The Title X Program: Setting Standards for Contraceptive and Health Equity

For more than 50 years, the Title X family-planning program has provided federal funding to ensure access to family-planning and related preventive care for people with low incomes, uninsured people, people living in areas with provider shortages, young people, people who otherwise would not have access to care, and people who simply want to receive care from expert, evidence-based, family-planning providers. The US Department of Health and Human Services, Office of Population Affairs (OPA), the agency administering the Title X program, has established standards and best practices and invested in research and quality improvement initiatives that have benefited more than just Title X–funded projects. The program’s investments in infrastructure have helped sustain health clinic operations to serve people regardless of insurance coverage, employer, or geographic location, among other factors, with equitable, high-quality family planning and preventive care services. And it is important to note that the family planning and preventive care services covered are wide ranging. Among other services, they provide sexually transmitted infections screenings and treatment, HIV testing and referral, human papillomavirus vaccines, and screenings for breast and cervical cancer, drug and alcohol use, mental health, and intimate partner violence.

Specifically, as it relates to contraceptives, the Title X program has played a leading role in providing access without regard to insurance, ability to pay, geographic location, immigration status, or other factors. Importantly, the program sets quality standards and serves as an example to other programs on how to deliver client-centered contraceptive care, counseling, and education. For this reason, Title X is often an important complement to other initiatives to expand contraceptive access, including state contraceptive access initiatives. Moreover, Title X funding enhances the capacity of state and local providers to offer an array of contraceptive methods, improving both access and choice.

Without a doubt, Title X is currently at a critical inflection point. The program has undergone intense, drastic changes in recent years, which has necessitated rebuilding the program to ensure that it continues to meet its mission. As a result, OPA has the strategic imperative to restore and modernize the program so that it reflects current population needs and an evolving understanding regarding family planning. Even more, building on lessons learned from decades of providing care primarily to underserved populations, the program is uniquely situated to advance health equity and serve as a model for state and other federal programs.

PROVIDING CONTRACEPTIVE ACCESS

The structure of the Title X family-planning program uniquely positions it to be a collaborator on and supporter of contraceptive access. The program is implemented through competitively awarded grants to state and local public health departments and family-planning, community health, and other private nonprofit agencies—which means the program has a wide reach across the country and through various settings. Health clinics receiving Title X funds are required to offer a range of reproductive and other preventive health services, including a “broad range of acceptable and effective family planning methods.”^1(p31) In 2020, nearly 75% of the females and 60% of the males served were using or adopted a contraceptive method during their last visit.

Title X complements other federal and state coverage and access policies. The demand for contraceptive services at Title X clinic sites has remained consistently high, despite federal coverage expansions (i.e., expanding Medicaid eligibility and increasing the affordability of private insurance) through the Affordable Care Act, state family-planning programs, and other policy changes in the federal and state health care systems; this demonstrates that the need for low- or no-cost contraceptives remains, especially given the remaining number of uninsured people and people who do not have insurance plans covering contraceptives, as well as the insured who continue to prefer to access contraceptives for high-quality, confidential care. Recognizing the ability to uniquely use these federal dollars, states—including those that have enacted statewide contraceptive initiatives—rely on Title X to afford real-world access to clinic sites and staff.² Some states and localities receive Title X funding directly. Still others partner with and provide additional state funding to Title X grantees to advance the state’s goals to increase access to contraceptives.

Beyond direct service delivery, Title X provides critical investments in health clinics’ infrastructure, including salaries and building overhead, often serving as a necessary complement to other family-planning resources. As a result, the program has been instrumental in supporting the availability of family-planning services in underserved areas. Illustratively, OPA recently awarded $35 million in grants to improve and expand telehealth infrastructure and capacity for Title X grantees.³ Title X investments in infrastructure also increase health clinics’ capacity to offer certain contraceptive methods. For example, Title X funding allows some providers to stock the most effective contraceptive methods, that is, long-acting reversible contraceptives (i.e., intrauterine devices and implants), which have higher upfront costs than do other forms of contraceptives.⁴

Because Title X funding provides investments in the grantee organization’s infrastructure, as opposed to providing insurance coverage or direct services to a defined population, the program equitably offers high-quality care to people regardless of health insurance status or level of coverage. Title X grantees are required to prioritize clients who have low incomes, and 87% of clients in 2020 had family incomes that qualified them for subsidized services or services without cost.¹ Many of these clients are uninsured. Even so, Title X remains important for people who have insurance. Since 2015, the percentage of clients with health insurance has exceeded the percentage without insurance, and nearly 60% of Title X clients have either public or private insurance.¹ Illustratively, Medicaid is the largest public funder of family-planning services and supplies,⁵ but Medicaid beneficiaries frequently turn to Title X clinics to access these services.¹ Title X has also played an important role in filling the gaps between reimbursement and the actual cost of services. Additionally, people who are insured might not want to use their coverage to access contraceptives or other family-planning services, particularly if they share an insurance policy with family or others, and Title X–funded health centers provide no- or low-cost confidential health care services.

SETTING FAMILY-PLANNING STANDARDS

Title X is a key driver nationwide in encouraging high-quality care for family-planning services and supplies, including contraceptives, because of the program’s participation requirements for its diverse array of grantees. In fact, recently finalized regulations governing the program require that the family-planning projects aim to ensure “equitable, affordable, client-centered, quality family-planning services.”⁶ Many Title X grantees align their projects across funding streams to improve consistency and efficiency in administering care; subsequently, Title X program standards can affect other non–Title X–funded health care services or activities that grantees oversee.

