BACKGROUND

Modern contraception allows women and couples to control whether and when to have children. In doing so, it has had important public health consequences for women and families, and has improved women’s ability to reach their educational, social and economic goals. But in part because affordable contraceptive services are not equally available to all, many women and couples find it difficult to avoid pregnancies they do not want and to time those they do want. Research demonstrates that the family planning services provided by publicly funded family planning programs and providers benefit women, families and society by expanding contraceptive use, helping women to prevent unintended pregnancies, and improving maternal and child health. Health centers are considered part of the national safety-net family planning network if they provide contraceptive care to the general public using various federal, state and local funding streams to offer reduced-cost or free services. To be considered part of this network, sites must serve at least 10 contraceptive clients per year.

Over time, states have imposed a number of abortion-related restrictions on state family planning funds and on other publicly funded programs intended to provide services to low-income individuals. Often these laws prohibit family planning providers that use private funds to offer abortion from being eligible for state family planning dollars and other types of public funding. These restrictions can extend to entities affiliated with abortion providers, and some laws exclude all privately operated reproductive health–focused providers from receiving these funds. Other laws create tiered allocation systems for distributing various state-allocated funds that make it difficult or impossible for privately operated reproductive health–focused providers to receive funding.

Spurred by efforts at the federal level to prohibit Planned Parenthood affiliates from participating in federally funded programs, legislators in some states are attempting to bar providers that offer abortion and those affiliated with a provider that does so from receiving any public funds—including Title X grant funding and Medicaid reimbursements—that pass through the state treasury. Some states have gone so far as ending their joint state-federal Medicaid family planning expansion programs in favor of entirely state-funded “spin-off” programs, which cover many of the same services but exclude providers that offer abortion services.

STATE LAWS AND POLICIES

For a chart of current laws and policies in each state, see State Family Planning Funding Restrictions.

For information on state laws and policies related to other sexual and reproductive health and rights issues, see State Laws and Policies, issue-by-issue fact sheets updated monthly by the Guttmacher Institute’s policy analysts to reflect the most recent legislative, administrative and judicial actions.

RELEVANT DATA AND ANALYSIS

Benefits of Family Planning

Women’s ability to make their own decisions about childbearing benefits individuals, families and society.

  • To prevent unintended pregnancy, women need access to a method of contraception that will work best for their personal circumstances.
    • About 38 million U.S. women of reproductive age are sexually active and do not want to become pregnant, but could become pregnant if they and their partners fail to use a contraceptive method correctly and consistently.1
    • Nearly half (45%) of all pregnancies in the United States—2.8 million in 2011—are unintended.2
    • Most American families want two children. Women who want two children will spend an average of about three years pregnant, postpartum or trying to become pregnant, and three decades—more than three-quarters of their reproductive life—trying to avoid an unintended pregnancy.3
  • The ability to delay and space childbearing is crucial to women’s social and economic advancement.
    • Historically, legal access to oral contraceptives contributed substantially to increases in the number of young women who obtained some college education.4
    • Effective contraceptive use can increase the amount of time women spend in the paid workforce, largely because it improves women’s ability to delay and time childbearing to best fit with educational and early professional opportunities.4
    • Access to contraception has contributed to increasing women’s earning power and decreasing the gender gap in pay.4
    • In a 2011 survey of women receiving services from safety-net family planning centers, the most common reason participants cited for using contraceptives was that they could not afford to take care of a baby at that time. Other reasons for use included getting or keeping a job, staying in school, and wanting to wait until life was more stable to have a baby.5
  • Family planning has well-documented health benefits for mothers, newborns, families and communities.
    • By reducing unintended pregnancy and abortion, contraceptive use decreases pregnancy-related morbidity and mortality.6
    • Spacing pregnancies is associated with reductions in the number of babies born premature, low-birth-weight or small for gestational age.6
    • Planning a pregnancy is associated with earlier initiation of prenatal care and more prenatal care visits.6

Need for Publicly Funded Family Planning

Not all women and couples have the resources necessary to affordably obtain the methods of contraception that work best for them.

