Support Title X and Family Planning Betty A. Chewning, PhD, University of Wisconsin; Lawrence M. Leeman, MD, MPH, University of New Mexico; Sarah S. Brown, MSPH, National Campaign to Prevent Teen and Unplanned Pregnancy; and Ellen Wright Clayton, MD, JD, Vanderbilt University September 2012 Family planning is one of the 10 greatest The views expressed in this commentary are public health achievements of the 20th cen- those of the authors and not necessarily of the tury, according to the Centers for Disease authors’ organizations or of the Institute of Medi- cine. The commentary is intended to help inform Control and Prevention (1999). Nearly 75 and stimulate discussion. It has not been sub- percent of women of reproductive age in the jected to the review procedures of the Institute of United States (64 million) receive at least Medicine and is not a report of the Institute of one family planning or related medical ser- Medicine or of the National Research Council. vice annually (Mosher et al., 2004). A re- markable consensus has emerged within the These Title X funds support programs scientific and health care communities about that provide contraceptive services and the value of reproductive health care and broadly promote reproductive health by, for evidence-based guidelines to shape its deliv- example, providing cancer screening and ery. Three Institute of Medicine committees, treatment of sexually transmitted infections as well as many medical societies and other (STIs). By law, no Title X funds may be professional health associations, have en- used for abortion. dorsed the adoption of evidence-based In 2010, Title X grantees provided care guidelines for family planning care. to 5 million individuals, of whom 89 percent One of the most visible and important (4.7 million) were below 200 percent of the public-sector investments in family planning federal poverty level (FPL) and 69 percent is the federally funded Title X program, were at or below 100 percent of the FPL. which has a long history of providing evi- Two-thirds were uninsured; one-quarter dence-based, cost-effective family planning were under age 20, with another quarter be- care. Begun during the Nixon administration tween ages 20 and 24 (OPA, 2011). In inter- in 1970, Title X’s mission is to provide views with programs receiving Title X fund- grants to public or nonprofit private entities ing, staff members throughout the country to “assist in the establishment and operation reported that they use Title X funds to serve of voluntary family planning projects which clients who otherwise would not have been shall offer a broad range of acceptable and able to get care. Title X also provides educa- effective family planning methods and ser- tion and guidelines for clinicians about best vices (including natural family planning practices in the field (IOM, 2009).This key methods, infertility services and services for federal program is led by the Office of adolescents)”—primarily for the benefit of Family Planning within the Department of low-income individuals. Health and Human Services (HHS). This *Participants in the activities of the IOM Standing Com- mittee on Family Planning. Copyright 2012 by the National Academy of Sciences. All rights reserved. office not only performs a range of adminis- things, requires new insurance plans to cov- trative tasks associated with the Title X pro- er, without copay or deductible, preventive gram, but is also a center of expertise and services including well-woman visits, wisdom within HHS and the nation on the screening for gestational diabetes, testing for rich and evolving field of family planning HPV (human papillomavirus), counseling care. for STIs, counseling and screening for HIV Despite its achievements and broad pub- (human immunodeficiency virus), contra- lic support for family planning (PAI, 2011), ceptive methods and counseling, breast feed- Title X has faced opposition and challenges ing support, supplies and counseling, and since its inception, coming under attack screening and counseling for domestic vio- from vocal members of the public and from lence. As important as these provisions are, members of Congress and the executive there is universal agreement that a subset of branch. Recently, some members of the the population will not be covered by the House of the Representatives have sought to ACA insurance provisions—that is, there defund or eliminate Title X (New York will still be a number of uninsured people— Times, 2012). Some have argued that tax which means that Title X will continue to be dollars should not be used to fund family important. For example, a study evaluating planning at all (Tamari, 2010). At times, po- Massachusetts’ sweeping health care reform, litical appointees who oversee the Title X which is quite similar to the ACA, found program have lacked relevant medical, pub- that while the Massachusetts plan enhanced lic health, or family planning experience family planning