What Policy Change Means for Women’s Health
The Reproductive Health Impact Study (RHIS) is a multiyear comprehensive research initiative that analyzes 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. For the study, the Guttmacher Institute is working with research and policy partners in each state.
The RHIS was 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 several relevant events—notably, the 2019 changes to the federal Title X regulations (the Trump administration’s “domestic gag rule”) and the COVID-19 pandemic.
The study uses original in-depth research and a wide range of secondary data sources to create a robust set of scientifically innovative, policy-relevant findings. The project’s objective is to illuminate the effects of policy change from a number of different angles:
- Family planning landscape: Identify how delivery networks are changing in composition and capacity as funding streams and programmatic guidance shift
- Clinics: Quantify changes to the number and types of safety-net health centers available to women, and to the number of women who visit these sites for contraceptive services
- Clinic staff: Describe the perspectives and experiences of clinic staff as they navigate the changing policy landscape while providing high-quality services to patients in their communities
- Patients: Describe the perspectives and experiences of family planning patients as they navigate access and barriers to access within a changing family planning service delivery system
- Reproductive health indicators: Monitor shifts in key reproductive health indicators and expenditures at the state level
These objectives will be achieved through the activities outlined below:
State policy context and study timeline
- Wisconsin (Feb.): The Republican-controlled legislature enacted a law requiring the Wisconsin Department of Health Services to apply for Title X funds, starting with the state’s 2018 application for the funding cycle that began in 2019. The law requires the state to prioritize public entities and exclude agencies that provide abortions or are affiliated with organizations that provide them.
- Iowa (Apr.): The state discontinued its Medicaid family planning waiver and created its own family planning program that prohibits funding clinics that provide, give referrals for, or have any connection to abortion care. The number of people enrolled in the state-funded family planning program dropped by 75% in the first year of the program.
- Iowa (Nov.): The RHIS launched in Iowa after the state left the federally run Medicaid family planning program and started its own family planning network that prohibits patients from accessing care from providers with any connection to abortion.
- United States (Feb.): The Trump administration released a grant opportunity that detailed new requirements for providers who want to receive Title X funds. This announcement foreshadowed how the administration would undercut the reach of Title X and the quality of care it supports, both of which were eventually codified in the domestic gag rule.
- Arizona (Jan.): The RHIS launched in the state to understand the effects of policy changes on family planning service delivery in a demographically diverse state with large numbers of immigrant, undocumented and Indigenous residents.
- United States (Mar.): After nearly two years of laying the groundwork, the Trump administration finalized its domestic gag rule by overhauling the Title X program’s administrative regulations.
- Wisconsin (Mar.): The Department of Health Services won the state’s entire Title X grant. The Trump administration took this opportunity to shift Title X funding from Planned Parenthood of Wisconsin, which had long been Wisconsin's largest Title X grantee, to the state.
- United States (Mar.): The District of Columbia and 20 states, including New Jersey and Wisconsin, filed a federal lawsuit opposing the domestic gag rule.
- United States (Aug.): Planned Parenthood Federation of America announced that all Planned Parenthood affiliates were leaving the Title X network as a result of the domestic gag rule.
- New Jersey (Aug.): The RHIS launched in the state, which has a long-established family planning network and policies that are generally supportive of sexual and reproductive health.
- Wisconsin (Nov.): The RHIS launched in the state, following confirmation of significant shifts in Title X funding among state grantees.
- United States (Feb.): A Guttmacher analysis estimated that the domestic gag rule had the potential to reduce the Title X network’s capacity to serve female patients seeking contraceptives by at least 46%, potentially affecting 1.6 million patients annually.
- In New Jersey, Title X network capacity was reduced by 50–89%.
- In Arizona and Iowa, Title X network capacity was reduced by 25–49%.
- In Wisconsin, the Title X network was not affected by the gag rule, as this shift had already occurred because of the 2016 state law.
- United States (Mar.): As a result of the coronavirus pandemic, family planning providers across the country shifted to telehealth services and made other safety changes to continue providing services to their clients.
- United States (Apr.): Governors across the country issued executive orders to shut down businesses and activities during the pandemic. Nearly half of the states addressed reproductive health services in their stay-at-home orders or essential procedures orders; policies regarding sexual and reproductive health and rights ranged from supportive to harmful.
- In New Jersey, an executive order protected abortion and the full range of family planning services and procedures.
- In Wisconsin, an executive order protected obstetricians, gynecologists and midwives.
- In Iowa, an executive order limited in-clinic abortion.
- United States (Sept.): The Office of Population Affairs, part of the Department of Health and Human Services, released the Title X Family Planning Annual Report: 2019 National Summary, which provides the first national and state data on the impact of the domestic gag rule. The report shows that the capacity of the Title X program to serve patients fell by 21% between 2018 and 2019. This decline represents only a partial picture of the damage the program sustained under the gag rule because the rule was finalized in March 2019 and had a staggered rollout, and entities began exiting Title X in large numbers only in the summer of 2019.
- United States (Jan.): The Biden-Harris administration took its first step toward rescinding the Title X domestic gag rule. President Biden signed a presidential memorandum directing the Department of Health and Human Services to review the Title X regulations and consider whether to suspend, revise or rescind them. It may take several months to complete this action and restore funding to family planning clinics that left the Title X program as a result of the rule.
Study states and partners
RHIS researchers and policy experts work in close collaboration with stakeholders in each study state.
We are grateful for the expertise shared by the following colleagues:
- Arizona Family Health Partnership
- Planned Parenthood of Arizona
- Planned Parenthood North Central States
- Family Planning Council of Iowa
- University of Wisconsin-Madison Collaborative for Reproductive Equity (UW CORE)
- New Jersey Family Planning League
- Other key stakeholders in each state
Key Guttmacher Institute project staff
- Tope Akinade
- Cynthia Beavin
- Nakeisha Blades
- Philicia Castillo
- Ayana Douglas-Hall
- Lori Frohwirth
- Madeleine Haas
- Rubina Hussain
- Leah H. Keller
- Marielle Kirstein
- Kathryn Kost
- Ellie Leong
- Tamrin Lever
- Ashley Little
- Kate MacFarlane
- Jennifer Mueller
- Rachel Murro
- Zoe Pleasure
- Emma Pliskin
- Lisa Remez
- Meg Schurr
- Melissa Stillman
- Parisa Thepmankorn
- Patrice Williams
- Ellie Witwer
- Mia Zolna
This study was funded in part through a generous grant from the William and Flora Hewlett Foundation. The views expressed are those of the authors and do not necessarily reflect the positions and policies of the donor.