  • In 2014, 20.2 million U.S. women were in need of publicly funded contraceptive services and supplies.(See state data)
    • Out of that total, 15.5 million were adults with incomes below 250% of the federal poverty level and 4.7 million were young women aged 13–19.1
  • Need for publicly funded contraceptive services rose by 5%, or one million women, between 2010 and 2014.1
  • Of the 20.2 million women in need of publicly funded contraceptive services, 4.5 million (23%) were uninsured in 2014.1(See state data)
    • Between 2013 and 2014, when the Affordable Care Act (ACA) was fully implemented, the number of uninsured women in need of publicly funded contraceptive care fell by 19% nationally.1 States that had implemented the ACA’s Medicaid expansion experienced particularly large declines. (See state data)

For many women, safety-net family planning centers are their entry point into the health care system.

  • Six in 10 women who obtained care in 2006–2010 at a publicly funded, reproductive health–focused center considered that provider their usual source of medical care.7
  • In that study, four in 10 women who obtained care at a publicly funded, reproductive health–focused center reported that center as their only source of health care.7

Meeting the Need for Publicly Funded Family Planning

Medicaid, the Title X national family planning program, and state and local funds all help provide affordable contraceptive care to women who need it.

  • In 2015, nationwide public expenditures for family planning client services totaled $2.1 billion.8
  • Of the total public expenditures for family planning services in 2015, Medicaid accounted for 75%, Title X for 10%, and state contributions for 13%.8(See state data)
  • In 2015, safety-net family planning centers reported that an average of nearly six in 10 visits for contraceptive care were made by clients using Medicaid or other public insurance coverage.9
  • Title X remains the backbone of the publicly funded family planning effort: Nationally, Title X‒funded providers serve one-fifth of all women in need of publicly funded contraceptive services.10
  • Thirty-eight states and the District of Columbia reported using some of their own funds to provide family planning services in 2015.8

 

Public funding supports a diverse network of health centers in delivering high-quality family planning care to low-income and otherwise underserved individuals. Sites that offer reduced-cost or free contraceptive services and serve at least 10 contraceptive clients per year are known as safety-net family planning centers.

  • Nationwide, in 2015, there were approximately 10,700 safety-net centers providing family planning services.11
  • Collectively, these safety-net family planning centers served 6.2 million women in 2015. Out of this total, 3.8 million were served at Title X–supported sites.11(See state data)
  • Safety-net family planning centers are operated by a diverse range of public and nonprofit entities.11 Nationwide, as of 2015:
    • Federally qualified health centers (FQHCs) operated 54% of centers and served 30% of all female clients who obtained contraceptive care at a safety-net family planning center.
    • Public health departments operated 21% of centers and served 20% of all safety-net contraceptive clients.
    • Planned Parenthood affiliates operated 6% of all centers and served 32% of all safety-net contraceptive clients.
    • Hospitals operated 8% of centers and served 10% of all safety-net contraceptive clients.
    • Other types of agencies operated 10% of centers and served 8% of all safety-net contraceptive clients. (See state data)
  • In 2015, 35% of safety-net family planning centers were supported by the Title X program.11  Nationwide, among Title X–funded sites:
    • FQHCs operated 26% of centers and served 19% of Title X clients.
    • Public health departments operated 48% of centers and served 28% of Title X clients.
    • Planned Parenthood affiliates operated 13% of centers and served 41% of Title X clients.
    • Hospitals operated 4% of centers and served 5% of Title X clients.
    • Other types of agencies operated 9% of centers and served 7% of Title X clients. (See state data)

Impact of Publicly Funded Family Planning

The family planning services delivered by safety-net family planning centers confer major public health benefits.

