Approaching 4 Decades of Legislation in the National Family Planning Program: An Analysis of Title X's History From 1970 to 2008

Abstract

Family planning is an important public health activity. Title X (Pub L No. 91-572), enacted in 1970, remains the only national family planning program in the United States dedicated to providing voluntary and confidential services to all individuals. We conducted a thematic analysis of Title X's legislative history.

Of 293 federal bills included in the legislative history, only 20 (6.8%) were enacted into law. Regardless of the proposed challenges, limited changes have been adopted. Except for technical amendments, bills involving restrictions accounted for the highest percentage of enacted bills, demonstrating efforts to undermine reproductive health rights.

Title X requires political will and bipartisan support if it is to continue to protect individuals' reproductive rights.

REPRODUCTIVE HEALTH IS recognized as a fundamental human right that “governments are legally and morally obligated to protect, respect and fulfill.”¹ The right to reproductive health, including access to family planning, is recognized in many treaties and laws both domestically and abroad.² Title X (Pub L No. 91-572), the national family planning program in the United States, was enacted in 1970 by President Richard Nixon with the purpose of

making comprehensive voluntary family planning services readily available to all persons desiring such services.^3a

Affirming reproductive health as a human right, President Nixon in 1969 articulated that

[n]o American woman should be denied access to family planning assistance because of her economic condition.^3b

Healthy People 2010, a national blueprint for improving health over the next decade,⁴ also identified several priority issues that have a direct impact on reproductive health: access to high-quality health services; cancer; educational and community-based programs; family planning; health communication; HIV; immunization and infectious disease; injury and violence prevention; maternal, infant, and child health; nutrition and overweight; sexually transmitted diseases; and substance abuse.

Other global policies and initiatives include the International Conference on Population and Development, held in Cairo, Egypt in 1994, which recognized the importance of empowering, educating, and providing family planning services to women and men and advocated for universal family planning by 2015.⁵ The Convention on the Elimination of All Forms of Discrimination against Women, enacted as an international treaty in 1981 by the United Nations, also affirms human rights and the abolishment of discrimination against women and promotes equal access to family planning services and pregnancy-related care. Although the United States was instrumental in the development of that treaty, it remains the only industrialized nation that has not ratified it.^5,6

OVERVIEW OF TITLE X

Title X evolved out of the War on Poverty era (originating in 1964),⁷ when attention was focused on economic development and averting welfare dependency.⁸ There was acknowledgment in the late 1960s of the effects of unintended childbearing on poverty levels, educational attainment, workforce participation, and the need for public assistance.⁹ In addition, Title X was developed to address escalating adverse maternal and child health outcomes, including rising rates of unintended pregnancies, teenage pregnancies, and closely spaced pregnancies, all leading to poor health among both mothers and babies.^8,10 For instance, low-income women were more than twice as likely as higher income women to experience an unintended pregnancy.⁸ Such significant public health and economic implications, largely resulting from a lack of access to care and family planning services among those most in need, fueled the bipartisan support for this policy.^8,10

Title X is administered by the US Department of Health and Human Services and is overseen by 10 regional offices across the country that review and award grants to a variety of grantees, including health departments, university and community centers, Planned Parenthood clinics, and other public and nonprofit agencies.¹¹ Any public or nonprofit entity (located in a designated state) that offers a broad range of acceptable family planning methods and services is eligible to apply.¹² Grants are awarded through a competitive process, and applicants must submit the requested information and abide by project guidelines.¹² In 2008, there were 4522 Title X clinics serving more than 5 million individuals.¹³

Services are delivered on a sliding fee scale. In addition to providing low-cost contraceptive services and supplies, Title X clinics also offer a range of comprehensive and preventive services (see box on this page).^11,12 In particular, among female family planning users in 2008, 44% received cervical cancer screening (Papanicolau tests), 46% received breast cancer screening (clinical breast examinations), and 49% received chlamydia testing; 57% of male family planning users received chlamydia testing. Among every 10 family planning users, on average 4.7, 1.4, and 1.6 gonorrhea, syphilis, and HIV tests were provided, respectively.¹³ Clinical family planning services represent 90% of Title X's overall appropriation.¹⁴ It is important to note that use of Title X funds for abortion services is prohibited.

