America's Family Planning Program: Title X
We need to make population and family planning household words. We need to take sensationalism out of this topic so that it can no longer be used by militants who have no real knowledge of the voluntary nature of the program but, rather are using it as a political steppingstone. If family planning is anything, it is a public health matter.
— President George H. W. Bush, then a congressman from Texas, 1969
The Title X Program
Title X has been key in helping millions of American women prevent unintended pregnancies and obtain reproductive health care for three decades.
Title X of the Public Health Service Act is America's family planning program. It was signed into law in 1970 by President Richard M. Nixon, who said
No American woman should be denied access to family planning assistance because of her economic condition. I believe, therefore, that we should establish as a national goal the provision of family planning services ... to all who want but cannot afford them.
For more than 30 years, Title X has been the nation's major program to reduce unintended pregnancy by providing contraceptive and related reproductive health care services to low-income women. Although public funds for family planning services also come from other programs — including Medicaid, state funds, Temporary Assistance for Needy Families (TANF), State Children's Health Insurance Program (SCHIP), and the Maternal and Child Health and Social Services block grants — Title X is the only federal program dedicated solely to funding family planning and related reproductive health care services. In 1999, it helped to support 61 percent of all family planning agencies (Finer et al., 2002). Title X accounts for 26 percent of the revenue of agencies receiving Title X funds (AGI, 2005a).
Title X is a vital source of funding for family planning clinics throughout the nation.
All Title X grants are administered through state health departments or regional agencies that subcontract with local clinics. In 2001, approximately 4,400 clinics, located in nearly three-quarters (73 percent) of all counties, provided family planning services funded by Title X. Of the 4.7 million women served by these clinics, 43 percent received care at health departments, 33 percent received care at Planned Parenthood health centers, 13 percent received care at other independent community-based clinics, seven percent received care at hospitals, and four percent received care at community or migrant health centers (AGI, 2004; Frost et al., 2004).
While this system allows for maximum flexibility in the administration of the program, Title X also sets a minimum standard of care for those individuals who want reproductive health care. The law's provisions include requirements that
- people be given a choice of contraceptive methods (including periodic abstinence and other fertility awareness-based methods)
- no one is coerced into accepting a particular method or any method at all
- services are provided in the context of related reproductive health care
- recipients are charged fees based on their income and ability to pay
- no Title X funds are used to pay for abortions (P.L. 91-572, 1970).
The law also mandates
- minimum national medical standards of care developed with the American College of Obstetricians and Gynecologists
- training of health care professionals, information outreach
- research designed to improve contraceptive use and the delivery of family planning services (P.L. 91-572, 1970).
Title X Services
Title X funds services essential for the health of women and their families.
The Title X program provides comprehensive family planning services that include a broad range of contraceptive methods and related counseling. The official program guidelines also require health care providers that receive this funding to offer a wide range of other preventive health care services that are critical to their clients' sexual and reproductive health (Gold, 2001). These services include
- pelvic exams and Pap tests (early detection of cervical cancer)
- breast exams and instruction on breast self-examination
- testing for high blood pressure, anemia, and diabetes
- screening and appropriate treatment for sexually transmitted infections
- safer-sex counseling
- basic infertility screening
- referrals to specialized health care
By law, no Title X funds have ever been spent on abortion (Sollom et al., 1996). The family planning regulations require that women who face unintended pregnancies be given nondirective counseling on all of their legal and medical options (Federal Register, 2000).
Title X Recipients
Title X serves more than 4.8 million women and 240,000 men a year who might otherwise be unable to afford family planning (AGI, 2005a).
In 2004, approximately 4.8 million women received health care services at family planning clinics funded by America's family planning program. They are predominantly young, poor, uninsured, and have never had a child. Seventy-three percent of women using Title X-funded clinics are 20 or older, and 64 percent are white. Sixty-eight percent have incomes at or below the federal poverty level (AGI, 2005a). It is estimated that these clinics are the only source of family planning services for more than 80 percent of the women they serve (Kaeser et al., 1996).
According to regulations, the amount a woman pays for family planning services at a Title X-funded clinic depends upon her income. If her income is at or below 100 percent of the federal poverty level, the services are completely subsidized. A woman will be charged on a sliding fee scale if her income is between 100-250 percent of poverty level, and she will pay full fees if her income is above 250 percent of poverty level (Kaeser et al., 1996).
