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 [11])
"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."
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 lifetimes."
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 said.
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 [12] 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.