Why We Cannot Afford to Undercut the Title X National Family Planning Program
- Title X is the cornerstone of the publicly funded family planning effort in the United States, setting the standard of care and helping providers skillfully and affordably deliver contraceptive care and related services to the most vulnerable communities.
- Title X yields significant health and economic benefits for individuals, families and society. The program is good government at its best and should be bolstered, not decimated.
Editor’s note: This article was updated on May 17, 2017 to incorporate newly released data from references 3 and 4.
Conservative congressional leadership and the Trump administration are positioned to accomplish a major piece of the anti–family planning agenda: undermining or eliminating the Title X national family planning program. Created in 1970 with broad bipartisan support, Title X was championed by then-Congressman George H.W. Bush and signed into law by President Nixon. The program has a decades-long record of helping low-income and underserved individuals obtain high-quality family planning and related preventive health care.
Yet, despite Title X’s proven effectiveness, social conservatives have turned on the program, in part because some of the safety-net providers Title X supports use their own funds to provide abortion services (see "Recent Funding Restrictions on the U.S. Family Planning Safety Net May Foreshadow What Is to Come," 2016). Conservatives have been looking to bar such providers from Title X funding, and the U.S. House of Representatives has been attempting to eliminate the program entirely since 2011.
These ideological attacks are not only shortsighted, but they also fly in the face of a wealth of evidence demonstrating the enormous health and economic benefits of Title X–supported services for individual women, families and society as a whole.
The Title X network is critical to meeting women’s need for affordable contraceptive care. Overall, the Title X network of about 4,000 health centers nationwide serves roughly four million clients seeking family planning services annually.1 One-fifth of all U.S. women in need of publicly funded contraceptive services and supplies are served by Title X.2,3 And among women who obtain publicly funded contraceptive care at some type of safety-net health center, six in 10 receive that care from a Title X–supported site.3
This considerable reach makes sense, given that the Title X network has health centers where women need them most. In 2015, 64% of U.S. counties had at least one safety-net family planning center supported by Title X, and 90% of women in need of publicly funded family planning care lived in those counties.4
Title X clients are among the nation’s most vulnerable populations: Two-thirds have incomes at or below the federal poverty level ($20,090 for a family of three in 20155), nearly half are uninsured—even after implementation of the Affordable Care Act’s (ACA) major insurance expansions—and another 35% have coverage through Medicaid and other public programs.1
Title X–supported services have greatly benefited women, families and society. In 2015, the contraceptive care delivered by Title X–funded providers helped women avoid 822,000 unintended pregnancies, which would have resulted in 387,000 unplanned births and 278,000 abortions.3 Without the contraceptive care provided by these health centers, the U.S. rates of unintended pregnancy and abortion would have been 31% higher, and the teen unintended pregnancy rate would have been 44% higher (see chart 1).
For many women, a visit to a family planning provider is about far more than birth control. During a visit for contraceptive services at a Title X site, women commonly receive other preventive sexual and reproductive health services, including preconception health care and counseling, STI testing and treatment, vaccines to prevent human papillomavirus and Pap tests for early detection of cervical cancer. Title X providers also screen for a host of other potential health issues, such as high blood pressure, diabetes and depression, connecting clients to further care when needed. And for four in 10 women who obtain their contraceptive care from a safety-net family planning center that focuses on reproductive health, that provider is their only source of care.6
Clearly, Title X improves people’s health beyond helping them plan and space their pregnancies: In 2010 (the most recent year for which these data are available), the services provided within the Title X network prevented 87,000 preterm or low-birth-weight births, 63,000 STIs and 2,000 cases of cervical cancer.7 And Title X is not just good individual and public health policy—it results in considerable savings to taxpayers. The services Title X supports save $7 for every public dollar invested. This amounted to an estimated $7 billion in net federal and state government savings in 2010.
Title X–funded providers offer high-quality and timely contraceptive care. Compared with publicly funded health centers that do not receive Title X funding, sites supported by Title X are more likely to offer the full range of contraceptive methods, and to help clients start and effectively use their chosen method (see chart 2).8
More specifically, Title X sites are more likely to offer the full range of reversible contraceptive methods approved by the U.S. Food and Drug Administration. Being able to choose from the full range of methods helps clients to select the methods that will work best for them and, in turn, to achieve their family planning goals. Moreover, Title X–supported providers make it easier for women to obtain highly effective and long-acting reversible contraceptive methods, as these health centers are particularly likely to offer on-site insertion of IUDs and implants on the same day as a client’s initial appointment.
Nearly three-quarters of Title X sites offer initial supplies of oral contraceptives and refills on-site, enabling women who choose the pill to avoid additional trips to a pharmacy. Plus, seven in 10 Title X providers allow women to delay a pelvic exam when medically appropriate in initiating hormonal contraceptives, and nearly nine in 10 use the "quick-start" protocol, enabling a client to start the pill on the day of her visit, regardless of where she is in her menstrual cycle.