Examples of Services Provided by Title X Clinics

Community education

Contraceptive services

HIV prevention education, counseling, testing, and referral

Infertility services (basic services along with specialized services if they are available from a trained clinician)

Outreach activities

Patient education and counseling

Physical assessments for women, including blood pressure measurements, breast and pelvic examinations, Papanicolau tests, colorectal screening (among women older than 40 years), and screening for HIV and other STIs as indicated

Physical assessments for men, including blood pressure measurements, colorectal screening (among men older than 40 years), screening for HIV and other STIs as indicated

Pregnancy testing and counseling

Referrals to other medical and social services

STI testing, counseling, and education

Training for provider and clinic personnel

Note. STI = sexually transmitted infection. Title X (Pub L No. 91-572).

Source. Data were derived from the Office of Population Affairs.¹²

Key functions of Title X include improving quality of services, ensuring evidence-based practices, and meeting the needs of individuals through provider and staff training, data collection and research, and community-based information, education, and outreach activities.¹⁴ For many individuals, Title X is their avenue of entry into the health care system.¹⁵

Title X is just one of the many multistatutory programs that provide funding for family planning services. In 2006, a total of $1.85 billion was spent on public expenditures for family planning services (Table 1).¹⁶ Since its inception, the appropriation provided for Title X programs has significantly decreased. For instance, Title X provided 1 of every 2 dollars devoted to publicly funded family planning in 1980, an amount that decreased to approximately 1 of every 10 dollars in 2006.^16–18 Although today Medicaid is the largest source of funding, many women do not qualify or cannot access Medicaid services owing to strict eligibility requirements and low provider reimbursement rates.¹⁶ Thus, Title X plays a critical role in the public health system by serving as a safety net and providing essential care to those in need.¹⁶

TABLE 1.

Public Expenditures for Family Planning Services: United States, 2006

Source of Funding	Public Expenditure, $	Total Public Expenditures,a %
Medicaid	1 304 006 000	70.6
State appropriations	241 149 000	13.1
Title X (Pub L No. 91-572)	215 297 000	11.7
Social Services Block Grant/Temporary Assistance for Needy Families	47 652 000	2.6
Maternal and Child Health Block Grant	38 188 000	2.1
Other federal sources	670 000	0.0
Total	1 846 292 000

Source. Data were derived from Sonfield et al.¹⁶

^aThe total percentage exceeds 100% as a result of rounding.

ACHIEVEMENTS AND CHALLENGES

Publicly funded family planning clinics, including Title X clinics, are responsible for many public health achievements. In 2004 alone, the use of publicly funded family planning services was associated with averting approximately 1.4 million unintended pregnancies (including 290 000 unintended pregnancies among teenagers), thus preventing 600 000 abortions and 640 000 unintended births.¹⁹ Title X also assists in reducing infertility, decreasing cervical cancer rates, and identifying, treating, and preventing sexually transmitted infections (STIs).²⁰ For every $1 spent on family planning services, $4.02 is saved in Medicaid-related pregnancy and birth costs.¹⁹

Because the “Title X program provides only a proportion of the funds for Title X clinics,”^20(p8) the independent impact of Title X services on direct reproductive health outcomes is difficult to isolate from the impact of publicly funded family planning services as a whole.²⁰ However, Title X can support clinic infrastructures, provide community outreach and education, serve the most vulnerable and underserved populations, and provide other types of support that cannot be offered by other publicly funded programs.^16,20

Moreover, Title X has revolutionized family planning services by setting the national standards of care.¹⁶ To this day, Title X remains the only federal policy devoted solely to providing comprehensive, confidential, and voluntary family planning services to all, regardless of their age or ability to pay. Because of its confidentiality and sensitivity to clients' needs, individuals from all age and socioeconomic groups may prefer to seek services at Title X clinics even if they have private health insurance out of fear of the potential consequences if information is disclosed to their parents or health insurance companies.

Title X improves the health of mothers and babies (e.g., through planning pregnancies and facilitating proper birth spacing²¹) because it allows women access to and education and counseling on a range of contraceptive methods, thus providing them autonomy in choosing when, whether, and how many children to bear. As noted by Frost et al., with such reproductive freedom women can explore educational and career opportunities and attain personal goals,¹⁹ and they are better positioned to achieve economic independence.

