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. Iowa was selected as a focus state in 2017 after leaving the federally run Medicaid family planning program and starting its own network that prohibits patients from accessing care at providers with any connection to abortion. For the Iowa study, the Guttmacher Institute is working with the Family Planning Council of Iowa, Planned Parenthood North Central States, 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 Iowa 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 Iowa
Iowa’s state policymakers are largely hostile to reproductive rights, although some support contraceptive access to prevent abortions. In 2018, Gov. Kim Reynolds signed a bill to ban abortion at or after six weeks’ gestation, but a district court promptly overturned it. In 2019, Reynolds championed an ultimately unsuccessful bill that would have allowed pharmacists to dispense birth control and offer 12-month supplies. In the 2020 election, Republicans retained their control of the governor’s office, Senate and House.
In 2017—two years before the Trump administration finalized the domestic gag rule—Iowa left the federal Medicaid family planning program. In making that decision, the state decided to forgo $3 million in federal funding and released itself from that program’s federal standards. Also in 2017, the Iowa legislature designated $3.4 million to create its own state family planning network; the express intent was to exclude any clinic that provides abortion, makes referrals for abortion care or has any other connection to abortion. This prohibition purposefully excluded Planned Parenthood from the program and had the unintentional consequence of excluding other health care facilities, including one of the state’s major hospital networks. In 2018, lawmakers amended the legislation to allow hospitals or clinics that do not provide abortion services on site to be part of the state network.
Funding for family planning in the state remains complex. Along with all other Planned Parenthood affiliates across the country, Iowa’s affiliate, Planned Parenthood North Central States, left the Title X network in August 2019 as a result of the domestic gag rule. The affiliate still receives reimbursement for some care, such as cancer screenings, through the larger federal Medicaid program. However, Iowa’s 2019 budget prohibited federal funding that is funneled through its Department of Public Health and Human Services (including Title X; the Personal Responsibility Education Program, a sex education program; and the Community Adolescent Pregnancy Prevention program) from going to entities that have anything to do with abortion—including providing abortion services and making abortion referrals. In 2020, a district court overturned these restrictions for the other programs, but not for Title X. The case was appealed and was recently argued before the Iowa Supreme Court. Federal funds that do not flow through the state, such as Title X funds that go directly to a grantee, are not restricted in this way.
The Family Planning Council of Iowa currently serves as the state’s Title X grantee.
Publicly funded family planning in Iowa
In 2018, 69 sites provided publicly supported contraceptive services in Iowa. Of these, 43 sites received Title X funding and served nearly 30,000 contraceptive patients. Three percent of these patients were served at health department clinics, 44% at Planned Parenthood clinics, 28% at federally qualified health centers, 15% at hospital-affiliated sites and 10% at other sites.
In August 2019, six Planned Parenthood clinics in Iowa that received Title X funding left the Title X program because of the domestic gag rule.
Exclusion of these 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 Iowa fell by 13%.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.
COVID-19 and reproductive health in Iowa
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 Iowa demonstrate the ongoing challenges of the pandemic at the state level.