Contraception enables women to effect some of the most fundamental and personal decisions of their lives, and its increasing availability over the past half- century has had major and well-documented health, social and economic benefits (related article, page 8). By giving women the ability to time and space their pregnancies, contraceptive use allows them to further their education, participate fully in the labor force, protect their health and improve the start they are able to give their children. And that, in turn, helps provide long-term economic security for women and their families.
For millions of young and economically disadvantaged women in the United States, the nationwide network of publicly subsidized, safety-net family planning centers is key to making all of this possible. Centers located in most counties across the country serve more than seven million women each year.1 Many of the women who obtain publicly subsidized contraceptive care do so from comprehensive health service providers, such as community health centers. But 70% are served at centers that specialize in the provision of family planning services.2
Women who have a choice of providers in their community say they choose specialized family planning centers because of the respectful, confidential, affordable and high-quality care they receive from them. For many women, these centers are their entry point into the health care system—or even their only source of health care. Yet, despite the pivotal role specialized family planning centers play in women’s lives, this nationwide network has been under relentless attack in the last few years.
Why Here?
In 2011 and 2012, Guttmacher Institute researchers surveyed 2,100 women receiving services at specialized family planning centers located in communities in which there was also a comprehensive health services provider.2 When asked why they chose to obtain care at a specialized center, women gave many reasons for their decision (see chart). The one given most often, however, was that center staff treat them with respect, which was important to women regardless of age, income, insurance status or whether they already had children.
Respect can have many faces, as Guttmacher analyses and research studies repeatedly attest. Family planning providers often point to the time they take not only to talk to, but also to listen to, clients as fundamental to what they do (related article, "An Enduring Role: The Continuing Need for a Robust Family Planning Clinic System," Winter 2008). And, indeed, women themselves say that the ability to get reliable information from a staff that takes the time to talk to them and with whom they feel comfortable talking are important factors in deciding where to go for contraceptive care.2
Indeed, taking time with clients is a hallmark of specialized family planning centers. Guidelines for the federal Title X program, which provides important support to the center network, call for "an individualized dialogue with a client" to assist clients "in reaching an informed decision regarding their reproductive health and the choice and continued use of family planning methods and services."3 Staff at specialized family planning centers spend more time with clients than do staff at agencies that provide contraception in a broader primary care context (see chart).4 Most importantly, staff at specialized family planning centers spend relatively even more time with clients who may need extra assistance, including those who are dealing with complex issues in their lives, such as homelessness, substance abuse or interpersonal violence.
Women in communities with a choice of providers indicate that accessibility is another important factor in their decision to use a specialized family planning center.2 Again, this takes many forms. Specialized family planning centers take a range of steps to make sure that women can get the method they want and start it without delay.4 Compared with sites offering comprehensive care, for example, specialized centers give women a wider choice of contraceptive methods and are more likely to offer the especially effective long-acting reversible methods, such as IUDs and implants. Also, they are more likely to provide methods on-site, rather than by writing a prescription that may require women to make multiple stops at pharmacies and health centers just to get their method. Moreover, specialized centers are more likely to use the "quick start" protocol that allows women to start a method immediately, rather than wait until a specific point in their menstrual cycle.
Confidentiality—yet another hallmark of family planning centers—also features prominently in women’s decision making about where to obtain care.2 This is especially true for teens, for whom confidentiality is the leading reason for choosing a specialized family planning center. Importantly, confidentiality plays a role not only in where women go, but also in how they pay for their care. Nearly one in five privately insured women not planning to use insurance to pay for their care cite confidentiality concerns as their reason. (Other reasons include the service not being covered or the family planning center not accepting their insurance.) Not surprisingly, teens are most likely to report confidentiality as their reason for not using their coverage. Teens are almost always insured as dependents on someone else’s insurance policy. Widely used claims-processing procedures—most notably the practice of sending explanation-of-benefit forms to the policyholder (who is often a parent or a spouse)—make it virtually impossible for someone insured as a dependent to access confidential care.5
Serving teens is a major focus of specialized family planning centers. Forty percent say that at least a quarter of their clients are younger than 18, compared with only 25% of comprehensive providers.4 In fact, specialized centers place a strong emphasis on meeting adolescents’ needs: They are more likely than comprehensive providers to have specially trained staff, operate programs geared to teens’ needs and concerns, and make efforts to reach out to the teens in their communities.
Unique Niche
In communities where women have a choice of health care providers, six in 10 of those seeking services at a specialized family planning center had received at least some health care elsewhere during the past year (see chart).2 But for four in 10 of their clients, the family planning center was their only source of care. This was especially true for uninsured women receiving care from specialized centers, 49% of whom received their only care from the family planning center, compared with 38% of those who were insured through Medicaid and 27% of those with private insurance coverage.