Regardless of Title X's public health achievements and the important role it plays in women's lives, it has endured significant opposition over the years, constantly facing political, economic, social, and ideological controversies and challenges.²⁰ Title X's goals began to lose momentum during the Reagan administration, when it was not reauthorized in 1985.²² From 1980 to 1999, Title X appropriations decreased 60% after adjustment for inflation.⁹ Since then, Title X funding has never maintained pace with inflation, the growing population (in respect to both diversity and the sheer number of those who are uninsured and in need), the demands for more comprehensive health care counseling and services, complicated health care financing, and the rising costs of medical, technological, and other related services.^9,15,20,23

Funds are also required to support additional infrastructure needs such as operating expenses (utility bills, medical equipment, supplies and services), availability and accessibility of clinics (locations of clinics, scheduling and hours of operation), and health information technology (electronic medical records).²⁴ Moreover, opponents of family planning clinics contend that family planning services disrupt family values, fuel promiscuity, and contribute to nonmarital sex, unintended pregnancies, and abortions.⁹

Title X has encountered numerous attacks, most arguably resulting from its association with sexuality, reproduction, and marginalized populations, including women, the young, and the poor. Proposals made by opponents of the policy have included, but are not limited to, the following:

• Federal regulations initiated in 1987 prohibiting clinics receiving Title X funding from disseminating abortion information or referrals (i.e., the “gag rule”). This legislation, although further supported by the Supreme Court as being constitutional in 1991, was later banned in 1993 by President Clinton.⁹

• An attempt by the Reagan administration in 1982 to require minors to obtain written parental consent before receiving services (i.e., the “squeal rule”).⁹ This legislation was later reintroduced as the Parental Notification Act of 1998.²⁵

• Legislation enacted in 1998 emphasizing abstinence-only education and ignoring the teaching of medically accurate and age-appropriate sexual information stressing health promotion and disease prevention.²⁶

• Legislative proposals to repeal sections of Title X or the policy in its entirety.^8,27

Policy development is one of the 3 core functions of public health.²⁸ However, the development of reproductive health policies is often controversial because they involve cultural taboos (sexuality and populations consisting of women, children, and the poor).²⁹ A disconnect exists between sexuality beliefs and behaviors among Americans that greatly affects fertility control politics as well as the broad range of adverse reproductive outcomes.³⁰ For instance, many Americans believe that sexual activity should occur only between an adult married couple, yet 46% of young people report that they have had sexual intercourse.³¹

The United States continually ranks highest among all industrialized countries in rates of unintended pregnancies and STIs.³² It has been well documented that unintended pregnancies and STIs carry significant public health consequences for the mother, baby, and society.³³ For instance, women with unintended pregnancies are less likely than those with intended pregnancies to receive preconception care and more likely to have poor birth outcomes (e.g., low birthweight and infant mortality).³³ Other public health issues connected with poor reproductive and sexual health, particularly among low-income and other vulnerable populations, include but are not limited to gender-based violence, maternal death and disability, substance abuse, mental health issues, infertility, and cervical cancer.³⁴ Access to reproductive health services is critical in decreasing a broad range of adverse health outcomes and upholding individuals' rights to reproductive health and well-being.

OBJECTIVES

Title X is approaching its fourth decade, and much of the related literature has focused on the policy's outputs (e.g., demographic breakdowns of family planning clients, number and types of contraceptives dispensed),¹³ achievements, and the barriers it has faced. Some of the literature has focused on the types of future research needed to improve clinical practice and delivery,³⁵ including a recent Institute of Medicine report²⁰ that reviewed Title X's goals and objectives and made recommendations for program administration and management. However, we were unable to locate an existing comprehensive legislative history of Title X after a review of the literature and communications with national reproductive health policy experts.

Therefore, the purpose of this study was to document and examine legislation that reflects the political will that has embodied Title X. Our specific aims were to (1) construct a comprehensive legislative history, including all federal bills that proposed changes to Title X; (2) determine the number of bills that were enacted into law; (3) examine the themes that emerged from the legislative history; and (4) underscore changes that Title X incurred as reflected in the language of its public law.

Without a firm understanding of the policy's history and evolution, public health practitioners and policymakers cannot make informed future policy decisions that will have a profound impact on public health and the lives of women, families, and the greater community. We hope that this analysis of Title X legislation will stimulate policymakers, service providers, consumers, and advocates to engage in informed efforts that advance public health on behalf of the underserved and uninsured.

