Title X: America's Family Planning Program

Title X has been key to helping millions of American women prevent unintended pregnancies and obtain reproductive health care for almost four decades.

The Title X family planning program began in 1970 as a bipartisan commonsense approach to ensuring that low-income Americans have access to contraceptive services and other preventive health care. For almost 40 years, Title X has been the nation's only program dedicated solely to reducing unintended pregnancy by providing contraceptive and related reproductive health care services to low-income women. In fact, Title X supports six in 10 of all family planning health centers in the United States, and Title X funds account for 24 percent of those health centers' total revenue (Frost, 2006; Fowler, et al., 2008).

Title X is a vital source of funding for family planning health centers throughout the nation.

All Title X grants are administered from the federal government to more than 80 grantees, who then distribute the funds to the approximately 4,480 health centers in the program (Fowler, et al., 2008). Many Planned Parenthood health centers play an integral role in the success of the Title X program. In fact, one analysis showed that of the women served by the program, 43 percent received care at health departments, 33 percent received care at Planned Parenthood health centers, 13 percent received care at other independent community-based clinics, seven percent received care at hospitals, and four percent received care at community or migrant health centers (Guttmacher Institute, 2004; Frost, et al., 2004). Title X also upholds important standards of care for those individuals who want reproductive health care. The law's provisions include requirements that

  • people be given a choice of contraceptive methods (including periodic abstinence and other fertility awareness-based methods)
  • no one is coerced into accepting a particular method or any method at all
  • services are provided in the context of related reproductive health care
  • recipients are charged fees based on their income and ability to pay

By law, no Title X funds are used for abortion services. (P.L. 91-572, 1970).

Title X Services

Title X funds services essential for the health of women and their families.

The Title X program provides comprehensive family planning services that include a broad range of contraceptive methods and related counseling. The official program guidelines also require health care providers that receive this funding to offer a wide range of other preventive health care services that are critical to their clients' sexual and reproductive health (Gold, 2001). These services include

  • pelvic exams and Pap tests (early detection of cervical cancer)
  • breast exams and instruction on breast selfexamination
  • testing for high blood pressure, anemia, and diabetes
  • screening and appropriate treatment for sexually Transmitted Infections
  • Safer-Sex Counseling
  • Basic infertility screening
  • referrals to specialized health care (Gold, 2001).

By law, no Title X funds have ever been spent on abortion(Sollom, et al., 1996). Keeping in line with basic standards of medical care, however, Title X regulations require that women who face unintended pregnancies be given nondirective counseling on all of their legal and medical options, including prenatal care and delivery, infant care, foster care or adoption, and pregnancy termination (Federal Register, 2000).

Title X Recipients

Title X-funded health centers serve about five million patients a year who might otherwise be unable to afford family planning(Fowler, et al., 2008). Patients served at Title X health centers are predominantly low-income, uninsured young women. In 2006, approximately 4.7 million women received health care services at Title X family planning health centers. Sixty-seven percent of patients have incomes at or below the federal poverty level, and 61 percent are uninsured. Seventy-four percent of women using Title X-funded clinics are 20 or older (Fowler, et al., 2008). It is estimated that these clinics are the only source of family planning services for more than 80 percent of the women they serve (Kaeser, et al., 1996).

According to regulations, the amount a woman pays for family planning services at a Title X-funded clinic depends upon her income. If her income is at or below 100 percent of the federal poverty level, the services are completely subsidized. A woman will be charged on a sliding fee scale if her income is between 100–250 percent of poverty level, and she will pay full fees if her income is above 250 percent of poverty level (Kaeser, et al., 1996).

From the beginning, America’s family planning program has also required that services be made available without regard to age or marital status. In 1977, family planning services — including the availability of contraception — were extended to minors under the age of 16 as a result of the U.S. Supreme Court's decision in Carey v. Population Services International (Carey v. Populations Services International, 1977). As a result of this court decision, clinics supported by Title X funds have traditionally served adolescents on a confidential basis. Clinics also provide preventive educational services to young people, including an emphasis on the postponement of sexual activity, as well as counseling and contraceptive care. Counselors in most family planning clinics are encouraged to spend extra time with teenage clients (Henshaw & Torres, 1994). Title X clinics are required by law to encourage minors to involve their parents in their decision-making regarding family planning (P.L. 108–447, 2005).

More than 30 Years of Title X Successes

Family planning programs are successful in preventing unintended pregnancies.

By providing access to contraceptive methods and counseling on how to use them effectively, family planning health centers — many of which receive funding through Title X — have been shown to reduce large numbers of unintended pregnancies. In fact, Title X health centers help women prevent one million unintended pregnancies each year (Dailard, 2001).

Each public dollar spent to provide family planning services saves an estimated $3 that would otherwise be spent in Medicaid costs for pregnancy-related care and medical care for newborns (Forrest & Samara, 1996). A study that measured the cost of contraceptive methods compared to the cost of unintended pregnancies when no contraception was used found the total savings to the health care system to fall between $9,000 and $14,000 per woman over five years of contraceptive use (Trussell, et al., 1995).

Title X has made a tremendous impact in the lives of millions of women. Over the last two decades, services provided at Title X-funded clinics

  • prevented 20 million unintended pregnancies
  • helped to prevent 5.5 million adolescent pregnancies. (Without Title X, there would have been 20 percent more teen pregnancies during this time period.)
  • provided an estimated 54.4 million breast exams and 57.3 million Pap tests, resulting in the early detection of as many as 55,000 cases of invasive cervical cancer (Gold, 2001).

In 2006, Title X providers performed more than 2.4 million Pap tests, 2.4 million breast exams, and 5.2 million tests for sexually transmitted infections (STIs), including 666,706 HIV tests (Fowler, et al., 2008).

