The Zika virus has arrived in the United States, threatening reproductive-age American women with the prospect of compromised pregnancies — and returning the country to its decades-long debate over reproductive rights. If a pregnant American woman wanted to end a Zika-compromised pregnancy, could she? If she wanted to prevent pregnancy until she knew that any Zika risk was past, could she find the contraception she would need?
For women with enough resources to travel, the answer is always yes. But for women with more limited means, the answer, over the past 20 or so years, has come to depend in very large part on where they live. Over the past few years, dozens of abortion clinics closed, largely in response to state policies enacted to make their existence impossible.
We’ve been researching an approach to restricting reproductive health care that fewer people know about: contraception deserts. A number of states and Congress have made it harder for women with few resources to get contraception by manipulating the regulation of Title X. Title X is the only federal program dedicated exclusively to family planning and related preventive health care.
Why does that matter? According to a recent study published in Obstetrics & Gynecology, while maternal mortality rates around the world are decreasing, they increased in the United States between 2000 to 2014.
We explain below.
A brief history of federally subsidized family planning
This family planning grant program was enacted, with bipartisan congressional support, in 1970 as Title X of the Public Health Service Act.
The federal Department of Health and Human Services allocates Title X funds to public and nonprofit private organizations across the country through a competitive grant process. Because of what’s known as the Hyde Amendment, attached as a rider to other bills beginning in 1976, these funds may not pay for abortions.
In 2011, Republicans in the House of Representatives proposed a budget that would eliminate “79 wasteful programs,” including Title X. While the budget proposal to completely eliminate the Title X program failed, Congress did reduce funding. In 2010, the federal budget for Title X was $317.5 million; in 2016, it is $286.5, a decrease of 9.8 percent over six years. And there’s another proposal to completely eliminate Title X funding in the 2017 fiscal year.
States have also been working to restrict the use of Title X funds. At least 13 state legislatures have not only reduced their own budgets for family planning resources but have imposed regulations and requirements on which organizations can receive Title X funds, reducing their availability. (Several other state legislatures tried but failed to eliminate Planned Parenthood from their Title X funds.)
Who needs Title X?
Data show that these increased restrictions have resulted in the elimination of Title X providers in some geographic pockets. Consequently, there are many families with limited resources who cannot easily gain access to the effective family planning services to which they are entitled.
Here’s how we looked at this. We did preliminary research on how North Carolina allocates Title X funds. In 2012, the North Carolina General Assembly restricted its family planning funds to the local health departments.
As a result, several of the state’s clinics — located, as it happens, in areas that are majority minority or have large Native American populations — have stopped offering Title X-funded contraception. As in many parts of the country, race and class are highly correlated in North Carolina, which is why Title X-funded family planning clinics were there to begin with. In North Carolina, the clinics are relatively equitably distributed, with a clinic associated with a county health department.
But a contraception desert is about more than just distance. A clinic that’s only a few miles away may be inaccessible to women if it’s not easy to get there by public transportation, if it takes weeks to get an appointment, if there are no evening and weekend office hours, and the like.
North Carolina isn’t alone. In the 2011-2012 legislative session, Republican lawmakers in Texas cut the state’s two-year family planning budget from $111 million to $38 million, which the nonpartisan State Legislative Budget Board estimated would end up costing Medicaid about $230 million.
According to a report by the Texas Policy Evaluation Project, this budget cut resulted in the closure of 76 women’s health clinics across the state. The researchers found that 55 percent of women reported at least one barrier in accessing reproductive health care (such as inability to pay, getting time off work or lack of transportation). The women who reported three or more barriers tended to be Hispanic, poor and have lower levels of education.
A new report issued by the Texas Department of State Health Services Maternal Mortality and Morbidity Task Force shows that pregnancy-related deaths have doubled since 2011, and that black women are particularly at risk. Despite having only 11.4 percent of Texas births, black women had 28.8 percent of pregnancy-related deaths. Pregnancy-related deaths started climbing before the latest cuts to Texas’s Title X family planning services, but the budget cuts are making it worse.
The Obama administration is trying to stop the restrictions
The federal Department of Health and Human Services wants all these restrictions to stop. It recently published a draft of a new rule that would prohibit states from withholding Title X federal family-planning money for any reason other than the provider’s “ability to deliver services to program beneficiaries in an effective manner.”
That means that state legislatures could no longer prevent, say, Planned Parenthood from using Title X funds to prescribe contraception. The proposed rule is currently in the notice and commenting period, which ends Oct. 7. Those interested may respond with comments on the proposed rule.
The Affordable Care Act makes contraception more affordable. But given state and congressional opposition to Title X, is contraception actually becoming more accessible? The answer isn’t at all clear.
Rebecca Kreitzer is assistant professor of public policy at the University of North Carolina at Chapel Hill. Follow her on Twitter @RebeccaKreitzer.
Candis Watts Smith is assistant professor of public policy at the University of North Carolina at Chapel Hill and the author of “Black Mosaic: The Politics of Black Pan-Ethnic Diversity.” Follow her on Twitter @ProfCandis.