Title X funding and policies help ensure a high standard of care for all clients. Since its inception, the Title X program has set the bar for what high-quality family planning care should look like: services that are comprehensive, timely, affordable, evidence-based, voluntary, confidential and respectful of all who need them.9
Since Title X funds go to providers as up-front grants (rather than as reimbursement for direct client services, as with Medicaid or private insurance), these dollars can be used in a variety of ways to support a health center’s infrastructure and ensure its services remain accessible and high quality. For example, because they receive Title X funds, many providers are able to serve clients on evenings and weekends, implement electronic health records and stock the full range of contraceptive options.
Moreover, Title X regulations emphasize meeting the family planning needs of the nation’s most vulnerable communities. Sites receiving Title X support must provide care to low-income individuals on a sliding fee scale, offering services free of charge to those with incomes below the federal poverty level. This can be especially important for uninsured individuals, including people who remained ineligible for coverage under the ACA, such as many immigrant women and their families.10,11 And the ranks of the uninsured are expected to increase drastically if Congress and the Trump administration move to end the ACA’s coverage advances.
In addition, program guidelines require that Title X–funded sites ensure confidentiality for all clients. This protection is most often needed among those insured as dependents on someone else’s health plan, particularly teens and young adults, and individuals experiencing or threatened by intimate partner violence.6,12
Finally, the Title X statute has always expressly prohibited using grant dollars to fund abortion. Pregnancy testing, however, is a core service, and a client who finds she is pregnant is entitled to receive nondirective counseling and referral for all of her options, including prenatal care, adoption and abortion. This is part of a broader emphasis within Title X on providing in-depth counseling to meet all of a client’s needs and offering referrals, as appropriate, to other health care providers in the community.
Title X helps advance fundamental reproductive rights. By supporting young and low-income women in planning their pregnancies, the Title X program advances the health and well-being of women and their children, while also helping women to obtain their educational and professional goals.13 Women themselves have long reported that contraception allows them to take better care of themselves and their families, support themselves financially, complete their education, and get or keep a job.14
Accessible, high-quality family planning care is essential in women’s lives. The health and economic benefits of these services start with women and extend to their families and society as a whole. In short, the public investment in Title X is smart government at its best and should be expanded, not diminished or eliminated.
1. Fowler CI et al., Family Planning Annual Report: 2015 National Summary, Research Triangle Park, NC: RTI International, 2016, http://www.hhs.gov/opa/sites/default/files/title-x-fpar-2015.pdf.
2. Frost JJ, Frohwirth LF and Zolna MR, Contraceptive Needs and Services, 2014 Update, New York: Guttmacher Institute, 2016, http://www.guttmacher.org/report/contraceptive-needs-and-services-2014-update.
3. 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.
4. Frost JJ and Zolna MR, Response to inquiry concerning the availability of publicly funded contraceptive care to U.S. women, memo to U.S. 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.
5. Office of the Assistant Secretary for Planning and Evaluation, 2015 poverty guidelines, 2015, https://aspe.hhs.gov/2015-poverty-guidelines.
6. 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.whijournal.com/article/S1049-3867(12)00073-4/pdf.
7. Sonfield A, Beyond preventing unplanned pregnancy: the broader benefits of publicly funded family planning services, Guttmacher Policy Review, 2014, 17(4):2–6, http://www.guttmacher.org/gpr/2014/12/beyond-preventing-unplanned-pregnancy-broader-benefits-publicly-funded-family-planning.
8. 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, http://www.guttmacher.org/report/publicly-funded-family-planning-clinic-survey-2015.
9. Centers for Disease Control and Prevention, Providing quality family planning services: recommendations of the CDC and the U.S. Office of Population Affairs, 2016, https://www.cdc.gov/reproductivehealth/unintendedpregnancy/qfp.htm.
10. Guttmacher Institute, Uninsured rate among women of reproductive age has fallen more than one-third under the Affordable Care Act, News in Context, Nov. 17, 2016, http://www.guttmacher.org/article/2016/11/uninsured-rate-among-women-reproductive-age-has-fallen-more-one-third-under.
11. Hasstedt K, The case for advancing access to health coverage and care for immigrant women and families, Health Affairs Blog, Nov. 19, 2014, http://healthaffairs.org/blog/2014/11/19/the-case-for-advancing-access-to-health-coverage-and-care-for-immigrant-women-and-families/.
12. Hasstedt K, Understanding intimate partner violence as a sexual and reproductive health and rights issue in the United States, Guttmacher Policy Review, 2016, 19:37–45, https://www.guttmacher.org/gpr/2016/07/understanding-intimate-partner-violence-sexual-and-reproductive-health-and-rights-issue.
13. Sonfield A, What women already know: documenting the social and economic benefits of family planning, Guttmacher Policy Review, 2013, 16(1):8–12, https://www.guttmacher.org/gpr/2013/03/what-women-already-know-documenting-social-and-economic-benefits-family-planning.
14. Frost JJ and Duberstein Lindberg L, Reasons for using contraception: perspectives of US women seeking care at specialized family planning clinics, Contraception, 2012, 87(4):465–472, https://www.guttmacher.org/sites/default/files/pdfs/pubs/journals/j.contraception.2012.08.012.pdf.