  • In 2015, the publicly funded contraceptive services provided by safety-net family planning centers helped women avoid 1.3 million unintended pregnancies.11 Of these, 631,900 would have resulted in unplanned births and 453,400 would have resulted in abortions. (See state data)
    • Contraceptive services provided at Title X sites alone helped women avoid 822,300 unintended pregnancies.11 Of these, 387,200 of would have resulted in unplanned births and 277,800 would have resulted in abortions. (See state data)
  • In 2015, without the publicly funded contraceptive services provided by safety-net family planning centers, rates of unintended pregnancy, unplanned birth and abortion in the United States would have been 67% higher, and the rates among teens would have been 102% higher.11
    • Without the contraceptive services provided by Title X‒funded sites, rates of unintended pregnancy, unplanned birth and abortion would have been 31% higher, and the rates for teens would have been 44% higher.11

Publicly supported family planning also yields considerable cost savings.

  • In 2010, publicly funded family planning services resulted in net federal and state government savings of $13.6 billion.12  (See state data)
    • Out of this total, Title X‒supported services alone accounted for more than half of these savings ($7 billion). (See state data)
  • Put another way, every $1 invested in publicly funded family planning services saves taxpayers more than $7.13

Protections Against Excluding Qualified Providers

Abortion opponents argue that qualified organizations should be excluded from participating in publicly funded programs if these providers use other funds to offer abortions or related services, such as abortion counseling or referral. They rely on an argument—which has been refuted in legal rulings—that doing so frees up resources that could then be used for abortion, and thus any funding to such organizations amounts to indirect government support for abortion.14

  • Funding needed for other areas of reproductive health service provision cannot be easily transferred to abortion services. Resources are already insufficient to cover the ever-increasing demand for contraceptive services.14
  • In addition, the statute and regulations governing Title X expressly prohibit the use of Title X funds to pay for abortion, meaning that Title X–supported activities must be separate and distinct from any non–Title X abortion services. Notably, any site receiving Title X support is required to offer counseling and referrals for all pregnancy options counseling, including parenting, adoption and abortion.15
  • Courts have repeatedly struck down restrictions on public funding for organizations providing abortion services. For example, in 1983, the U.S. Court of Appeals for the Ninth Circuit found that “the freeing-up theory cannot justify withdrawing all state funds from otherwise eligible entities merely because they engage in abortion-related activities disfavored by the state.”16
  • The Medicaid statute specifies that Medicaid enrollees are guaranteed the right to receive family planning services from the qualified Medicaid provider of their choice.17
    • As the Centers for Medicare and Medicaid Services reminded states in 2016, “states may not deny qualification to family planning providers, or take other action against qualified family planning providers, that affects beneficiary access to those providers…solely because they separately provide family planning services or…abortion services.”18

Impact of Funding Restrictions on Women’s Access to Care

Disqualifying reproductive health‒focused providers, particularly Planned Parenthood health centers, from receiving public funding would jeopardize many women’s ability to obtain publicly funded contraceptive care.

  • If Planned Parenthood were excluded from publicly funded programs, all other types of safety-net family planning centers would have to increase their client caseloads by an average of 47% to serve all of the women who currently obtain contraceptive care from Planned Parenthood.19(See state data)
  • If Planned Parenthood were excluded from publicly funded programs and the funding was instead allocated to FQHC sites that offer contraceptive care, those FQHCs would have to double their contraceptive client caseloads, taking on a total of two million more contraceptive clients.20(See state data)
  • If Planned Parenthood were excluded from Title X, all other types of Title X providers would have to increase their contraceptive client caseloads by an average of 70%.19(See state data)
  • If all Title X funding went to FQHC sites that offer contraceptive care, in total those sites would have to increase their contraceptive client caseloads more than two and a half times over, taking on an additional 3.1 million contraceptive clients.20(See state data)

 

