How Will the Title X Family Planning Rule Affect Community Health Centers? Geiger Gibson / RCHN Community Health Foundation Research Collaborative Policy Issue Brief #62 April 2020 Jessica Sharac, MSc, MPH Sara Rosenbaum, JD Maria Velasquez, MPH About the Geiger Gibson / RCHN Community Health Foundation Research Collaborative The Geiger Gibson Program in Community Health Policy, established in 2003 and named after human rights and health center pioneers Drs. H. Jack Geiger and Count Gibson, is part of the Milken Institute School of Public Health at the George Washington University. It focuses on the history and contributions of health centers and the major policy issues that affect health centers, their communities, and the patients that they serve. The RCHN Community Health Foundation is a not-for-profit foundation established to support community health centers through strategic investment, outreach, education, and cutting-edge health policy research. The only foundation in the U.S. dedicated solely to community health centers, RCHN CHF builds on a long-standing commitment to providing accessible, high-quality, community-based healthcare services for underserved and medically vulnerable populations. The Foundation’s gift to the Geiger Gibson program supports health center research and scholarship. Additional information about the Research Collaborative can be found online at https://publichealth.gwu.edu/projects/geiger-gibson-program-community-health-policy or at www.rchnfoundation.org. Geiger Gibson / RCHN Community Health Foundation Research Collaborative 2 Executive Summary As the coronavirus pandemic affects communities across the nation, preserving access to essential preventive health care remains critical. The Trump Administration’s Title X Family Planning program regulations became effective July 2019; as of March 4th, 2020, funding recipients must comply with all of the rule’s new restrictions, including restrictions on counseling pregnant women and physical and financial separation requirements. Community health centers are a major source of family planning and primary health care to low-income women of reproductive age. This survey, fielded during January and February 2020, examined community health centers’ current participation In the Title X program, as well as their plans for future participation once the rule became fully effective. Among its key findings: • Community health centers’ Title X participation plans: Among all respondents, two-thirds (65 percent) were either current non-participants and did not intend to apply for Title X funding (58 percent of total respondents) or Title X grantees that either already had left the program or intended to do so (an additional 7 percent of total respondents). The remaining one-third of total respondents were either current grantees that planned to remain in the Title X network (21 percent of the total) or current non- grantees that planned to apply (12 percent of the total). • Community health centers that are current Title X participants: Among health centers reporting participation during the survey period, nearly 1 in 4 (24 percent) reported that they had left the program or planned to do so by March 4th; another 6 percent had not yet decided. Among participating health centers ending participation or planning to do so, 70 percent cited concerns regarding the impact of the new requirements and restrictions on the quality of care, and two-thirds (66 percent) cited concerns regarding the impact of the new rule on patient health. More than half (51 percent) reported their intent to maintain current service levels using both other health center revenue such as Section 330 grant funds and replacement state funding. • Community health centers considering future participation: Community health centers considering participation tended to be located in the South, South Central, or Western regions of the country. • Meeting patient needs and capacity to absorb a patient surge: Fifty-three percent of respondents not planning to participate estimated that they could meet current patient need without Title X funds. To the extent that needs grow, fewer than 1 in 10 (9 percent) reported that they could expand their care capacity by 50 percent or more. Nearly one-third (32 percent) expected access to decrease in their service areas. health centers is associated with enhanced family Overview planning capacity and a broader range of services.2 As the coronavirus pandemic sweeps across the Family planning is also a required service for all nation, an enormous challenge becomes maintaining community health centers funded under Section 330 access to essential preventive services, including of the Public Health Service Act.3 While most health preventive services related to reproductive health. centers offer family planning services without Family planning and related services are among the participating in Title X, previous research has found most critical of these services. that about 25 percent do so.4,5,6 Research also has The Title X Family Planning Program provides federal found that Title X participation by community health grants for family planning and related services. Title X centers is associated with their ability to maintain helps fund low- or no-cost family planning services more robust family planning programs.7 