METHODS

We compiled a comprehensive legislative history to examine the evolution of Title X since its enactment. Researchers often examine a policy's legislative history, “a chronology of events and the documents generated in the legislative process,”³⁶ when analyzing the content and maturation of the policy.³⁷ To this end, we compiled a legislative history consisting of federal House of Representatives and Senate bills that proposed amendments to Title X between the 91st Congress (beginning December 24, 1969, after the bill was passed) and the 110th Congress (through August 31, 2008, the end of the data collection period for this study). Because bills proposed before 1989 (101st Congress) were not available electronically, we consulted both online and print databases. As noted by Wilhelm,

by combining traditional paper sources with electronic ones, a researcher can delve into Congress' business and explore the decisions that have brought this government into its third century.^38(p498)

We used the Congressional Record print database to search for bills proposed between 1969 and 1988 (91st–100th Congresses). To maximize the identification of all applicable bills, a government document specialist and the primary researcher (C. A. V.) developed the following set of search terms according to how bills were indexed in the Congressional Record and the topical areas of Title X: abortion, birth control, contraception, contraceptive, family planning, health, population, public health, and Public Health Service Act. The Congressional Record was consulted for each of these search terms, and all applicable Title X bills were documented. A thorough examination was also conducted after the full text of the bill was retrieved via microfiche from a federal library depository³⁹ to ensure that each bill indeed proposed an amendment to Title X law.

We used LexisNexis Congressional,⁴⁰ an online database, to search for bills proposed during 1989 through 2008 (101st–110th Congresses). Because this database can search electronically for key terms, we were able to use the following precise search terms: Title X and family planning, Title X, and family planning. This combination of search terms ensured that relevant bills were not inadvertently excluded if their text referenced the policy only by its proper title (Title X) or its general program name (family planning program).

We conducted a thematic analysis of the full texts of the proposed bills included in Title X's legislative history. The analysis included 5 in-depth and interrelated steps: reading, coding, displaying, reducing, and interpreting.⁴¹ The first author (C. A. V.) read the full text of each bill multiple times and attached codes to the themes that emerged. Sections of the bill text were displayed by thematic area and were reduced to essential points. Interpretation was iterative and continued throughout the analysis to indicate how themes related and diverged, providing further context to the proposed legislation.⁴¹

An independent researcher separately reviewed and coded 20% of the bills to establish coding reliability. Any discrepancies in coding were discussed, and the boundaries for each code were established to ensure that codes were mutually exclusive. Establishing reliability of coding ensured that the analysis was performed systematically and minimized any researcher bias.

RESULTS

A total of 293 federal bills were documented and included in the Title X legislative history compiled for this study. This legislative history included all federal bills that proposed changes to Title X law regardless of whether the bills were enacted into law. The following 7 broad themes emerged from the legislative history: administration, appropriation, requirements, restrictions, related legislation, related policies, and technical amendments. Only 20 of the 293 bills (6.8%) included in the legislative history were enacted into law (Table 2). Common bills enacted into law included amendments to Title X program administration and operations, appropriations, and program requirements and restrictions, as well as minor technical changes (e.g., renumbering sections of the law).

TABLE 2.

Summary of Amendment Topics and Bills Enacted Into Title X's Law

Amendment Topic and Bill(s)	Thematic Area
Establishment of appropriations (Pub L No. 92-449, Pub L No. 93-45, Pub L No. 94-63, Pub L No. 95-83, Pub L No. 95-613, Pub L No. 97-35, Pub L No. 98-512, Pub L No. 102-170, Pub L No. 104-134, Pub L No. 105-78, Pub L No. 106-113, Pub L No. 106-554, Pub L No. 107-116, Pub L No. 108-199, Pub L No. 109-149)	Appropriations
Establishment of reporting requirements (Pub L No. 94-63)	Administration
Assurance that economic status is not a deterrent for individuals to participate in the program (Pub L No. 94-63)	Administration
Provision of training regarding the offering of adoption information and referrals (Pub L No. 106-310)	Requirements
Stipulation that, under any provision of the act, no funds appropriated may be used to conduct or support research (except for research subsection) (Pub L No. 94-63)	Restrictions
Provision of a broad range of acceptable and effective methods, including natural family planning methods (Pub L No. 94-63)	Requirements
Assurance of right of local and regional entities to apply for grants/contracts (Pub L No. 94-63)	Administration
Stipulation that clinics should offer and encourage early intervention services related to HIV/AIDS (Pub L No. 101-381)	Requirements
Title X entities granted the ability to apply for AIDS grants (Pub L No. 101-381)	Administration
Title X covered as an entity in which drugs can be purchased under state plans for medical assistance (Title XIX of the Social Security Act) (Pub L No. 102-585)	Related legislation
Provision of infertility services and adolescent services (Pub L No. 95-613)	Requirements
Encouragement of family participation (Pub L No. 105-78, Pub L No. 106-113, Pub L No. 106-554, Pub L No. 107-116, Pub L No. 108-199, Pub L No. 109-149)	Requirements
Stipulation that funds must not be expended for abortions (Pub L No. 104-134, Pub L No. 105-78, Pub L No. 106-113, Pub L No. 106-554, Pub L No. 107-116, Pub L No. 108-199, Pub L No. 109-149)	Restrictions
Provision of nondirective pregnancy counseling (Pub L No. 104-134, Pub L No. 105-78, Pub L No. 106-113, Pub L No. 106-554, Pub L No. 107-116, Pub L No. 108-199, Pub L No. 109-149)	Requirements
Provision of counseling to minors with respect to resisting sexual coercion (Pub L No. 105-78, Pub L No. 106-113, Pub L No. 106-554, Pub L No. 107-116, Pub L No. 108-199, Pub L No. 109-149)	Requirements
Title X clinics not exempted from notifying/reporting child abuse, child molestations, sexual abuse, rape, or incest according to state laws (Pub L No. 106-113, Pub L No. 106-554, Pub L No. 107-116, Pub L No. 108-199, Pub L No. 109-149)	Requirements
Funds for abortions prohibited (except where the life of the mother would be endangered if the pregnancy was carried to term) (Pub L No. 102-170)	Restrictions
Funds for promoting/opposing any legislative proposal or candidate for public office prohibited (Pub L No. 104-134, Pub L No. 105-78, Pub L No. 106-113, Pub L No. 106-554, Pub L No. 107-116, Pub L No. 108-199, Pub L No. 109-149)	Restrictions
Minor technical amendments (renumbering sections, grammatical and punctuation changes) (Pub L No. 97-414, Pub L No. 98-555)	Technical amendments
Stipulation that information and education distributed must be culturally appropriate and must be reviewed and approved by a community advisory committee (Pub L No. 95-613)	Requirements

