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Overview of Family Planning in the United States

According to the Centers for Disease Control and Prevention (CDC), family planning is one of the 10 great public health achievements of the twentieth century, on a par with such accomplishments as vaccination and advances in motor vehicle safety (CDC, 1999). The ability of individuals to determine their family size and the timing and spacing of their children has resulted in significant improvements in health and in social and economic well-being (IOM, 1995). Smaller families and increased child spacing have helped decrease rates of infant and child mortality, improve the social and economic conditions of women and their families, and improve maternal health. Contemporary family planning efforts in the United States began in the early part of the twentieth century. By 1960, modern contraceptive methods had been developed, and in 1970 federal funding for family planning was enacted through the Title X program, the focus of this report.

This chapter provides an overview of family planning in the United States. It begins by explaining the importance of family planning services and the crucial needs they serve. Next is a review of milestones in family planning, including its legislative history. The third section provides data on the use of family planning services. This is followed by a discussion of the changing context in which these services are provided, including changes in the populations served by Title X, changes in technology and costs, the growing evidence base for reproductive health services, and social and cultural factors. The fifth section addresses the financing of family planning. The final section presents conclusions.



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2 Overview of Family Planning in the United States According to the Centers for Disease Control and Prevention (CDC), family planning is one of the 10 great public health achievements of the twentieth century, on a par with such accomplishments as vaccination and advances in motor vehicle safety (CDC, 1999). The ability of individuals to determine their family size and the timing and spacing of their chil- dren has resulted in significant improvements in health and in social and economic well-being (IOM, 1995). Smaller families and increased child spacing have helped decrease rates of infant and child mortality, improve the social and economic conditions of women and their families, and improve maternal health. Contemporary family planning efforts in the United States began in the early part of the twentieth century. By 1960, modern contraceptive methods had been developed, and in 1970 federal funding for family planning was enacted through the Title X program, the focus of this report. This chapter provides an overview of family planning in the United States. It begins by explaining the importance of family planning services and the crucial needs they serve. Next is a review of milestones in family planning, including its legislative history. The third section provides data on the use of family planning services. This is followed by a discussion of the changing context in which these services are provided, including changes in the populations served by Title X, changes in technology and costs, the growing evidence base for reproductive health services, and social and cul- tural factors. The fifth section addresses the financing of family planning. The final section presents conclusions. 2

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0 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM WHY FAMILY PLANNING IS IMPORTANT According to the World Health Organization (WHO), family planning is defined as “the ability of individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through use of contraceptive methods and the treatment of involuntary infertility” (working definition used by the WHO Department of Reproductive Health and Research [WHO, 2008]). The importance of family planning is clear from its benefits to individuals, as well as to families, communities, and societies (AGI, 2003). Family planning serves three critical needs: (1) it helps couples avoid unintended pregnancies; (2) it reduces the spread of sexually transmitted diseases (STDs); and (3) by addressing the problem of STDs, it helps reduce rates of infertility. These benefits are reflected in the federal government’s continued rec- ognition of the contribution of family planning and reproductive health to the well-being of Americans. Responsible sexual behavior is one of the 10 leading health indicators of Healthy People 2010, a set of national health objectives whose goal is to increase the quality of life and years of healthy life. The Healthy People indicators reflect major public health concerns. The United States has set a national goal of decreasing the percentage of pregnancies that are unintended from 50 percent in 2001 to 30 percent by 2010 (HHS, 2000). The objectives for increasing responsible sexual behav- ior are to increase the proportion of adolescents who abstain from sexual intercourse or use condoms if currently sexually active, and to increase the proportion of all sexually active persons who use condoms. The 2007–2012 Department of Health and Human Services (HHS) Strategic Plan is intended to provide direction for the Department’s efforts to improve the health and well-being of Americans. The provision of family planning services promotes several HHS goals, including increasing the availability and accessibility of health care services, preventing the spread of infectious diseases (through testing for STDs/HIV), promoting and encour- aging preventive health care, and fostering the economic independence and social well-being of individuals and families. The contribution of Title X to these goals is discussed in Chapter 3.1 1 Itshould be noted that, despite the clear contributions of family planning to important public health goals, the public varies widely in its attitudes toward family planning and contraception. A large majority (86 percent) of the American public supports family plan- ning services as part of health care for low-income women (where family planning is defined to exclude abortion) (Adamson et al., 2000). However, not everyone wants or believes in birth control. Some believe it should be available for married couples but not for unmarried people or teenagers for fear of encouraging sexual activity. Some religions, notably the Roman Catholic Church, oppose certain methods of contraception, although these strictures often are not followed by their congregants. Recent years have also seen vigorous political debates about emergency contraception (Plan B®), the rights of providers to refuse to offer care that