Strengthening and supplies. Title X also helps fund family planning- family planning services at community health centers related preventive health services such as testing for is especially important since health centers serve 3 in HIV and other sexually transmitted infections (STIs), 10 low-income women nationally. pregnancy diagnosis and counseling, and screening In March 2019, the Department of Health and Human for breast and cervical cancer. In 2018, health Services published a final rule that significantly providers and programs funded through Title X served revised Title X program requirements for funding over 3.9 million patients.1 Previous research has recipients.8 The rule became effective July 15th, 2019, found that Title X program participation by community Geiger Gibson / RCHN Community Health Foundation Research Collaborative 3 with full compliance required as of March 4th, 2020.9 Guttmacher Institute similarly has estimated that Three new requirements are especially notable. First, nearly one-quarter (22 percent) of all Title X- Title X-funded entities must maintain complete participating providers have ended their participation; physical and financial separation between their Title X- Guttmacher further estimates that the providers funded activities and any activity classified by the rule withdrawing from the Title X network account for as provision of, or advocacy for, abortion. Except nearly half (46 percent, or 1.6 million) of all patients under extremely limited circumstances, the rule served by Title X in 2019.13 classifies the provision of information to pregnant It is unclear how much the family planning services women who request an abortion a form of advocacy. gap has grown. Previous research shows that Second, the rule places new restrictions on treating community health centers have struggled to fill already pregnant patients. In addition to withholding material existing gaps by expanding their own services. information regarding qualified abortion providers even According to a 2017 survey,14 only 6 percent of when asked, Title X-funded clinics must refer all community health centers could absorb an increase in pregnant women for prenatal care, even if they choose new patients of 50 percent or more. A survey not to continue with a pregnancy. The rule restricts the conducted over the May-July 2019 time period types of clinical staff who can counsel pregnant reported similar findings: slightly more than three- women to doctors and advanced practice clinicians. quarters of respondents (77 percent) reported either Third, the rule requires complete physical and financial that they could not increase capacity at all, or else separation of Title X-funded services from those could expand capacity by no more than 24 percent. considered “advocacy” such as non-directive Only 10 percent could expand family planning capacity counseling by trained staff for patients who seek full by 50 percent or more.15 information. As sources of affordable, accessible family planning As noted, community health center Title X participation care shrink, three important questions arise. First, will historically has been low. Low participation may reflect community health centers that do not already do so the modest nature of Title X grants coupled with the seek Title X funding in order to expand capacity? program’s relatively extensive requirements. Second, will those that do so remain in the program? Furthermore, many community health centers have Third, how feasible is it for community health centers taken a collaborative approach to Title X, working to expand their capacity to meet growing need? closely with independent Title X-funded clinics to refer patients for a broader array of family planning services Community Health Center Survey than may be provided at the health center. The Geiger Gibson/RCHN Community Health Community health centers may find that opportunities Foundation Research Collaborative conducted a for such collaborations are shrinking under the new nationwide survey of community health centers to rule, as independent clinics opt to leave the Title X ascertain the extent of community health center network rather than to comply with its restrictions. In participation in Title X as of March 4th, 2019, when the some cases, states are attempting to replace federal final rule was published. We also sought to measure funding with state funding in order to maintain service future Title X participation plans and service capacity, levels.10 In others, independent family planning clinics particularly as other Title X grantees began to may be attempting to remain operational by charging withdraw.16 In addition, we sought to learn more about patient fees, offering more limited services, or the types of changes community health centers maintaining more limited staffing and hours of anticipated in family planning service capacity, both at operation.11 The Kaiser Family Foundation has their own health center and in their service area, as reported that of 4,008 Title X sites that were operating well as how community health centers choosing to in June 2019, as of December 2019, 1,041 (26 continue participation would adapt to the new percent) were no longer participating.12 The requirements. 