3
Title X Goals, Priorities, and Accomplishments

The mission of the Title X program as stated in statute (see Appendix B) is to provide grants to public or nonprofit private entities “to assist in the establishment and operation of voluntary family planning projects which shall offer a broad range of acceptable and effective family planning methods and services (including natural family planning methods, infertility services, and services for adolescents).” According to the Title X Program Guidelines (see Appendix D), the program’s mission is “to provide individuals the information and means to exercise personal choice in determining the number and spacing of their children” (OFP, 2001, p. 2).

Clinics supported by the Title X program provide basic contraceptive care; related preventive health services, such as patient education and counseling; breast and pelvic examinations; screenings for cervical cancer and sexually transmitted diseases (STDs)/HIV; and pregnancy diagnosis and counseling. In addition, the Title X program helps clinics respond to patients’ needs by supporting training for family planning clinic personnel, information dissemination and community-based education and outreach activities, and data collection and research to improve the delivery of family planning services. In 2006, the most recent year for which national-level data on the program are available, care was provided to almost 5 million women, men, and adolescents in clinics supported by the program (RTI International, 2008). Consistent with the congressional directive to give priority to low-income individuals, 67 percent of Title X clients have incomes below 100 percent of the federal poverty level, and 90 percent have incomes below 200 percent of that level (RTI International, 2008).



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3 Title X Goals, Priorities, and Accomplishments The mission of the Title X program as stated in statute (see Appendix B) is to provide grants to public or nonprofit private entities “to assist in the establishment and operation of voluntary family planning projects which shall offer a broad range of acceptable and effective family planning methods and services (including natural family planning methods, infertility services, and services for adolescents).” According to the Title X Program Guidelines (see Appendix D), the program’s mission is “to provide individuals the infor- mation and means to exercise personal choice in determining the number and spacing of their children” (OFP, 2001, p. 2). Clinics supported by the Title X program provide basic contraceptive care; related preventive health services, such as patient education and counseling; breast and pelvic examinations; screenings for cervical cancer and sexually transmitted diseases (STDs)/HIV; and pregnancy diagnosis and counseling. In addition, the Title X program helps clinics respond to patients’ needs by supporting training for family planning clinic per- sonnel, information dissemination and community-based education and outreach activities, and data collection and research to improve the deliv- ery of family planning services. In 2006, the most recent year for which national-level data on the program are available, care was provided to almost 5 million women, men, and adolescents in clinics supported by the program (RTI International, 2008). Consistent with the congressional directive to give priority to low-income individuals, 67 percent of Title X clients have incomes below 100 percent of the federal poverty level, and 90 percent have incomes below 200 percent of that level (RTI Interna- tional, 2008). 7

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72 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM While the core mission of the program has remained clear over the years, a shifting and expanding set of operational priorities, along with a growing number of individuals requesting care and increasing expenses with no significant expansion in funding, has made it difficult for the pro- gram to fulfill that mission. This chapter begins by reviewing the original goals of the program and amendments to the law. It then examines shifts in program emphasis since 1970 and the problems associated with these shift- ing emphases. The third section presents the committee’s findings regarding the extent to which the program has fulfilled its mission and goals. The final section offers conclusions and recommendations. ORIGINAL GOALS AND AMENDMENTS TO THE LAW In establishing the Title X program, Congress made clear that one major goal was to decrease the adverse health and financial effects on children, women, and their families of inadequately spaced childbearing (S. Rep. 91-1004, 91st Cong., 2d Sess., July 7, 1970; H. Rep. No. 91-1472, 91st Cong., 2d Sess., September 26, 1970; Family Planning Services and Popula- tion Research Act of 1970, P.L. 91-572 [1970]). Congress also emphasized that services offered through Title X were to be thoroughly voluntary. The Senate commented that the program “is properly a part of comprehensive health care and should consist of much more than the dispensation of birth control devices” (S. Rep. 91-1004, 91st Cong., 2d Sess., July 7, 1970, p. 10). The Senate cited with apparent approval the recommendations of a promi- nent family planning director for: 1. Medical services, including consultation, examination, prescrip- tion, and continuing supervision, supplies, instruction, and referral to other medical services as needed. 2. Outreach/follow-up systems, including patient identification, con- tact, recruitment, appointment support, follow-up, and continuing education. 3. Planning, evaluation, development, and coordination, including application of modern management technology to a goal-oriented program. 4. Financial management to assure a cost-effective, efficiently run program. 5. Research, both of an operational and a clinical nature, to be built into the medical and evaluation systems. 6. Social and ancillary services, including such necessary and support- ive services as gonorrhea screening and social as well as medical services for teenagers.