Because family planning centers are many of their clients’ only point of contact with the health care system, they are well placed to connect large numbers of young and lower-income women to both other needed health care and insurance coverage for which they may be eligible (see "The Role of Family Planning Centers as Gateways to Health Coverage and Care," Spring 2011). In fact, family planning centers have taken important steps in recent years in both of these directions, by providing application assistance that facilitates Medicaid enrollment and by establishing linkages and referral mechanisms to meet clients’ needs. Ninety-six percent of specialized family planning centers refer clients to primary care agencies for services they do not themselves provide.4 But clearly there is more that can—and should—be done, including establishing formal linkages with comprehensive service providers (see "Strengthening the Safety Net: Pathways for Collaboration Between Community Health Centers and Family Planning Programs," Fall 2011).
This role of specialized family planning centers as the entry point to the health care system is one powerful reason why government at all levels needs to continue to support this network on which so many clients clearly rely. Another is the documented evidence that many women are likely to continue to want to rely on these centers, even if sources of comprehensive care are available in their communities. Both are powerful reasons why health plans should be eager to recognize these centers as the essential community providers their clients clearly view them to be, and include them in their networks (see "Becoming Adept at Working with Health Plans a Necessity for Family Planning Centers," Summer 2012).
A Network Besieged
Despite the importance of publicly funded family planning services and the providers that deliver them, federal and state family planning programs have been singled out for drastic cuts in recent years. In both 2011 and 2012, the House of Representatives approved legislation that would eliminate all funding for Title X—money that provides critical support not only for clinical family planning services, but also for the service delivery infrastructure nationwide. Title X provides funds to seven in 10 specialized family planning providers (compared with only three in 10 sites offering family planning as part of broader primary care)4 and plays a key role in giving agencies the resources to operate programs focused on providing high-quality family planning services to hard-to-reach and difficult-to-serve clients. Compared with sites that do not receive funding through Title X, family planning centers supported by the program serve more uninsured clients, do more to help clients easily obtain and quickly begin using a contraceptive method well-suited to them, and devote extra time and bring expertise to serving clients with special needs (see "Going the Extra Mile: The Difference Title X Makes," Spring 2012).
The same legislation that would have defunded Title X entirely included a separate provision that would have preemptively barred Planned Parenthood affiliates from eligibility for any federal funds, including through the Medicaid program. If Title X undergirds the infrastructure of the nationwide system, Medicaid provides the bulk of the resources for direct patient care; the program contributes 75 cents of every public dollar spent on contraceptive services nationwide.6 Reportedly, it was only the 11th hour intercession of the Obama administration and a small group of senators led by Sen. Patty Murray (D-WA) that blocked these moves.7 Nonetheless, funding for Title X has dropped by $20 million, or just over 6%, over the last two years.8
Assaults at the state level, meanwhile, have proven more successful. Of the 19 states that include line items for family planning in their budgets, five have made cuts disproportionate to those aimed at other health programs since 2010, with Montana and New Jersey eliminating funding altogether (see chart). As a result of the cuts in Texas, the number of women served in the state family planning program fell from 212,000 in 2010 to 75,000 in 2012; the state estimates that it will serve only 61,000 in 2013.9
In addition, several states have taken aim directly at specialized family planning providers, by excluding them from being able to receive state funds and often even federal funds that pass through the state treasury. These attacks have come in different forms, with some states barring any specialized family planning provider and others targeting Planned Parenthood affiliates—either by name or by barring agencies that also provide abortion services. Finally, Texas—after slashing its funding overall—effectively made specialized centers ineligible, by instituting a priority system that put them at the bottom of the heap in the competition for the funds, behind health departments, hospitals and community health centers.
When Arizona and Indiana moved to exclude some specialized family planning providers from being eligible to participate in Medicaid, the Obama administration finally drew the line. The Centers for Medicare and Medicaid Services (CMS)—the federal agency that administers the massive program—interceded in both cases, noting that the federal Medicaid statute and regulations require that enrollees be able to obtain care from any provider of their choice qualified to perform the service.10,11 CMS informed all state Medicaid agencies that they may not "exclude providers from the program solely on the basis of the range of medical services they provide" and that "Medicaid programs may not exclude qualified health care providers—whether an individual provider, a physician group, an outpatient clinic, or a hospital—from providing services under the program because they separately provide abortion services…as part of their scope of practice."12 With courts accepting the administration’s argument, the attempts to exclude family planning providers were turned back.13,14
A similar and lengthy saga in Texas that involves not the state’s "regular" full-benefit Medicaid program, but rather its Medicaid family planning expansion, has taken a particularly circuitous course. Confronted with CMS’s refusal to allow the state to exclude abortion providers from that program, the state vowed to abolish the joint federal-state expansion and replace it with a state-only program that would exclude these providers. Recent court decisions cleared the way for the state to implement its program, which excludes many of the largest family planning providers in the state.15
In light of the scuffles of the past few years, supporters of reproductive health and rights have some reason to be cautiously optimistic going forward, but likely more reason to be extremely concerned. True, 2012 brought fewer successful state legislative attacks on abortion rights than had 2011, and the drive to exclude family planning providers from funding abated somewhat as well.16 In addition, Republican attacks on contraception in general—and on the contraceptive coverage mandate in health reform and on Planned Parenthood in particular—were soundly rebuffed during the recent election.
