Five Figures to Consider
Milk, diapers, babysitters, sneakers, school supplies, braces — children are expensive. In 2015 it was estimated that the average family spent $233,610 raising a child from birth to age 17. When those expenses, which take a big bite out of a family’s income, are unanticipated, poverty can result. Research in the 1960s showed that unintended pregnancies increased the likelihood that a family would become impoverished and rely on public assistance. Studies also found that it wasn’t a desire for more children but the inability to access contraception that was largely responsible for the difference between high and low-income women’s ability to determine family size. In response, Title X, championed by then-Congressman George H.W. Bush and signed into law by President Nixon in 1970, became the nation’s first federal program devoted solely to providing affordable birth control and reproductive health care to low-income women. Now, proposed changes to Title X regulations designed to curtail abortions would, if approved, significantly limit the network of Title X healthcare providers. How would this reduction affect the delivery of healthcare services to the four million people who use Title X each year?
Title X dispenses funds to providers as upfront grants (rather than as reimbursement for direct client services as with Medicaid or private insurance). These dollars can be used by a provider to cover any expenses – from funding staff salaries to keeping the lights on – except abortions. (This is in accordance with the 1976 Hyde Amendment blocking federal funding for abortions.) Providers have been allowed to offer abortions and abortion-related guidance and services at the same location and through the same health care personnel. Under the new policy proposal that would change. On June 1, 2018, the Trump Administration advanced a new regulation (called the “gag” rule by pro-choice advocates and “protect life” rule by anti-abortion advocates) that would prohibit providers from receiving or applying for Title X grants if they provide abortions, refer patients for abortions or tell pregnant patients who don’t ask about abortion that abortion is an option (even though providers are required to counsel patients about prenatal care and adoption). The rule would also eliminate requirements that a woman wanting an abortion be provided a list of abortion providers and a woman wanting contraception be provided a full range of birth control choices beyond natural family planning. There is a 60-day public comment period which closes in four days — on July 31, 2018 — after which the administration must consider comments before the regulation can be finalized. As expected comments are divided: “To think that abortions will just go away if you don’t talk about them is absolutely ludicrous…” — Elisa Maginnis. “Please stop abortions. They not only take a human life but they also take a SOUL that only belongs to God not the Mother.” — Tom Letz.
For nearly fifty years Title X has helped women, men and adolescents avoid unplanned pregnancies. The result has been a decreased abortion rate, taxpayer savings and reduced poverty. Today there are 4,000 Title X health clinics providing patients with comprehensive reproductive care including birth control, sexually transmitted infection screening, breast and cervical cancer screening, family planning counseling and other reproductive health services. In 2015, according to research by the Guttmacher Institute, Title X grants helped women avert 822,000 unintended pregnancies that otherwise would have resulted in an estimated 387,000 unplanned births and 278,000 abortions. In 2010, every $1 invested in publicly funded family planning services saved $7.09 in Medicaid expenditures that would otherwise have been needed to pay the medical costs of pregnancy, delivery and well-baby visits. Consider the economics. Long-acting contraception costs as little as $1,500 for the lifetime of a woman’s fertility. A Medicaid birth costs an average of $12,770. Now consider the family economics. Children born after public family planning programs were established were 7% less likely to live in poverty and 11% less likely to live in households receiving public assistance.
If the government removed abortion providers from Title X family planning programs, it is likely that reproductive healthcare would become more difficult for millions of patients to access. The proposed rule changes would eliminate Planned Parenthood, which serves 41% of Title X clients, from the program. At least another one in 10 Title X sites could be eliminated from the program for providing abortions. There is not enough capacity in alternative Title X clinics to accommodate the clients formerly treated by clinics that also provide abortions. Texas tried something similar in 2011 when it kicked Planned Parenthood out of its Title X program and then in 2013 replaced its federally funded family planning program (subject to federal regulations) with a state-funded program (the Texas Women’s Health Program) that excluded all clinics affiliated with an abortion provider. After the changes in Texas, long-acting contraception use declined, Medicaid births increased by 27%, the teen birth rate increased by 3.4% and the teen abortion rate increased 3.1% over three years. Furthermore, a quarter of publicly funded family planning clinics closed between 2011 and 2013 leading to a 46% reduction in clients served. While overall abortions in the state fell 20.7%, there is evidence that Texas women traveled to nearby states to obtain abortions when access became restricted in Texas. Among mothers ages 40 to 44, abortions in the state increased by 8.5%.
Of U.S. women of reproductive age one-third (25 million) live in households that earn less than 200% of the federal poverty level ($40,180 for a family of three) and, unlike higher-income women, they have less ability to take off work or travel when their county reproductive clinic closes. In order to serve all the women who currently obtain reproductive care at Title X-supported Planned Parenthood health centers nationwide, other Title X sites would have to increase their client caseloads by 70%. Opposed by both the American Medical Association and the American Association of Gynecologists and Obstetricians, the new rule would endanger women’s health, leaving them with fewer options for safe, timely and comprehensive care. The result? More unintended pregnancies, more families in need of public assistance and higher abortion rates among some groups of women who will find it more difficult to access long-term contraceptive care.
FIVE FIGURE THINKING
Evaluating Title X providers on criteria other than professional qualifications undermines the primary objective of Title X and limits access to preventative and reproductive care for low-income women. Taxpayers (and poor families) will pay the price if the proposed changes are adopted.
American Journal of Public Health, census.gov, federalregister.gov, forabettertexas.org, Stefanie Fischer – Cal Poly State University, San Luis Obispo, Guttmacher Institute, Kaiser Family Foundation, regulations.gov, National Institutes of Health, New England Journal of Medicine, Analisa Packham – Miami University, Heather Royer – University of California, Santa Barbara, NBER, IZA, Schuyler Center for Analysis and Advocacy, University of California at Santa Barbara, University of Texas, Corey White – Cal Poly State University, San Luis Obispo, USDA