In addition to the statutory and regulatory standards to which Title X grantees must adhere, grantees are required to implement quality standards that are aligned with nationally recognized standards of care. OPA and the Centers for Disease Control and Prevention (CDC) led the process to develop and publish “Providing Quality Family Planning Services: Recommendations from CDC and the US Office of Population Affairs,” and these standards have been adopted by Title X participants and other providers.⁷ The document provides guidance to primary care providers to help patients achieve pregnancy as well as obtain basic infertility services, preconception health services, contraceptive services, pregnancy testing and counseling, and sexually transmitted infections services.

OPA also funds the Reproductive Health National Training Center⁸ and the National Clinical Training⁹ Center for Family Planning, which provide trainings to Title X grantees and clinicians on a range of topics, such as supporting LGBTQI+ (lesbian, gay, bisexual, transgender/-sexual, queer or questioning, and intersex) clients with gender-affirming language and incorporating health equity into family-planning visits. Title X is also unique among other health care delivery programs in that the Title X program issues research grants and contracts related to family planning to ensure continued learning and improvements in the delivery of family-planning and other related preventive health services.

SETTING STANDARDS FOR HEALTH EQUITY

Building on the program’s long history, Title X clinics can position themselves to serve as an example of how health centers and providers can provide equitable, culturally sensitive care. The Biden–Harris administration has made separate commitments that guide OPA and, subsequently, the Title X program, including the following two. First, in October 2021, the White House released the first ever National Strategy on Gender Equity and Equality as a part of “efforts to ensure that all people are treated fairly and equitably and have the opportunity to reach their full potential.”^10(p8) Second, within the first month that President Biden assumed office, the White House issued the executive order Advancing Racial Equity and Support for Underserved Communities Through the Federal Government, which tasked agencies across the federal government with reviewing systems, data, funding, and policies to consider the impact on health disparities.¹¹ Consequently, OPA has enacted new policies and standards to ensure that the program is best serving the clients who seek care at Title X health clinics. Title X’s program priorities for the next five years include (1) advancing health equity through the delivery of Title X services, (2) improving and expand access to Title X services, and (3) delivering Title X services of the highest quality.

Title X clinics already disproportionately serve medically underserved and underrepresented communities. In 2020, 86% of the clients served identified as female,¹ meaning Title X clinics’ provision of contraceptives plays a significant role in helping women prevent and plan pregnancies, which has proven to affect women’s ability to seek and maintain educational and career advancements. Even so, Title X is serving an increasing number of young men. The Title X program also disproportionately serves people of color. In particular, in 2020, 26% of clients identified as Black or African American, and 35% identified as Hispanic or Latino ethnicity.¹

More than 40% of immigrant women who accessed contraceptives did so at a safety net family provider such as a Title X clinic.¹² In addition, because Title X grantees provide confidential services and because eligibility for no-cost or subsidized services is based on an unemancipated minor’s income rather than family income, adolescents frequently seek a range of health care from Title X programs. Some LGBTQI+ organizations have also noted that Title X serves as an important resource to ensure that LGBTQI+ people, particularly youths, can obtain unbiased and, as needed, gender-affirming care.¹³ However, there is more that can be done to purposely center these communities’ unique health needs and preferences and provide culturally and linguistically appropriate care to other historically underserved communities, such as people with disabilities.

The Title X program is currently rebuilding the network’s capacity with a focus that places health equity at the center. A regulation governing the program that was finalized in 2019 led to 19 grantees withdrawing their participation, whereas 18 additional grantees continued use but reported losses of clients, subrecipients, or sites.¹ There were no Title X–funded services in Hawaii, Maine, Oregon, Utah, Vermont, or Washington, and there were substantially reduced services in Alaska, Connecticut, Illinois, Massachusetts, Minnesota, New Hampshire, and New York. It follows that this reduced participation led to reduced access to reproductive and preventive health care services, including contraceptives. COVID-19 further impaired Title X clinics’ ability to provide services—an impact that is still being evaluated. The 2019 rule and the COVID-19 pandemic together accounted for 1.6 million fewer family-planning users between 2019 and 2020 and nearly 3.0 million fewer clients from 2018 to 2020.

In late 2021, OPA finalized a rule rescinding the 2019 rule and restoring the program’s focus on providing evidence-based reproductive health care, including nondirective options counseling for people who are pregnant.¹⁴ Once the 2021 final rule is implemented and additional health centers are added to the program, it is estimated that Title X clinics will serve more than four million women using contraception annually. The rule includes new standards, including newly considering prospective grantees’ ability to achieve health equity, and defines such terms as “client-centered care,” “culturally and linguistically appropriate services,” “inclusivity,” and “health equity.”

OPA is also enhancing its data collection, reporting, and analysis in the Title X program, including collecting more disaggregated data to better understand clients served and resources needed.¹⁵ OPA will also continue to more broadly ensure that various tools, such as performance measures and surveys, are employed to assess whether and how client preferences in the provision of family-planning services—including but not limited to contraceptives—are being met.

The Title X program has historically been structured to provide necessary resources to states and localities, organizations, and health clinics in exchange for these entities agreeing to deliver care that is high quality and evidence based. This has led to the program being not only a resource but also an example for how to deliver equitable contraceptive care. Moving into the future, the program can play even more of a role in serving as a resource for and example of health equity more broadly. Because the program funds contraceptives provision and a wide range of preventive services, such an example would positively benefit a range of public health issues. Even more, efforts to more intentionally center health equity will improve health outcomes among the people that entrust Title X clinics with their health.