Support Title X and Family Planning

Family planning is one of the 10 greatest public health achievements of the 20th century, according to the Centers for Disease Control and Prevention (1999). Nearly 75 percent of women of reproductive age in the United States (64 million) receive at least one family planning or related medical service annually (Mosher et al., 2004). A remarkable consensus has emerged within the scientific and health care communities about the value of reproductive health care and evidence-based guidelines to shape its delivery. Three Institute of Medicine committees, as well as many medical societies and other professional health associations, have endorsed the adoption of evidence-based guidelines for family planning care.

One of the most visible and important public-sector investments in family planning is the federally funded Title X program, which has a long history of providing evidence-based, cost-effective family planning care. Begun during the Nixon administration in 1970, Title X’s mission is to provide grants to public or nonprofit private entities to “assist in the establishment and operation of voluntary family planning projects which shall offer a broad range of acceptable and effective family planning methods and services (including natural family planning methods, infertility services and services for adolescents)”—primarily for the benefit of low-income individuals.

These Title X funds support programs that provide contraceptive services and broadly promote reproductive health by, for example, providing cancer screening and treatment of sexually transmitted infections (STIs). By law, no Title X funds may be used for abortion.

In 2010, Title X grantees provided care to 5 million individuals, of whom 89 percent (4.7 million) were below 200 percent of the federal poverty level (FPL) and 69 percent were at or below 100 percent of the FPL. Two-thirds were uninsured; one-quarter were under age 20, with another quarter between ages 20 and 24 (OPA, 2011). In interviews with programs receiving Title X funding, staff members throughout the country reported that they use Title X funds to serve clients who otherwise would not have been able to get care. Title X also provides education and guidelines for clinicians about best practices in the field (IOM, 2009). This key federal program is led by the Office of Family Planning within the Department of Health and Human Services (HHS). This office not only performs a range of administrative tasks associated with the Title X program, but is also a center of expertise and wisdom within HHS and the nation on the rich and evolving field of family planning care.

Despite its achievements and broad public support for family planning (PAI, 2011), Title X has faced opposition and challenges since its inception, coming under attack from vocal members of the public and from members of Congress and the executive branch. Recently, some members of the House of the Representatives have sought to defund or eliminate Title X (New York Times, 2012). Some have argued that tax dollars should not be used to fund family planning at all (Tamari, 2010). At times, political appointees who oversee the Title X program have lacked relevant medical, public health, or family planning experience (Lee, 2006, 2007).

Despite the criticisms, the mandated responsibilities of Title X programs have continually expanded. Funding, however, has lagged in the last 15 years, while the number of people who need care, the complexity of their health problems, and the cost of care have all grown significantly. Thanks to scientific advances, there have been dramatic improvements in contraception (especially the current generation of long-acting reversible contraceptives) and in the prevention and detection of STIs—both of which are needed by many of the clients served through Title X (Winner et al., 2012). The initial costs of these newer methods are more than offset by their greater effectiveness in helping to plan and space pregnancies and preventing infections (Chesson et al., 2012; Sonnenberg et al., 2004; Trussel et al., 2009).

Title X is complemented but not replaced by the Patient Protection and Affordable Care Act (ACA). The ACA emphasizes evidence-based care and, among other things, requires new insurance plans to cover, without copay or deductible, preventive services including well-woman visits, screening for gestational diabetes, testing for HPV (human papillomavirus), counseling for STIs, counseling and screening for HIV (human immunodeficiency virus), contraceptive methods and counseling, breastfeeding support, supplies and counseling, and screening and counseling for domestic violence. As important as these provisions are, there is universal agreement that a subset of the population will not be covered by the ACA insurance provisions—that is, there will still be a number of uninsured people—which means that Title X will continue to be important. For example, a study evaluating Massachusetts’ sweeping health care reform, which is quite similar to the ACA, found that while the Massachusetts plan enhanced family planning access for many women, some had difficulty maintaining continuous insurance enrollment, securing timely appointments, managing prescriptions and high costs, and determining which health care providers accepted the plan and had the desired contraceptives (Dennis et al., 2012).

Title X’s decades of experience in delivering high-quality family planning care offers the new systems supported by the ACA a wide range of expertise and many opportunities for learning. Evidence already suggests that many of the family planning services provided in this country do not meet the high standards of care promoted by Title X (Park et al., 2012). For this reason, Title X should be viewed not only as a key part of the service delivery system but also as a center of excellence in education and training that is well-positioned to help other health systems (especially those offering primary care) promote evidence-based family planning services. Together, these complementary programs can enhance access to the health services needed to screen for and treat STIs, plan and space pregnancies, and address health conditions such as gestational diabetes which may interfere with healthy births. These efforts have the additional benefits of cost savings for the broader health care system as well as averting the lasting consequences of unplanned and/or adolescent pregnancies (Crissey, 2006; Fletcher and Wolfe, 2009, 2012; Joyce et al., 2000).