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7 GOALS, PRIORITIES, AND ACCOMPLISHMENTS 7. Community education, to bring to the various parts of the commu- nity an understanding of the goals and importance of the program. It is important to add that when the Title X program was established, it also reflected current concern that the United States and the world faced serious risks as the direct result of unfettered population growth (Nixon, 1969) (see also Chapter 2). Indeed, the formal name of the bill was the “Family Planning Services and Population Research Act of 1970.” The new legislation was designed to address the population challenge directly by dramatically expanding voluntary family planning services. Before the introduction of modern contraceptive methods, many women, particularly low-income women, had more children than they desired (H. Rep. No. 91- 1472, 91st Cong., 2d Sess., September 26, 1970; e.g., comments of Rep. Hawkins, Cong. Rec. H37369 and Rep. Kyros, Cong. Rec. H37381-2, November 16, 1970). The basic rationale for the new law was that through an aggressive effort by the government to make family planning services fully available and affordable, couples would have only the number of chil- dren they desired, and that as a result, the rate of U.S. population growth would decrease and ultimately stabilize (Nixon, 1969). The optimism evident when the program was enacted is worth not- ing as well. Family planning was presented as a highly effective approach to reducing a broad range of maternal and infant health problems and as essential to abolishing poverty (Congressman Hawkins, Cong. Record- House 37369, November 16, 1970). Its overall benefits to communities and, indeed, the nation were cited with enthusiasm—a perspective that has repeatedly been affirmed (IOM, 1995). Supporters specifically mentioned the widespread and growing use of oral contraceptives and intrauterine devices (IUDs) and the pressing need to give low-income women the same access as more affluent women and couples to these methods and to fam- ily planning counseling and education more generally (Hearings before the Subcommittee on Health of the Committee on Labor and Public Health, December 8–9, 1969, and February 19, 1970; e.g., comments of Rep. Hawkins, Cong. Rec. H37369 and Rep. Kyros, Cong. Rec. H37381-2, November 16, 1970). As Senator Tydings of Maryland stated in 1969, “The right to plan to size one’s family is an inalienable individual right, as impor- tant as the right to a job and a decent education in this country” (Hearings before the Subcommittee on Health of the Committee on Labor and Public Health, December 8–9, 1969, and February 19, 1970). Congress empha- sized the importance of training for practitioners, research to strengthen the evolving field, the development of educational methods, and accountability to Congress. Supporters argued that by increasing public investment in fam- ily planning services, training, and research, the United States would not

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7 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM only meet a major domestic need but also serve as an international leader in addressing population pressures (Nixon, 1969). Finding 3-1. Family planning is a fundamental component of health care. Congress has amended the law on several occasions, three of which involved substantive changes. Changes made in 1975 (1) increased report- ing requirements to “address and assess the availability and adequacy of family planning services for the general population, and identify the deficiencies in the provision of services to certain groups and subgroups” (Conf. Rep. No. 94-348, 94th Cong., 1st Sess., July 11, 1975); (2) clari- fied the definition of “low-income family” to maximize inclusiveness; and (3) required that family planning projects “offer a broad range of accept- able and effective family planning methods (including natural family plan- ning methods)” (P.L. 94-63, 89 Stat. 304, July 29, 1975). Congress amended the law again in 1978 to make clear its intent that services be provided to adolescents, to address infertility services, and to protect providers who conscientiously object to abortion or sterilization (P.L. 95-613, 92 Stat. 3093, November 8, 1978). In 1981, Congress added a requirement that adolescents be encouraged to talk with their parents about family planning (P.L. 97-35, August 13, 1981). However, Congress specifically rejected requiring parental notification and, significantly, chose to retain Title X as a categorical grant program rather than rolling it into block grants to states as was common at that time (H. Conf. Rep. 97-208). In addition, yearly appropriations were to include provisions that grantees must comply with state laws requiring reporting of “child abuse, child molestation, sexual abuse, rape, or incest” (HHS, 2004a). Shortly after the program was established, Congress dramatically expanded its funding, which peaked in 1980. Since then, however, real funding has declined significantly in relation to inflation; to the increase in the U.S. population (now almost twice as large as in 1970); and to the increasing costs of medical services and supplies, especially the more effec- tive methods of family planning, such as IUDs. Taking inflation alone into account, funding for Title X in constant dollars was 62 percent lower in fiscal year (FY) 2008 than in FY 1980 (Sonfield, 2009) (see the further discussion of program funding in Chapter 4). SHIFTS IN PROGRAM EMPHASIS Within its statutory framework, Title X has developed (1) Program Guidelines that indicate required services, (2) annual program priorities and key issues, and (3) performance measures developed in response to

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75 GOALS, PRIORITIES, AND ACCOMPLISHMENTS the Program Assessment Rating Tool (PART) review (see Chapter 1). To learn more about these three systems and about the program’s opera- tions, the committee conducted a series of site visits and public work- shops during which grantees, delegates, and other stakeholders provided their perspectives on the strengths of and challenges facing Title X. The information thus gathered indicated to the committee that, despite the program’s many accomplishments and the optimism that clearly existed at its outset, several problems undermine its ability to achieve its goals. In particular, many Title X grantees suggested that the program’s specific operational priorities lack clarity and frequently change without either an orderly process or a basis in strong science or basic public health principles. To understand this concern in greater depth, the committee carefully examined the Program Guidelines, the annual program priorities and key issues, research and training priorities, program leadership, and the PART process. Program Guidelines The Program Guidelines set out clearly the scope of services that must be provided by all clinics funded by the program, as well as criteria by which the quality of care is to be measured to ensure uniformity across all regions. The guidelines were last updated in 2001. According to the guide- lines, each Title X clinic must offer the following: • Client education and counseling, including specialized counseling; • History, physical assessment, and laboratory testing, including breast and cervical cancer screening; • Fertility regulation, including provision of contraceptive methods and/ or prescriptions for contraceptive supplies and other medications; • Basic infertility services; • Pregnancy diagnosis and counseling; • Adolescent services, including abstinence counseling and counseling to minors on how to resist attempts to coerce them into engaging in sexual activities; • Reporting of child abuse, child molestation, sexual abuse, rape, or incest; • Identification of estrogen-exposed offspring; • Gynecological services; • STD and HIV/AIDS prevention education, screening, and referral; • Genetic information and referral; • Health promotion and disease prevention; and • Postpartum care.

