The Impact of Driving Time to Family Planning Facilities on Preventive Service Use in Ohio

Abstract

Introduction:

Publicly funded family planning clinics provide preventive health services to low-income populations in the U.S. In recent years, several states, including Ohio, have restricted public funds for organizations that provide or refer patients to abortion care, often resulting in clinic closures. This research evaluates the effects of such closures on preventive service use and access to care among female adults in Ohio.

Methods:

With data from the 2010 to 2015 Ohio Behavioral Risk Factor Surveillance System, trends in health service use were assessed for female respondents aged 18−45 years with household incomes <$50,000. Clinic locations were combined with restricted-access survey ZIP codes to compute respondents’ driving times to the nearest family planning clinic. The association between changes in driving time and the use of routine preventive and unmet care owing to cost were assessed with linear probability models. Analyses took place from March 2019 to February 2020.

Results:

Each additional 10 minutes of driving time was associated with an 8.9 percentage point increase in the likelihood of avoided care owing to cost (95% CI=1.7, 16.2), a 10.4 percentage point decrease in the likelihood of mammogram receipt during the past 12 months (95% CI= −22.3, 1.5), and a 12.5 percentage point decrease in the likelihood of ever receiving a clinical breast examination (95% CI= −18.7, −6.3). Driving time had insignificant associations with other utilization outcomes. Similar results were obtained when using driving distance.

Conclusions:

Reduced access to family planning clinics was associated with unmet care due to cost and a reduction in preventive service use among low-income, reproductive-aged females.

INTRODUCTION

Publicly funded family planning clinics provide free or subsided preventive health care to young, poor, and otherwise medically underserved populations.¹ In March 2019, the Trump administration implemented the domestic gag rule, effectively barring all affiliates of abortion providers from receiving federal Title X funds.² Because many clinics that provide or make referrals for abortion care are also safety net providers of routine preventive care, understanding the broader consequences of funding restrictions is increasingly important.

Previous research demonstrates that increased driving distance after funding cuts and subsequent clinic closures in Wisconsin and Texas led to reductions in breast examinations, mammograms, and Pap testing.^3,4 Ohio has since made several attempts to limit the distribution of federal and state funds to affiliates of abortion providers and, in 2013, successfully deprioritized public funds for private family planning facilities.⁵ Given the implementation of the domestic gag rule nationally, it is important to understand the consequences of funding restrictions across geographic locations. As such, this research expands on previous work to evaluate the effect of driving distance on the use of routine preventive services among female Ohio residents and on the cost-related barriers to care among female Ohio residents. Following previous literature on the role of distance in access to care, the assumption was that increased driving time and distance to the nearest family planning facility would reduce preventive health service use among reproductive-aged, low-income female adults.

METHODS

Estimates of driving distance and time from each ZIP code centroid to the nearest clinic were obtained from the same clinic database used in Lu and Slusky.³ These estimates covered a nationwide network of family planning clinics from 2010 to 2015, which allowed the authors to observe the distance/time traveled to the clinics in neighboring states. Driving distance/time was then linked to restricted data from the 2010 to 2015 Ohio Behavioral Risk Factor Surveillance System (BRFSS), which included home ZIP code for each respondent. The BRFSS is an annual, state-based telephone survey of health behaviors, conditions, and preventive health service use.⁶ The study sample included female respondents aged 18−45 years with household incomes ≤$50,000 because this group represents the majority of the family planning clinic users.⁷

Outcomes included the use of each of the following within the past year: annual checkup, influenza vaccination, mammogram, clinical breast examination, and Pap test. Whether the respondent reported ever receiving a mammogram, breast examination, or Pap test was assessed as a validity check. These were the most common health screenings for reproductive-aged female respondents during the study period.⁸ Finally, whether the respondent experienced unmet medical care owing to cost within the past year was assessed as a general measure of access. Clinical breast examination, Pap test, and mammogram outcomes were limited to those aged ≥20, ≥21, and ≥35 years, respectively, on the basis of screening guidelines during the study period.^9,10 Exact texts of all outcome measures and covariates are listed in Appendix Tables 1 and 2 (available online).

Hot deck imputation was used to replace missing answers to survey questions and reduce potential nonresponse bias.^11,12 Observations with missing outcome data were excluded in sensitivity analyses (Appendix Table 3, available online). ZIP code −level maps of the changes in driving times to the nearest family planning clinic during the study period were then created. Finally, linear probability models estimated the effect of driving distance on each outcome, adjusting for respondent age, insurance status, race/ethnicity, marital status, self-reported health, veteran status, education, and household income. Covariates also included whether the survey was conducted using cell phone or landline, whether the nearest family planning clinic was out of state, and both year- and ZIP code‒fixed effects. All models used BRFSS sampling weights, with robust SEs clustered by county.¹³

Data were analyzed from March 2019 to February 2020. This study was approved by the IRBs at the Ohio Department of Health and the Boston University Medical Campus. IRB approval by the Ohio Department of Health should not be considered an endorsement of this study or its conclusions.

RESULTS

The final sample included 4,722 low-income female respondents. Driving distance (time) from ZIP code centroids to the nearest family planning clinic ranged from <0.1 to 95.3 miles (from <1 minute to 116.2 minutes). From 2010 to 2015, the respondents’ mean driving distance increased from 20.3 to 22.2 miles (+1.9, 95% CI= −0.8, 4.6) and time increased from 28.1 to 31.0 minutes (+2.9, 95% CI= −0.1, 6.0). These patterns were highly localized and attributable to family planning clinic closures in Western, Northwestern, and Northeastern Ohio (Figure 1A and B). The largest increases were observed for the residents of Montpelier, Ohio: driving times increased from 37.7 to 66.2 minutes, and distances increased from 25.9 to 55.9 miles.