From the beginning, America's family planning program has also required that services be made available without regard to age or marital status. In 1977, family planning services — including the availability of contraception — were extended to minors under the age of 16 as a result of the Supreme Court's decision in Carey v. Population Services International (Carey v. Populations Services International, 1977). As a result of this court decision, clinics supported by Title X funds have traditionally served adolescents on a confidential basis. Clinics also provide preventive educational services to young people, including an emphasis on the postponement of sexual activity, as well as counseling and contraceptive care. Counselors in most family planning clinics are encouraged to spend extra time with teenage clients (Henshaw & Torres, 1994). Title X clinics are required by law to encourage minors to involve their parents in their decision-making regarding family planning (P.L. 108-447, 2005).
More than 30 Years of Title X Successes
Family planning programs are successful in preventing unwanted pregnancies and, consequently, abortions.
By providing access to contraceptive methods and counseling on how to use them effectively, family planning clinics — many of which receive funding through Title X — have been shown to reduce large numbers of unintended pregnancies, abortions, and births. Each year
- Among women who have never married, public family planning funds prevent approximately 888,200 unintended pregnancies, 421,900 abortions, and 356,200 births
- Among single-parent adolescents aged 15-19, publicly funded family planning prevents 385,800 unintended pregnancies, 154,700 teenage births, and 183,300 abortions
- In total, publicly subsidized family planning services, of which Title X is the core, prevent 1,331,100 unintended pregnancies and 632,300 abortions
(Forrest & Samara, 1996)
Each public dollar spent to provide family planning services saves an estimated $3.00 that would otherwise be spent in Medicaid costs for pregnancy-related care and medical care for newborns (Forrest & Samara, 1996). A study that measured the cost of contraceptive methods compared to the cost of unintended pregnancies when no contraception was used found the total savings to the health care system to fall between $9,000 and $14,000 per woman over five years of contraceptive use (Trussell et al., 1995).
Title X has made a tremendous impact in the lives of millions of women. Over the last two decades, services provided at Title X-funded clinics
- prevented 20 million unintended pregnancies and nine million abortions
- helped to prevent 5.5 million adolescent pregnancies. (Without Title X, there would have been 20 percent more teen pregnancies during this time period.)
- provided an estimated 54.4 million breast exams and 57.3 million Pap tests, resulting in the early detection of as many as 55,000 cases of invasive cervical cancer
In 2004, Title X funds supported 2.8 million Pap tests, 2.7 million breast exams, and 5.4 million tests for sexually transmitted infections (STIs), including 530,000 HIV tests (AGI, 2005a).
Continued Need for Title X
Family planning programs continue to provide essential services to women seeking to plan their pregnancies and maintain their health.
A 1995 report on unintended pregnancy by the Institute of Medicine noted with concern the increasing number of births from unintended pregnancies in the early 1990s. It urged that financial barriers to contraceptive services be reduced, and that public funding — including Title X specifically — should continue, especially for low-income women and adolescents. The report pointed to the serious public health consequences that result from a lack of family planning services:
- A woman with an unintended pregnancy is less likely to seek early prenatal care and is more likely to expose the fetus to harmful substances such as alcohol and tobacco.
- Births from unintended pregnancies are more likely to occur to mothers who are adolescent, unmarried, or over age 40 — characteristics that carry special medical risks and socioeconomic burdens.
- The child of an unwanted conception is at greater risk of being born at low birthweight, of dying in its first year of life, of being abused, and for having developmental disabilities. Mothers are at risk for depression, and both parents may suffer economic hardship or failure to reach educational or career goals.
- The U.S. ratio of about one abortion to every three live births is two to four times higher than in other developed countries, although access to abortion in those countries is often easier than in the U.S.
(Institute of Medicine, 1995)
While family planning programs have helped to increase the percentage of adolescents who use contraception at first intercourse (79 percent in 2002), there is still a great need for Title X (NCHS, 2004a). A recent evaluation of the National Survey of Family Growth has shown that the number of women at risk of unintended pregnancy due to a lack of contraception has increased to 10.7 percent (NCHS, 2004b). According to the Office of Population Research, this could potentially lead to an 18 percent increase in unintended pregnancies ("Teens Improve ...", 2005).
Public Support for Family Planning
The majority of Americans supports increased public funding for services to prevent unintended pregnancies.