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76 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM This expansive list poses problems. While most providers and program administrators wish to offer as broad a range of services as possible for Title X clients, many of whom have no other source of care, the limited amount of funding available means that not all these services can be pro- vided at a high level of quality to all who want them. Nor are all mandated services appropriate for all clients. Some of these requirements might be eliminated, or they might be prioritized (for example, categorized as essen- tial, highly desirable, or optional). A related issue, the need to update the guidelines, is discussed in Chapter 4. Annual Program Priorities and Key Issues In addition to the general program requirements outlined in the Pro- gram Guidelines, the program is subject to annual program priorities that change and expand frequently, sometimes in response to congressional mandate or directives of the Office of Inspector General. Each year the Office of Family Planning (OFP) establishes these program priorities, which are published in the annual announcements of funding availability issued by the Office of Population Affairs (OPA), and applicants must address them in their annual requests for support (see Box 3-1 for the 2009 priorities). Several priorities appear each year, while others are added or deleted. For example: • In 1995, a call was made for applicants to propose ways to increase the involvement of male partners, focus on HIV prevention and STD and cancer screening and prevention, and attend to both training and retaining nurse practitioners specializing in women’s health. • In 1996, increasing outreach to males was added. • In 1999, the priorities included expanding and enhancing part- nerships with entities that have “related interests and work with similar priority populations.” • In 2001, an emphasis on clinical services for difficult-to-reach populations, such as the uninsured or underinsured, substance abusers, migrant workers, and the homeless, became a priority. • In 2003, abstinence education was added to the list of priorities, and persons with limited English proficiency were added to the difficult-to-reach populations that grantees are to address. • In 2003, applicants were directed to encourage family participa- tion in the decisions of minors to seek family planning services by including activities that promote positive family relationships; they were also directed to partner with faith-based organizations. • In 2006, ensuring compliance with state laws requiring notification or reporting of child abuse, child molestation, sexual abuse, rape,

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77 GOALS, PRIORITIES, AND ACCOMPLISHMENTS BOX 3-1 2009 Program Priorities 1. Assuring the delivery of quality family planning and related preventive health services, where evidence exists that those services should lead to improve- ment in the overall health of individuals, with priority for services to individuals from low-income families; 2. Assuring access to a broad range of acceptable and effective family planning methods and related preventive health services that include natural family planning methods, infertility services, and services for adolescents, includ- ing adolescent abstinence counseling. The broad range of services does not include abortion as a method of family planning; 3. Providing preventive health care services in accordance with nationally recog- nized standards of care. This includes, but is not limited to, breast and cervical cancer screening and prevention services; sexually transmitted disease (STD) and HIV prevention education, testing, and referral; and, other preventive health services; 4. Assuring compliance with State laws requiring notification or the reporting of child abuse, child molestation, sexual abuse, rape, or incest; 5. Encouraging participation of families, parents, and/or legal guardians in the decision of minors to seek family planning services; and providing counseling to minors on how to resist attempts to coerce minors into engaging in sexual activities; and 6. Addressing the comprehensive family planning and other health needs of in- dividuals, families, and communities through outreach to hard-to-reach and/or vulnerable populations, and partnering with other community-based health and social service providers that provide needed services. or incest was added to the list of priorities. In addition, programs were encouraged to provide counseling to minors on how to resist attempts to coerce them into engaging in sexual activities. New directions in service priorities are often announced with little advance notice and without a clearly articulated rationale. These changing mandates pose a number of challenges. Given static funding levels, they have required grantees to adjust existing services to meet the new priori- ties. Some grantees feel that the Central Office does not elicit enough input from them and from delegates about how decisions regarding priorities will affect them1 (The Lewin Group, 2009). As a result, according to testi- 1 Grantees have an opportunity to express their concerns at the national grantee meeting hosted biennially by the Central Office, but this venue does not allow for such communications at an individual level. This situation is improved somewhat by the attendance of Central Office staff members at annual regional meetings (time and money permitting), which grantees con- sider a very effective way of communicating information directly (The Lewin Group, 2009).