Compared with safety-net centers that provide family planning as part of a broader slate of primary health care services, Planned Parenthood and other centers that focus on reproductive health are more likely than others to facilitate women’s timely access to a wide range of contraceptive methods.21

  • Centers that focus on reproductive health care are more likely than those that offer family planning care as part of a broader range of primary care services to:
    • offer the full range of contraceptive method choices (74% vs. 48% of sites);
    • offer same-day insertion of IUDs (49% vs. 32%);
    • offer same-day insertion of contraceptive implants (57% vs. 43%); and
    • dispense oral contraceptives on-site (72% vs. 40%).9
       
  • Planned Parenthood health centers are more likely than other types of safety-net family planning centers to:
    • offer the full range of contraceptive method choices (93% compared with 61% of health department sites and 52% of FQHC sites);
    • offer same-day insertion of IUDs (81% compared with 35% of health department sites and 30% of FQHC sites);
    • offer same-day insertion of implants (83% compared with 43% of health department sites and 44% of FQHC sites); and
    • dispense oral contraceptives on-site (83% compared with 76% of health department sites and 34% of FQHC sites).9

DATA CENTER

RECENT STATE ACTION ON THIS ISSUE

States that have addressed this issue over the past three years are listed below.

EState enacted a relevant measure

V: State vetoed measure

A: State adopted measure in at least one chamber or filed application with the federal government

 

States that restrict or bar the allocation of state family planning funds to certain types of family planning or abortion providers

Arkansas (2015)

E

Arizona (2017)

E

Indiana (2016)

A

Iowa (2017)

E

Kentucky (2017)

E

Michigan (2017)

E

Missouri (2017)

E

North Carolina (2015)

E

South Carolina (2017)

E

Texas (2017)

A, E

Wisconsin (2015)

A

 

States attempting to bar abortion providers from receiving Medicaid reimbursement for family planning and other covered services

Alabama (2015)

E

Arizona (2016)

E

Arkansas (2015)

E

Florida (2016)

E

Iowa (2016)

A

Kansas (2016)

E

Kentucky (2016)

A

Louisiana (2015)

E

Mississippi (2016)

E

Oklahoma (2015)

A

Texas (2015, 2017)

E, A

 

States that have established a Medicaid spin-off program for family planning services that excludes abortion providers

Iowa (2017)

E

Missouri (2016)

E

 

States attempting to restrict access to funds beyond those for family planning services

Kansas (2016)

E

Kentucky (2016)

A

Michigan (2016)

A

Ohio (2016)

E

Texas (2015)

E

Utah (2015)

E

Virginia (2016, 2017)

V

Wisconsin (2016)

E

REFERENCES

1. Frost JJ, Frohwirth LF and Zolna MR, Contraceptive Needs and Services, 2014 Update, New York: Guttmacher Institute, 2016, https://www.guttmacher.org/report/contraceptive-needs-and-services-2014-update.

2. Finer LB and Zolna MR, Declines in unintended pregnancy in the United States, 2008–2011, New England Journal of Medicine, 2016, 374(9):843–852, http://www.nejm.org/doi/full/10.1056/NEJMsa1506575.

3. Sonfield A, Hasstedt K and Gold RB, Moving Forward: Family Planning in the Era of Health Reform, New York: Guttmacher Institute, 2014, https://www.guttmacher.org/report/moving-forward-family-planning-era-health-reform.

4. Sonfield A et al., The Social and Economic Benefits of Women’s Ability to Determine Whether and When to Have Children, New York: Guttmacher Institute, 2013, https://www.guttmacher.org/report/social-and-economic-benefits-womens-ability-determine-whether-and-when-have-children.

5. Frost JJ and Lindberg LD, Reasons for using contraception: perspectives of U.S. women seeking care at specialized family planning clinics, Contraception, 2012, 87(4):465–472, http://www.guttmacher.org/pubs/journals/j.contraception.2012.08.012.pdf.