1 Fowler, C. I., Gable, J., Wang, J., Lasater, B., & Wilson, E. (2019, August). Family Planning Annual Report: 2018 national summary. Research Triangle Park, NC: RTI International. https://www.hhs.gov/opa/sites/default/files/title-x-fpar-2018-national-summary.pdf 2 Community health centers and family planning in an era of policy uncertainty, op. cit. 3 https://www.hrsa.gov/sites/default/files/grants/apply/assistance/Buckets/definitions.pdf 4 Wood, S., Goldberg, D., Beeson, T., Bruen, B., Johnson, K., Mead, H., … Rosenbaum, S. (2013). Health Centers and Family Planning: Results of a Nationwide Study. The Geiger Gibson/RCHN Community Health Foundation Research Collaborative and the Jacobs Institute of Women’s Health, George Washington University. https://www.rchnfoundation.org/?p=2975 5 Wood, S.F., Strasser, J., Sharac, J., Wylie, J., Tran, T.C., Rosenbaum, S., Rosenzweig, C., Sobel, L., & Salganicoff, A. (2018). Community health centers and family planning in an era of policy uncertainty. Kaiser Family Foundation. https://www.kff.org/womens-health-policy/report/community-health-centers-and-family- planning-in-an-era-of-policy-uncertainty/ 6 Sharac, J., Markus, A., Tolbert, J., & Rosenbaum, S. (Forthcoming 2020). Community Health Centers in a Time of Change: Results from an Annual Survey. Kaiser Family Foundation. 7 Community health centers and family planning in an era of policy uncertainty, op. cit. Geiger Gibson / RCHN Community Health Foundation Research Collaborative 4 We fielded this survey between January and February program (21 percent of all respondents) or were 2020. An email link to the survey was sent to the current non-participants planning to apply (12 percent CEOs or project directors of all 1,362 federally-funded of total respondents). The remaining two percent were community health centers nationwide identified in the Title X grantees unsure about future participation. In 2018 Uniform Data System (UDS). Similar to our other words, the percentage of community health family planning survey conducted in 2017,17 the centers planning to apply for Title X funds or to remain survey data was weighted by federal region18 and in the program appears to be slightly higher than the health center size in terms of the number of patients 30 percent participating as of March 2019. However, served. these responses were provided before the full compliance date (March 4th, 2020) and therefore may Results change as the fuller implications of what compliance entails become clearer. Overall Findings: Community Health Center Participation Community Health Centers that Do Not The response rate to the survey was 25 percent, with Currently Participate in Title X 341 responses from community health centers in 47 Among the 70 percent of responding health centers states, the District of Columbia, and three U.S. that were not Title X participants as of March 2019, territories/freely associated states. Survey about one in six (17 percent) indicated that they would respondents and non-respondents did not significantly be interested in applying for Title X funding in the differ by HRSA region, although survey respondents future (Figure 2). As Figure 2 shows, nearly two- had a significantly higher average number of patients thirds of non-participants (64 percent) reported that compared to non-respondents. they were not interested in doing so. One in 5 non- participants (20 percent) said that they were interested Among respondents, 70 percent reported that they did in applying for Title X funding but did not plan to do so not participate in Title X, while 30 percent reported because they did not think they would receive funding participation. This 30 percent participation rate is if they applied. While about 83 percent of non-Title X- somewhat higher than the 26 percent reported by funded respondents were not planning to participate in health centers’ largest sites in 201119 and 2017;20 it is Title X in the future, they accounted for 58 percent of also slightly higher than the 25 percent participation all survey respondents, as shown in Figure 1. rate reported by health center grantees in a separate 2019 survey.21 This slightly higher figure may reflect a Respondents indicating that their health center has not greater survey response rate from Title X-participating participated in Title X and does not plan to do so were health centers rather than any actual change in Title X asked about their reasons for not participating. Over participation rates over the 2011-2019 time period. half (53 percent) reported that they were able to meet their patients’ needs for family planning and related With respect to health centers’ current status and services without Title X funds, while more than one in future plans for Title X participation, Figure 1 shows four (27 percent) reported that program complexity the responses across all respondents. Across the and reporting requirements were barriers to entire surveyed group, two-thirds (65 percent) were participation (Table 1). One in five (20 percent) cited either current non-participants that did not intend to other reasons, including several who noted in open- apply for Title X funding (58 percent of total text responses that they did not want to compete with respondents) or Title X grantees that had left or local providers for Title X funding. Roughly one in six intended to leave the program (7 percent of total respondents reported that other