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Contraception Editorial September 2011

Title X: A Proud Past, An Uncertain Future

Clare Coleman, Kirtly Parker Jones

In the mid and late 1960s, the United States was at war, both abroad and at home. Amidst the battles being fought in Vietnam and in our cities and on the greens of our campuses, President Lyndon Johnson declared war on an entirely different kind of enemy: poverty. President Johnson and a politically divided Congress found the common ground to pass laws for the benefit of the people of the United States that we take for granted today as our inherent, civil rights: the Civil Rights Act, Medicaid and Medicare. They committed resources for the improvement of our natural resources: the Clean Air Act, the Clean Rivers Act and the National Environmental Policy Act, which created the Environmental Protection Agency.

After the extremely divisive presidential election in 1968, a conservative president, his conservative vice president and a divided Congress continued the War on Poverty by passing the laws that would create Title X: dedicated funding for family planning, so that the most vulnerable in our country could receive services to plan their families. In 1969, President Richard M. Nixon said: “It is my view that no American woman should be denied access to family planning assistance because of her economic condition.… This we have the capacity to do”.1 The chief sponsor of the Title X statute, George H.W. Bush, then a US Representative, said even more powerfully: “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 stepping stone. If family planning is anything, it is a public health matter”.2

In 1970, Title X of the Public Health Service Act passed the House by a vote of 298 to 32 and passed the Senate unanimously. Today, those who have dedicated their careers to the service of the poor and the low-income sector remember the early days of Title X as a golden age of sorts. The network of health centers was growing, encouraged by Congressional appropriations. From 1971 to 1980, appropriations grew from $6 million to $162 million. Four of the six largest increases in the program's 40-year history happened in its first 10 years. However, by 1981, Title X would fall victim to the burgeoning culture war; former champion George H.W. Bush would serve as Ronald Reagan's vice president and go onto his own term as President — repudiating his pro-family planning position in favor of using it as the “political stepping stone” he had once publicly abhorred.

Today, the Title-X-funded network serves over five million people each year in more than 4500 sites, serving as many patients' usual and even only source of health care. According to the Guttmacher Institute, family planning services at Title-X-funded health centers helped prevent 973,000 unintended pregnancies in 2008, which would likely have resulted in 432,600 unintended births and 406,200 abortions.3 Title-X-funded services produce significant cost savings to the federal and state governments; services provided at Title-X–supported clinics accounted for $3.4 billion in such savings in 2008 alone.4 When all 2008 public funds are taken into account, more than $5 billion in public funds were saved — for every public dollar invested in family planning care, nearly $4 in Medicaid expenditures were averted.4

Despite the benefit to the public health and the public purse, Title X appropriations have not grown with the need for subsidized care. The program has been chronically underfunded by both Democratic and Republican administrations — if appropriations had kept up with inflation since FY 1980, the program would be funded at $840.1 million rather than the FY 2010 funding level of $317.5 million.5 Put another way, funding for Title X in constant dollars (i.e., taking inflation into account) is 62% lower today than it was 30 years ago.5

Yet the Title X program retains its preeminent role as the standard-setter for domestic family planning care. Title X, to a degree that is perhaps unprecedented in public health programs, prescribes the scope of services, counseling and quality indicators that shape a patient's clinic experience, and program administrators closely monitor delegates nationwide. In part because state governments and private not-for-profit agencies often reference Title X's statute, regulations or guidelines when making policy related to family planning care, its standards have an effect on care well beyond what might be expected given its limited appropriations.

Now that the federal health reform law, the Affordable Care Act (ACA), promises to expand health care coverage for many of the historically uninsured or underserved, there will be questions about the continued need for categorical programs such as Title X. There can be no question that Title X remains vitally important, and advocates must prepare to vigorously defend the full breadth of the program, its record of success and the compelling role it must play under the ACA.

Title X today pays for a substantial amount of needed medical care, and that need will continue — not all those in need of health insurance coverage will gain that coverage under the ACA. The Obama administration estimates that approximately 32 million people will become eligible for participation in Medicaid or a state-based commercial insurance exchange under the ACA; however, an estimated 58 million were without health insurance in 2009. Patients without access to insurance will experience health conditions and crises — just as insured individuals do — and they will seek care in safety-net settings like Title-X-funded centers, where no one is turned away.