access for many women, (Lee, 2006, 2007). some had difficulty maintaining continuous Despite the criticisms, the mandated re- insurance enrollment, securing timely ap- sponsibilities of Title X programs have con- pointments, managing prescriptions and tinually expanded. Funding, however, has high costs, and determining which health lagged in the last 15 years, while the number care providers accepted the plan and had the of people who need care, the complexity of desired contraceptives (Dennis et al., 2012). their health problems, and the cost of care Title X’s decades of experience in deliv- have all grown significantly. Thanks to sci- ering high-quality family planning care of- entific advances, there have been dramatic fers the new systems supported by the ACA improvements in contraception (especially a wide range of expertise and many oppor- the current generation of long-acting re- tunities for learning. Evidence already sug- versible contraceptives) and in the preven- gests that many of the family planning ser- tion and detection of STIs—both of which vices provided in this country do not meet are needed by many of the clients served the high standards of care promoted by Title through Title X (Winner et al., 2012). The X (Park et al., 2012). For this reason, Title X initial costs of these newer methods are should be viewed not only as a key part of more than offset by their greater effective- the service delivery system but also as a cen- ness in helping to plan and space pregnan- ter of excellence in education and training cies and preventing infections (Chesson et that is well positioned to help other health al., 2012; Sonnenberg et al., 2004; Trussel et systems (especially those offering primary al., 2009). care) promote evidence-based family plan- Title X is complemented but not re- ning services. Together, these complemen- placed by the Patient Protection and Afford- tary programs can enhance access to the able Care Act (ACA). The ACA emphasizes health services needed to screen for and treat evidence-based care and, among other STIs, plan and space pregnancies, and ad- 2 dress health conditions such as gestational Fletcher, J., and B. L. Wolfe. 2009. Education and diabetes which may interfere with healthy labor market consequences of teenage childbear- ing: Evidence using the timing of pregnancy out- births. These efforts have the additional comes and community fixed effects. Journal of benefits of cost savings for the broader Human Resources 44(2). health care system as well as averting the Fletcher, J., and B. L. Wolfe. 2012. The effects of lasting consequences of unplanned and/or teenage fatherhood on young adult outcomes. adolescent pregnancies (Crissey, 2006; 2012. Economic Inquiry 50(1):182-201. IOM (Institute of Medicine). 2009. A review of the Fletcher and Wolfe, 2009, 2012; Joyce et al., HHS family planning program: Mission, man- 2000). agement and measurement of results. Washing- For these reasons, there should be a ton, DC: The National Academies Press. strong commitment to providing evidence- Joyce, T. J., R. Kaestner, and S. Korenman,. 2000. based family planning services for both The effect of pregnancy intention on child devel- opment. Demography 37(1):83-94. women and men. This commitment should Lee, C. 2006. Bush choice for family planning post include specific support for criticized. Washington Post. http://www.washingtonpost.com/wp- adequately funded Title X programs that dyn/content/article/2006/11/16/AR20061116019 promote state-of-the-art reproductive 29.html (accessed September 20, 2012) Lee, C. 2007. Birth-control foe to run office on fami- health care nationally and provide ser- ly planning. Washington Post. vices to those who remain uninsured, http://www.washingtonpost.com/wp- have difficulty accessing needed contra- dyn/content/article/2007/10/16/AR20071016017 ception, and/or are uncomfortable re- 62.html (accessed September 20, 2012) ceiving family planning services through Mosher, W. D., G. M. Martinez, A. Chandra, J. C. Abma, and S. J. Willson. 2004. Use of contra- other sources; and ception and use of family planning services in insurance coverage for the delivery of the United States: 1982-2002. Advance Data key reproductive health services mandat- from Vital and Health Statistics 350:1-46. ed in the Affordable Care Act. New York Times. 2012. Republicans vs. women. http://www.nytimes.com/2012/07/30/opinion/rep ublicans-vs-women.html?_r=0 (accessed July 30, 2012). References: OPA (Office of Population Affairs). 2011. Family Centers for Disease Control and Prevention. 1999. planning annual report, 2010 national summary. Ten great public health achievements: United http://www.hhs.gov/opa/pdfs/fpar-2010-national- States, 1900-1999. Morbidity and Mortality summary.pdf (accessed August 20, 2012). Weekly Report 48(12):241-243. PAI (Population Action International). 2011. Review Chesson, H. W., D. U. Ekwueme, M. Saraiya, M. of polling on family planning. Watson, D.