providers in the respondents). One third of respondent health centers community were able to meet local patients’ demands were either current participants planning to stay in the 8 https://www.federalregister.gov/documents/2019/03/04/2019-03461/compliance-with-statutory-program-integrity-requirements 9 HHS.gov. (2019). Compliance with Statutory Program Integrity Requirements: Title X Program Guidance. https://www.hhs.gov/opa/title-x-family-planning/about- title-x-grants/statutes-and-regulations/compliance-with-statutory-program-integrity-requirements/index.html 10 Sadeghi, N.B. & Wen, L. (September 24, 2019). After Title X regulation changes: difficult questions for policymakers and providers. Health Affairs Blog. https:// www.healthaffairs.org/do/10.1377/hblog20190923.813004/full/ 11 Ollstein, A.M. & Roubein, R. (September 2019). Family planning clinics watch their safety nets vanish. https://www.politico.com/story/2019/09/01/family- planning-trump-abortion-1479239 12 Kaiser Family Foundation. (December 20, 2019). The Status of Participation in the Title X Federal Family Planning Program. https://www.kff.org/interactive/the- status-of-participation-in-the-title-x-federal-family-planning-program/ 13 Dawson, R. (2020). Trump Administration’s Domestic Gag Rule Has Slashed the Title X Network’s Capacity by Half. The Guttmacher Institute. https:// www.guttmacher.org/article/2020/02/trump-administrations-domestic-gag-rule-has-slashed-title-x-networks-capacity-half 14 Wood, S.F., Strasser, J., Sharac, J., Wylie, J., Tran, T.C., Rosenbaum, S., Rosenzweig, C., Sobel, L., & Salganicoff, A. (2018). Community health centers and family planning in an era of policy uncertainty. Kaiser Family Foundation. https://www.kff.org/womens-health-policy/report/community-health-centers-and-family- planning-in-an-era-of-policy-uncertainty/ 15 Sharac, J., Markus, A., Tolbert, J., & Rosenbaum, S. (Forthcoming 2020). Community Health Centers in a Time of Change: Results from an Annual Survey. Kaiser Family Foundation. Geiger Gibson / RCHN Community Health Foundation Research Collaborative 5 Figure 1. Community Health Centers’ Expected Participation in Title X After March 4, 2020 Figure 2. Intended Future Participation of Community Health Centers that Are Not Currently Title X-Funded for family planning services (17 percent) and the cost participate going forward. of meeting Title X requirements (16 percent) as Slightly less than half (46 percent) reported that they reasons for non-participation. Notably, about one in had received supplemental funding in 2019. However, eight respondents (12 percent) explicitly reported more than one in five (22 percent) Title X-funded concern about legal risks to the health center should respondents already had withdrawn from the program; there be a lapse in their compliance. and another 2 percent were planning on ending their Title X-Participating Community Health participation by March 4th, 2020 (Figure 3). In addition, 71 percent reported that they planned to Centers continue to participate, while 6 percent had not yet Respondents indicating that they had participated in decided on their future participation. Title X as of March 2019 (30 percent of the total) were asked if they had received supplemental FY2019 Title X funding. They also were asked about their intent to Geiger Gibson / RCHN Community Health Foundation Research Collaborative 6 Table 1. Reasons Given by Community Health Centers for Not Participating in Title X Our health center is able to meet our patients’ needs for family planning and related 53% services without Title X funds The regulations and required documentation required of Title X participation are too 27% complex Other reason 20% Other providers in the community are able to meet local patients’ demand for family 17% planning services Meeting Title X requirements is too costly 16% We are concerned that an accidental lapse in compliance could have significant 12% enforcement impacts Other health care providers are prioritized for Title X funding so we don’t think our 12% health center would receive funding if we applied Our health center does not have staff who are trained to provide Title X clinical services 11% Our health center lacks physical space and/or storage required for family planning 11% services and supplies Our health center does not have staff who are trained to provide Title X counseling 10% services Our health center struggles to meet current patient demand and lacks capacity to add significantly more family planning services and other services that Title X patients would 9% need Our health center contracts out for family planning services 7% Our health center does not have many patients who need family planning and related 5% services Religious or moral concerns on the part of health center staff or board members 5% regarding certain types of family planning methods that would be required under Title X We were planning to apply in the future but our Title X agency or state has withdrawn 2% from the program Source: Geiger Gibson/RCHN Survey of Community Health Centers’ Family Planning Services Geiger Gibson / RCHN Community Health Foundation Research Collaborative 7 Figure 3. Title X-Funded Community Health Centers’ Intent to Participate After March 4, 2020 Compliance Date Participation by Federal Region Title X regulations (53 percent), while about one- third (32 percent) planned to change patient counseling Community health center participation in Title X varied protocols and information provided (Table 3). Nearly by HRSA region as did respondents’ plan going three in ten (28 percent) planned to create or revise forward. Relatively high proportions of community the list of providers that pregnant patients are referred health centers that had participated in the past but to, as well as to modify documentation of services to withdrew were located in Region I (New England) and minors while expanding documentation of parental Region IX (the West) (35 percent and 24 percent, involvement, also required under the new rule. About respectively). Similarly high percentages of previous one quarter (26 percent) did not expect to make any participants in those regions were unsure of whether changes in clinic operations. they would continue (Table 2). While a very small proportion of Title X participants that had plans to Title X-Funded Health Centers That Either continue their participation were located in Region I Have Ended or Soon will End Participation in (four percent), a higher proportion (27 percent) were located in Region IX. Title X Respondents not funded at the time of survey but Health centers have ended or soon will end their interested in applying for Title X funding are most participation in the Title X program were asked for likely to be located in the Western (25 percent) and their reasons for doing so. Most (70 percent) cited Southern regions (20 percent in Region IV, 18 percent concerns that the new requirements would in Region VI). This higher rate of interest in the compromise the quality of care for patients; two-thirds Southern region may reflect a greater loss of (66 percent) of respondents cited concerns that the independent Title X providers in these parts of the new requirements could negatively affect patients’ country. health (Figure 4). Over half (54 percent) reported that they did not want to direct what providers can and Community Health Centers that Participate in cannot say to patients, while 45 percent indicated that their state or Title X agency had withdrawn from the Title X and Plan to Continue to Do So program. Nearly four in ten (39 percent) reported Among Title X-funded health centers planning to concerns about risk of medical liability, while a quarter continue participation in the Title X program, over six (26 percent) were concerned that the new in ten (61 percent) expected to apply for supplemental requirements would conflict with their Section 330 funding in FY2020. Over half of those planning to obligations. remain expected to provide staff training on the new Geiger Gibson / RCHN Community Health Foundation Research Collaborative 8 Table 2. Status of Responding Health Centers’ Participation in Title X, by HRSA Region Title X-funded Not funded by Not funded by Title X-funded Title X-funded but recently Title X and not Title X but and plan to but is unsure HRSA Region ended or soon planning to planning to continue if they will still plan to end apply apply participation participate participation I (CT, ME, MA, NH, RI, 5% 2% 35% 4% 34% VT) II (NJ, NY, PR, VI) 7% 16% 7% 3% 14% III (DE, DC, MD, PA, 7% 5% 5% 18% 0% VA, WV) IV (AL, GA, FL, KY, MS, 19% 20% 4% 15% 0% NC, SC, TN) V (IL, IN, MI, MN, OH, 13% 7% 6% 1% 0% WI) VI (AR, LA, NM, OK, 12% 18% 4% 11% 0% TX) VII (IA, MO, NE, KS) 11% 2% 0% 12% 17% VIII (CO, MT, ND, SD, 4% 4% 0% 6% 0% UT, WY) IX (AZ, CA, HI, NV, AS, 11% 25% 24% 27% 35% FM, MH) X (AK, ID, OR, WA) 10% 0% 15% 3% 0% Total 100% 100% 100% 100% 100% Source: Geiger Gibson/RCHN Survey of Community Health Centers’ Family Planning Services 16 HHS.gov. (September 30, 2019). HHS Issues Supplemental Grant Awards to Title X Recipients. https://www.hhs.gov/about/news/2019/09/30/hhs-issues- supplemental-grant-awards-to-title-x-recipients.html 17 Wood, S.F., Strasser, J., Sharac, J., Wylie, J., Tran, T.C., Rosenbaum, S., Rosenzweig, C., Sobel, L., & Salganicoff, A. (2018). Community health centers and family planning in an era of policy uncertainty. Kaiser Family Foundation. https://www.kff.org/womens-health-policy/report/community-health-centers-and-family- planning-in-an-era-of-policy-uncertainty/ 18 The 2017 family planning survey used US Census region, but because respondents of the current survey included health centers in U.S. territories/COFA states, the weight was based on HRSA region. 19 Wood, S., Goldberg, D., Beeson, T., Bruen, B., Johnson, K., Mead, H., … Rosenbaum, S. (2013). Health Centers and Family Planning: Results of a Nationwide Study. The Geiger Gibson/RCHN Community Health Foundation Research Collaborative and the Jacobs Institute of 20 Women’s Health, George Washington University. https://www.rchnfoundation.org/?p=2975 20 Wood, S.F., Strasser, J., Sharac, J., Wylie, J., Tran, T.C., Rosenbaum, S., Rosenzweig, C., Sobel, L., & Salganicoff, A. (2018). Community health centers and family planning in an era of policy uncertainty. Kaiser Family Foundation. https://www.kff.org/womens-health-policy/report/community-health-centers-and-family- planning-in-an-era-of-policy-uncertainty/ 21 Sharac, J., Markus, A., Tolbert, J., & Rosenbaum, S. (Forthcoming 2020). Community Health Centers in a Time of Change: Results from an Annual Survey. Kaiser Family