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 OVERVIEW OF FAMILY PLANNING IN THE UNITED STATES Finding 2-1. The provision of family planning services has impor- tant benefits for the health of individuals, families, communities, and societies. There is a continued need for investment in family planning and related reproductive health services, particularly for those who have difficulty obtaining these important services. Avoiding Unintended Pregnancy The ability to time and space children reduces maternal mortality and morbidity by preventing unintended and high-risk pregnancies (World Bank, 1993; Cleland et al., 2006). Unintended pregnancy is associated with an increased risk of morbidity for the mother and with health-related behaviors during pregnancy, such as delayed prenatal care, tobacco use, and alcohol consumption, that are linked to adverse effects for the child. According to the Institute of Medicine (IOM) report The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families: The child of an unwanted conception especially (as distinct from a mistimed one) is at greater risk of being born at low birth weight, of dying in its first year of life, of being abused, and of not receiving sufficient resources for healthy development. The mother may be at greater risk of depression and of physical abuse herself, and her relationship with her partner is at greater risk of dissolution. Both mother and father may suffer economic hardship and may fail to achieve their educational and career goals. Such conse- quences undoubtedly impede the formation and maintenance of strong families. (IOM, 1995, p. 1) In 2000, approximately half of unintended pregnancies resulted in abortion (Finer and Henshaw, 2006); thus the availability and appropriate use of contraception can also reduce abortion rates (AGI, 2003).2 In addi- tion to preventing unintended pregnancies, effective use of contraceptives (latex condoms) can reduce the transmission of STDs (see the discussion below). When children are adequately spaced (with conception taking place no sooner than 18 months after a live birth, or about 2.5 years between births), they are less likely to suffer complications. Such complications include low birth weight, which is associated with a host of health and developmental problems (Conde-Agudelo et al., 2006). Low birth weight and premature birth are more likely to occur to women under 18 and over 35, and to those who have already had four or more births (WHO, 1994). violates their beliefs, and whether teens have a right to access reproductive health care without parental involvement. 2 By law, Title X funds cannot be used in programs that provide abortion services.

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2 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM In addition to its maternal and infant health benefits, family planning can increase the involvement of partners in decisions about whether and when to have children. One of the most important aspects of helping people plan for pregnancy is helping them avoid unintended pregnancy. Couples who are able to plan their families experience less physical, emotional, and financial strain; have more time and energy for personal and family development; and have more economic opportunities (Cleland et al., 2006). In turn, effective family planning results in fewer strains on community resources, such as social services and health care systems (WHO, 1994). According to the IOM report cited above, women are considered at risk of unintended pregnancy if they “(1) have had sexual intercourse; (2) are fertile, that is, neither they nor their partners have been contracep- tively sterilized and they do not believe that they are infertile for any other reason; and (3) are neither intentionally pregnant nor have they been try- ing to become pregnant during any part of the year” (IOM, 1995, p. 28). Among the nearly 50 million sexually active women aged 18–44, 28 million (56 percent) are at risk of unintended pregnancy (Frost et al., 2008a). Given that the onset of sexual activity increasingly occurs before marriage, when the proportion of pregnancies that are unintended is greatest (see below), the highest proportion of women at risk of unintended pregnancy is found among those aged 18–29 (70 percent), although a significant proportion of women aged 30–44 (40 percent) are also at risk (IOM, 1995). While significant advances have been made in contraceptive technology and the availability of family planning services, rates of unintended preg- nancy in the United States remain high, particularly for certain segments of the population. In 2001, 49 percent of pregnancies were unintended, a rate that had not changed since 1994 (Finer and Henshaw, 2006). In 2001, unintended pregnancies resulted in 1.4 million births, 1.3 million induced abortions, and an estimated 400,000 miscarriages (Frost et al., 2008a). Notably, the United States has high rates of unintended pregnancy compared with other developed countries. For example, the percentage of unintended pregnancies in France is 33 percent and in Scotland 28 percent (Trussell and Wynn, 2008). Unintended pregnancies result in societal bur- den, and significant economic savings are realized through investment in family planning services. The Guttmacher Institute has estimated that every $1.00 invested in helping women avoid unwanted pregnancies saved $4.02 in Medicaid expenditures (Frost et al., 2008b). A variety of factors contribute to unintended pregnancy, including lack of access to contraception, failure of chosen contraceptive methods, less than optimal patterns of contraceptive use or lack of use, and lack of adequate motivation to avoid pregnancy (Frost et al., 2008a). The reasons for the high rate of unintended pregnancies in the United States, particularly in relation to rates in other industrialized countries, are poorly understood.

