter of home rule, is the one that bans the District of Columbia from using its own local revenues to pay for abortions for its indigent residents—the way states may do. The administration is sending an ominous signal about the priority that access to abortion services will have in the context of health care reform.

Domestic Family Planning: Modest Improvements. Given all the hoopla surrounding the president’s initiative to reduce the need for abortion, his budget request is somewhat underwhelming when it comes to the quintessential middle ground—preventing unintended pregnancy. The Title X family planning program would receive a 3%, or $10 million, increase, which would bring funding to $317.5 million from the current $307.5 million. When it comes to Medicaid, the president proposes congressional action to remove barriers for states seeking to expand eligibility for family planning. This is a welcome development and a down payment on the president’s promise from earlier this year to find a way (other than with the stimulus package) to win this important policy change. The president’s proposed version in the budget is somewhat less robust than the version that has been pending in Congress—one that gives states the option of covering family planning for the same group of women eligible for pregnancy-related care. The administration’s proposal would cap the ability of states to extend coverage to women at 200% of poverty.

Services to New Mothers: Promising. The president proposes the creation of a new “home visitation” program for low-income parents and pregnant women to the tune of $8.6 billion over the next 10 years. It would be an entitlement program for states, which would have to apply for the money and put up their own matching funds. Although some funds would go toward testing promising newer models, the program would, like the teen pregnancy initiative, primarily fund models with a strong research evidence base. The most prominent of those models, the Denver-based Nurse-Family Partnership, is currently serving more than 16,000 women in 28 states and has been shown over more than 30 years to have numerous long-term benefits for children and families, including reductions in preterm births and improved birth-spacing.

Global Health Initiative: Moving Toward a More Integrated Approach. The president presented his recommendations for global health funding in the context of his new Global Health Initiative. “We cannot simply confront individual preventable illnesses in isolation. The world is interconnected, and that demands an integrated approach,” he said. The idea is to consider the synergies among global health programs in order to seek a more comprehensive and integrated approach to fighting disease, improving health and strengthening health systems. The initiative will focus on preventing millions of new HIV infections, reducing maternal and newborn deaths, averting millions of unintended pregnancies and eliminating some neglected tropical diseases. Over the next six years (FY 2009–2014), the administration plans to spend $63 billion under the Global Health Initiative, with $51 billion allocated to global HIV/AIDS and malaria efforts and $12 billion to other global health priorities, including maternal and child health, family planning and neglected tropical diseases.

For FY 2010, the president is requesting $5.3 billion for the global HIV/AIDS programs, a slight increase over the current amount. Overall funding for maternal and child health programs would rise from $494 million to $524 million. (Maternal health efforts are not broken out separately.) Funding for international family planning and reproductive health programs would increase to $543 million—$48 million more than current levels. Additionally, the president is recommending a $50 million contribution to the United Nations Population Fund (UNFPA), the same amount as this year. The budget does propose deleting all the limitations on the U.S. contribution to UNFPA, including one that prevents any U.S. funds from being used in UNFPA’s China program and another that deducts from the annual U.S. contribution the amount that UNFPA spends in China that same year. If approved by Congress, the overall amount proposed for international family planning and reproductive health programs—$593 million—would represent the highest level ever from the U.S. government.