Note. Title X (Pub L No. 91-572). Each law could appear in more than one topic and thematic area.

Table 3 describes the themes and the numbers and percentages of bills enacted. Because some bills involved more than one amendment to Title X law, bills could be classified into more than one thematic category. The majority of the proposed bills did not successfully progress through the legislative process and were not enacted into law. Excluding the technical amendments category, which included only minor syntax and technical changes such as grammatical changes and renumbering of sections, the restrictions category accounted for the highest percentage of bills enacted (20%).

TABLE 3.

Description of Thematic Areas and Percentages of Bills Enacted Into Law

Thematic Area	Bills Proposed per Thematic Area,a No.	Bills Enacted per Thematic Area, No. (%)b	Enacted Bills per Thematic Area by Total No. of Enacted Bills (n = 20),c %
Administration: bills affecting the administration of the program, such as attempts to extend or repeal the program, administrative and grant requirements, coordination with state activities, administration of grants to special populations, administration of grants related to particular program sections, and data and reporting	85	4 (4.7)	20
Appropriations: bills with appropriation amendments originating either from Title X bills or from bills whose focus was not on Title X but was on another related policy that included a line item concerning Title X	138	15 (10.9)	75
Requirements: bills proposing services/provisions that a Title X–funded entity must provide, such as specific family planning services, information, education, and other related activities	141	12 (8.5)	60
Restrictions: bills proposing services/provisions that a Title X–funded entity is prohibit from offering, such as specific family planning services, information, education, and other related services	50	10 (20.0)	50
Related legislation: bills that focused on other policies (not Title X–specific bills) but included language with integrated text affecting Title X (e.g., Adolescent Pregnancy Grant, Women's and AIDS Outreach and Prevention Act)	39	2 (5.1)	10
Related policies: bills that proposed establishing global and national institutes, administrations, and centers and bills that proposed respecting family planning principles, establishing a US family planning and population policy, and upholding the right to privacy	51	0	0
Technical amendments: bills proposing syntax changes (e.g., grammatical changes) and other technical changes (e.g., retitling and renumbering of sections)	10	4 (40.0)	20

Note. Title X (Pub L No. 91-572).

^aFrequency of bills per thematic area is greater than the 297 bills included in Title X's legislative history because more than one theme may have emerged per bill.

^bStatistics were calculated by dividing the number of bills enacted (numerator) by the number of bills proposed (denominator) per thematic area.

^cStatistics were calculated by dividing the number of enacted bills per thematic area by the total number of enacted bills.

The final column of Table 3 offers a different perspective, demonstrating the percentage of bills per thematic area among the final enacted 20 bills. When considering only the 20 bills enacted, the appropriations category (75%) accounted for the most bills enacted, followed by the requirements category (60%). This distinction (comparing the number of bills enacted by thematic area according to whether the denominator was the number of bills proposed or the number of bills enacted) highlights the immense political “noise” (the voluminous number of bills proposed) that has surrounded this policy.

