About two weeks ago, federal health officials released a new funding announcement for the nation’s Title X family planning program, which serves millions of women each year. In the entire 60-page document, you won’t find the words “contraception” or “contraceptive” mentioned even once.
Even more worrisome than that, advocates say, is the sidelining of evidence-based guidelines for providing quality family planning services. In 2014, the Centers for Disease Control and Prevention and the U.S. Department of Health and Human Services’ Office of Population Affairs, which oversees Title X, developed evidence-based clinical recommendations for providing a range of patient-centered services, such as contraception, pregnancy counseling and preconception health. However, the new Title X Funding Opportunity Announcement (FOA) released in February eliminates all mention that Title X providers follow the quality standards. Instead the FOA calls on applicants to offer “innovative” services not currently happening within the Title X provider network. For comparison, the 2017 FOA — released before Trump took office — mentioned the standards eight times.
“We knew this was the (Trump) administration’s first opportunity to make changes to the program, so we anticipated that they’d try to transform parts of it,” said Jessica Marcella, vice president for advocacy and communications at the National Family Planning and Reproductive Health Association (NFPRHA). “But the disregarding of nationally recognized standards on family planning care and the removal of all references to contraceptive services in the funding announcement is very concerning from a public health perspective.”
Enacted in 1970, the Title X program is the only federal funding source dedicated to family planning. In 2016, according to the Office of Population Affairs, Title X supported a network of nearly 4,000 service sites, with Title X providers serving more than 4 million patients. Among those patients, 64 percent had family incomes at or below the federal poverty level and 43 percent were uninsured. Marcella noted that six in 10 women who depend on Title X clinics consider the clinic their primary source of care, while four in 10 women consider the clinics their sole source of care. The contraception care women receive at the clinics has prevented millions of unintended pregnancies, which nets the public billions of dollars in savings.
“We’ve made really great strides in lowering the teen pregnancy rate and unintended pregnancy rate, so anything we do to weaken the infrastructure of our family planning safety net could reverse those trends,” Marcella told me.
The new Title X FOA includes a list of “program priorities,” none of which mention “contraception.” However, it does specifically mention that providers offer a broad range of services, including “natural family planning methods,” also known as “fertility awareness.” The FOA also prioritizes educational activities that focus on “avoiding sexual risk” or “returning to a sexually risk-free status” — language that advocates say is often used among abstinence-only proponents. Another big change: this year’s Title X FOA doesn’t mention “confidentiality” once, even though access to confidential family planning services is a hallmark of Title X. Instead, the FOA makes a point of encouraging the involvement of spouses and parents in the family planning decisions of patients.
Kinsey Hasstedt, senior policy manager at the Guttmacher Institute, said it’s not unusual for a Title X FOA to encourage family participation for adolescents when it’s appropriate. But prioritizing that while not re-affirming a right to confidentiality — a critical component for many young people seeking family planning services — is a departure from previous years.
“It’s quite clear that this administration is seeking to subvert the Title X program to push its own ideological priorities,” Hasstedt told me.
One goal behind the new funding language, Hasstedt said, could be reshaping the network of Title X providers. The FOA “really stacks the deck against providers that focus solely on reproductive health care,” she said, noting that such sites currently comprise 72 percent of Title X-supported clinics. Such providers are more likely to ensure patients can choose from a full range of family planning and contraceptive options, which upholds one of Title X’s main tenets that women’s contraceptive choices be totally voluntary and not coerced in any way, Hasstedt said. (Both Hasstedt and Marcella noted that fertility awareness is a legitimate family planning method that providers should offer, though relatively few women choose that option.)
Hasstedt said the current funding announcement seems aimed at steering women away from more comprehensive family planning providers and puts a greater emphasis on clinical sites that offer family planning in the broader context of primary care. She noted that that’s a “favorite talking point for social conservatives,” who often argue that there’s no need to fund family planning clinics such as Planned Parenthood, as primary care sites can offer the same services.
“Prioritizing these primary care-focused sites over skilled providers who form the backbone of the Title X program has the potential to undermine women’s ability to access affordable and high-quality care,” Hasstedt said.
Both Hasstedt and Marcella said the FOA’s omission of CDC’s evidence-based clinical standards for family planning services is a particularly alarming red flag. Previously, Title X providers were broadly expected to align with the standards.
“If the administration can ignore or silo nationally recommended standards for family planning care then they can do so for other nationally recognized clinical standards and that should be troubling for the public health community,” Marcella told me.
The American College of Obstetricians and Gynecologists also put the new FOA language and omissions in stark perspective, with its president warning that: “These changes will effectively block Title X patients from the qualified providers of their choice, steering them toward organizations or providers singularly focused on abstinence and fertility awareness methods – political interference at its worst. This will reduce individuals’ options for care and jeopardize their access to the most effective forms of contraception, most notably, long-acting reversible contraception, like the IUD and implant.”
Applications for this round of Title X funding are due in May and award announcements are expected in September, which is many months late. That’s because the funding announcement, released in February, was supposed to come out last fall. Current Title X providers will run out of funds in either March or June; however, HHS has issued instructions to apply for funding extensions to prevent any gaps in services. Despite the late announcement, advocates don’t expect service shutdowns, but Hasstedt said the months-long delay may be indicative of bigger problems.
“It seems to me that the delay is another indicator of the type of chaos we’re seeing at HHS,” she told me. “This is so far from business as usual that we can’t think everything is just fine.”
While the new funding announcement seems like a “deliberate” strategy to undermine Title X, Marcella noted that Title X providers have been remarkably resilient over the years — and, hopefully, that won’t change.
“This network has been able to adapt under a number of administrations to ensure that they can continue to deliver quality family planning in their communities,” she said. “Even with a shift in emphasis that this FOA presents, I think (providers) are still well-positioned to do what they do best.”