For these reasons, there should be a strong commitment to providing evidence-based family planning services for both women and men. This commitment should include specific support for

• adequately funded Title X programs that promote state-of-the-art reproductive health care nationally and provide services to those who remain uninsured, have difficulty accessing needed contraception, and/or are uncomfortable receiving family planning services through other sources; and
• insurance coverage for the delivery of key reproductive health services mandated in the Affordable Care Act.

 

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References

1. Centers for Disease Control and Prevention. 1999. Ten great public health achievements: United States, 1900-1999. Morbidity and Mortality Weekly Report 48(12):241-243. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm (accessed February 3, 2020).
2. Chesson, H. W., D. U. Ekwueme, M. Saraiya, M. Watson, D. R. Lowy, and L. E. Markowitz. 2012. Estimates of the annual direct medical costs of the prevention and treatment of disease associated with human papillomavirus in the United States. Vaccine 30(42):6016-6019. https://doi.org/10.1016/j.vaccine.2012.07.056
3. Crissey, S. 2006. Effect of pregnancy intention on child well-being and development: Combining retrospective reports of attitude and contraceptive use. Population Research and Policy Review 24(6):594-615. Available at: https://link.springer.com/article/10.1007/s11113-005-5734-1 (accessed February 3, 2020).
4. Dennis, A., J. Clark, D. Cordova, J. McIntosh, K. Edlund, B. Wahlin, L. Tsikitas, and K. Blanchard. 2012. Access to contraception after health care reform in Massachusetts: A mixed methods study investigating benefits and barriers. Contraception 85(2):166-72. Available at: https://ibisreproductivehealth.org/publications/access-contraception-after-health-care-reform-massachusetts-mixed-methods-study (accessed February 3, 2020).
5. Fletcher, J., and B. L. Wolfe. 2009. Education and labor market consequences of teenage childbearing: Evidence using the timing of pregnancy outcomes and community fixed effects. Journal of Human Resources 44(2). https://doi.org/10.3368/jhr.44.2.303
6. Fletcher, J., and B. L. Wolfe. 2012. The effects of teenage fatherhood on young adult outcomes. 2012. Economic Inquiry 50(1):182-201. https://doi.org/10.1111/j.1465-7295.2011.00372.x
7. Institute of Medicine (IOM). 2009. A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results. Washington, DC: The National Academies Press. https://doi.org/10.17226/12585.
8. Joyce, T. J., R. Kaestner, and S. Korenman. 2000. The effect of pregnancy intention on child development. Demography 37(1):83-94.
9. Lee, C. 2006. Bush choice for family planning post criticized. Washington Post. Available at: http://www.washingtonpost.com/wpdyn/content/article/2006/11/16/AR2006111601929.html (accessed September 20, 2012)
10. Lee, C. 2007. Birth-control foe to run office on family planning. Washington Post. Available at: http://www.washingtonpost.com/wpdyn/content/article/2007/10/16/AR2007101601762.html (accessed September 20, 2012)
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13. OPA (Office of Population Affairs). 2011. Family planning annual report, 2010 national summary. Available at: http://www.hhs.gov/opa/pdfs/fpar-2010-nationalsummary.pdf (accessed August 20, 2012).
14. PAI (Population Action International). 2011. Review of polling on family planning. Available at: http://populationaction.org/advocacyguides/review-of-polling-on-family-planning/ (accessed Sept 18, 2012)
15. Park, H., M. I. Rodriguez, D. Hulett, P. D. Darney, and H. Thiel de Bocanegra. 2012. Long-acting reversible contraception method use among Title X providers and non-Title X providers in California. Contraception 86(5): 557-561. https://doi.org/10.1016/j.contraception.2012.04.006
16. Tamari, J. 2010. Family planning a big loser in N.J. budget. Available at: http://womenshealthmattersnj.org/news/articles/20100318_losernjbudget (accessed September 20, 2012)
17. Trussel, J., A. M. Lalla, Q. V. Doan, E. Reyes, L. Pinto, and J. Gricar. 2009. Cost effectiveness of contraceptives in the United States. Contraception 79(1):5-14. https://doi.org/10.1016/j.contraception.2008.08.003
18. Sonnenberg, F. A., R. T. Burkman, C. G. Hagerty, L. Speroff, and T. Speroff. 2004. Costs and net health effects of contraceptive methods. Contraception 69(6):447-459. https://doi.org/10.1016/j.contraception.2004.03.008
19. Winner, B., J. F. Peipert, Q. Zhao, C. Buckel, T. Madden, J. E. Allsworth, and G. M. Secura. 2012. Effectiveness of long-acting reversible contraception. New England Journal of Medicine 366(21):1998-2007. https://doi.org/10.1056/NEJMoa1110855

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