In addition to medical care, Title X supports activities that are not reimbursable under Medicaid and commercial insurance plans. Participating in Title X provides an indispensable link to a federal program that offers low-price contraceptive drugs and devices, and supports clinics' purchases of other needed supplies. Title X has made a major contribution to the training of clinicians; that need remains today. Family planning programs competing for staff often find new graduates interested in women's health but without significant clinical experience, or find experienced nurse practitioners who need to train in women's health procedures. Title X pays for that training, provides a system of data collection so epidemiologists can learn “what works” and provides continuing education to ensure consistent medical care under protocols built upon the program's successes. Title X helps to support staff salaries, not just for clinicians but for front-desk staff, educators and finance and administrative staff. Title X provides for individual patient education as well as community-level outreach and public education about family planning and women's health issues. Title X also helps to support the infrastructure necessary to keep the doors open — subsidizing rent, utilities and infrastructure needs like health information technology.

These are essential elements of a quality and effective health delivery system, and all can be supported by Title X. Neither public insurance programs like Medicaid nor commercial insurance products like those expected to be offered under the ACA's state-based exchanges provide the kind of support needed to keep safety-net systems open to patients who need care.

These are just a few of the reasons why the Title X network is as necessary as ever. Millions of people who have not had consistent medical care or insurance coverage will become eligible for coverage under the ACA, but these are not new patients to the Title X network. They are the people we have served for the last 40 years and will continue to serve with compassion, quality and respect.

The network, however, must be prepared for the political fight ahead. Members of Congress opposed to family planning — but claiming concern for fiscal responsibility — have targeted Title X for elimination, a direct attack not seen in 15 years. This political challenge comes at a time when patient visits — driven by the worst recession in 70 years — are rising nationwide. While advocates were successful at defeating the drive to eliminate Title X in the spring of 2011, it is likely that Title X administrators and advocates will once again have to marshal the necessary evidence to defend the program's impact on the public's health and people's lives.

Fortunately, the evidence is on our side. The US Centers for Disease Control and Prevention has cited family planning as one of the 10 great public health achievements of the 20th century. “Smaller families and longer birth intervals have contributed to the better health of infants, children, and women, and have improved the social and economic role of women. Publicly supported family planning services prevent an estimated 1.3 million unintended pregnancies annually”.6 TheAmerican Journal of Preventive Medicine calls family planning one of the “twentieth-century triumphs of public health in the United States”.7 In 2009, the Institute of Medicine's assessment of Title X found that “Title X is a valuable program that successfully serves its target audience” and called for funding to be “increased so the program can meet its statutory responsibility to provide family planning services to those who cannot obtain them through other sources”.8

The Title X network is preparing to continue serving its longtime patients and welcome new patients, while better integrating with other primary and preventive care providers. In order to succeed, however, we must once again help a new class of lawmakers understand what our providers, patients and the general public already know — that family planning is an essential preventive health service and that Title X is an essential public health program.

Clare Coleman
National Family Planning & Reproductive Health Association
Washington, DC

Kirtly Parker Jones
Department of Obstetrics and Gynecology
University of Utah
Salt Lake City, UT

References

  1. Message to Congress from President Richard M. Nixon, July 18, 1969. Reprinted in: 91st Congress, second session, House of Representatives Hearing Report, Subcommittee on Public Health and Welfare of the Committee on Interstate and Foreign Commerce, August 3, 4 and 7, 1970; Serial No. 91–70.
  2. Friedman D. Planned Parenthood Federation of America. America's family planning program: Title X. 2003;
  3. Guttmacher Institute . Contraceptive needs and services, 2008 update. New York: Guttmacher Institute; 2010;Available from:http://www.guttmacher.org/pubs/win/contraceptive-needs-2008.pdf
  4. Frost JJ, Finer LB, Tapales A. The impact of publicly funded family planning clinic services on unintended pregnancies and government cost savings. J Health Care Poor Underserved. 2008;19:778–796
  5. Sonfield A. Interested Parties Memo: Title X Funding Chart, February 17, 2011. Washington, DC: The Guttmacher Institute.Centers for Disease Control and Prevention (CDC). Achievements in public health, 1900–1999: family planning. MMWR Morb Mortal Wkly Rep 1999;48:1073–80 Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4847a1.htm
  6. Ducatman A, Vanderploeg JM, Johnson M, et al. Residency training in preventive medicine: challenges and opportunities. Am J Prev Med. 2005;28:403–412
  7. Institute of Medicine . A review of the HHS family planning program: mission, management, and measurement of results.Washington, DC: The National Academies Press; 2009;

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Used with permission from Elsevier, Inc.