In some of the enacted bills (Pub L No. 106-554, Pub L No. 108-199, Pub L No. 109-149), restrictions were placed on abortions, and requirements included promotion of family participation, pregnancy counseling, and counseling of minors who had been sexually coerced; such stipulations could be considered as restricting reproductive rights and specifically advancing a pro-life agenda. This analysis suggests a subtle yet potentially effective way in which amendments can be used to further oppose individuals' complete reproductive autonomy.

Interestingly, none of the bills classified in the related policies category were enacted into law. These bills proposed global and national reproductive health institutes, administrations, and centers, along with broader policies and values related to family planning that endorsed, supported, and recognized the importance of family planning or Title X (or both) to the overall health and well-being of Americans.

Further analysis of the 7 broad themes revealed numerous subthemes with political, economic, practical, and value-laden implications. These subthemes, which both implicitly and explicitly affect the purpose, function, utility, and substance of the Title X program, included but were not limited to the following: empowering women and providing them with a choice regarding their fertility, funding, technical guidance (requirements and restrictions) regarding Title X grants, providing family planning services to all individuals (and reiterating such inclusiveness by highlighting specific at-risk and traditionally underserved populations even though the initial law stressed that services must be delivered to all), providing a range of family planning methods, and improving public health.

Furthermore, the effects of the various presidential administrations and surrounding politics on this policy and the continual incorporation of traditional controversial issues focusing on abortion and adolescents in the proposed amendments demonstrate how the legislation affects family planning practice and enforces limits on the care that providers can and cannot provide to their clients.

Although all of the themes we identified in our legislative history emerged in the bills proposed throughout the various presidential administrations covered by our study period (probably as a result of the large number of bills continually proposed), characteristic proposals were found in each administration, such as the following:

• Extending Title X for future years and establishing global and national institutes (Nixon administration, 92nd–93rd Congress, January 20, 1969–August 9, 1974).

• Stipulating that a broad array of family planning methods be offered and ensuring that economic status is not a deterrent to participation. Also, bills regarding abortion began to emerge (Ford administration, 94th Congress, August 9, 1974–January 20, 1977).

• Implementing demonstration projects for infertility services, providing specific guidelines regarding the content of pregnancy information delivered, and stipulating that information and education be developed and disseminated through the community (Carter administration, 95th–96th Congress, January 20, 1977–January 20, 1981).

• Stipulating that programs providing abortion referrals and services are not eligible for a Title X grant even if they provide these services with other funds (non–Title X funds) and that personnel cannot be terminated if they do not advise or provide specific methods of contraception. Proposals for repeals of Title X also appeared (Reagan administration, 97th–100th Congress, January 20, 1981–January 20, 1989).

• Providing HIV counseling and testing, applying Title X restrictions to global family planning funding, and adhering to state parental notification laws (George H. W. Bush administration, 101st Congress, January 20, 1989–January 20, 1993).

• Encouraging family participation among minors, stipulating that directing clinic staff be sensitive to a community's culture, and prohibiting funds supporting or opposing legislative proposals or candidates (Clinton administration, 103rd–106th Congress, January 20, 1993–January 20, 2001).

• Reiterating that funds are prohibited from being used for abortion services and requiring counseling for minors on how to resist sexual activities, including sexual coercion (the combination of this language was found to be continually proposed in appropriation bills during this administration) (George W. Bush administration, 106th–110th Congress, January 20, 2001–January 20, 2009).

An additional view of the enacted laws appears in Table 4, which shows that although some of the enacted laws listed in Table 2 addressed single issues such as providing training regarding the provision of adoption information and referrals, other enacted laws covered a myriad of topics, ranging from restricting funds for abortion services to prohibiting funds from being used to promote or oppose any legislative proposal or candidate for public office. It is not known whether these multitopic enactments were the result of the involvement of multiple legislators as authors of the bills or the result of political strategies to pass legislation. However, the characteristics of these more complex bills are of some interest because they may provide an example of the political tactics that legislators use to either highlight or overshadow a proposed amendment and thus manipulate the level of attention on that proposed bill.

TABLE 4.