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 OVERVIEW OF FAMILY PLANNING IN THE UNITED STATES A better understanding of these reasons from the perspective of current, former, and potential users of family planning services is needed (see Chap- ter 5 for discussion of the need for better data collection systems to capture client perspectives). Unintended pregnancy is most likely among women who are young, unmarried, low-income, and/or members of racial or ethnic minorities (see Figures 2-1 through 2-3, respectively), although it occurs in significant num- bers across demographic groups (IOM, 1995). Teenagers and young adults aged 18–24 have the highest rates of unintended pregnancy—more than one intended pregnancy occurred for every 10 women in this age range, which is twice the rate for women overall (Finer and Henshaw, 2006). Unsurprisingly, unintended pregnancies represent the highest proportion of all pregnancies among teenagers and young adults as well, ranging from 100 percent for those under 15, to 82 percent among those aged 15–19, to 60 percent among those aged 20–24 (Finer and Henshaw, 2006). However, teenage pregnancy rates dropped 38 percent between 1990 and 2004, from 116.8 per 1,000 to 72.2 per 1,000 among those aged 15–19 (NCHS, 2008). The pregnancy rate dropped more sharply among teenagers aged 15–17 (from 77.1 per 1,000 in 1990 to 41.5 in 2004, a 46 percent decline) than among those aged 18–19 (167.7 per 1,000 to 118.6 per 1,000, a 29 percent decline). The teenage birth rate also declined over the past two decades, from a peak of 61.8 per 1,000 in 1991 to 40.5 per 1,000 in 2005, a 35 percent decrease. The birth rate among teenagers aged 15–19 increased 3 percent between 2005 and 2006, to 41.9 per 1,000 (NCHS, 2008). Teenage pregnancy rates are currently available only through 2004, but preliminary data suggest that there may also have been an increase in the teen pregnancy rate between 2005 and 2006 (The National Campaign, 2009). With regard to marital status, the rate of unintended pregnancy is significantly higher among unmarried women (67 per 1,000) than among married women (32 per 1,000) (Finer and Henshaw, 2006). Fully 74 per- cent of pregnancies among unmarried women were unintended in 2001, compared with 27 percent of those among married women (Finer and Henshaw, 2006). The rate of unintended pregnancy is also substantially higher among poor women (112 per 1,000) than among women living at or above 200 percent of the federal poverty level (29 per 1,000) (Finer and Henshaw, 2006). The proportion of unintended pregnancies is inversely related to income: among pregnant women living at or below the poverty level in 2001, 62 percent of pregnancies were unintended; in comparison, 38 percent of pregnancies were unintended among women at or above 200 percent of the poverty level (Finer and Henshaw, 2006). However, because women with higher incomes are more likely to have an abortion when they experience an unintended pregnancy, the rate of unintended births among poor women (58 per 1,000) is more than five times greater

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 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM 10 0 80 1994 60 Percent 2001 40 20 0 15 -19 20-24 25 -29 30-34 35 -39 > 40 Age FIGURE 2-1 Percentage of pregnancies that were unintended, by age, 1994 and 2001. Figure 2-5 SOURCE: Finer and Henshaw, 2006. 10 0 80 1994 Percent 60 40 2001 20 0 <100 10 0-199 200 or more Income FIGURE 2-2 Percentage of pregnancies that were unintended, by income as a per- centage of the federal poverty level, 1994 and 2001. Figure 2-2 SOURCE: Finer and Henshaw, 2006. 10 0 80 60 Percent 1994 40 2001 20 0 White Black Hispanic Race and Hispanic Origin FIGURE 2-3 Percentage of pregnancies that were unintended, by race and ethnicity, 1994 and 2001. SOURCE: Finer and Henshaw, 2006. Figure 2-3

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5 OVERVIEW OF FAMILY PLANNING IN THE UNITED STATES than that among women in the highest income category (11 per 1,000) (Finer and Henshaw, 2006). Unintended pregnancy rates are also higher among women with lower levels of education and minority women (Finer and Henshaw, 2006). Preventing Sexually Transmitted Diseases and Reducing Infertility In addition to preventing unintended pregnancies, Title X was designed, particularly after the 1978 amendment, to emphasize services for adoles- cents and infertility services. As discussed later in this chapter, the 1995 program priorities provided for expansion of reproductive health services to include screening for and prevention of STDs, including HIV/AIDS. The diagnosis and treatment of STDs is an essential component of comprehen- sive reproductive health care and, as noted above, also helps reduce rates of infertility. Notable shifts have occurred in the prevalence of STDs. In 1970, gonorrhea was the most prevalent STD (see Figure 2-4). Rates of gonorrhea peaked in 1975 at 464 cases per 100,000 and declined dramatically during the 1980s and early 1990s following the implementation of the national gonorrhea control program in the mid-1970s (CDC, 2007). Rates leveled 500 450 Syphilis Rates per 100,000 Population 400 Chlamydia Gonorrhea 350 300 250 200 150 100 50 0 1970 1975 1980 1985 1990 1995 2000 2005 FIGURE 2-4 Rates of sexually transmitted diseases reported by state health depart- ments per 100,000 population, United States, 1970–2006. NOTE: Chlamydia rates were not reported until 1984. SOURCE: CDC, 2007. Figure 2-4 (originally Figure 3-9) redrawn

