Access to family planning services for low-income women in the United States will continue at least through the current fiscal year. This was not at all clear until mid-April, when Congress and the administration finally agreed on a spending bill to fund the federal government for the rest of FY 2011, already half-over by that point. For the remainder of this year, $299 million is appropriated for the Title X national family planning program, a 5% cut below last year’s level. Earlier, conservative Republicans who control the House of Representatives passed a bill that—while exacting deep cuts in a wide array of federally funded activities—would have eliminated funding for Title X entirely. Separate and apart from defunding Title X, that bill also would have disqualified all Planned Parenthood affiliates from receiving Title X or any federal funds, including Medicaid reimbursement. The standoff over Planned Parenthood between the House, on the one side, and the Senate and Obama administration, on the other, almost shut down the government. It also obscured the underlying direct assault on the availability of contraceptive services for lowincome women regardless of whether they are provided by Planned Parenthood health centers, health departments or other freestanding health centers.
Title X likely survived, in no small part, because the evidence is so clear that it is precisely the kind of government program that should be strengthened, not gutted. Because Title X exists, there are far fewer unintended pregnancies, teenage pregnancies and abortions—nationwide and in each of the 50 states and the District of Columbia—than there otherwise would be. Moreover, by helping almost a million low-income women to prevent unplanned births every year, Title X–supported services save the states and federal government billions of dollars in medical costs that otherwise would be paid for by Medicaid. If all that were not enough, the many thousands of family planning centers around the country that receive Title X funding remain the entry point into the health care system for large numbers of young and low-income women.
What Success Looks Like
Some lawmakers may have doubts about the value of Title X, but women do not. Because Title X not only subsidizes contraceptive services directly, but also provides the essential support to create and sustain the network of health centers where women go to obtain these services, it is the lynchpin of the national family planning effort. In fact, one-fourth of all poor women who obtain contraceptive services in the United States do so at a Title X–supported center.1 In addition, Title X–supported centers are major sources of STI counseling, testing and treatment services. In 2009, Title X–supported centers reported that 2.5 million clients were tested for chlamydia, 2.6 million for gonorrhea, 740,000 for syphilis and one million for HIV.2 Beyond contraceptive and STI services, women at Title X– supported centers also receive a set of closely related, critical preventive health care services, including Pap tests to detect early signs of cervical cancer and breast exams to detect warning signs of breast cancer. Not surprisingly, therefore, six in 10 women obtaining care at Title X– supported centers consider them to be their usual source of health care.3
Although Title X's mission is to provide comprehensive preventive reproductive health care (by law from its inception in 1970, Title X funds may not be used to pay for abortion), the program exists—first and foremost—to enhance access to contraceptive services. Title X is the nation's only federal program devoted solely to this purpose. By and large, its primary grantees are state governments, which in turn subcontract with public health departments, community health centers, Planned Parenthood affiliates and other independent, community-based agencies (see chart).4,5 The program places a priority on meeting the reproductive health needs of low-income women, and young women and men.
|A DIVERSE SYSTEM
|Health departments comprise more than half of Title X–supported sites nationwide; three-quarters of all clients obtained their contraceptive services at either a health department or a Planned Parenthood center with the remainder receiving care at other independent clinics, hospitals or community health centers.
|Note: 2006 data. Sources: References 4 and 5.