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7 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM mony heard by the committee, many grantees have the impression that the shifts are often politically driven and not based on an orderly assessment of population needs or ways to achieve more effective service delivery or improved outcomes. In addition to the program priorities, OFP lists key issues in the annual funding announcement (see Box 3-2 for the key issues for 2009). OFP states that these issues have implications for and should be considered by Title X service providers. The key issues have remained the same for the past several years. The committee learned that there is no strategic process for establishing or revising the program priorities or key issues. It also appears that there is no organized system within the program for evaluating the latest scientific evidence, or for seeking advice and guidance from the scientific community or from program providers about emerging needs and how the program BOX 3-2 2009 Key Issues 1. Cost of contraceptives and other pharmaceuticals; 2. Efficiency and effectiveness in program management and operations; 3. Management and decision making through performance measures and accountability for outcomes; 4. Linkages and partnerships with community-based and faith-based organizations; 5. Addressing CDC’s “Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings,” and incorporat- ing “ABC” concepts for HIV prevention counseling (that is, “A” for extramarital abstinence; “B” for be faithful in marriage or committed relationships; and “C” for correct and consistent condom use). For individuals at increased risk for contracting or transmitting HIV, the message should include “A,” “B,” and “C” (added in 2003); 6. Compliance with HIPAA (Health Insurance Portability and Accountability Act) and the Infant Adoption Awareness Act (added in 2003); 7. The use of electronic technologies, such as electronic grants management capabilities, electronic health information infrastructures, electronic access to health quality information, and similar electronic systems (added in 2006); 8. Data collection (such as the Family Planning Annual Report [FPAR]) for use in monitoring performance and improving family planning services; 9. Service delivery improvement through translation into practice of research outcomes that focus on family planning and related population issues; and 10. Utilizing practice guidelines and recommendations, developed by recognized national professional organizations and federal agencies, in the provision of evidence-based Title X clinical services.

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7 GOALS, PRIORITIES, AND ACCOMPLISHMENTS could or should adapt to meet them. During testimony at the committee’s public workshops, program administrators reported that changing program priorities impede orderly program functioning and also add significant stress to the application process. Research Priorities As 90 percent of Title X funds must be devoted to services, a very small portion of the funds are used for research. Even so, OPA issues an annual announcement on the availability of research funds and seeks applications. The committee examined the research portfolio of the Title X program (see Appendix I), keeping in mind the intent of Congress that the program’s research efforts would serve to improve the delivery of family planning ser- vices. OPA determines research priorities in a variety of ways, both internal and external. Internal processes include meetings among OPA staff mem- bers to determine priorities, as well as more informal means. External pro- cesses include working groups convened by OPA to help identify research gaps and needs. For example, in 2004 OPA contracted with the Urban Institute to convene and consult with an expert panel. This effort resulted in a document entitled Future Directions for Family Planning Research: A Framework for Title X Family Planning Delivery Improvement Research (see Chapter 5 for further discussion of the findings of this panel). OPA also takes note of field and other formative research that may indicate particu- lar directions that would strengthen the Title X program’s overall delivery of services. This type of information, for example, led OPA to determine that the program needed to focus on how to serve males more effectively. Neither relevant research communities nor family planning providers them- selves (Title X recipients or others) are consulted in any systematic way about the issues they believe require research. Perhaps more important, the committee learned that OPA has no formal advisory structure or board to assist in identifying research priorities over time or assess the many research ideas that arise. National Training Priorities The overall Title X training priority is “providing training to Title X providers on improving clinic efficiency in an effort to address increasing costs of health care without sacrificing quality” (OPA, 2007). Each regional training center is awarded special funding for this purpose. In addition to focusing on the main priority, grantees are expected to provide training to help providers in:

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0 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM 1. Addressing clinical training needs of Title X providers and collabo- rating with the National Family Planning Clinical Training Center; 2. Encouraging family participation in the decision of minors to seek family planning services and providing counseling to minors on how to resist attempts to coerce minors into sexual activities, and complying with state laws requiring the notification or reporting of child abuse, child molestation, sexual abuse, rape, or incest; and 3. Integrating HIV prevention activities into Title X services. Training priorities are determined by training needs that cut across regions. However, there has been little assessment of the effectiveness of training in achieving these goals. Program Leadership A number of people who testified before the committee reported concern about the OPA leadership (particularly the Deputy Assistant Secretary for Population Affairs), which has changed frequently in recent years (see also the section titled “Effect of Political Issues on Program Administration and Management” in Appendix J). Since 1994, the leadership has turned over 12 times (personal communication from OFP, September 2, 2008). For 3 of the last 8 years, the office of the Deputy Assistant Secretary for Popula- tion Affairs was vacant and managed by federal career leadership. Some who have held this position have lacked relevant medical, public health, or family planning experience (Lee, 2006, 2007). Some also have had no his- tory of commitment to the full mission of Title X, such as providing family planning services to minors, a situation that has created uncertainty among grantees regarding the direction of the program and its priorities. Some speakers who testified before the committee argued that the program has not been adequately protected from controversies rooted in the nation’s ongoing “culture wars” about such sensitive issues as abortion (which Title X funds do not support), parental consent for contraceptive services to minors, and sexual activity among unmarried individuals. The importance of shielding the Title X program from polarization on such issues was emphasized in 1969 by then Representative, now former President George H. W. Bush, who stated: We need to make population and family planning household words. We need to take sensationalism out of this topic so that it can no longer be used by militants who have no real knowledge of the voluntary nature of this program, but rather are using it as a political steppingstone. If family planning is anything, it is a public health matter. (115 Congressional Record H4207 [February 24, 1969] [statement of Rep. Bush])