At the same time, pressure to limit federal spending—especially on so-called discretionary programs such as Title X—is almost certain to remain acute for the foreseeable future. The budget deal agreed to in 2011 is slated to cut federal spending each year through 2021, even as Congress and the administration continue to tussle over layering on even more cuts going forward. All of this is likely to make for very tough sledding, as supporters of family planning programs argue for the resources and support these programs need to bring high-quality contraceptive and closely related preventive services to the millions of American women who need them.
REFERENCES
1. Frost JJ, Henshaw SK and Sonfield A, Contraceptive Needs and Services: National and State Data, 2008 Update, New York: Guttmacher Institute, 2010, <http://www.guttmacher.org/pubs/win/contraceptive-needs-2008.pdf>, accessed Mar. 4, 2013.
2. 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–e525, <http://www.guttmacher.org/pubs/journals/j.whi.2012.09.002.pdf>, accessed Mar. 4, 2013.
3. Office of Population Affairs, Department of Health and Human Services, Program Guidelines for Project Grants for Family Planning Services, 2001, <http://www.hhs.gov/opa/pdfs/2001-ofp-guidelines.pdf>, accessed Mar. 4, 2013.
4. Frost JJ et al., Variation in Service Delivery Practices Among Clinics Providing Publicly Funded Family Planning Services in 2010, New York: Guttmacher Institute, 2012, <http://www.guttmacher.org/pubs/clinic-survey-2010.pdf>, accessed Mar. 4, 2013.
5. English A et al., Confidentiality for Individuals Insured as Dependents: A Review of State Laws and Policies, New York: Guttmacher Institute, 2012, <http://www.guttmacher.org/pubs/confidentiality-review.pdf>, accessed Mar. 4, 2013.
6. Sonfield A and Gold RB, Public Funding for Family Planning, Sterilization and Abortion Services, FY 1980–2010, New York: Guttmacher Institute, 2012, <http://www.guttmacher.org/pubs/Public-Funding-FP-2010.pdf>, accessed Mar. 4, 2013.
7. Helderman RS, Patty Murray likely to be a key voice in Senate on budget deal, Washington Post, Nov. 23, 2012, <http://www.washingtonpost.com/politics/patty-murray-will-be-key-voice-i…;, accessed Mar. 4, 2013.
8. Office of Population Affairs, Department of Health and Human Services, Title X funding history, <http://www.hhs.gov/opa/title-x-family-planning/title-x-policies/title-x-funding-history/>, accessed Mar. 4, 2013.
9. Texas Department of State Health Services, Council Agenda Memo for State Health Services Council, November 28–29, 2012, <http://www.dshs.state.tx.us/council/agendas/Nov2012/5c-FamilyPlanning.p…;, accessed Mar. 4, 2013.
10. Planned Parenthood of Indiana v. Commissioner of the Indiana State Department of Health, Statement of Interest of the United States, June 16, 2011.
11. Planned Parenthood of Arizona v. Betlach, Statement of Interest of the United States, Sept. 11, 2012.
12. Mann C, CMCS Informational Bulletin: Update on Medicaid/CHIP, 2011, <http://downloads.cms.gov/cmsgov/archived-downloads/CMCSBulletins/downloads/6-1-11-Info-Bulletin.pdf>, accessed Mar. 4, 2013.
13. Planned Parenthood of Arizona v. Betlach, No. CV-12-01533-PHX-NVW, United States District Court, Arizona, Order, Feb. 8, 2013.
14. Planned Parenthood of Indiana v. Commissioner of the Indiana State Department of Health, No. 11-2464, U.S. Court of Appeals for the Seventh Circuit, Oct. 23, 2012.
15. Aaronson B, Judge: Texas WHP can proceed without Planned Parenthood, Texas Tribune, Dec. 31, 2012, <http://www.texastribune.org/2012/12/31/judge-denies-request-allow-planned-parenthood-twhp>, accessed Mar. 4, 2013.
16. Guttmacher Institute, Laws affecting reproductive health and rights: 2012 state policy review, 2013, <http://www.guttmacher.org/statecenter/updates/2012/statetrends42012.html>, accessed Mar. 4, 2013.