Common Themes Among Selected Bills Enacted

Amendment	Year	Theme	Features
Pub L No. 94-63	1975	Appropriations	Established appropriations
		Administration	Established reporting requirements
		Administration	Economic status not a deterrent for individuals to participate
		Administration	Ensured right of local and regional entities to apply for grants/contracts
		Restrictions	Use of funds to conduct or support research prohibited
		Requirements	Broad range of acceptable and effective methods, including natural family planning methods
Pub L No. 95-613	1978	Appropriations	Established appropriations
		Requirements	Provided infertility services and adolescent services
		Requirements	Stipulated that information and education distributed must be culturally appropriate and must be reviewed and approved by a community advisory committee
Pub L No. 101-381	1990	Requirements	Stipulated that clinics should offer and encourage early intervention services related to HIV/AIDS
		Administration	Granted Title X entities the ability to apply for AIDS grants
Pub L No. 106-113	1999	Appropriations	Established appropriations
		Requirements	Encouraged family participation
		Restrictions	Stipulated that funds must not be expended for abortions
		Requirements	Provided nondirective pregnancy counseling
		Requirements	Provided counseling to minors on resisting sexual coercion
		Requirements	Stipulated that Title X clinics are not exempted from notifying/reporting child abuse, child molestations, sexual abuse, rape, or incest according to state laws
		Restrictions	Prohibited funds for promoting/opposing any legislative proposal or candidate for public office
Pub L No. 106-554	2000	Appropriations	Established appropriations
		Requirements	Encouraged family participation
		Restrictions	Stipulated that funds must not be expended for abortions
		Requirements	Provided nondirective pregnancy counseling
		Requirements	Provided counseling to minors on resisting sexual coercion
		Requirements	Stipulated that Title X clinics are not exempted from notifying/reporting child abuse, child molestations, sexual abuse, rape, or incest according to state laws
		Restrictions	Prohibited funds for promoting/opposing any legislative proposal or candidate for public office
Pub L No. 108-199	2003	Appropriations	Established appropriations
		Requirements	Encouraged family participation
		Restrictions	Stipulated that funds must not be expended for abortions
		Requirements	Provided nondirective pregnancy counseling
		Requirements	Provided counseling to minors on resisting sexual coercion
		Requirements	Stipulated that Title X clinics are not exempted from notifying/reporting child abuse, child molestations, sexual abuse, rape, or incest according to state laws
		Restrictions	Prohibited funds for promoting/opposing any legislative proposal or candidate for public office
Pub L No. 109-149	2005	Appropriations	Established appropriations
		Requirements	Encouraged family participation
		Restrictions	Stipulated that funds must not be expended for abortions
		Requirements	Provided nondirective pregnancy counseling
		Requirements	Provided counseling to minors on resisting sexual coercion
		Requirements	Stipulated that Title X clinics are not exempted from notifying/reporting child abuse, child molestations, sexual abuse, rape, or incest according to state laws
		Restrictions	Prohibited funds for promoting/opposing any legislative proposal or candidate for public office

Note. Title X (Pub L No. 91-572).

DISCUSSION

Title X provides essential family planning and preventive health services, research, training, and dissemination activities throughout the nation. The ability of this program to reach all individuals regardless of age or economic status and deliver culturally appropriate services throughout diverse communities has allowed it to serve as an important safety net provider.¹⁵ Title X has now spanned nearly 4 decades and has accumulated much political support and opposition, but only limited content and structural changes have been made to the policy as reflected in the language of its law. Although the policy has remained intact, it has not received the political and financial support²⁰ needed to fully carry out its goal of providing family planning services to all individuals in need.²⁷

The continued erosion of Title X funding has most certainly limited family planning programs' ability to prevent unintended pregnancies, STIs, and breast and cervical cancer. Data are not available to fully assess the total economic consequence of these decreasing funds; that is, there is no way to actually identify individuals who may have been served by Title X funding but subsequently acquired an STI or became pregnant unintentionally. We can achieve some measure of the impact through extrapolating the economic cost of these health outcomes, but there is no way to assess the overall impact of decreasing funds in other, equally critical ways, such as quality of life issues.

To our knowledge, this is the first study to develop a systematic legislative history on Title X—a policy that has endured 6 presidential administrations and embodies significant public health achievements—and include all proposed amendments regardless of whether they were enacted into law. In addition to developing a legislative history, we conducted an extensive thematic analysis of almost 300 bills and calculated the percentages of bills, by theme and topic area, that were passed into law. The 7 broad themes and associated subthemes that emerged highlight the factors that restrict providers' ability to translate Title X into practice. These factors also further confirm the uncertainty of the policy and its future role in providing the necessary family planning services and related preventive health care to those in most need.