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 GOALS, PRIORITIES, AND ACCOMPLISHMENTS Finding 3-2. The political and social pressures and arguments that surround Title X have adversely affected the program’s operations and eroded morale among those who operate the program. Program Assessment Rating Tool (PART) Process The committee examined the PART process to gain further insight into the program priorities of Title X and their stability over time. For the Title X PART process, OFP stated that the program’s purpose is to: provide individuals the medical, educational and social services necessary to (1) exercise personal choice in determining the number and spacing of their children, and (2) ensure their reproductive health and well-being (through prevention of STDs, HIV and routine cancer screenings), with a priority given to low-income persons. By increasing utilization of family planning services within underserved populations, and by providing pre- ventive health care that prevents the acquisition and spread of STDs and HIV, the program seeks to improve the health of individuals who would otherwise not have access to family planning and related preventative health services. (OMB, 2005, Section 1.1) OFP developed three long-term measures intended to reflect the pur- pose of the program and its progress in achieving its goals. As noted in the 2005 PART, “these long-term measures are linked to Healthy People 2010 and are responsive to both the Health Resources and Services Administra- tion’s (HRSA’s) long-term plan and the HHS Strategic Goals and Objectives, reflected in the FY HRSA budget/performance integration plan” (OMB, 2005, Section 2.1). The measures are as follows: 1. Increase the number of unintended pregnancies averted by provid- ing Title X Family Planning services, with priority for services to low-income individuals; 2. Reduce infertility among women attending Title X Family Planning clinics by identifying chlamydia infections through screening of females ages 15–24; and 3. Reduce invasive cervical cancer among women attending Title X Family Planning by providing Pap tests. OFP’s choice of these three long-term measures reflected guidance from the Office of Management and Budget (OMB), which suggested that the measures (1) reflect health outcomes; (2) be obtainable and capable of being documented; and (3) reflect the mission of the program, as well as federal and nonfederal clinical and preventive health practice and guidance. All of

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0 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM TABLE 3-2 Target Versus Actual Number of Chlamydia Screenings Among Female Clients of Title X Clinics Ages 15–24, 2005–2011 Actual Year Target 2005 Baseline: 1,349,884 2006 1,398,000 1,353, 319 2007 1,398,000 1,361,901 2008 1,352,000 Fall 2009 2009 1,349,000 Spring 2010 2010 1,347,000 Spring 2011 2011 1,345,000 Spring 2012 SOURCE: OMB, 2009. annual screening has become a standardized Healthcare Employer Data and Information Set measure for sexually active adolescents (ages 15–24) (USPSTF, 2007). The Centers for Disease Control and Prevention (CDC) has partnered with the Title X program and provided funding for addi- tional chlamydia screenings and treatment, reflecting the priority it places on preventing infertility and its recognition of the critical role of Title X grantees in reaching many of the same clients CDC is interested in serving. As an indicator of the performance of Title X’s clinics, the ability to screen this age group effectively and in compliance with national standards is a key quality measure. As illustrated in Table 3-2, in 2006 Title X clinics performed chlamydia screening for approximately 1.4 million clients aged 15–24 (OMB, 2009), the age group at highest risk of this disease, numbering approximately 42 million in the United States (U.S. Census Bureau, 2007). While the FPAR provides information on the numbers of screens conducted, it is currently not feasible to track individuals longitudinally and match clients who were screened with those who were found to have a positive screen and received treatment. As a result, it is difficult to assess how successful the program has been in treating chlamydia infections. Overall, more sensitive and noninvasive chlamydia screenings of both men and women have resulted in larger numbers of individuals being screened and more accurate reporting of the actual incidence of this disease. While screenings are clearly increasing, however, it is not possible to link screening to decreased infertility given the data systems maintained by OPA. Establishing this link would require a significant investment in tracking and following clients until they were ready to become pregnant. Reducing the Rate of Invasive Cervical Cancer by Providing Pap Tests While OFP has no historical data available on this measure, and national standards for prevention of and screening for invasive cervical cancer are

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 GOALS, PRIORITIES, AND ACCOMPLISHMENTS TABLE 3-3 Number of Pap Tests Performed and Target Versus Actual Number of Title X Clients Found to Have Invasive Cervical Cancer Following Pap Tests, 2005–2011 Pap Tests Target Actual Year 2005 2,447,498 Baseline: 808 2006 2,326,153 809 799 2007 809 798 2008 800 Spring 2009 2009 798 Spring 2010 2010 796 Spring 2011 2011 795 Spring 2012 NOTE: The number of pap tests performed was identified from the 2005 and 2006 FPARs produced by RTI International. All other information was found in the 2009 Family Planning Program Assessment Details. SOURCES: RTI International, 2006, 2008; OMB, 2009. evolving, OFP is moving toward establishing targets for this performance measure. The baseline of clients who are diagnosed with invasive cervical cancer is approximately 800 new cases on an annual basis (see Table 3-3). Given the age and ethnic/racial profile of these clients, OFP anticipates similar outcomes for the next 5 years. However, these targets are likely to change over time as the number of Latina women, who have a greater incidence of cervical cancer, increases (Ries et al., 2008); as the program documents more specific data on the actual number of clients screened and detected as having invasive cervical cancer; and as the human papillomavirus vaccine is more widely implemented. As discussed earlier, the committee considers this performance measure to be less central to the program’s mission than the previous two. Maintaining the Actual Cost per Family Planning Client Below the Medical Care Inflation Rate In accordance with the PART process, OFP established an efficiency measure—to keep the cost per client below the medical care inflation rate. According to the PART review, “Over the past several years the Family Planning program has continued to demonstrate both increasing efficiencies and cost effectiveness. The Title X service sites have seen more users per site while requiring less revenue per user. Between 1998 and 2002, the total adjusted revenue per user in Title X projects decreased 5%. During this same time period, the average number of users per service site, across all regions, increased 11%” (OMB, 2005, section 4.3). According to HRSA’s 2009 performance appendix, there was a “small decrease (1.49%) in over- all users between 2004 and 2006 [that] suggests a continuing leveling off