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6 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM off during the past decade to a low of 112.4 cases per 100,000 in 2004, but increased in both 2005 and 2006 (to 120.9 cases per 100,000). Changes in screening and reporting practices, as well as the use of varying diagnostic tests, may mask true increases or decreases in the disease (CDC, 2007). Rates of chlamydia (reported since 1984) have steadily increased over time, although the increase in reported infections reflects increased screening activities, improvements in diagnostic testing, stronger reporting require- ments, and better reporting systems, as well as possible true increases in the disease (CDC, 2007). There is evidence that chlamydia is associated with subsequent infertility (Mol et al., 1997; Land and Evers, 2002), although it is not absolutely clear whether routine screening will reduce tubal infertility. However, screening is a CDC recommendation and Healthcare Employer Data and Information Set requirement. In 2006, there were 347 cases of chlamydia per 100,000 individuals in the civilian population. Compared with gonorrhea and chlamydia, rates of syphilis have remained relatively low. In 2006, there were 12.5 cases of syphilis at all stages per 100,000 individuals in the United States. Nonetheless, the disease remains an important problem that is more common in the south and in urban areas in other parts of the country (CDC, 2007). Nonexistent at the time Title X was enacted, HIV/AIDS emerged in the early 1980s, and today more than 1.2 million people in the United States are living with HIV/AIDS. While the number of new AIDS cases and deaths has declined since the early to mid-1990s, the number of Americans living with AIDS has steadily increased (see Figure 2-5). In 2006, the CDC estimated that approximately 1.1 million persons were living with HIV infection, three-quarters of whom were men and one-quarter of whom were women. In 2006, nearly half (48 percent, or 532,000 persons) of all people living with HIV were men who have sex with men (CDC, 2008b). People exposed through high-risk heterosexual contact (which includes those who report specific heterosexual contact with a person known to have or to be at high risk for HIV infection, such as injection drug users) accounted for an additional 28 percent (305,700 persons) of all people living with HIV in 2006 (CDC, 2008b). Minorities, particularly African Americans and Hispanics, are dispro- portionately affected by HIV. While African Americans make up only 12 percent of the U.S. population, they accounted for nearly half (46 per- cent) of all people living with HIV in the United States in 2006. The HIV prevalence rate for African Americans (1,715 per 100,000 population) was almost eight times as high as that for whites (224 per 100,000) in 2006. Hispanics, who make up 15 percent of the total U.S. population, accounted for 18 percent of people living with HIV in 2006. The prevalence rate for Hispanics (585 per 100,000) was nearly three times that for whites (CDC, 2008b).

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7 OVERVIEW OF FAMILY PLANNING IN THE UNITED STATES FIGURE 2-5 Estimated new AIDS cases, 3-10 among persons with AIDS, and Figure deaths bitmap image people living with AIDS, 1985–2004. SOURCE: The Henry J. Kaiser Family Foundation, 2005. This information was reprinted with permission from the Henry J. Kaiser Family Foundation. The Kaiser Family Foundation is a nonprofit private operating foundation, based in Menlo Park, California, dedicated to producing and communicating the best possible in- formation, research, and analysis on health issues. As shown in Figure 2-6, the HIV prevalence rate is far higher among men than women regardless of race or ethnicity. Nonetheless, women are also severely affected, particularly African American and Hispanic women, who experience HIV prevalence rates 18 and 4 times the rate for white women, respectively (CDC, 2008). Finding 2-2. A significant number of people remain at risk for unintended pregnancy, sexually transmitted diseases, and infertility, and therefore are in need of family planning services. MILESTONES IN FAMILY PLANNING The United States saw a dramatic decline in maternal and infant mor- tality, as well as the total fertility rate,3 during the twentieth century. These 3The total fertility rate reflects the total number of live births per 1,000 women aged 15–44.

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 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM 2,500 2,388 Prevalence Rate per 100,000 Population Male 2,000 Female 1,500 1,122 1,000 883 500 395 340 263 220 127 63 46 0 White Black Hispanic/Latino Asian/ American Indian/ Pacific Islander Alaska Native Race/Ethnicity FIGURE 2-6 Estimated HIV prevalence rate per 100,000 population by race and ethnicity and gender, United States, 2006. SOURCE: CDC, 2008b. Figure 2-6 (originally Figure 3-11) redrawn declines are associated with the achievements in family planning that took place in this country during that a vector drawing now period. At the beginning of the twentieth century in the United States, the sub- ject of birth control was not openly discussed. For example, anti-obscenity laws, including the federal Comstock law (March 3, 1873, Ch. 258, § 2, 17 Stat. 599), banned the discussion or distribution of contraceptives. These laws were not declared unconstitutional until 1972 (Eisenstadt v. Baird, 405 U.S. 438). Nonetheless, public interest in and acceptance of birth con- trol increased greatly between 1920 and 1960. Three primary factors fueled these rapid shifts in attitude toward family planning: (1) the changing role of women in American society; (2) concern about population growth; and (3) the availability of new, highly effective contraceptive methods, such as the birth control pill and intrauterine devices (IUDs). Figure 2-7 provides an overview of milestones in family planning in the United States. The women’s movement, which gained ground during the late eigh- teenth and early nineteenth centuries, centered largely on women’s suffrage until the right to vote was won in 1920. The birth control movement was founded around that time by a public health nurse, Margaret Sanger, who argued that women had the right to control their own bodies and fertility,

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1918. Judge Frederick Crane 1937. North Carolina is the rules that New York first state to include birth physicians can legally control in a public health dispense contraceptive program advice and devices for “ therapeutic” purposes 1950s. Americans spend approximately $ 200 million a year on contraceptives. However, more than 30 states prohibit or restrict the 1925. First diaphragms are sale, advertisement, or manufactured in the U.S. provision of birth control 1910 1915 1920 1925 1930 1935 1940 1945 1950 1955 1960 1923. Sanger opens the first legal birth control clinic 1957. The average number of children per U.S. family peaks at 3.7 1916. Margaret Sanger opens the first birth control clinic in America; she is arrested and the clinic is closed FIGURE 2-7 Milestones in family planning in the United States (Part 1 of 3, continues).  SOURCES: AGI, 2000; AMA, 2000; PBS, 2003. Figure 2-1 part 1.eps landscape