Except for technical amendments (as mentioned), the restrictions category encompassed the highest percentage of enacted bills of the 293 proposed bills assessed, and when the analysis was limited to the bills enacted, the requirements category accounted for the second highest percentage of enacted bills (following appropriations). These findings suggest that reproductive rights in the United States have been debilitated through mechanisms associated with Title X restrictions and requirements, and policymakers and practitioners who support reproductive rights must be cognizant of such attacks and realize the subtle ways in which amendments can further limit individuals' reproductive choices.

Major legislative debates surrounding Title X have persisted throughout the past 40 years. For instance, debates concerning abortion, teenage pregnancy, school-based health clinics, and parental notification and consent were cited in a Congressional Research Service issue brief in 1988,²² and these topics remain controversial today.²⁷ Since its enactment, Title X has mandated that family planning services be delivered voluntarily and confidentially to all individuals regardless of their age or ability to pay, and the program's funds have been prohibited from being used for abortion services. Irrespective of these mandates, issues related to the adolescent population and abortion permeate family planning policy discussions. Opposition voices continually threaten women's health and impede individuals' right to reproductive freedom by limiting access to safe and effective family planning services.

Limitations

Although our secondary data collection procedure was exhaustive and comprehensive, a limitation of this study is that some legislative proposals may not have been captured during the compilation of our legislative history. Future research should continue to document legislation that proposes amendments to Title X, and as policy databases are enhanced, legislative history compilations should be replicated to ensure that all applicable bills are included. Also, we did not examine other policy documents, such as committee and hearing reports, testimonies, and legislative briefs, that could have provided a thorough and in-depth analysis of each proposed bill. Only the full text version of each bill was analyzed, which allowed an assessment of Title X's legislative history and its overall maturation as a policy.

In addition, our identification of themes and topics did not extend to a more detailed analysis demonstrating the cost and impact of each proposal. For example, the issue of funding (requested vs enacted) was not explored explicitly but remains a critically important aspect of this policy, given that levels of appropriation have not only failed to maintain pace with inflation but have decreased alarmingly. Future research is needed in which policy analyses are conducted for each enactment, including accountability and evaluative measures. Furthermore, future research should examine the proposals made by different presidential administrations in more depth, noting the political conversations taking place during those periods as well as the support of and challenges to Title X documented in these proposals.

Conclusions

Family planning is hailed as one of the top 10 public health achievements of the 20th century.⁴² Regardless, approximately 13 million (about 1 of 5) women of reproductive age (15–44 years) do not have health insurance,⁴³ and more than 17 million women are in need of publicly funded contraceptive services and supplies.⁴⁴ The 2009 Institute of Medicine report²⁰ mentioned earlier concluded that family planning has important health and well-being benefits for society, that it serves a critical social and public health function, and that the federal government has a responsibility to support the aims of Title X. Political support is greatly needed to make the government accountable for its responsibility to ensure that women have access to safe, effective, and affordable family planning services, not only to uphold their reproductive freedom but also to decrease the plethora of public health consequences that result when such services are not met.

Title X may benefit directly and indirectly from some of the provisions of the new health care reform policy, such as discounted prices from pharmaceutical manufacturers and funding for community- and school-based health centers.⁴⁵ In addition, the expansion of Medicaid to cover individuals below 133% of the poverty level, which may lessen the burden of individuals relying on Title X services, and the development of home visiting programs for mothers and their infants have the potential to strengthen the nation's capacity to deliver pertinent family planning counseling and services, especially in the case of at-risk women and families.⁴⁵ As the health care reform policy is implemented over the next year, public health advocates are hopeful that this policy will include measures for comprehensive reproductive health care.

It is important to note that the political climate is dynamic and is constantly evolving. However, in the current political climate in which the Republican party holds the majority in the House, there is great pressure to further downsize federal programs, and maintaining the momentum of health care reform will be a constant challenge.

With today's renewed attention on health care reform, politicians and public health advocates alike need to understand the evolution of Title X and the significant impact it has on the health and well-being of both women and families. The translation and application of policy to basic human rights, including reproductive health rights, is a key principle that must be kept in the forefront when discussing preventive health care. Family planning is an essential public health service and necessitates political will and bipartisan support. As noted in a recent commentary on reforming health systems to meet women's needs, the essential elements of successful programs (e.g., removing financial constraints to access, including women's participation) need to be supported both financially and politically if Title X is to truly achieve its purpose.⁴⁶

According to Gold et al.,

reinvigorating the national family planning program—in terms of financing, infrastructure and leadership—would be an important contribution to the broader health care reform effort.^15(p31)

Public health practitioners are charged with the responsibility of understanding, critically evaluating, and advocating for sound policy actions that benefit the greater population.