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2 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM trend in client numbers, following the more substantial gain experienced between 2000–2001 when additional funds were provided to the Program” (HRSA, 2008, p. 141). The baseline for efficiency—measured as the cost per Title X client in a given year relative to the cost in 2004 increased by the rate of medical inflation between 2004 and that year—was established in 2004, with tar- gets provided for 2005–2013. To calculate the efficiency measure, the total revenue from all Title X clinics is divided by the number of unduplicated Title X users. The result is compared with the change from the previous year and with the increase in the consumer price index (CPI) for medical care. The baseline was established at $193.92 per client (see Table 3-4). According to HRSA, “In 2006 the actual cost per client was $215.56, $8.41 less than the targeted projection. This resulted in cost avoidance of approximately $42 million in client costs. The program has consistently met or come under the annual target for this measure and historically has kept its increase in total cost per client below that of the CPI for medical care costs” (HRSA, 2008, p. 143). The committee does not believe, however, that revenue per client is the same as cost per client. To determine whether cost per client has increased at a lower rate than overall medical care inflation, OFP would have to control for the mix of patients seen (women, men, adolescents), as well as the major reason for the clinic visit (e.g., to obtain contraception or counseling). The committee questions whether the efficiency demonstrated by the program has come at the expense of quality and/or access. As dis- cussed above, the target population for Title X services continues to grow, while funding for the program in constant dollars has continued to decline. TABLE 3-4 Measure of Efficiency: Target Versus Actual Cost per Title X Client in Relation to Medical Care Inflation, Actual and Projected, Fiscal Years 2004–2013 Target Actual Year 2004 Baseline: $193.92 2005 $214.61 $200.81 2006 $223.97 $215.56 2007 $233.73 $229.32 2008 $243.92 Fall 2009 2009 $245.55 Spring 2010 2010 $265.62 Spring 2011 2011 $277.18 Spring 2012 2012 $289.25 Spring 2013 2013 $301.85 Spring 2014 SOURCE: OMB, 2009.

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 GOALS, PRIORITIES, AND ACCOMPLISHMENTS Testimony before the committee revealed that Title X providers feel pres- sure to provide more comprehensive family planning care, serve increasing numbers of clients, and comply with new program priorities that are fre- quently introduced, but receive no additional resources for these purposes. While the committee agrees that the efficient use of resources is essential, an efficiency measure should take into account such factors as the cost of more effective contraceptive techniques and the challenges of serving an increasing and more diverse population. Contribution of Title X Goals to HHS Goals As discussed in Chapter 2, public health leaders in the federal govern- ment continue to recognize the contribution of family planning services to the public’s health and well-being, as well as to the fulfillment of national health objectives as reflected in a number of HHS goals. HHS’s goals are embodied in its current Strategic Plan—FY 2007–202 and the goals of various agencies within the Department, and in the broader context of Healthy People 2010, a set of national health objectives for 2000–2010 focused on improving the public’s health (www.healthypeople.gov). The goals of Title X are consistent with these HHS goals, to which the program contributes significantly. HHS Strategic Plan The Strategic Plan identifies four goals to guide HHS’s actions toward helping Americans live longer, healthier, and better lives: health care afford- ability and access; public health promotion and disease prevention; pro- motion of the economic and social well-being of individuals, families, and communities; and scientific research and development. Affordability and Access. The clinical, educational, and counseling ser- vices that are provided at no or low cost by Title X clinics help improve affordability and access to “efficient, high-quality health care services” and “appropriate information for informed choices” (Goal 1). The loca- tion of clinics throughout the country in both rural and medically under- served areas furthers HHS’s interest in reaching out to vulnerable and underserved populations. Training provided to Title X personnel helps address the Strategic Plan’s objective of “recruit[ing], develop[ing], and retain[ing] a competent health care workforce” (Objective 1.4). Title X training can ensure that program staff obtain current information about the latest family planning develop- ments, maintain their professional competency, and develop skills that meet their patients’ needs (such as cultural competency).