Two-thirds of the 7.1 million women obtaining care at publicly funded family planning centers receive services at the more than 4,000 Title X– supported sites nationwide.6 In fact, these sites are able to serve one-quarter of the 17 million women in this country who are in need of publicly supported contraceptive services; seven in 10 of these clients have incomes below the federal poverty level.2,6 The services provided at these sites enabled women to avoid 973,000 unplanned pregnancies in a single year. As a result, 433,000 unplanned births and 406,000 abortions did not occur. Put another way, without the services provided at Title X–supported centers, levels of unintended pregnancy and abortion in the United States would be one-third higher than they are.1 In addition, by helping so many low-income women and couples determine themselves how many children to have and when to have them, the services provided at Title X–supported centers conservatively saved the federal government and the states $3.4 billion in costs that otherwise would have been borne by Medicaid for prenatal care, delivery and infant care—amounting to $3.74 saved for every $1 spent on contraceptive care.6 The dramatic impact of Title X can be seen at the level of the individual states as well (see table, page 22).1,2,6–11
Beyond the Numbers
The tremendous achievements of the Title X program are apparent in the numbers—measured in services provided, health outcomes averted and dollars saved; however, the program's value is far greater than the sum of its parts. By providing aid to establish family planning health centers in local communities and assistance for their ongoing infrastructure needs, Title X is able to leverage the availability of other sources of support, public and private, to stretch the reach of its services. Whereas insurance—either public or private—may cover the costs of contraceptive services for many, women need a place to go to obtain high-quality specialized care. As the federal program organized around the provision of contraceptive services and closely related preventive care, Title X sets national policies and medical standards to ensure clients are receiving optimal care. This includes guaranteeing a client's informed consent before choosing to use contraception and access to the full range of the most up-to-date contraceptive methods either directly or by referral.
Women who do not use contraception or who do so inconsistently represent one-third of all the women at risk of unintended pregnancy in the United States. And they account for 95% of all the unintended pregnancies that take place each year.1 Unintended pregnancy has long been associated with an increased risk of low-birth-weight newborns and other negative pregnancy outcomes. The broader economic and social benefits of preventing unintended pregnancies and the abortions or births that result may be harder to quantify, but they are no less real.12 Empowering women with the information and services necessary to plan the timing and spacing of their children means empowering them with the chance to invest in higher education, obtain a secure and fulfilling job and develop a stable home environment for raising a family.
Being able to determine whether and when to have a child is something that many women in the United States take for granted—and they are fortunate to be able to do so, unless and until they lose that ability. Too many lawmakers may be the worst offenders, however, in glossing over the fact that preventing unintended pregnancy does not simply take care of itself. In this instance, it requires a low-cost investment in basic information and services that yields returns many times over in public health, public dollars and quality of life for economically disadvantaged women and their families. Especially during these difficult economic times, the evidence is clear that it is an investment well worth making.
1. Gold RB et al., Next Steps for America's Family Planning Program: Leveraging the Potential of Medicaid and Title X in an Evolving Health Care System, New York: Guttmacher Institute, 2009.
2. Fowler CI et al., Family Planning Annual Report: 2009 National Summary, Research Triangle Park, NC: RTI International, 2010.
3. Frost JJ, U.S. women's reliance on publicly funded family planning clinics as their usual source of medical care, paper presented at the 2008 Research Conference on the National Survey of Family Growth, Hyattsville, MD, Oct. 16 and 17, 2008.
4. Guttmacher Institute, Contraceptive Needs and Services, 2006, 2009, <http://www.guttmacher.org/pubs/win/allstates2006.pdf>, accessed Feb. 14, 2011.
5. Special tabulations of data from the 2006 Guttmacher Institute Contraceptive Needs and Services Study.
6. Frost JJ, Henshaw SK and Sonfield A, Contraceptive Needs and Services, National and State Data, 2008 Update, New York: Guttmacher Institute, 2010.
8. Guttmacher Institute Data Center, Number of unintended pregnancies averted to clients aged <20 by Title X–funded family planning centers, 2006, <http://www.guttmacher.org/datacenter/>, accessed Feb. 14, 2011.
9. Finer LB and Kost K, Unintended pregnancy rates at the state level, Perspectives on Sexual and Reproductive Health, 2011, 43(2):78–87, doi:10.1363/4307811.
11. Kost K, Henshaw S and Carlin L, U.S. Teenage Pregnancies, Births and Abortions: National and State Trends and Trends by Race and Ethnicity, 2010, <http://www.guttmacher.org/pubs/USTPtrends.pdf>, accessed Feb. 14, 2011.
12. Guttmacher Institute, Testimony of Guttmacher Institute, Submitted to the Committee on Preventive Services for Women, Institute of Medicine, 2011, <http://www.guttmacher.org/pubs/CPSW-testimony.pdf>, accessed Feb. 14, 2011.