The United States introduced its first official domestic family planning program for low-income Americans in 1970: the Family Planning Services and Population Research Act, Title X of the Public Health Service Act (known by the shorthand Title X, which is pronounced “ten”). Republican President Richard Nixon oversaw the program’s development and implementation, demonstrating just how bipartisan U.S. support for family planning once was.
Clinics in the United States that provide family planning can apply for Title X grants, which allow them to offer services to patients on a sliding, income-based scale. In 2018, 3.9 million people were financially assisted by Title X subsidies. A total of 4 million Americans obtained services at clinics receiving Title X grants (this number is higher than the number who received subsidies because people with Medicaid and other forms of public and private insurance also visit Title X clinics). Because of sweeping restrictions made under the Trump administration, described below, by 2021, the number of Title X patients served was down to 1.66 million (it was even lower in 2020, at 1.54 million).
Title X grants cover a broad array of services that fall under the umbrella of family planning: contraceptive services, supplies, and information; breast and cervical cancer screenings; and STI prevention, testing, and treatment. In keeping with federal law (the Hyde Amendment), Title X funds are not permitted to be used for abortion services.
Total appropriations for 2023 are $286.5 million, down from a high of $317.5 million in 2010. Current funding levels are less than 40 percent of what is needed to meet the need for publicly funded family planning in the United States, according to an analysis in the American Journal of Public Health, which found that the program would need $737 million annually. Despite this need, the budget appropriation has remained at the same level—$286.5 million—since 2014. This means that Title X funding has dropped by about $80 million in real dollars, while the population of people of reproductive age (15–49) has grown by over 5 million.
In June 2018, the Trump administration proposed a new rule for Title X, the substance of which amounted to a domestic version of the Global Gag Rule. After months of legal challenges, the rule went into effect on August 19, 2019. The new rule removed the requirement that providers discuss all pregnancy options with patients, it forbade Title X providers from referring patients for abortion services unless the patient explicitly asked for such a referral, and it allowed all providers to refuse to provide abortions on “moral” grounds. It also removed the requirement that providers offer all FDA-approved methods of birth control and prioritizes abstinence and natural family planning methods, and it infringed on the rights of minors by requiring that clinic staff attempt to involve family members in their contraceptive decisions.
Additionally, clinics had to draw a “bright line” between abortion services and all other services: separate accounting, physical spaces, staff, contact info, patient health records, etc. Previously, clinics that received Title X grants for family planning services were able to offer abortion services with separate, non-federal funding, in the same facility, by the same staff.
The consequences to the program in the wake of the new rule were devastating. An estimated 981 clinics left the program in 2019, slashing the program’s capacity by half. Six states (Hawaii, Maine, Oregon, Utah, Vermont, and Washington) were left with no remaining Title X-funded providers. The number of patients served by Title X subsidies dropped from 3.9 million in 2018 to 1.5 million in 2020.
The rule was an obvious and blatant attack on Planned Parenthood, which withdrew from the Title X program the day it went into effect. Until that point, Planned Parenthood clinics covered the family planning needs of 41 percent of women who rely on Title X.
On January 28, 2021, President Biden signed an order directing the Department of Health and Human Services (HHS) to begin the process of rolling back the Trump Domestic Gag Rule. On April 14, 2021, HHS released the proposed new rule that would end the Domestic Gag Rule, beginning the requisite 30-day comment period. The final rule was published in the Federal Register on October 7, 2021, and went into effect on November 8, 2021, bringing an end to over two years of funding cuts to family planning clinics that provide abortion services.
• Health centers would have to increase their capacity to provide contraceptive services by 116%.
• Health departments would need to expand their capacity to deliver these services by 31%.
• Hospitals would need to increase their capacity to provide these services by 77%.
• Independent agencies would have to increase their capacity to provide these services by 101%.
Source: Guttmacher Institute