The consequences of x-ing out Title X

Health reform and a renewed energy around expanding access to health care is on Congress’ agenda following November’s mid-term election. The new Congress has pushed past attempts to repeal the Affordable Care Act (ACA) and instead, seeks to sustain the marked improvements that the health law enabled nearly a decade ago. Presidential candidates, members of Congress, health-care providers, industry stakeholders and advocates are putting forward their ideas to make the health-care system work better for more people and the American public is responding with interest.

The ACA made it possible for millions of people to gain insurance coverage and access health care and has improved consumer protections for those with insurance. Health-care providers that work in the health care “safety net,” such as members of the organization I lead, the National Family Planning & Reproductive Health Association (NFPRHA), saw the immediate impact of insurance expansion and coverage for key services on the health and well-being of our patients. 

{mosads}Especially important for the millions of poor, low-income and vulnerable people who rely on safety-net agencies was the option for Medicaid expansion, which has been adopted by the majority of states and is a hallmark of the ACA, along with private coverage expansion. As the nation contemplates the next phase of health reform, it’s essential we sustain the momentum of the ACA while also address critical challenges.

At the top of that list should be recognizing the importance of family planning and sexual health care for every person throughout their lifetime. Thanks to the ACA, these essential, sensitive services, are now broadly covered by insurance. For the millions who remain uninsured, or fear that using their insurance might lead to a violation of privacy, access to specialized care is a significant challenge. That’s why the health-care safety net, especially for services such as sexual and reproductive health care, remains so important. 

Administration attempts to disrupt family planning access 

The Trump administration has made several attempts to disrupt access to family planning and sexual health care and its efforts to fundamentally alter the Title X family planning program put our nation’s poor and low-income populations particularly at risk. By finalizing its harmful Title X rule, the administration is aiming to drastically change the nearly 50-year-old program that facilitates access to free or low-cost, high-quality family planning and sexual health care to millions of women, men and teens who otherwise might go without care.

With its new requirements and restrictions, the administration is undermining patient autonomy — the decision if, when and how to expand a patient’s family. The rule requires that all pregnant people be referred for prenatal care, regardless of their wishes. NFPRHA members — the highly qualified family planning providers of the Title X program — are rightly horrified by the administration’s attempt to assert ideological influence over the type of counseling and care these trusted providers offer their patients who come in with questions about pregnancy. No matter what care they seek — whether a new contraceptive method, concern about a sexually transmitted infection or cancer risk, or their ability to get pregnant — the standard of care requires that patient needs and values guide any clinical visit.

The rule diminishes the program’s long standing guarantee of comprehensive family planning services. Providers will be coerced into withholding essential health-care information and referral options to patients, breeding distrust and risking poor health outcomes for their patients. The rule strikes at the core of what makes this program a public health success story — the atmosphere of expertise, confidentiality and understanding that is so important to patients seeking such intimate care — while also sapping the program’s scarce resources.

A hallmark of the Title X family planning program is its confidentiality guarantee for all patients, including young people. If not for this bedrock protection, many would not seek health-care counseling and services without such a guarantee. 

The administration’s rule will erode that confidentiality guarantee by forcing providers to press for information about sexual partners and emphasize family participation in family planning decisions, which will be especially damaging for young people and those who worry about their safety. Such pressure tactics undermine trust and will drive those who may desperately need care away from accessing family planning services.

Patient impact 

This rule shows a callous disregard for patients, a denial of science and evidence and a disrespect for the experts who dedicate themselves to family planning care.

Put simply, this rule targets patients with the greatest need who have the most to lose. For most patients seen in publicly funded family planning centers across the country, these health centers are their primary if not sole source of care. Six in ten women receiving contraceptive care at a Title X-funded health-care center report that their family planning visit was the only medical care they accessed in the previous year.

By setting aside the evidence on which the nationally recognized standard of care is built and eliminating the term “medically approved” from the longstanding requirement of providing a broad range of medically approved family planning methods, the administration empowers new providers to withhold critical information about a range of contraceptive options.

The rule will destroy networks of trusted providers built up over decades. Patients will walk into health centers and experience something very different than in the past. To maintain their current approach with fidelity, organizations may forego Title X funds and lose the capacity to offer free or subsidized care. To keep their commitment to safety-net care for those in need, organizations may restrict information and options. Patients will inevitably suffer in either case. Providers will refuse to work in health centers under these restrictions. Organizations with years of service in needy communities may be forced to close. In some places in the country, patients will be left without any health-care option.

Since 1970, the nation’s family planning program has had a hugely positive social and economic impact on women, families and society as a whole. Access to family planning improves women’s health, earnings and educational opportunities; it reduces poverty and saves taxpayers money. Title X is a proven example of what government can do when evidence and expertise are brought together to meet critical needs. 

The administration’s rule violates the law and runs counter to what Congress intended for the program when it was first created.

Clare Coleman is the president and CEO of the National Family Planning & Reproductive Health Association, representing publicly funded family planning providers and administrators nationwide.