Publicly Funded Family Planning Under Unprecedented Attack

Never in its history has the nation’s family planning safety net been in such jeopardy as it is today. The policy agendas of the Trump administration, Congress, and many states are being shaped by leaders adamant in their ideological opposition to—and intent to dismantle—the funding streams and providers that have long constituted the US publicly funded family planning effort.

PUBLICLY FUNDED FAMILY PLANNING

For decades, government programs—primarily Medicaid and Title X—have worked together to expand access to contraceptive care for low-income and other underserved individuals. Guttmacher Institute research shows that in 2015, a total of 6.2 million women received publicly funded contraceptive services from some type of safety-net health center, which helped them to avoid 1.3 million unintended pregnancies.¹ These unintended pregnancies, in turn, would have resulted in 453 400 abortions. Without publicly funded family planning, rates of unintended pregnancy and abortion would have been 67% higher.

Publicly supported family planning also yields considerable dividends for taxpayers. According to Guttmacher’s most recent estimates, in 2010, these services resulted in federal and state government savings of $13.6 billion.²

Despite the importance of contraception in women’s lives and the demonstrated effectiveness of the US publicly funded family planning effort, the providers and programs comprising that effort are under sustained—and intensifying—political attack.

Medicaid provides insurance coverage to millions of low-income women, enabling them to affordably obtain needed health services. Title X provides grants to safety-net health centers, making it the national family planning effort’s cornerstone that sets the standard of care and helps providers deliver family planning services to the most vulnerable communities. And Planned Parenthood health centers are a particularly vital component of the nationwide network of safety-net family planning providers that those public programs support.

MEDICAID IN JEOPARDY

Safety-net health care providers of all types are facing broad threats as the Trump administration and many in Congress seek sweeping changes to Medicaid. Regardless of the exact form these changes might take, one thing is certain: conservative federal policymakers are intent on dramatically expanding states’ flexibility to restructure their Medicaid programs. This includes granting states greater authority in determining eligibility for coverage, deciding which services to cover, limiting enrollees’ provider options, and imposing paternalistic restrictions on enrollees’ behavior. Indeed, states are already asking for, and receiving, such authority from the administration.

These broad-based changes would diminish Medicaid coverage overall, with particular consequences for family planning. According to Guttmacher’s most recent analysis, Medicaid is the largest single health insurance program in the United States, covering 20% of women aged 15 to 44 years, including 48% of those living below the poverty line in 2015 (http://bit.ly/2fZueiS). Medicaid is also central to the US family planning effort, not only because it accounts for three quarters of all public dollars invested in family planning, but also because it ensures enrollees can access family planning without copays, free from coercion, and from the qualified provider of their choice.

STATE-LEVEL THREATS

On top of these threats posed by restructuring Medicaid, many safety-net family planning providers—particularly Planned Parenthood—are facing additional, pointed attacks from socially conservative policymakers in Washington, DC, and across the states, motivated by efforts to shut out and shut down providers associated with abortion (Table 1). For example, Missouri and Iowa recently ended joint federal–state Medicaid programs that expanded eligibility specifically for family planning services, opting instead for entirely state-funded efforts through which they could exclude Planned Parenthood and other family planning providers that also offer abortion, using other funds.

TABLE 1—

US State Restrictions on Funding for Family Planning Providers Adopted Since July 2015, as of July 1, 2017

State	Who Is Affected?	What Is Affected?	How Are States Imposing Restrictions?
Arizonaa	Private reproductive health–focused providers	Title X	Seeks control of federal funding source Blocks funding to affected providers by tiering eligibility for funding
Arkansas	Abortion providers and affiliates Entities providing abortion counseling or referral	All state funds, Title X, and other federal grants	Blocks funding
Kansas	Private reproductive health–focused providers	Title X	Blocks funding to affected providers by tiering eligibility for funding
Kentucky	Private reproductive health–focused providers	Title X and federal and state grants	Blocks funding
Michigan	Abortion providers and affiliates Entities providing abortion counseling or referral	State family planning funds	Blocks funding
North Carolina	Abortion providers	State family planning funds and some other funds	Blocks funding
South Carolina	Private reproductive health–focused providers	Title X and state family planning funds	Blocks funding
Wisconsin	Abortion providers and affiliates Entities providing abortion counseling or referral Abortion providers	Title X 340B federal drug discount program	Seeks control of federal funding source Blocks funding to affected providers by tiering eligibility for funding Forces affected providers to accept lower prescription drug reimbursement rates

^aState amended a pre-2015 provision.