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60 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM licly funded family planning agencies more ($11 and $26 per patient per cycle, respectively, in 2005) than the most commonly used oral contracep- tives among Title X clients ($2 per cycle) (Lindberg et al., 2006). In addition to the cost of contraceptive supplies, the cost of diagnostic tests has increased significantly. Federal regulation of clinical laboratories (Clinical Laboratory Improvement Amendments Act of 1988, P.L. 100-578) contributed to increased costs for Pap tests (Dailard, 1999). Costs are also greater for new technologies such as improved Pap smears for the detec- tion of cervical cancer and human papillomavirus, DNA-based tests for chlamydia, and STD/HIV tests. The Growing Evidence Base for Reproductive Health Services Guidelines for reproductive health services issued by professional soci- eties and organizations reflect advances in medical technology and increased understanding that various groups (such as those with low incomes and adolescents) have unique reproductive health and other health care needs. These guidelines are intended to disseminate current clinical and scientific advances. They are issued on a variety of topics by several organizations, most notably the American College of Obstetricians and Gynecologists. Other bodies issuing guidelines, policy statements, opinions, and statements regarding reproductive health services include the Society for Adolescent Medicine, the American Academy of Pediatrics, and WHO. Examples of guidelines that are relevant to family planning are listed in Box 2-1. These guidelines represent the recommendations of experts in the field, and there- fore should play an important role in shaping the delivery of family plan- ning services, particularly to the extent that they have a sound evidence base. Social and Cultural Factors The many guidelines identified above reflect the recognition that effec- tive family planning requires more than the existence of effective biomedical interventions. Family planning by nature requires close attention to social and cultural factors as well. Women and men may experience a number of sociocultural barriers to accessing family planning services, including dis- tance to a family planning provider, difficulty in arranging transportation, limited days and hours of service operation, costs to receive services, long waiting times either to schedule an appointment or to be seen by a provider, poor quality of care, concerns about confidentiality, language barriers for those with limited English proficiency, lack of awareness of the availability of services, and perceived or real cost barriers (discussed further below) (Bertrand et al., 1995; Brindis et al., 2003).

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6 OVERVIEW OF FAMILY PLANNING IN THE UNITED STATES BOX 2-1 Examples of Guidelines for Reproductive Health Care American College of Obstetricians and Gynecologists • 2008—Routine Human Immunodeficiency Virus Screening • 2008— uman Immunodeficiency Virus and Acquired Immunodeficiency H Syndrome and Women of Color • 2007—Intrauterine Device and Adolescents • 2007—Brand Versus Generic Oral Contraceptives • 2006—Primary and Preventative Care: Periodic Assessments • 2006— enstruation in Girls and Adolescents: Using the Menstrual Cycle as M a Vital Sign • 2006—The Initial Reproductive Health Visit • 2006—Psychosocial Risk Factors: Perinatal Screening and Intervention • 2006—Routine Cancer Screening • 2006—Breast Concerns in the Adolescent • 2006— valuation and Management of Abnormal Cervical Cytology and E Histology in the Adolescent • 2006— ole of the Obstetrician-Gynecologist in the Screening and Diagnosis R of Breast Masses • 2005—Racial and Ethnic Disparities in Women’s Health • 2005—Health Care for Homeless Women • 2005— he Importance of Preconception Care in the Continuum of Women’s T Health Care • 2005—Meningococcal Vaccination for Adolescents • 2004— renatal and Perinatal Human Immunodeficiency Virus Testing: P Expanded Recommendations • 2004—Sexually Transmitted Diseases in Adolescents • 2004—Guidelines for Adolescent Health Research • 2004—Cervical Cancer Screening in Adolescents • 2004—The Uninsured • 2003—Induced Abortion and Breast Cancer Risk • 2003—Tool Kit for Teen Care—Lesbian Teens • 2003—Tool Kit for Teen Care—Contraception Society for Adolescent Medicine • 2006—Abstinence-Only Education Policies and Programs • 2006—HIV Infection and AIDS in Adolescents—Update • 2004—Emergency Contraception • 2004— rotecting Adolescents: Ensuring Access to Care and Reporting P Sexual Activity and Abuse • 1981—Reproductive Health Care for Adolescents American Academy of Pediatrics • 1998—Counseling the Adolescent About Pregnancy Options World Health Organization • 2007—Provider Brief on Hormonal Contraception and Bone Health • 2007—Provider Brief on Hormonal Contraception and Risk of STI Acquisition • 2005—WHO Statement on Hormonal Contraception and Bone Health