Continued Need for Title X

Family planning programs continue to provide essential services to women seeking to plan their pregnancies and maintain their health.

A 1995 report on unintended pregnancy by the Institute of Medicine noted with concern the increasing number of births from unintended pregnancies in the early 1990s. It urged that financial barriers to contraceptive services be reduced, and that public funding — including Title X specifically — should continue, especially for low-incomewomen and adolescents. The report pointed to the serious public health consequences that result from a lack of family planning services:

  • A woman with an unintended pregnancy is less likely to seek early prenatal care and is more likely to expose the fetus to harmful substances such as alcohol and tobacco.
  • Births from unintended pregnancies are more likely to occur to mothers who are adolescent or over age 40 — characteristics that carry special medical risks.
  • The U.S. ratio of about one abortion to every three live births is two to four times higher than in other developed countries, although access to abortion in those countries is often easier than in the U.S. (Institute of Medicine, 1995).

While family planning programs have helped to increase the percentage of adolescents who use contraception at first intercourse (79 percent in 2002), there is still a great need for Title X (NCHS, 2004a). A recent evaluation of the National Survey of Family Growth has shown that the number of women at risk of unintended pregnancy due to a lack of contraception has increased to 10.7 percent (NCHS, 2004b). According to the Office of Population Research, this could potentially lead to an 18 percent increase in unintended pregnancies ("Teens Improve ...", 2005).

Public Support for Family Planning

The majority of Americans supports increased public funding for services to prevent unintended pregnancies.

Publicly funded family planning programs enjoy overwhelming public support. According to research conducted for Planned Parenthood, 67 percent of voters strongly support launching a major effort to reduce the number of unintended pregnancies through commonsense measures increasing access to contraception and comprehensive sex education (Peter D. Hart Research Associates, 2007).

Funding for Title X

In spite of its proven track record as a cost-effective program for preventing unintended pregnancies and improving the health of women, Title X faces threats from Congress to cut funding or attach harmful restrictions, making it less likely that people will receive the care they need. Title X lost a significant amount of funding during the 1980s, and while appropriations increased during the Clinton administration, the decreased purchasing power of the dollar meant that the program was operating with less money each year. In fact, the Title X program is $425 million short of keeping up with inflation (NFPRHA, 2008).

President Bush has not proposed any increase in Title X funding since taking office in 2001. Because the program has remained underfunded for so long, health centers are struggling to pay for newer, more effective — but more costly — methods of contraception and stateof- the-art diagnostic tests that promise improved rates of detecting STIs and cervical cancer.

Recent Threats to Title X

Since the inception of Title X, opponents of family planning have long tried to use the issues of abortion and the reproductive rights of minors to attack the family planning program.

In October 1998, members of the House attempted to pass legislation restricting minors’ access to family planning services. Representative Ernest Istook (R-OK) proposed an amendment to the Labor, Health and Human Services and Education Appropriations Act of 1999 mandating that the parents of dependent teenagers be notified before their children receive contraceptives from Title X clinics (Congressional Record, 1998). Supporters of parental consent argue that the availability of confidential contraceptive services encourages teenage sexual activity and undermines parental authority. However, research shows that confidentiality is crucial to teens’ willingness to seek sensitive services such as family planning (Jones, et al., 2005; Reddy, et al., 2002). Moreover, the fact that the average teen does not visit a family planning clinic until 14 months after she has become sexually active provides clear evidence that clinics do not encourage sexual activity. In fact, requiring parental consent will not discourage teens from having sex but will only deter them from seeking needed reproductive health care in a timely manner (Guttmacher Institute, 2000). A recent study has shown that 20 percent of adolescent girls currently visiting family planning clinics for contraceptive services would have unsafe sex instead of accessing birth control through a clinic if mandatory parental notification laws went into effect. Only one percent of the adolescents surveyed said that they would remain abstinent if their parents were notified of their visits to the family planning clinic (Jones, et al., 2005). Fortunately, the Istook amendment was dropped from the final bill and never became law (Guttmacher Institute, 2000).

In 2005, Rep. Dave Weldon (R-FL) successfully tacked a so-called "Abortion Non-Discrimination Act (ANDA)" on to the federal government's budget. Proposed by the U.S. Conference of Catholic Bishops, the Weldon Amendment allows virtually any health care institution to refuse to comply with existing federal, state, and local laws and regulations pertaining to abortion services, including referral for abortion services (Feldt, 2004). Health care institutions, as defined by the law, include hospitals, provider-sponsored organizations, health maintenance organizations, health insurance plans, or any other kind of health care facilities, organizations or plans (PPFA, 2004). ANDA seriously undermines Title X by prohibiting the federal government from enforcing its own requirement that Title X-funded clinics must refer clients to abortion providers upon request. The State of California is currently taking legal action to challenge this legislation.

Family planning opponent Rep. David Vitter (R-LA) has continuously introduced legislation and offered amendments to the pending appropriations legislation designed to undermine Title X and access to family planning services. The Vitter amendments would have prevented private organizations from receiving Title X funds to provide contraception and other preventive health care services even though they provide abortions or abortion related services with their own, non-Title X funds — in accordance with federal law. Had these amendments succeeded, it would have restricted the funding availability of contraceptives and other preventive health care affecting one million low-income women by prohibiting nearly 600 hospitals, Planned Parenthood affiliates, and other established health care providers from receiving Title X funds (Gold, 2000). Vitter's attacks would have endangered the health of low-income women, and threatened the Title X family planning clinic network.

Title X has a long and remarkable history. It has enabled millions of women to plan their pregnancies, to prevent unintended births, and to receive vital reproductive health care. For the benefit of American families, funding of Title X must continue to be a national priority, and Planned Parenthood is proud of the role it has played in preserving this crucial women’s health program.

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