Both of these states followed the lead of Texas, which, in 2011, became the first state to make such a move, deciding to forgo federal support of what had been its Medicaid family planning expansion program to exclude providers with ties to abortion, particularly Planned Parenthood. Texas’s own reporting shows that, following those changes, the reach and effectiveness of its program drastically declined.³ Even so, Texas is now asking the Trump administration to provide an infusion of federal Medicaid funding to support its diminished program—an effort with the potential to set dangerous new national Medicaid precedents.

Looking beyond Medicaid, since 2015, eight additional states have restricted certain family planning providers’ participation in other publicly funded programs.⁴

EXCLUDING PLANNED PARENTHOOD

At the federal level, attempts by Congress to repeal the Affordable Care Act and spending proposals for fiscal year 2018 from both the US House of Representatives and the Trump administration would bar Planned Parenthood from federally funded programs including Medicaid and Title X. Recent Guttmacher analyses show that doing so would place unrealistic expectations on other safety-net family planning centers and jeopardize women’s access to publicly funded contraceptive care.

For example, in justifying efforts to exclude Planned Parenthood, many in Congress argue that federally qualified health centers (FQHCs) could readily meet women’s needs. These claims ignore the fact that only 60% of all sites operated by FQHCs in the 50 states and the District of Columbia report serving at least 10 contraceptive clients each year (and are so are counted among the nationwide network of safety-net family planning centers).⁵ Moreover, experts have widely denounced this suggestion, arguing that it would overburden primary care providers, who are already stretched thin, and threaten the availability of basic care, particularly in vulnerable communities.⁶

Nationwide, Planned Parenthood health centers serve nearly one third of the 6.2 million women who obtain contraceptive care from some type of safety-net family planning provider.¹ To serve all those women, FQHC sites that provide contraceptive care would have to double their capacity to provide these services, taking on an additional 2 million contraceptive clients.⁵ This stretch would be even more pronounced in many states and counties. This is all grounded in the fact that the average FQHC site offering such care serves 320 contraceptive clients in a year, whereas the average Planned Parenthood health center serves 2950.¹

THREATS TO TITLE X

Socially conservative policymakers are also going after the heart of the nation’s family planning effort: the Title X program. Following what has become its standard practice, the US House recently proposed eliminating Title X altogether in the coming fiscal year.

Eliminating Title X would deal a devastating blow to safety-net family planning providers and the communities who rely on them. In 2015, the program helped approximately 3700 service sites in all 50 states and the District of Columbia to deliver contraceptive care to 3.8 million women, accounting for a little more than 60% of all women served by safety-net family planning centers.¹ Title X‒supported services alone helped women to avoid more than 822 000 unintended pregnancies (out of 1.3 million unintended pregnancies avoided by all safety-net family planning centers), thus preventing 278 000 abortions (out of 453 400 abortions avoided by safety-net family planning centers overall). Along with yielding important public health benefits, every public dollar invested in Title X saves $7; claims that eliminating the program would save taxpayers money are clearly short-sighted.²

If Title X funding survives but Planned Parenthood were excluded, Guttmacher’s analysis shows that the rest of the Title X network would be hard-pressed to maintain the program’s current reach. To serve all the female contraceptive clients currently served by Title X–supported Planned Parenthood health centers, the other remaining types of Title X sites—including those operated by health departments, hospitals, and FQHCs—would need to increase their caseloads by 70%, on average.⁷ Alternatively, if Title X funds were directed only to FQHC sites offering contraceptive care, those sites would have to more than double their contraceptive client caseloads by taking on an additional 3.1 million clients.⁶ Again, the particular impact of these scenarios varies by state, depending on the composition of the local Title X network.

DEFENDING CRITICAL PROGRAMS, PROVIDERS

Federal and state policymakers must work together to blunt ideological attacks that threaten to dismantle programs and providers that have for years yielded important public health benefits to women, their families, and society as a whole. This means stopping efforts to reduce access to high-quality family planning services for Medicaid enrollees, turning back efforts to slash Title X funding, and standing firm against attempts to undermine women’s access to Planned Parenthood health centers and other critical safety-net providers. Doing so would help ensure that US women have access to the basic health care they need—and deserve.