A Guttmacher Institute study of publicly funded reproductive healthcare providers in Arizona, Iowa and Wisconsin shows that restrictive policies hindered providers from offering care that meets their patients’ needs and negatively impacted providers’ ability to protect patient confidentiality, clinic finances, contraceptive counseling and service provision, and pregnancy options counseling.
Researchers for the Reproductive Health Impact Study (RHIS) conducted interviews in late 2020 and early 2021 with 57 sexual and reproductive health care providers in the Affirm (AFHP) Title X network, and in Iowa and Wisconsin. The research was used to determine the impact of restrictive state and federal policy changes – including the Title X “domestic gag rule” imposed on providers by the Trump administration in 2019 and rescinded last November by the Biden administration.
“This study clearly shows the adverse effects that restrictive family planning policies have on providers’ ability to offer the care needed to meet patients’ needs and preferences,” says Alicia VandeVusse, Senior Research Scientist at the Guttmacher Institute. “Restrictions on publicly supported contraceptive care intersect with other barriers to sexual and reproductive healthcare, such as federal and state abortion restrictions. These ideologically driven disruptions to care most severely impact patients in marginalized communities, diminishing or eliminating the right to control their bodies and sexual and reproductive health decisions.”
In the study, publicly funded providers—a mix of providers that had maintained Title X funding through the policy changes, were new to the program, had left the Title X program in response to the domestic gag rule or had never participated in the program—reported the following policy-related impacts:
- Patient confidentiality: The domestic gag rule mandated additional documentation of counseling, including encouraging patients younger than 18 to discuss their care with their parent or guardian. One provider said, “Patients now have to weigh out the options as far as, ‘Do I tell my parents…or do I go this other route and pay a portion of it?’” Patients’ increased reliance on private insurance also threatens patient confidentiality, particularly for patients who are not the primary insurance policy holder.
- Clinic finances: Providers who left the Title X network lacked funding and support to maintain existing payment structures, forcing them to weaken or discontinue their sliding-fee scales. One provider said, “We went from being able to give our patients [an] up to 100% discount down to a 40% discount based on income.” Without sliding-fee scales, more patients pay out of pocket or use private insurance.
- Contraceptive counseling and service provision: The domestic gag rule prioritized fertility awareness–based methods and natural family planning, interfering with providers’ ability to provide unbiased contraceptive counseling to patients. Providers reported having to increase counseling on and stock supplies for methods that are not popular among patients, compromising the quality of patient care. Sites that joined the Title X program were able to expand the number of contraceptive methods offered, whereas providers that left the program lost access to discounted contraceptive supplies and often had to pass increased method costs to patients. One provider said, “We are seeing a decrease in those that are choosing long-term contraceptives, based on just not being able to afford the up-front cost.”
- Pregnancy options counseling: The domestic gag rule prevented sites that receive Title X funding from referring patients to abortion services or providing comprehensive pregnancy options counseling. Providers felt stress about saying the wrong thing and frustration about being unable to provide patients with all the information relevant to their care. One provider said, “As a family planning provider, it’s our job to educate women on all of their options, and when it comes to abortion, I feel like I’m swearing when I say it now; it’s become a curse word.”
Working to Meet Patient Needs
Publicly funded family planning providers worked diligently to meet their patients’ needs despite these challenges. Their strategies included:
- Connecting patients with other government funding sources
- Drawing on reserve or emergency funds to offer discounted services and financial assistance to patients in need, including undocumented and adolescent patients
- Protecting confidentiality by ordering pills online, providing financial assistance for adolescent patients and avoiding sending bills home
- Using patient assistance funds, relying on donated supplies and participating in discount programs to offset increased method costs
Bré Thomas, CEO at Affirm, Arizona’s designated Title X agency which funds more than 50 health centers across the state, said “our number one priority is to ensure that medically accurate, affordable and confidential sexual and reproductive health care is accessible to individuals across Arizona. Most of the patients served at Title X-funded health centers in Arizona are low-income, and for many, the care they receive at these health centers is their only interaction with the healthcare system. The restrictions imposed by the previous administration, in addition to increasingly volatile legislative policies around reproductive health care, create significant challenges that impact the health and well-being of those we serve.”
More information on publicly funded family planning services in the United States and related policies is available in Guttmacher’s analysis of how to strengthen the Title X program, Title X comprehensive guide and fact sheet about paying for contraception. Additional information about the Reproductive Health Impact Study is available here.