The Reproductive Health Impact Study (RHIS) is a multiyear comprehensive research initiative analyzing the effects of federal and state policy changes on publicly funded family planning care in the United States. The study, which focuses on Arizona, Iowa, New Jersey and Wisconsin, documents the impact of these policies over the period 2017−2022 on family planning service delivery and on patients who rely on this care. Arizona was selected as a focus state for the RHIS in 2018, in anticipation of state-specific shifts in Title X grantee funding, to document how policy changes in family planning service delivery might affect a demographically diverse state with large numbers of immigrant, undocumented and Indigenous residents. For the Arizona study, the Guttmacher Institute is working with Arizona Family Health Partnership, Planned Parenthood of Arizona, and other in-state research and policy partners.
The RHIS was initially conceived in the aftermath of the 2016 election, in anticipation of federal and state efforts to change funding streams and service delivery for publicly funded family planning. As the study progressed, the RHIS team adapted ongoing study activities to document the impact of several events—notably, the 2019 changes to the federal Title X regulations (the Trump administration’s “domestic gag rule”) and the COVID-19 pandemic.
In early 2021, the Biden administration took the first step toward rescinding the domestic gag rule by signing a presidential memorandum directing the U.S. Department of Health and Human Services to review the rule and other restrictive Title X regulations and consider whether to suspend, revise or rescind them. In mid-April 2021, the Biden-Harris administration published a notice that signaled its intention to restore Title X to its pre-Trump regulatory framework with certain updates. The rule then opened for comments for 30 days; the Trump-era regulations remain in effect for now.
Some of the key reproductive outcomes for Arizona residents that are being tracked in the study appear below. Documenting changes to these outcomes over the study period helps identify the effects of changes related to publicly funded family planning care in the state.
The policy landscape in Arizona
Arizona is a state in political transition. Republicans have controlled the governorship and state legislatures since 2009, but in recent years, the Democratic Party has been earning increased voter support. In the 2020 election, Democrats gained seats in the state Senate and, for the first time since 1996, the state’s voters selected a Democratic candidate for president. The Republican majority consistently passes anti–reproductive health legislation, but a strong progressive coalition has been fighting back against hostile policies and slowly making gains.
Arizona has unique demographics that are shaped by its history and its location on the United States-Mexico border. Nearly a third of Arizona residents identify as Hispanic or Latino. Arizona also has sizeable populations of immigrant, undocumented and Indigenous residents: Thirteen percent of state residents were born in another country.
For many years, the Arizona Family Health Partnership (AFHP) served as the sole grantee for Arizona’s Title X funds. As the Title X administrator, AFHP oversaw a diverse network of subgrantees, including public health departments, federally qualified health centers and Planned Parenthood Arizona. The latter received almost half of the state’s Title X funds.
The Arizona Title X network changed significantly in 2019 as a result of state and national program shifts. In 2017, the Arizona Department of Health Services (AZ DHS) was awarded 25% of the state’s Title X funding in 2019, leaving the rest of the network with 75% of its previous funds. In the seven-month period during which it received funding, AZ DHS did not provide any services with that money. The network was further disrupted in August 2019, when Planned Parenthood affiliates across the country, including Planned Parenthood Arizona, left the Title X network because of the domestic gag rule regulations. Planned Parenthood Arizona continued to offer family planning services via other funding streams.
AFHP is currently Arizona’s sole Title X grantee. After the domestic gag rule was implemented and Planned Parenthood Arizona left the program, AFHP reallocated some Title X funding to clinics in the Navajo Nation, clinics in underserved counties and a project to prevent reproductive coercion for people with disabilities.
Publicly funded family planning in Arizona
In 2018, 215 sites provided publicly supported contraceptive services in Arizona. Of these, 29 sites received Title X funding, serving more than 28,000 contraceptive patients. Twenty-four percent of these patients were served at health department clinics, 58% at Planned Parenthood clinics and 17% at federally qualified health centers (FQHCs).
In August 2019, the five Planned Parenthood clinics in Arizona that received Title X funding left the program because of the domestic gag rule. Although 20 new FQHC or hospital-affiliated sites were added to the Title X program in 2019 and 2020, these new sites served far fewer contraceptive patients than the Planned Parenthood clinics.
Exclusion of the Planned Parenthood clinics from Title X resulted in a decline in the program’s capacity. Between 2018 and 2019, the number of female contraceptive patients served in Arizona fell by nearly 30%.1,2 Because these clinics left the network in the middle of 2019, the decline represents only a partial picture of the damage to publicly funded family planning services in the state that year.
COVID-19 and reproductive health in Arizona
The COVID-19 pandemic has led to significant interruptions in patients’ ability to access family planning—particularly for those who rely on publicly funded clinics. Guttmacher researchers found that 33% of U.S. women participating in a national study in April–May 2020 had faced delays or had been unable to get contraceptive or other care because of the pandemic. Initial RHIS data on the impact of the COVID-19 pandemic on individuals’ ability to access contraceptive methods and sexual and reproductive care in Arizona demonstrate the ongoing challenges of the pandemic at the state level.