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62 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Women in rural areas may have particular difficulty finding and obtain- ing family planning services (Frost et al., 2001). Some special populations, such as homeless women (Wenzel et al., 2001) and those who are incar- cerated, may be especially likely to face access and cost barriers. Among teenagers, concern about confidentiality is the most significant barrier to obtaining family planning services (NRC, 2008). Additional barriers for adolescents may include community disapproval of their use of family planning, stigma related to obtaining contraceptives, lack of knowledge about the existence of publicly funded clinics, a perceived lack of affordable services, ambivalence, a history of sexual abuse, and fears of side effects (Frost and Kaeser, 1995; Brindis et al., 2003). Medical barriers can also inhibit the use of family planning services. These barriers include service providers basing care decisions on outdated information or contraindications (IUDs, for example, are underutilized in the United States in part because of outdated information regarding the risks of this contraceptive method [Morgan, 2006]); process or schedul- ing impediments, such as physical exams that clients must undergo before receiving contraceptives; service provider qualifications or regulations that unnecessarily limit the types of personnel who can provide a service; pro- vider bias toward a particular method or procedure; inappropriate manage- ment of side effects; and regulatory barriers (Bertrand et al., 1995). Providing Culturally Appropriate Care The increasing numbers of racial and ethnic minorities in the United States highlight the importance of providing culturally appropriate care to these populations. HHS’s Office of Minority Health has issued Standards for Culturally and Linguistically Appropriate Services (CLAS) in health care, which are directed primarily at health care organizations. Fourteen standards include culturally competent care, language access services, and organizational supports for cultural competence (see Box 2-2). Some of the standards are required for all recipients of federal funds (standards 4, 5, 6, and 7); others are recommended for adoption as mandates by federal, state, and national accrediting organizations (standards 1, 2, 3, 8, 9, 10, 11, 12, and 13); and one is suggested for health care organizations to adopt voluntarily (standard 14). Patient-centered care is also an important goal to improve the func- tioning of the health care system generally. It is particularly important for the delivery of care for underserved populations, including low-income individuals, the uninsured, immigrants, and racial and ethnic minorities (Silow-Carroll et al., 2006). Patient-centered care is defined as “providing care that is respectful of and responsive to individual patient preferences,

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6 OVERVIEW OF FAMILY PLANNING IN THE UNITED STATES BOX 2-2 National Standards on Culturally and Linguistically Appropriate Services (CLAS) 1. Health care organizations should ensure that patients/consumers receive from all staff members effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and prac- tices and preferred language. 2. Health care organizations should implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area. 3. Health care organizations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguisti- cally appropriate service delivery. 4. Health care organizations must offer and provide language assistance ser- vices, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation. 5. Health care organizations must provide to patients/consumers in their pre- ferred language both verbal offers and written notices informing them of their right to receive language assistance services. 6. Health care organizations must assure the competence of language assis- tance provided to limited English proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpre- tation services (except on request by the patient/consumer). 7. Health care organizations must make available easily understood patient- related materials and post signage in the languages of the commonly encoun- tered groups and/or groups represented in the service area. 8. Health care organizations should develop, implement, and promote a writ- ten strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services. 9. Health care organizations should conduct initial and ongoing organizational self-assessments of CLAS-related activities and are encouraged to integrate cultural and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction assessments, and outcomes-based evaluations. 10. Health care organizations should ensure that data on the individual patient’s/ consumer’s race, ethnicity, and spoken and written language are collected in health records, integrated into the organization’s management information systems, and periodically updated. 11. Health care organizations should maintain a current demographic, cultural, and epidemiological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area. continued

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6 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM BOX 2-2 Continued 12. Health care organizations should develop participatory, collaborative partner- ships with communities and utilize a variety of formal and informal mecha- nisms to facilitate community and patient/consumer involvement in designing and implementing CLAS-related activities. 13. Health care organizations should ensure that conflict and grievance reso- lution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers. 14. Health care organizations are encouraged to regularly make available to the public information about their progress and successful innovations in imple- menting the CLAS standards and to provide public notice in their communities about the availability of this information (see http://www.omhrc.gov/templates/ browse.aspx?lvl=2&lvlID=15). needs, and values, and ensuring that patient values guide all clinical deci- sions” (IOM, 2001, p. 40). Beach and colleagues (2006, p. vii) note that proponents of “the patient-centeredness movement, [as well as] pioneers of cultural compe- tence recognized that disparities in health care quality may result not only from cultural and other barriers between patients and health care providers but also between entire communities and health care systems.” Patient- centeredness and cultural competence represent different aspects of quality. Patient-centeredness focuses on better individualized care through improved relationships with the health care system, while the aim of cultural compe- tence is to increase equity and reduce disparities in health care by focusing on people of color or those otherwise disadvantaged. The merging of these movements would help support the current push to develop “patient- centered medical homes” (Bergeson and Dean, 2006; The Patient Center Primary Care Collaborative, 2008) and provide “inter-professional educa- tion for collaborative patient-centered practice” (Health Canada, 2008). In 2000, Approximately 17 percent of the U.S. population (47 million people) spoke a language other than English at home; 7 percent of the population (21 million Americans) had limited English proficiency (Flores et al., 2005; U.S. Census Bureau, 2008d). Meeting the needs of those who are limited English proficient is a challenge for the health care system. Adequate communication between patients and their providers is essen- tial to high-quality medical care. Many clinics have staff, including clini-

