How Has the ACA Affected Title X Services?

What you may think: Given the health insurance landscape created by the Affordable Care Act, clients at Title X–supported sites have coverage for services, and costs to clinics are therefore reduced.

What the research shows: Two studies that have run in Perspectives show that this isn’t entirely the case. In a 2016 survey of clients at Title X–funded clinics, 71% reported having some form of insurance, and 83% of this group planned to use it to pay for their services. The research team, led by Megan L. Kavanaugh, found that foreign-born respondents were less likely than U.S.-born respondents both to have coverage and to be planning to use it; clients with private insurance were less likely than those enrolled in public plans to be intending to use their coverage. The main reason people gave for not intending to use their insurance was concern about confidentiality.

A 2015 focus group study involving Title X–funded health center staff members and state program administrators revealed that clients aren’t the only ones with confidentiality concerns: Program personnel are well aware that billing procedures can threaten patients’ confidentiality. And, according to Leah E. Masselink and coauthors, this sometimes leads staff to be “risk-averse about billing insurance” or to avoid doing so when patients have confidentiality concerns. Study participants described other obstacles to billing insurance for care, too, such as administrative burdens and confusion (on the part of staff or clients) about coverage.

When clients are unable to use their insurance, for whatever reason, everybody loses: People may pay more than they need to for services or may forgo getting care altogether, and clinics stretch themselves financially in ways that they shouldn’t have to stretch. If the ACA’s gains in ensuring coverage for greater numbers of Americans are reversed, or if Title X is eliminated, the situation will inevitably deteriorate.

Cover illustrations of Margaret Sanger © Matthew and Eve Levine