Publicly funded family planning programs enjoy overwhelming public support. According to research conducted for Planned Parenthood by Sosin Snell Perry & Associates, 88 percent of voters believe the use of contraceptives and other family planning measures to be important, while 74 percent favor increased public funding for family planning services to reduce the number of unintended pregnancies (Feldt, 1999).
Funding for Title X
In spite of its proven track record as a cost-effective program for preventing unintended pregnancies, preventing abortion, and improving the health of women, Title X faces threats from Congress to cut funding or attach harmful restrictions, making it less likely that people will receive the care they need.
Title X lost a significant amount of funding during the 1980s, and while appropriations increased during the Clinton administration, the decreased purchasing power of the dollar meant that the program was operating with less money each year. Therefore, the $286 million allotted to Title X for FY 2005 was worth 59 percent less than the $162 million appropriated for FY 1980 (AGI, 2005b).
President Bush has not proposed any increase in Title X funding since taking office in 2001. Because the program has remained underfunded for so long, clinics are struggling to pay for newer, more effective, but more costly, long-lasting methods of contraception and state of the art diagnostic tests that promise improved rates of detecting STIs and cervical cancer.
Recent Threats to Title X
Since the inception of Title X, opponents of family planning have long tried to use the issues of abortion and the reproductive rights of minors to attack the family planning program.
In October of 1998, members of the House attempted to pass legislation restricting minors' access to family planning services. Representative Ernest Istook (R-Oklahoma) proposed an amendment to the Labor, Health and Human Services and Education Appropriations Act of 1999 mandating that the parents of dependent teenagers be notified before their children receive contraceptives from Title X clinics (Congressional Record, 1998). Supporters of parental consent argue that the availability of confidential contraceptive services encourages teenage sexual activity and undermines parental authority. However, research shows that confidentiality is crucial to teens' willingness to seek sensitive services such as family planning (Jones et al., 2005; Reddy et al., 2002). Moreover, the fact that the average teen does not visit a family planning clinic until 14 months after she has become sexually active provides clear evidence that clinics do not encourage sexual activity. In fact, requiring parental consent will not discourage teens from having sex but will only deter them from seeking needed reproductive health care in a timely manner (AGI, 2000). A recent study has shown that 20 percent of adolescent girls currently visiting family planning clinics for contraceptive services would have unsafe sex instead of accessing birth control through a clinic if mandatory parental notification laws went into effect. Only one percent of the adolescents surveyed said that they would remain abstinent if their parents were notified of their visits to the family planning clinic (Jones et al., 2005). Fortunately, the Istook amendment was dropped from the final bill and never became law (AGI, 2000).
In 2001, family planning opponent Rep. David Vitter (R- Louisiana) announced his intent to offer an amendment to the pending appropriations bill that was designed to undermine Title X. The Vitter amendment would have prevented private organizations from receiving Title X funds to provide contraception and other preventive health care services even if they provided abortions or abortion related services with their own, non Title X funds. Had the amendment succeeded, it would have restricted the funding availability of contraceptives and other preventive health care affecting one million low-income women by prohibiting nearly 600 hospitals, Planned Parenthood affiliates, and other established health care providers from receiving Title X funds (Gold, 2000). The amendment would have endangered the health of low-income women, threatened the Title X family planning clinic network, and disregarded the current prohibition on the use of Title X funds to provide, promote, or encourage abortions.
In 2005, Rep. Dave Weldon (R- Florida) successfully tacked a so-called "Abortion Non-Discrimination Act (ANDA)" on to the federal government's budget. Proposed by the U.S. Conference of Catholic Bishops, the Weldon Amendment allows virtually any health care institution to refuse to comply with existing federal, state, and local laws and regulations pertaining to abortion services, including referral for abortion services (Feldt, 2004). Health care institutions, as defined by the law, include hospitals, provider-sponsored organizations, health maintenance organizations, health insurance plans, or any other kind of health care facilities, organizations or plans (PPFA, 2004). ANDA seriously undermines Title X by prohibiting the federal government from enforcing its own requirement that Title X funded clinics must refer clients to abortion providers upon request. The State of California is currently taking legal action to challenge this legislation.
Title X has a long and remarkable history. It has enabled millions of women to plan their pregnancies, to prevent abortions and unintended births, and to receive vital reproductive health care. For the benefit of American families, funding of Title X must continue to be a national priority, and Planned Parenthood is proud of the role it has played in preserving this crucial women's health program.
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