Foundation. Geiger Gibson / RCHN Community Health Foundation Research Collaborative 9 Table 3. Changes that Title X-Funded Health Centers Plan to Make in Response to the New Title X Rule Among Title-X funded If you plan to participate in Title X after March 2020, what health centers changes, if any, do you expect will be needed in clinic continuing to operations? participate in Title X Provide training to staff on Title X regulations 53% Change counseling and information given to pregnant patients by 32% providers Create or revise the list of providers to whom pregnant patients 28% are referred Modify documentation of and services to minors to expand 28% documentation of parental involvement We do not expect to make any changes 26% Modify counseling activities involving minors to promote parental 16% involvement Review current financial practices to ensure that your 14% organization meets financial separation requirements Other change 9% Change scope of contraceptive services provided by limiting the 6% number of contraceptive methods offered Separate physical locations for pregnancy testing and counseling versus primary family planning and preventive screening and 2% other clinical services for patients who are not pregnant or do not suspect pregnancy Change scope of contraceptive services provided by adding a fertility awareness method, if not already provided by your health 2% center Source: Geiger Gibson/RCHN Survey of Community Health Centers’ Family Planning Services Geiger Gibson / RCHN Community Health Foundation Research Collaborative 10 Figure 4. Reasons Title X-Funded Health Centers Recently Ended or Plan to End Participation in the Title X Program Figure 5. Expected Response to Reduced Funds Among Health Centers that Will End Participation in Title X Title X-participating community health centers were use both. then asked about how they would maintain or expand family planning services in response to the reduction Access to Family Planning Services and in Title X funds. No respondents indicated plans to Capacity for New Patients reduce services. One in five (21 percent) reported that they would rely on other health center revenue, for All health centers were asked how they expected example, by charging more for family planning patients’ access to family planning services to change services or by allocating 330 grant funds to cover in the next year as a result of the new Title X rules, associated costs (Figure 5). Twenty-eight percent both at their health center and in the broader service said they would use replacement funding from their area. The majority of health centers reported that state. Over half (51 percent) reported that they would access to family planning services would not change Geiger Gibson / RCHN Community Health Foundation Research Collaborative 11 in their service area (59 percent) or at their health suggests that higher levels of concern about access center (83 percent). Yet nearly one third (32 percent) may correlate with health center willingness to apply expected access to decrease in their service area, for Title X funding, shown in Table 2. The cautionary while only four percent expected a decrease in access note, however, is that these concerns and intent to at their health center (Table 4). These percentages apply were expressed before the full implications of did not differ significantly by HRSA region, but the full compliance became evident. highest percentages of those expecting decreased access within their service areas were found in Regions VIII and IX – where health centers accounted for 29 percent of those that had not participated in Title X but planned to seek Title X funding (Table 2). Furthermore, health centers in these same regions (VIII and IX) were most likely to raise concerns about decreased access at their own health center. This Table 4. Anticipated Changes to Patients’ Access to Family Planning Services in the Next Year, by HRSA Region In your service area At your health center Patients will Patients will Patients will Patients will Patients will Patients will HRSA Region have experience no have have experience no have increased change in decreased increased change in decreased access to access to access to access to access to access to family family family family family planning family planning planning planning planning services planning Total 9% 59% 32% 14% 83% 4% I (CT, ME, MA, NH, 0% 74% 26% 7% 89% 4% RI, VT) II (NJ, NY, PR, VI) 26% 51% 23% 28% 67% 5% III (DE, DC, MD, PA, 12% 66% 22% 12% 82% 5% VA, WV) IV (AL, GA, FL, KY, 11% 57% 32% 20% 77% 3% MS, NC, SC, TN) V (IL, IN, MI, MN, 4% 62% 34% 4% 92% 4% OH, WI) VI (AR, LA, NM, OK, 9% 62% 29% 9% 91% 0% TX) VII (IA, MO, NE, KS) 10% 63% 27% 0% 100% 0% VIII (CO, MT, ND, 6% 52% 41% 19% 75% 6% SD, UT, WY) IX (AZ, CA, HI, NV, 9% 45% 45% 22% 69% 8% AS, FM, MH) X (AK, ID, OR, WA) 0% 73% 27% 8% 92% 0% Source: Geiger Gibson/RCHN Survey of Community Health Centers’ Family Planning Services Geiger Gibson / RCHN Community Health Foundation Research Collaborative 12 Figure 6. Estimated Percentage Increase in New Family Planning Patients Health Centers Could Accept with Current Staffing and Clinic Space in the Next Year Figure 7. Health Center Capacity for an Increase in New Family Planning Patients of 50 percent or More, by Title X Status Respondents also were asked about their