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65 OVERVIEW OF FAMILY PLANNING IN THE UNITED STATES cians, who can converse with clients in their own language. In addition, evidence suggests that access to trained interpreters helps improve patient– provider communication, patient satisfaction, and health outcomes, and that quality of care is compromised when interpreters are not provided for those who need them (Flores, 2005). HHS’s Guidance Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons requires agencies that receive federal funding from HHS to ensure that such clients have access to the services provided by the agency (HHS, 2004b). An additional challenge that may affect adequate communication is a patient’s basic literacy in his or her native language. The cost of making interpreter services available and hiring bilingual staff may be a challenge for agencies. Serving the Undocumented Population The Personal Responsibility and Work Opportunity Act of 1996 limits federal Medicaid coverage for noncitizens. Coverage is limited to legal immigrants; no coverage is provided for the undocumented. (Legal immi- grants must have arrived in the United States before 1996 or have resided here for at least 5 years.) However, hospitals must provide emergency medical services to the undocumented, including labor and delivery services (Kullgren, 2003). There have been no large-scale studies of births to undocu- mented women. However, a recent study describes birth outcomes for undocumented women in the state of Colorado (Reed et al., 2005). It indi- cates that, compared with the general population, undocumented mothers were younger, less educated, and more likely to be unmarried. While their infants had better birth outcomes (lower rates of low birth weight and preterm birth) than infants in the general population, they were at greater risk for certain abnormalities (including infant anemia, birth injury, fetal alcohol syndrome, hyaline membrane disease, seizures, and requirements for assisted ventilation) (Reed et al., 2005). Undocumented mothers also experienced higher-risk pregnancies and more complications of labor. Many in the health care community argue that government’s failure to pay for primary and preventive health care services for undocumented noncitizens under the federal Medicaid program places a heavy burden on institutions that care for immigrant populations and also threatens the public’s health (Kullgren, 2003). The limitations on care mean that many immigrant women have no prenatal care and thus receive their first pregnancy-related medical attention when they are about to deliver. Such an absence of prenatal care may result in avoidable problems with a woman’s pregnancy or delivery and the health of the woman or her child. There are efforts at the state level to provide reproductive health services to undocu- mented populations. For example, the state of California recognizes the

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66 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM value of family planning care for this population and its cost-effectiveness, and uses state dollars to support this care when the federal government does not reimburse for these services under the state’s 1115 waiver. Kullgren (2003) argues that this restriction of health services jeopar- dizes legal immigrants’ and citizens’ access to care by making it necessary to review immigration documents, thereby increasing administrative costs and reducing the efficiency-of-care provision. Moreover, failing to cover preven- tive care for the undocumented while requiring hospitals to provide them with emergency care, which is typically more expensive, prevents resources from being used in the most cost-effective manner. Finally, limiting access to care undermines efforts to control the spread of disease among the general population and compromises the ethical obligations of clinicians. Finding 2-4. Providing the many effective methods of birth control now available requires careful attention to the complex social and cultural factors that affect access and utilization. FINANCING OF FAMILY PLANNING Financing for reproductive health services comes from a variety of sources. As noted earlier, the proportion of public funds for family planning contributed by Title X has decreased over the last several decades. In 1980, Title X was the source of 44 percent ($162 million) of all public dollars spent for contraceptive services and supplies (AGI, 2000); by 2006, Title X accounted for just 12 percent ($215.3 million) of public funding (Sonfield et al., 2008a). Medicaid expenditures on family planning followed the opposite trajectory, accounting for 20 percent ($70 million) of total funding in 1980 (Gold et al., 2007) but increasing to 71 percent ($1.3 billion) by 2006 (Sonfield et al., 2008a). In large measure, the growth of Medicaid’s role in family planning has been driven by state-initiated expansions of these services. To date, 27 states have sought and received permission from the Centers for Medicare and Medicaid Services, the federal agency that administers Medicaid, to expand eligibility under the program specifically for family planning (Guttmacher Institute, 2008a). While the expansion efforts in six states are limited and extend eligibility only to individuals who are otherwise losing Medicaid coverage, efforts in the remaining 20 states extend eligibility for family planning based solely on income, regardless of whether the individual has ever been enrolled in Medicaid. Most of these latter states set the income eligibility ceiling for Medicaid-covered family planning services at the same level used to determine eligibility for pregnancy-related care, generally at or near 200 percent of the federal poverty level—well above the usual state-set income ceilings (The Henry J. Kaiser Family Foundation, 2008).

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67 OVERVIEW OF FAMILY PLANNING IN THE UNITED STATES State efforts to expand eligibility for family planning under Medicaid have infused new funding into the system. Two-thirds of the growth in family planning spending nationwide from 1994 to 2006 occurred in states that initiated broadly based Medicaid family planning expansions during that period (Sonfield et al., 2008a). As a result, those states have twice the resources per woman in need of programs in other states.4 Between 1994 and 2001, family planning clinics in states with income-based waivers increased the number of clients served and also increased by one-quarter the proportion of women who received needed family planning care, while clinics in states without waivers experienced no increase at all (Frost et al., 2004). Although the expansion of Medicaid has infused new funds into family planning, tremendous unmet need remains. In 2005, while 12 per- cent of women (7.4 million) aged 15–44 were enrolled in Medicaid, 20.8 percent (12.9 million) remained uninsured (Guttmacher Institute, 2007). Title X offers critical services not offered under other insurance programs (see Chapter 3). Some of the unmet need for family planning services may be attribut- able to increasing gaps in health insurance coverage. The increased cost of insurance has been affected by several factors, including technological advances in medicine, pharmaceutical development, and the aging popula- tion (Heffler et al., 2001). The growing cost of health insurance in turn has led to an increase in the number of people who are uninsured. In 1987, 12.9 percent of Americans lacked health insurance; that figure rose to 15.3 percent in 2007 (see Figure 2-19) (DeNavas-Walt et al., 2008). Among women aged 15–44, 20.8 percent were uninsured in 2005 (Guttmacher Institute, 2007). A high proportion of the uninsured are young: 18 percent are below age 18 and 58 percent below age 34 (U.S. Census Bureau, 2008e). Adults aged 18–34 are disproportionately uninsured relative to their representa- tion in the overall population. This is most likely because younger adults have lower incomes than older adults and are more likely to have jobs without health insurance benefits. Figure 2-20 presents the percentages of the uninsured and of the total population by age group among those below 100 percent of the federal poverty level. While children and the elderly have among the highest rates of poverty, they have the lowest rates of uninsur- ance because of targeted government programs, such as the State Children’s Health Insurance Program and Medicare. Thus the population most in need of family planning is least likely to have health insurance coverage. Those with full-time, year-round employment and an annual income greater than 200 percent of the federal poverty level are most likely to have health insurance (Custer and Ketsche, 2000). However, health insurance 4Unpublished Guttmacher Institute tabulations.

