No American woman should be denied access to family planning assistance because of her economic condition. I believe, therefore, that we should establish as a national goal the provision of family planning services…to all who want but cannot afford them. - President Richard M. Nixon, 1970

The Title X Program

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

Title X of the Public Health Service Act was signed into law by President Nixon in 1970 and is America’s family planning program. For more than 30 years, Title X has been the nation’s major program to reduce unintended pregnancy by providing contraceptive and related
reproductive health care services to low-income women. Although public funds for family planning services also come from other programs — including Medicaid, state funds, Temporary Assistance for Needy Families (TANF), State Children's Health Insurance Program (SCHIP), and the Maternal and Child Health and Social Services block grants — Title X is the only federal program dedicated solely to funding family planning and related reproductive health care services. In 1999, it helped to support 61 percent of all family planning agencies (Finer et al., 2002). Title X accounts for 27 percent of the revenue of agencies receiving Title X funds (AGI, 2002a).

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

All Title X grants are administered through state health departments or regional agencies that subcontract with local clinics. In 1997, approximately 4,200 clinics, located in nearly three-quarters (73 percent) of all counties, provided family planning services funded by Title X. Of the 4.3 million women served by these clinics, 47 percent received care at health departments, 28 percent received care at Planned Parenthood clinics, 14 percent received care at other independent community-based clinics, seven percent received care at hospitals, and three percent received care at community or migrant health centers (Frost et al., 2001).

While this system allows for maximum flexibility in the administration of the program, Title X also sets a minimum standard 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 fertility awareness 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
• no Title X funds are used to pay for abortions (P.L. 91–572, 1970).

The law also mandates:
• minimum national medical standards of care developed with the American College of Obstetricians and Gynecologists
• training of health care professionals, information outreach, and
• research designed to improve contraceptive use and the delivery of family planning 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 include:

• pelvic exams and pap tests (early warning about cervical cancer)
• breast exams and instruction on breast self-examinations
• 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). The family planning regulations require that women who face unintended pregnancies be given nondirective counseling on all of their legal and medical options (Federal Register, 2000).

Title X Recipients

Title X serves more than four million people a yearwho might otherwise be unable to afford family planning.

In 2002, nearly five million women received health care services at family planning clinics funded by America’s family planning program. They are predominantly young, poor, uninsured, and have never had a child. Seventy-one percent of women using Title X-funded clinics are 20 years or older; and 63 percent are white. Sixty-five percent have incomes at or below the federal poverty level (AGI, 2002a). 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. She 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. Consequently, clinics supported by these funds have always 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. 106–554, 1999-2000).

More than 30 Years of Title X Successes

Family planning programs are successful in preventing unwanted pregnancies and, consequently, abortions.

By providing access to contraceptive methods and counseling on how to use them effectively, family planning clinics — many of which receive funding through Title X — have been shown to reduce large numbers of unintended pregnancies, abortions, and births. Each year:

• Publicly subsidized family planning services, of which Title X is the core, prevent 1,331,100 pregnancies: consequently, 632,300 abortions
are prevented.
• Studies have found that public family planning funds prevent approximately 888,200 unintended pregnancies to women who have never married, thereby avoiding an estimated 421,900 abortions and 356,200 out-of-wedlock
births.
• Publicly funded family planning prevents 385,800 unintended pregnancies to adolescents aged 15–19 annually, avoiding 154,700 teenage births and 183,300 abortions. (Forrest & Samara, 1996)

Each public dollar spent to provide family planning services saves an estimated $3.00 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 and nine million abortions
• helped to prevent 5.5 million adolescent pregnancies. (Without Title X, there would have been 20 percent more teen pregnancies than there were for 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)

Additionally, between 1995–1998, Title X clinics performed 19 million tests for sexually transmitted infections (STIs), including 1.4 million for HIV (Gold, 2001).

