The Future of Family Planning: Where Are We Headed?

Kay Steiger

The nation's family planning program, Title X, is effective but needs an overhaul, a new Guttmacher study finds. Gains made against unintended pregnancy are stagnating, and funding is flat.

After objections from conservative Republicans, Congress quickly
withdrew a provision from the stimulus package that would have made it easier
for states to extend to women Medicaid coverage for family planning services.
It was a stark reminder that family planning is more controversial in this
country than it ought to be. After all, as a comprehensive study from
Guttmacher Institute released today points out, using birth control is a
"nearly universal" experience in this country – more than 98 percent of women
use birth control at some point during their reproductive lives.

However, the study also revealed that the use of
contraceptives is becoming less common in this country for woman who are black,
Hispanic, and low-income. Gaps between usage levels among white women and other
populations that had been narrowing during the 1980s and early ‘90s have been
widening again. Only 7 to 10 percent of white women from 1982 to 2002 (the most
recent year data is available) did not use contraception, but rates among black
and Hispanic women actually rose to 15% and 12%, respectively, in 2002, figures
that had dropped to 10% and 9% in 1995. And the gap isn’t just race-based. Now,
about 20 percent of women who are at risk of unintended pregnancy who are at or
below the poverty line aren’t using contraception, a rate that had dropped to
just 8% in 1995. 

As a result, unintended pregnancy is on the rise for
minority and low-income groups.  Though
the overall national rate of unintended pregnancy has held steady in recent
years, falling rates among affluent women masked an increase among poor and
low-income women. "Between 1981 and 1994, the national rate of unintended
pregnancy fell 14%, from 60 to 51 unintended pregnancies per 1,000 women aged
15-44. But between 1994 and 2001, that overall national rate stagnated. Worse
yet, rates among poor and low-income women rose considerably over the latter
period, even as they continued to fall among more affluent women, thereby
exacerbating already substantial disparities," reported to study, called "Next
Steps for America’s Family Planning Program." (PDF

"We were seeing the successes of the family planning efforts
in this country [that were giving] poor and low-income women equal access to
contraception in this country and seeing that translate into reduced levels of
unintended pregnancy and increased levels of contraceptive use to the point
where there was very little difference between a low-income woman and a higher
income woman in this country," said Adam Sonfield, Senior Public Policy
Associate at the Guttmacher Institute and one of the co-authors of the study.
"To see that reversing itself during the late 1990s was a really disturbing
trend for us." 

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The study examines both how
important family planning is in today’s medical landscape but also reveals that
family planning, a program that has had flat funding for the last eight years
and hasn’t been reevaluated for the last 25, leaving the program with an
"antiquated structure." There are often needless overlaps and bureaucratic
loopholes that create an inefficient use of family planning funds.
Additionally, the funding isn’t adequate for newer, more expensive family
planning technologies. 

Startlingly, six in ten of all
women who visit Title X-funded family planning clinics say the clinics are
their primary source of medical care. Like upper-income women, these women
might go to a gynecologist for an annual exam, but might also get referrals to
other doctors for other forms of care. "It’s their entry into the health care
system," Sonfield said. In fact, of women who are on Medicaid, some other form
of public insurance, or are uninsured, 67%, 78%, and 75% of them respectively
consider family planning centers their "usual" source of medical care. 

Medicaid, while it does address
family planning needs, is funded separately from Title X funds. The funds for
Title X are distributed in large operational grants to individual clinics or
care centers, while providers charge Medicaid on a per-service basis. A family
planning provider might receive both Title X and Medicaid funding, but because
there are more restrictions on how Medicaid reimbursements are processed,
Title X fills important gaps that
might otherwise cause a provider to turn away someone in need of family
planning services. 

Title X family planning funds
can provide increased quality of service by paying for counseling and other
kinds of services not covered by Medicaid. And increasingly, Title X provides funding
to clinics to serve those for those who don’t qualify for Medicaid, notably immigrants. "That’s one big piece of the puzzle is the extensive
counseling and education that women need," Sonfield said. "The average woman
uses four different methods of birth control over the course of her life. It’s not
just the first-time users. Women have different needs over the course of their

Even though women use many
different types of birth control over the courses of their lives, family
planning clinics all too often can only offer a narrow range of options. New
technologies in contraception, like the NuvaRing, the patch, and IUDs, do a
better job of preventing unintended pregnancy but they are also much more
expensive. With funding remaining stagnant the last eight years, what to offer
patients becomes a difficult choice for many clinics. "These new technologies
are wonderful for their clients but on limited or stagnant funding it creates a
real dilemma for them," Sonfield said. "‘Do we make these methods available for
our clients and therefore be able to serve fewer clients or reduce our hours or
do things like that? Or do we limit women’s choices so that we are able to
serve more women?" 

The first step to improving
access to family planning will be to increase levels of funding. Laurie
Rubiner, Vice President for Public Policy at Planned Parenthood Federation of
America, an organization whose clinics are one of the largest recipients of
Title X funding, said that they’re asking for a total of $700 million to bring
funding levels up to inflation-adjusted rates that match those in 2000. Current
funding levels are at about $300 million. "The money is obviously key," Rubiner

But it is about more than just
increasing funding. The Guttmacher study outlines a number of steps that would
make the relationship between Medicaid and Title X funding to work more
seamlessly together. Some of the changes are straightforward, like the Medicaid
family planning waiver that was proposed for inclusion in the stimulus package. 

"Unfortunately there was a lot
of misrepresentation about what that bill would have done," Rubiner said. "It
doesn’t cost $200 million. It actually saves money." Though the Medicaid waiver
is a bureaucratic savings, reducing the amount of paperwork to obtain a waiver,
the Guttmacher report also shows that for every dollar invested in family
planning, Medicaid saves $4.02 in expenses on pregnancy-related care. 

An earlier report from
Guttmacher by Rachel Gold that was released last summer showed that
many clinics are still behind in providing bilingual services, and are lacking
in evaluating patients for substance abuse or if they are victims of domestic
violence. These are all things that require clinic administrators to spend
more, not less time with their patients. Currently, family planning
effectiveness is measured by the number of patients served and the amount of
dollars spent. Rather than just focusing on the number of total patients,
Sonfield said, perhaps they could look at the number of months of contraceptive
use provided for. A one-time visit is a one-time visit, regardless of the
method of contraception received. "Right now, inserting an IUD counts the same [in
congressional evaluations] as giving a woman a condom," he said. 

Some of the biggest changes in
the US approach to family planning, though, might be ideological ones. The Bush
administration appointed Susan Orr, who came from the anti-choice and
anti-contraception group the Family Research Council, to be deputy assistant
secretary of Health and Human Services and head the Office of Population
Affairs, the office primarily responsible for overseeing the distribution of
Title X funds. "This past administration, the Bush administration, is one that
just put evidence- and science-based evidence to the side in favor of ideology,"
Rubiner said. "We’d like to see evidence and clinical guidelines put back in
place so that’s what’s driving policy." 

With the Health and Human
Services Secretary yet to be confirmed, changes to the OPA, an office within
HHS, may be a while in coming. Still, the Guttmacher report and PPFA urge
Congress and the administration to take on legislation that would increase
access to family planning services sooner rather than later.

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