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 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Public Health Promotion and Disease Prevention. Title X contributes to health promotion and disease prevention across the lifespan (Goal 2) by providing education on a range of health issues, healthy family functioning, and prevention of domestic violence, as well as medical services that detect chronic and infectious diseases (including cardiovascular disease, cancers, HIV/AIDS, and other STDs) that are the focus of this goal. Economic and Social Well-Being. Family planning services under Title X were developed to decrease the adverse health and financial effects on children, women, and their families of inadequately spaced and unplanned childbearing. In fulfilling that goal of the Title X program, these services also contribute to the fulfillment of HHS’s goal of promoting “the economic and social well-being of individuals, families, and communities” (Goal 3). HHS notes that this goal embodies “moving disadvantaged families to work and economic self-sufficiency,” which is enhanced by family planning that helps families choose when to have children (see Chapter 2 for a discus- sion of the benefits of family planning). Protecting the safety and fostering the well-being of children and youth is another objective under this goal (Objective 3.2). The overall Title X goal of preventing teenage pregnancy is critical to the achievement of this objective (although Title X clinics provide services beyond the abstinence education activities emphasized by HHS in this objective). Scientific Research and Development. Although only a small percentage of Title X–funded activities involve research, the investment of those funds furthers HHS’s goal of scientific research and development (Goal 4), in particular, communicating and transferring research results into clinical, public health, and human service practice (Objective 4.4). CDC Health Protection Goals Agencies within HHS have also articulated goals for the nation’s health, the achievement of which is supported by Title X’s accomplishments (see, e.g., HRSA, n.d.; OPHS, 2007; OMH, 2008). CDC, for example, has established Health Protection Goals (which include a number of strategic goals and objectives), intended to support improvements in people’s lives by accelerating health impact and reducing health disparities. One of the four strategic goals under the Health Protection Goals is Healthy People in Every Stage of Life, encompassing services that address many objectives in several life stages. In connection with Start Strong (which targets infants and toddlers aged 0–3), Title X’s services help promote healthy pregnancy and birth outcomes; foster social and physical environments that support the health, safety, and development of infants and toddlers; and prevent

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5 GOALS, PRIORITIES, AND ACCOMPLISHMENTS infectious diseases and their consequences in this age group (Objectives 1, 2, 5) by helping people space their pregnancies. For adolescents, Title X advances CDC’s Achieve Healthy Independence objectives by promoting access to and receipt of recommended quality, effective, evidence-based preventive and health care services, and prevent- ing STDs/HIV and unintended pregnancies and their consequences among adolescents (Objectives 17, 20). For adults aged 20–49, Title X furthers the objectives of CDC’s Live a Healthy, Productive, and Satisfying Life by pro- moting access to and receipt of recommended quality, effective, evidence- based preventive and health care services, and promoting reproductive and sexual health for adults. Achieving these objectives in turn promotes social, emotional, and mental well-being for adults and prevents chronic and infec- tious diseases and their consequences (Objectives 24–28). Healthy People 200 There are Leading Health Indicators under Healthy People 20103 designed to measure Americans’ health in the areas of greatest concern (HHS, 2000). Two of these indicators—responsible sexual behavior and access to health care—are particularly furthered by Title X family planning services. Responsible Sexual Behavior. The indicator of responsible sexual behav- ior has the goal of reducing unintended pregnancies and STDs, including HIV/AIDS. The broad 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. There are numerous additional measurable objectives regarding increasing the use of contraception, increasing the proportion of pregnancies that are intended, and reducing STDs.4 By making available a broad range of contracep- 3Physical activity, overweight and obesity, tobacco use, substance abuse, responsible sexual activity, mental health, injury and violence, environmental quality, immunization, and access to health care. 4For example, increase the proportion of pregnancies that are intended (9-1); reduce the pro - portion of births occurring within 24 months of a previous birth (9-2); increase the proportion of females at risk of unintended pregnancy (and their partners) who use contraception (9-3); reduce the proportion of females experiencing pregnancy despite use of a reversible contracep- tive method (9-4); reduce pregnancies among adolescent females (9-7); increase the proportion of sexually active, unmarried adolescents aged 15–17 who use contraception that both effec- tively prevents pregnancy and provides barrier protection against disease (9-10); increase the proportion of adults in publicly funded HIV counseling and testing sites who are screened for common bacterial STDs (13-12); increase the proportion of all sexually transmitted disease clinic patients who are being treated for bacterial STDs (chlamydia, gonorrhea, and syphilis) and who are offered provider referral services for their sex partners (25-19) (HHS, 2000).

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6 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM tives, testing for STDs, and providing education and counseling regarding reproductive health, including abstinence, Title X arguably contributes to improving outcomes in this area, although it is not feasible to demonstrate this fully without long-term data (see the discussion in Chapter 5). Access to Health Care. The indicator of access to health care encompasses objectives of increasing the proportion of persons with health insurance and a specific source of ongoing care and increasing the proportion of pregnant women who begin prenatal care in the first trimester. Title X clinics pro- vide a source of ongoing care and help women obtain early prenatal care through early diagnosis of pregnancy, counseling, and provision of such clinical care or referral to other facilities. Finding 3-5. The Title X program’s key elements enable it to play a critical role in achieving the overall goals of HHS through the program’s focus on () making contraceptive and reproductive health services accessible and affordable, thus helping to prevent unintended pregnancies and the spread of sexually transmitted dis- eases, and (2) promoting the health and social well-being of indi- viduals and families by allowing individuals to plan for families. CONCLUSIONS AND RECOMMENDATIONS The committee’s findings on the clarity, consistency, and achievement of the goals of the Title X program support the following conclusions: While the program’s core goal and contributions to the broader goals of HHS are clear, its operational priorities have fluctuated over time without a clear rationale or grounding in science. This situation has created confusion among the program’s grantees about the relative importance of the program’s priorities and where to invest the limited resources available. The program has not engaged sufficiently in long-term strategic planning. Such planning is needed to produce directives that are evi- dence based and age appropriate, and to cover increasing costs. Although data do not currently exist to permit a comprehensive evaluation of the program, it has clearly delivered care to millions of people despite very limited resources. More funds will be needed, however, to serve the growing number of individuals of reproduc- tive age who lack the means to obtain family planning care and to keep pace with changes and improvements in technologies.

