Challenges facing family planning clinics and Title X.

The Title X family planning program, and the entire U.S. network of family planning clinics, currently face enormous challenges. Rising costs of contraceptives and of state-of-the-art medical technology, as well as the managed care revolution and an increasingly uninsured clientele, complicate the delivery of services to existing clients. At the same time, family planning clinics are being asked to provide a more comprehensive range of services to women, to broaden their outreach to men and to close access gaps among those women who are the hardest and most expensive to reach and serve. Meeting these substantial challenges requires a renewed political and financial commitment to publicly subsidized family planning services--one that is long overdue.

In 1970, Congress enacted Title X of the Public Health Service Act, the only federal program--then and now--devoted solely to the nationwide provision of family planning services. Introduced with bipartisan support and signed into law by President Nixon, Title X was designed to make contraceptive supplies and services available to all who want and need them but are unable to afford them without government assistance. The new program sought to fulfill Nixon's historic 1969 promise that "no American woman should be denied access to family planning assistance because of her economic condition."

Thirty years after its enactment, the Title X program remains the centerpiece of the U.S. family planning effort. By supporting the clinic infrastructure and clinics' operating budgets, Title X enables them to draw on other sources of revenue for family planning, such as Medicaid reimbursements and state appropriations. Together, these funds support more than 7,000 family planning clinics nationwide, more than 4,500 of which receive Title X funds. Of the 6.5 million women who receive subsidized family planning services each year, two-thirds do so at a Title X-supported clinic.

In addition to providing high-quality, affordable family planning services to low-income women, many of whom are uninsured and who would have no other source of care, Title X also established a set of principles that guide the ethical delivery of those services. Those principles require that services be voluntary, confidential and affordable. Accordingly, women must be offered a broad range of contraceptive methods (including natural family planning), and may not be pressured to accept a particular method or any method at all; confidentiality must be guaranteed, even to teenagers (although clinics are required to encourage parental involvement); and services must be offered free of charge to clients with incomes below the federal poverty level (who comprise two-thirds of clients of Title X-supported clinics), and on a sliding fee scale for clients with incomes between 100% and 250% of poverty. (Women with higher incomes pay the full cost of their care.)

Program guidelines specify the range of services to be delivered to women who visit Title X-supported clinics. These include pelvic and breast examinations, blood pressure checks, pregnancy tests, Pap smears and, as indicated, tests for sexually transmitted diseases (STDs) and HIV. The Title X statute specifies that program funds cannot be used for abortion, but that a pregnant woman must be offered "nondirective counseling" about all of her options, "including prenatal care and delivery; infant care, foster care or adoption; and pregnancy termination."

Title X has been enormously successful in helping American women plan their births and avoid one million unintended pregnancies each year, thus improving the public health. Yet despite these significant accomplishments, the Title X program--as the central legislative vehicle controlling U.S. family planning policy--has been besieged both politically and financially for most of its life. Funding for the program grew rapidly in the 1970s, as clinics proliferated throughout the country; however, in 1981, shortly after taking office, President Reagan tried to repeal Title X entirely and to send federal family planning funds--and policymaking authority--to the states. While Congress rejected the president's block grant proposal, retaining Title X as a discrete federal program came at the price of a steep funding cut.

The 1980s saw further controversy emerge when social and religious conservatives began alleging that the very availability of family planning services promoted promiscuity and abortion, and that the provision of confidential services to teenagers encouraged the circumvention of parental authority. These controversies, which remain alive today, helped keep funding low throughout the decade. During the 1990s, appropriations began to rise again, but the program never regained the ground it lost during the previous decade. In fact, taking inflation into account, the $254 million in FY 2000 funding is 58% lower than the $162 million appropriated in 1980, the final year of the Carter administration. Had spending kept pace with inflation, the program would be funded at $564 million today.