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6 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM 50 Numbers (millions) /Rates (percent) 45.7 million 45 40 35 Number uninsured (millions) 30 Uninsured rate (percent) 25 Recessions 20 15 15.3 percent 10 5 0 1999a 1996 1987 1990 1993 2002 2005 2007 Years FIGURE 2-19 Number of uninsured and uninsured rate, 1987–2007. aImplementation of Census 2000–based population controls occurred for the 2000 Annual Social and Economic Supplement, which collected data for 1999. These estimates also reflect the results of follow-up verification questions that were asked of people who responded “no” to all questions about specific types of health insur- Figure 2-19 (originally Figure 3-12) ance coverage in order to verify whether they were actually uninsured. This change increased the number and percentage ofwn redra people covered by health insurance, bring- ing the Current Population Survey (CPS) more in line with estimates from other national surveys. NOTES: Respondents were not asked detailed health insurance questions before the 1988 CPS. The data points are placed at the midpoints of the respective years. SOURCE: DeNavas-Walt et al., 2008. coverage has become less stable even for those who are employed (National Coalition on Health Care, 2009). Rapidly rising health insurance premiums have prevented many, particularly small, businesses from offering coverage to their employees (DeNavas-Walt et al., 2008). The increase in the number of uninsured has occurred to a large degree among working adults. The percentage of working adults ages 18 to 64 without health coverage was 20.2 percent in 2006 (DeNavas-Walt et al., 2008). In addition to the population of uninsured Americans, millions of adults are underinsured: they have insurance, but their medical costs are high rela- tive to their income. Being underinsured is defined as either (1) having out- of-pocket medical expenses for care amounting to 10 percent of income or more; (2) for low-income adults (below 200 percent of the federal poverty level), having medical expenses amounting to at least 5 percent of income; or (3) having deductibles equal to or exceeding 5 percent of income (Schoen et al., 2008). Schoen and colleagues estimate that in 2007, approximately 25 million people aged 19–64 were underinsured—a 60 percent increase

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6 OVERVIEW OF FAMILY PLANNING IN THE UNITED STATES 60 52 % 50 47% 44% 41% 40 Percent 31% 30 21% 21% 20 17% 17% 17% 16 % 15% 12 % 10 9% 10 % 8% 9% 6% 0 65 and 0-5 6-11 12-17 18 -24 25 -34 35 -44 45 -54 55 -64 older Uninsured Below 10 0% FPL Total Population Below 10 0% FPL FIGURE 2-20 Percentage of uninsured and total U.S. population below 100 percent of the federal poverty level (FPL), by igure 2-20 Fage, 2007. SOURCE: U.S. Census Bureau, 2008e. since 2003. In total, the authors report that 42 percent of adults under age 65 are uninsured or underinsured. Even those who have employer-based insurance may find that basic family planning services are not a covered benefit. In 2003, 7 percent of health plans did not cover an annual obstetrical and gynecologic visit, 12 percent did not cover oral contraceptives, 13 percent did not provide payment for sterilization, and 28 percent did not cover all major types of contraceptives. Health maintenance organizations were more likely to cover contraceptives and sterilization than were preferred provider organizations or point-of-service plans (Klerman, 2006). This situation has improved in recent years, and by 2008, 24 states required insurers that cover prescrip- tion drugs to also provide coverage for any FDA-approved contraceptive (National Conference of State Legislatures, 2009); however, it is important to recognize that state mandates do not apply to self-insured plans. Women find it particularly difficult to obtain coverage in the individual insurance market. They are frequently charged higher premiums than men and have difficulty finding affordable coverage for maternity care. They can also have difficulty finding affordable coverage for prescription drugs, such as contraceptives.

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70 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM CONCLUSIONS The following conclusions emerged from the committee’s review of the literature on the role and history of family planning in the United States: The provision of family planning services has important ben- efits for the health and well-being of individuals, families, communi- ties, and the nation as a whole. Planning for families—helping people have children when they want to and avoid conception when they do not—is a critical social and public health goal. The federal government has a responsibility to support the attainment of this goal. There is an ongoing need for public invest- ment in family planning services, particularly for those who are low income or experience other barriers to care.