For more than 40 years, Title X has provided family planning and reproductive health services to millions of American women. More recently, conservative lawmakers have targeted Title X as part of their obsession with shrinking the social safety net and restricting access to women’s health care. Those same opponents are now likely to argue that the Affordable Care Act’s (ACA) focus on women’s health renders Title X unnecessary. But as I argue in my new paper published by the Roosevelt Institute, that is simply not the case. In reality, the success of the ACA and the health of women across the country are dependent on even greater support for existing family planning programs.
Title X is the nation’s only program solely dedicated to family planning. It was passed into law in 1970 with overwhelming bipartisan support and can in fact be credited to two Republican presidents: Richard Nixon, who signed the bill into law, and then-Congressman George H.W. Bush, who led the legislative effort. It provides critical medical care to low-income, immigrant, and young women and enables clinics to pay for and maintain facilities, train and hire staff, and purchase equipment and supplies.
Despite being perennially underfunded, the program delivers incredible health results. Last year it served 4.76 million women, preventing an estimated 996,000 unintended pregnancies, 200,000 of which were among teens. Research has shown that services provided at Title X clinics save federal and state governments more than $3 billion every year.
As millions of Americans gain health coverage for the first time thanks to the ACA, clinics funded by Title X will become an even more critical building block of our nation's health system. Even when individuals obtain coverage, many will continue to choose publicly funded clinics as their main source of care. In the four years following the implementation of Massachusetts’ health care reform, which served as the model for the ACA, publicly funded health centers experienced a 31 percent increase in patients, even though the number of uninsured visiting those facilities fell by more than 15 percent.
Even women who are already fully insured will continue to rely on Title X clinics for family planning because they can do so in complete confidence. Issues like intimate partner violence and religious beliefs of employers, family, and partners, cause many women to circumvent their insurance plans when accessing family planning services and instead rely on public providers.
The fact is, despite the GOP’s relentless strategic misinformation campaigns and the technology problems that bedeviled the rollout this month, the ACA is good for women. It mandates that insurance plans fully cover all methods of contraception, prohibits gender discrimination and denial of care based on pre-existing conditions, and enables young people to stay on their parent’s plans until they are 26. It requires plans to cover pap tests, STD screening, preconception and prenatal care visits, postpartum counseling and breastfeeding support, and one well visit a year. Make no mistake: this is groundbreaking.
Despite these historic advancements, many women will remain uninsured in the years to come. There are lots of reasons for this, not the least of which is the refusal of many states to accept federal funding for the expansion of Medicaid.
The ACA was intended to be a path to health care for all Americans, and a major pillar of the law was the expansion of Medicaid to all individuals who fall below 138 percent of the federal poverty level ($15,415 for an individual or $26,344 for a family of three), with subsidies for individuals above that level to buy insurance in the marketplaces. But last year the Supreme Court ruled that the federal government could not constitutionally require states to expand Medicaid, and conservative lawmakers pounced on the opportunity to block a major component of the ACA.
Today, 22 states refuse to expand Medicaid even though the federal government will foot 100 percent of the bill for the first three years and cover at least 90 percent of the cost after that. These states are denying care to more than 3.5 million low-income women who badly need it. The New York Times reportedthat as a result, two-thirds of poor black and single mothers and more than half of uninsured, low-wage workers will remain without coverage.
Basically, women who fall into the coverage gap are not considered poor enough for Medicaid by their states, but because the ACA originally intended for them to be covered by the expansion, they also don't qualify for subsidies. And even if they did, the cost of subsidized insurance would likely still be prohibitive given their income level. These individuals will have no choice but to rely on the social safety net – in this case, Title X-funded clinics – for care.
The very critics who have staked their political careers on sinking the ACA and preventing scores of women from accessing family planning services – and who shut down the government in an attempt to do so – would love nothing more than to do away with Title X. They have tried unsuccessfully in recent years, and the program will certainly be in their crosshairs as they continue to chip away at the host of social programs on which low-income women rely.
The ACA, while an enormous advancement for women’s health, does not eliminate the need for the Title X program. Rather, Title X will maximize the impact and reach of the ACA and ensure quality care for those who will remain uninsured.
In the forthcoming budget battles, women’s health advocates will have to fight tooth and nail to maintain Title X’s current funding level, which has already been diminished by sequestration. The program is as critical today as it was when it was created. Today’s very different breed of GOP lawmakers could use a reminder that it was their own party four decades ago that realized investing in family planning was a critical way to improve the health of women, communities, and the entire nation. Who ever thought we’d be longing for Nixon?
Read Andrea's paper, "The Title X Factor: Why the Health of America's Women Depends on More Funding for Family Planning," here.