6. Kavanaugh ML and Anderson RM, Contraception and Beyond: The Health Benefits of Services Provided at Family Planning Centers, New York: Guttmacher Institute, 2013, https://www.guttmacher.org/report/contraception-and-beyond-health-benefits-services-provided-family-planning-centers.

7. 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):e519–515, https://www.guttmacher.org/article/2012/11/specialized-family-planning-clinics-united-states-why-women-choose-them-and-their.

8. Hasstedt K, Sonfield A and Gold RB, Public Funding for Family Planning and Abortion Services, FY 1980–2015, New York: Guttmacher Institute, 2017, https://www.guttmacher.org/report/public-funding-family-planning-abortion-services-fy-1980-2015.

9. Zolna MR and Frost JJ, Publicly Funded Family Planning Clinics in 2015: Patterns and Trends in Service Delivery Practices and Protocols, New York: Guttmacher Institute, 2016, https://www.guttmacher.org/report/publicly-funded-family-planning-clinic-survey-2015.

10. Hasstedt K, Why we cannot afford to undercut the Title X national family planning program, Guttmacher Policy Review, 2017, 20:20–23, https://www.guttmacher.org/gpr/2017/01/why-we-cannot-afford-undercut-title-x-national-family-planning-program.

11. Frost JJ et al., Publicly Funded Contraceptive Services at U.S. Clinics, 2015, New York: Guttmacher Institute, 2017, https://www.guttmacher.org/report/publicly-funded-contraceptive-services-us-clinics-2015.

12. Sonfield A, Beyond preventing unplanned pregnancy: the broader benefits of publicly funded family planning services, Guttmacher Policy Review, 2014, 17(4):2–6, https://www.guttmacher.org/gpr/2014/12/beyond-preventing-unplanned-pregnancy-broader-benefits-publicly-funded-family-planning.

13. Frost JJ et al., Return on investment: a fuller assessment of the benefits and cost savings of the US publicly funded family planning program, Milbank Quarterly, 2014, 92(4):667–720, https://www.guttmacher.org/article/2014/10/return-investment-fuller-assessment-benefits-and-cost-savings-us-publicly-funded.

14. Dreweke J, “Fungibility”: the argument at the center of a 40-year campaign to undermine reproductive health and rights, Guttmacher Policy Review, 2016, 19:53–60, https://www.guttmacher.org/gpr/2016/10/fungibility-argument-center-40-year-campaign-undermine-reproductive-health-and-rights.

15. 42 CFR 59.5.

16. Planned Parenthood of Central and Northern Arizona v. State of Arizona, 718 F.2d 938 (9th Cir. 1983).

17. 42 USC 1396a.

18. Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services, Letter to state Medicaid directors re: clarifying “free choice of provider” requirement in conjunction with state authority to take action against Medicaid providers, SMD #16-005, Apr. 19, 2016, https://www.medicaid.gov/federal-policy-guidance/downloads/SMD16005.pdf.

19. Frost JJ and Zolna MR, Response to inquiry concerning the impact on other safety-net family planning providers of “defunding” Planned Parenthood, memo to Senator Patty Murray, Senate Health, Education, Labor and Pensions Committee, New York: Guttmacher Institute, June 15, 2017, https://www.guttmacher.org/article/2017/06/guttmacher-murray-memo-june-2017.

20. Frost JJ and Zolna MR, Response to inquiry concerning the availability of publicly funded contraceptive care to U.S. women, memo to Senator Patty Murray, Senate Health, Education, Labor and Pensions Committee, New York: Guttmacher Institute, May 3, 2017, https://www.guttmacher.org/article/2017/05/guttmacher-murray-memo-2017.

21. Hasstedt K, Understanding Planned Parenthood’s critical role in the nation’s family planning safety net, Guttmacher Policy Review, 2017, 20:12–14a, https://www.guttmacher.org/gpr/2017/01/understanding-planned-parenthoods-critical-role-nations-family-planning-safety-net.