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-income women 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, unmarried, or over age 40 — characteristics that carry special medical risks and socioeconomic burdens.
• The child of an unwanted conception is at greater risk of being born at low birthweight, of dying in its first year of life, of being abused, and
for having developmental disabilities. Mothers are at risk for depression, and both parents may suffer economic hardship or failure to reach
educational or career goals.
• 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)

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 by Sosin Snell Perry & Associates, 88 percent of voters believe the use of contraceptives and other family planning measures to be important, while 74 percent favor increased public funding for family planning services to reduce the number of unintended pregnancies (Feldt, 1999).

Funding for Title X

In spite of its proven track record as a cost-effective program for preventing unintended pregnancies, preventing abortion, 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. Therefore, the $275 million
allotted to Title X for FY 2003 was worth 57 percent less than the $162 million appropriated for FY 1980 (AGI, 2002b).

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, clinics are struggling to pay for newer, more effective, but more costly, long-lasting methods of contraception and state of the art diagnostic tests that promise improved rates of detecting STIs and cervical cancer.

Parental Consent for Minors’ Access to Family Planning

In October of 1998, members of the House attempted to pass legislation restricting minors’ access to family planning services. Representative Ernest Istook (R-Oklahoma) 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 (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, foregoing the contraceptives they need to avoid unintended pregnancy and STIs, as well as testing and treatment for STIs that can have serious consequences if left untreated (AGI, 2000). Fortunately, the Istook amendment was dropped from the final bill
and never became law.(AGI, 2000).

Title X has a long and remarkable history. It has enabled millions of women to plan their pregnancies, to prevent abortions and 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.

Cited References
AGI — Alan Guttmacher Institute. (2000). Fulfilling the Promise: Public Policy and U.S. Family Planning Clinics. New York: Alan Guttmacher Institute.
_____. (2002a). Family Planning Annual Report: 2001 Summary, Submitted to the Office of Population Affairs, Department of Health and Human Services.
_____. (2002b, February 20). Unpublished memorandum to Planned Parenthood Federation of America. Congressional Record [Online]. 105th Cong., 2d sess. (8 October 1998, accessed 1999, April 13). http://www.access.gpo.gov/su_docs/aces/aces150
Federal Register. (2000, July 3), 65(128), 41278–41282.
Feldt, Gloria. (1999, May). “Congress Is Foiling Americans’ Desire for Reproductive Choice.” USA Today, 127, 50–52.
Finer, Lawrence, et al. (2002). “U.S. Agencies Providing Publicly
Funded Contraceptive Services in 1999.” Perspectives on Sexual and Reproductive Health, 34(1), 15–24.
Forrest, Jacqueline & Renée Samara. (1996). “Impact of Publicly Funded Contraceptive Services on Unintended Pregnancies and Implications for Medicaid Expenditures.” Family Planning Perspectives, 28(4), 188–195.
Frost, Jennifer, et al. (2001). “Family Planning Clinic Services in the United States: Patterns and Trends in the Late 1990s.” Family Planning Perspectives, 33(3), 113–122.
Gold, Rachel Benson. (2001, February). “Title X: Three Decades of Accomplishments.” The Guttmacher Report on Public Policy, 5–8.
Henshaw, Stanley K. & Aida Torres. (1994). “Family Planning Agencies: Services, Policies and Funding.” Family Planning Perspectives, 26 (2), 52–59.
Institute of Medicine, National Academy of Sciences. (1995). The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families. Washington, D.C.: National Academy Press.
Kaeser, Lisa, et al. (1996). Title X at 25: Balancing National Family Planning Needs with State Flexibility. New York: Alan Guttmacher Institute.
P.L. 572, 91st Congress (1970). Title X: Population Research And Voluntary Family Planning Programs.
P.L. 554, 106th Congress (1999–2000). The Consolidated Appropriation Act for FY 2001.
Sollom, Terry, et al. (1996). “Public Funding for Contraceptive, Sterilization and Abortion Services, 1994.” Family Planning Perspectives, 28(4), 166–173.
Reddy, Diane, et al. (2002). “Effect of Mandatory Parental Notification on Adolescent Girls’ Use of Sexual Health Care Services.” Journal of the American Medical Association, 288(6), 710–714.
Trussell, James, et al. (1995). “The Economic Value of Contraception: A Comparison of 15 Methods.” American Journal of Public Health, 85, 494–503.