Figure 1.

Changes in driving (A) distance and (B) time to the nearest family planning clinic from 2010 to 2015 in Ohio.

Note: Maps show the distribution of changes in driving (A) distance and (B) time to the nearest family planning clinic from 2010 to 2015. Spatial units represent ZIP code tabulation areas.

In adjusted regressions, driving time was significantly associated with 3 of the 9 study outcomes (Table 1). A total of 10 additional minutes of driving time was associated with an 8.9 percentage point increase in the respondents’ likelihood of avoided care owing to cost (95% CI=1.7, 16.2), a 10.4 percentage point reduction in the likelihood of receiving a mammogram within the past year (95% CI= −22.3, 1.5), and a 12.5 percentage point reduction in the likelihood of ever receiving a clinical breast examination (95% CI= −18.7, −6.3). Driving time was also associated with a reduced likelihood of receiving a Pap test in the past year, and although this result was not robust without imputation, overall patterns in nonimputed models were similar to those in the primary analyses (Appendix Table 3, available online). The effect of driving times on receiving a past-year influenza vaccine and past-year checkup and on ever receiving a mammogram or Pap test were in the expected direction (negative) but not significant. Similar estimates were obtained when using driving distance instead of driving time.

Table 1.

The Association Between Driving Distance/Time to the Nearest Family Planning Facility, Preventive Service Use, and Cost-Related Barriers to Care

Outcome	Mean value, %	Distance to the nearest clinic (10s of miles) (95% CI)	Time to the nearest clinic (10s of minutes) (95% CI)
Influenza vaccination in the past 12 months	28.1	−5.6 (−13.2, 2.0)	−4.4 (−10.8, 1.9)
Annual checkup in the past 12 months	64.2	−1.9 (−9.2, 5.4)	−0.4 (−7.1, 6.3)
Avoided care due to cost in the past 12 months	25.4	8.3* (−0.7,17.4)	8.9** (1.7, 16.2)
Ever had a mammograma	52.4	−2.4 (−16.3,11.4)	−3.8 (−16.7, 9.1)
Had a mammogram in the past 12 monthsa	27.1	−10.7* (−23.1,1.8)	−10.4* (−22.3, 1.5)
Ever had a Pap testb	94.6	−2.1 (−5.4, 1.2)	−1.9 (−4.8, 0.9)
Had a Pap test in the past 12 monthsc	59.9	−6.8 (−17.0, 3.4)	−6.5* (−13.4, 0.4)
Ever had a clinical breast examinationc	87.4	−13.6*** (−21.6, −5.6)	−12.5*** (−18.7, −6.3)
Had a clinical breast examination in the past 12 months	57.1	−7.5 (−21.7, 6.6)	−5.1 (−18.1, 7.9)

Note: Boldface indicates statistical significance

^*(p<0.10;

^**p<0.05;

^***p<0.01).

All models are estimated as linear probability models using BRFSS sampling weights and with SEs clustered by county. Estimates represent percentage point changes in outcomes. Models included controls for insurance coverage, age, race, self-reported general health, marital status, rurality, veteran status, year, number of adults in the household, educational attainment, household income, and whether the survey was conducted using cellphone or landline.

^aLimited to women aged ≥35 years.

^bLimited to women aged ≥21 years.

^cLimited to women aged ≥20 years.

BRFSS, Behavioral Risk Factor Surveillance System.

DISCUSSION

Increased driving time (distance) to a family planning clinic was associated with cost-related healthcare avoidance, reduced likelihood of ever having had a clinical breast examination, and past-year mammogram receipt among female Ohio residents. Similarly, driving distance was associated with a lower likelihood of breast examination (lifetime) and mammogram receipt (past-year). There was no significant effect of driving time or distance on influenza vaccination, annual checkup, or Pap test use. Previous studies demonstrated similar effects in Wisconsin and Texas.³ Together, this research highlights how political hostility toward abortion may have consequences on access to other preventive health services.

In the 11 months after implementation of the domestic gag rule, approximately 1 in 4 clinics left the Title X program, reducing the capacity of the Title X network to provide contraceptive care by at least 46%.¹⁴ Moving forward, it will be important to understand the consequences of this policy on preventive service use and outcomes nationally. Because abortion providers are often safety net providers of other preventive services, funding restrictions and facility closures will likely have disproportionate, negative effects on low-income female adults who already experience substantial barriers to care.

Limitations

This analysis is limited to Ohio, and findings may not generalize to other states. Requests for access to restricted BRFSS data from other states that took aggressive policy actions against abortion-affiliated healthcare providers were not granted to the study team. In addition, some respondents may not have received the preventive services of interest owing to differing clinical guidelines across age groups or disruptions in care unrelated to clinic accessibility. Finally, because the data source on clinic locations ends in 2015, it was not possible to identify the effects on access to care in later years. Findings therefore may not reflect the effect of present-day access barriers and forgone services resulting from recent federal funding restrictions.

CONCLUSIONS

Family planning clinics are also safety net providers of preventive health care for low-income, reproductive-aged female adults. Findings from this research suggest that attempts to restrict access to abortion may have spillover effects on other essential preventive health services.