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7 GOALS, PRIORITIES, AND ACCOMPLISHMENTS Based on the above conclusions, the committee offers the following recommendations: Recommendation 3-1: Reassert family planning as a core value in public health practice. The Department of Health and Human Ser- vices (HHS) and Congress should recognize and support the Title X program as the leading voice for the nation’s family planning effort, especially because the program’s benefits apply not only to indi- viduals and families, but also to communities and the nation. The program’s leaders should clearly articulate the content and ratio- nale for family planning care for all Americans and work with the Secretary of HHS and other agencies within HHS to disseminate these core ideas widely. They should stress the program’s public health value and ties to various federal goals (such as Healthy People 2010 and the HHS Strategic Plan). Recommendation 3-2: Reassert and commit to the original goals of the Title X program. HHS should reassert the original mission of the Title X program—helping individuals plan for pregnancy if they so desire, as well as avoid unintended pregnancy. HHS, the Office of Population Affairs (OPA), and their leadership, as well as Title X grantees, should be clearly dedicated to this mission and the goals of the Title X program, supportive of family planning as a critical public health intervention, committed to evidence-based practice, and knowledgeable about the field of family planning and reproductive health. The Title X program materials and the program’s implementation are focused strongly on preventing pregnancy, often to the exclusion of the broader vision of family planning, which includes planning for families as well. An important part of achieving healthy pregnancies is addressing pre- conception and interconception health and care, increasing the knowledge and skills needed to avoid unintended pregnancy, performing infertility assessment, and screening and treating STDs and HIV/AIDS. This broader focus, while undoubtedly requiring more resources, is supported by CDC’s recent emphasis on preconception and interconception care and planning for pregnancy. Among other benefits, this broader focus underscores the “family” in “family planning” and makes clear that the health and well- being of children and families depend in part on making family planning services and information available to adults and adolescents.

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 A REVIEW OF THE HHS FAMILY PLANNING PROGRAM Recommendation 3-3: Develop and implement a strategic plan. The Office of Family Planning (OFP) should develop and imple- ment a multiyear, evidence-based strategic plan that (a) reflects the mission of the Title X program and an understanding of its target population, as well as the field of family planning and reproduc- tive health; (b) provides a vision for coordination, leadership, and evaluation; (c) addresses the family planning needs of individuals over the full reproductive lifespan; and (d) specifically references its evidence base. OPA’s operation and ongoing management of the program should be guided by this plan and linked to ongoing evaluation. The strategic plan should be developed with input from a diverse group of experts assembled for the purpose. This group should include individuals who administer and operate programs funded under Title X; representa- tives of Title X clients; and a variety of outside experts and scientists with knowledge of the family planning field, reproductive health more broadly, public policy, and strategic planning. Attention should be paid to geo- graphic, racial, ethnic, and gender diversity. It will also be important to include input from grantees as well as from federal agencies whose work relates to reproductive health, including CDC, the Agency for Healthcare Research and Quality (AHRQ), HRSA, and the Centers for Medicare and Medicaid Services (CMS). It would also be useful to solicit the views of other sectors whose work is—or should be—related in some way to family planning. These include, for example, the fatherhood and marriage com- munities, Head Start and other early intervention sectors, and those who work in the area of adoption as well as in family violence prevention. Many of these sectors have an important presence in states and communities, and many also are represented at the federal level in HHS, especially in the Administration for Children and Families. Because family planning has so many important benefits for children and families, such ties are potentially very important, and strategic planning offers a concrete vehicle for these sectors to learn more about and be supportive of each other. The strategic plan should accomplish at least the following: • Clearly articulate the basic focus and components of the Title X program. Where practical and useful, core services and functions should be distinguished from those that are less central to fulfilling the program’s mission of providing comprehensive family planning services, especially to low-income individuals. The plan should specifically address what services the program can realistically require grantees to provide given limited funding and the presence

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 GOALS, PRIORITIES, AND ACCOMPLISHMENTS of multiple funding sources for family planning services (see also the section on funding of grantees and delegates in Chapter 4). • Specify a process by which emerging issues, problems, and oppor- tunities in the field of family planning will be identified in the future and how the program can make needed adjustments in an orderly fashion based on broad consultation and relevant evidence. This process must include explicit consideration of the cost (both in actual dollars and in terms of other services that would be forgone) and programmatic implications of any changes being seriously considered. • Address the ways in which the program should find additional ways to link efforts and resources with those of other agencies within the federal government, including at a minimum CDC, AHRQ, HRSA, and CMS. • Outline a robust, ongoing system for increasing the amount of scientific and research expertise brought to bear on the overall operation of the program (see also the discussion of this issue in Chapter 5).

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