capacity to funded health centers that plan to apply for Title X serve more family planning patients in the next year, funding, to a low of 5 percent for Title X-funded health with current staffing and clinic space. Nine percent centers that plan to continue participation in the could accept no new patients, and two-thirds (66 program (Figure 7). Eight percent of respondents that percent) could accept an increase of less than 24 were not funded and not planning to apply, and of percent (Figure 6). Only nine percent indicated that those that were funded and planned to continue their they could accept an increase of 50 percent or more. participation, reported they could accept an increase The percentage that could accept an increase in in family planning patients of 50 percent or more. patients of 50 percent or more varied significantly by Title X status, from a high of 23 percent of non-Title X- Geiger Gibson / RCHN Community Health Foundation Research Collaborative 13 health center revenue to maintain services, either Discussion alone or in combination with additional state funding. As of March 2019, when the Title X family planning This may mean loss of resources and funding for other rule was published, the large majority of community patients and services. To the extent that community health centers (70 percent) indicated that they do not health centers turn to increased patient fees as a participate in Title X, a figure consistent with prior strategy for maintaining capacity, upward adjustment reports assessing Title X participation among in the sliding fee scale could create barriers to care. community health centers. Within this group, the Some states have opted to provide replacement majority (83 percent) have no plans to apply for Title X funding or to increase Medicaid payments for care funding. Among the respondents that did participate in insured through that program. How long states will be Title X, nearly one in four (24 percent) already had able to maintain this supplemental funding, especially ended participation or planned to leave the program. in light of the crisis created by the COVID-19 In both cases, a principal reason appears to be the pandemic, remains unclear. impact of the new regulatory requirements. Concerns Third, nearly one third of all respondents expect about ongoing access to family planning services access for family planning services to decrease in the appear to be somewhat related with health centers’ next year in their service area, having an impact willingness, in certain regions, to seek Title X funding. beyond their own health center. This means the loss of For example, higher shares of health centers in one of the most important of all public health Regions VIII and IX expected that patients would services.22 Furthermore, it is clear that community experience decreased access to family planning health centers do not view themselves as able to services (Table 4), and health centers from these two replace this lost capacity. Only nine percent report that regions accounted for nearly three in ten community they can accept 50 percent or more new family health centers that are not presently funded but plan to planning patients in the next year, with existing space apply for Title X funding (Table 2). and staffing. Our findings also suggest that community health Finally, because the survey fielding period ended centers view maintaining and expanding services as before the date of full compliance with the physical- important but that few are in a position to undertake separation requirement, it may be that Title X major capacity growth, defined as an increase of 50 participation by community health centers diminishes percent or more in new family planning patients. further once the complexities of full compliance come Our findings also show regional variation. Higher more clearly into view. Follow-up research into the shares of community health centers that have not impact of the rule, once fully in effect, becomes critical. previously participated in Title X but show interest in applying for funds are located in the Western, South, and South-Central regions (Regions IX, IV, and VI). Health centers in these regions may be somewhat more likely to view adaptation to the new requirements as feasible, or willingness to seek funding may be driven more by concern over loss of access to family planning services. The findings also signal certain areas of concern. First, the percentage of community health centers willing to join the Title X provider network remains low; among those leaving the network, concerns over the practical and legal cost of compliance are commonly raised. A second concern is the potential impact on health center revenue – both revenue dedicated to enhancing and strengthening family planning services and revenue that must be diverted from other critical activities in order to maintain family planning programs. Among community health centers that participate in Title X but that have exited or plan to exit the Title X program, 72 percent plan to substitute other 22 Centers for Disease Control and Prevention. (1999). Achievements in public health, 1900–1999: Family planning. MMWR Weekly, 48(47):1073-80. https:// www.cdc.gov/mmwr/preview/mmwrhtml/mm4847a1.htm Geiger Gibson / RCHN Community Health Foundation Research Collaborative 14