We’re nearing the end of another government funding debate, and the next one is already fast approaching. On September 18, People For the American Way and allied organizations urged the Trump administration to chart a different course next year and support the publicly funded family planning network and the millions of people who rely on it. You can download our letter here.

Dear Director Mulvaney:

The undersigned organizations collectively represent millions of providers, patients, administrators, researchers, and advocates who have a mission of supporting and protecting federal funds for critical, cost-saving programs that ensure millions of individuals and their families can access high-quality family planning services. It is essential that individuals can determine for themselves whether and when to have children. Furthermore, we agree with then-Representative George H.W. Bush’s statement about Title X in 1969:

We need to take sensationalism out of this topic so that it can no longer be used by militants who have no real knowledge of the voluntary nature of the [Title X national family planning] program but, rather are using it as a political stepping stone. If family planning is anything, it is a public health matter.ⁱ

Over a six-month period, the administration has taken steps that represent an existential threat to the publicly funded family planning network across the country. The administration released a funding opportunity announcement (FOA) for Title X family planning services grants that discounted the importance of contraception and expertise in sexual and reproductive health. It subsequently provided Title X service delivery grants for a period of only seven months, exacerbating strain on agencies that are forced to operate in an unstable funding environment and requiring grantees to prepare to redirect already limited resources to fulfill the administrative burden associated with yet another competition. Of greatest consequence, the administration proposed a regulation in June that would devastate the Title X network and jeopardize access to high-quality family planning services for millions of individuals by limiting provider participation, constraining the health care information that patients can receive, and repurposing the program from its core intent of ensuring the availability of modern, medical methods of contraception to all, regardless of their income.

The administration has also sought to undermine Medicaid, the nation’s public insurance program on which 67 million low-income individuals rely, in part by rescinding a 2016 letter that underscored the free choice of provider provision of the Medicaid statute. Furthermore, the administration has issued a proposed rule that would significantly expand the ability of health care providers to withhold treatment, counseling, or medical information based on their religious or moral beliefs without regard for patients’ needs. We urge the administration to demonstrate support for the publicly funded family planning network and the millions of people who rely on it, including by suspending its harmful proposal to alter the regulations governing Title X and by making investments in the following essential federal programs.

Critical Role of Family Planning

We believe that diverse sources of public financing for family planning and sexual health services—including Title X, Medicaid, the section 330 federally qualified health center program, federal block grants (including the Maternal and Child Health Block Grant and the Social Services Block Grant), and state funding programs—are essential to the survival of the family planning safety net. Furthermore, we support efforts to ensure that family planning and sexual health continue to be delivered through a family planning safety net that is designed by communities for communities. For decades, family planning administrators, both governmental and non-governmental, have established service delivery networks that include a range of providers: state, county, and local health departments, as well as hospitals, family planning councils, Planned Parenthoods, federally qualified health centers, and other nonprofit organizations.

The nation’s family planning safety net leverages multiple public funding sources to deliver care to predominantly low-income, uninsured, and underinsured individuals and to those seeking confidential care. The providers’ programs are largely anchored by Title X, the nation’s only dedicated source of federal family planning funds, and Medicaid. These programs make up, on average, 19% and 38% of a participating health center’s revenue, respectively. Other sources of funding include private insurance reimbursement, state and local government support, other federal programs, patient fees, and other funding, such as grants from private foundations.ⁱⁱ There are an estimated 20.2 million U.S. women in need of publicly funded contraceptive care, but the network of publicly funded health centers is only able to meet approximately 30% of that need, in part due to ever-shrinking public funding.ⁱⁱⁱ

Title X

We request that the administration reverse its dangerous course for the Title X program, as detailed above, and support a modest increase in funds for FY 2020 to meet the need for services.

The program remains a cornerstone of the publicly funded family planning safety net. Six in ten women receiving contraceptive care at a Title X-supported health care center report that provider was their sole source of medical care in the previous year.^iv Under the current regulations and program guidance, Title X sets the standard for high-quality family planning and sexual health service provision by focusing on patient-centered care driven by evidence. Providers’ adherence to the guidelines in Providing Quality Family Planning Services—Recommendations of CDC and the US Office of Population Affairs make Title X-supported health centers the provider of choice for millions of people with and without insurance.^v

Patients at Title X health centers receive evidence-based, confidential family planning and sexual health care, including contraceptive services and supplies, STD testing and treatment, preconception counseling, breast and cervical cancer screenings, and non-directive counseling in the event of a positive pregnancy test.^vi Under well-established, existing regulatory standards that comply with statutory prohibitions, Title X does not pay for abortion care. In 2015, Title X-funded health centers helped patients prevent approximately 822,300 unintended pregnancies, thereby preventing 277,800 abortions and 387,200 unplanned births.^vii Access to family planning also promotes healthy babies, by increasing the ability of parents to plan births with spacing that is appropriate for them.^viii

In spite of the high need for publicly funded family planning services and the demonstrated public health and fiscal benefits of the program, Title X investments have been substantially cut in recent fiscal years. In FY 2010 the program received $317 million, but in FY 2018 it received only $286.5 million. The reduced program investment is counter to research published in the American Journal of Public Health stating that Title X would need at least $737 million to support all women in need of publicly funded family planning services.^ix The cuts also unfortunately align with dramatic decreases in the number of Title X-supported service sites—from 4,389 in 2010^x to 3,858 in 2017^xi—and in the number of patients served—from 5.22 million in 2010^xii to 4.00 million in 2017.^xiii We are deeply concerned about patients’ diminished access to high-quality family planning and sexual health services and urge increased funding of at least $317 million in FY 2020 to help reverse this devastating trend.

Medicaid

Medicaid is the predominant funding source (75%) for publicly funded family planning care.^xiv It is proven to save taxpayer dollars by expanding access to contraception and helping to ensure that people are able to use whatever method(s) of contraception work best for them—which is essential to their ability to successfully avoid unintended pregnancy.^xv

We support the provision of family planning and sexual health services and supplies through Medicaid as an essential component of preventive care. We strongly oppose any changes to the structure or financing of Medicaid, including a conversion to a per-capita cap system or a block grant, which would shift costs to states and result in reductions in eligibility, benefits, protections for enrollees, and provider reimbursement.

Title V Maternal and Child Health (MCH) Block Grant

In addition to the many other important activities it supports, the Maternal and Child Health (MCH) block grant provides funds that states can use to help women plan their families. As a result, Title V funding is an important part of the publicly funded family planning network. Unfortunately, MCH block grant funding has been reduced in recent years, even as the number of women and children in need of these support services increases. Increasing Title V funds is vital in sustaining the coordinated care system between family planning and maternal and child health services. We support $678 million for Title V MCH block grant in FY 2020, equal to the FY 2019 request of the Senate Appropriations Committee. We further oppose cuts to, or the elimination of, any other maternal and child health programs as a trade-off for this increase.

Centers for Disease Control and Prevention (CDC)—National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP)

Local health departments, nonprofit health care organizations, and state and local education agencies use NCHHSTP funds for HIV, other STDs, viral hepatitis, and TB prevention efforts. In some of these health settings, funding from NCHHSTP is combined with Title X and other federal funds to create robust sexual health programs by paying for the cost of family planning nurse practitioners, testing supplies, and medications. We request that the administration recommends $1.43 billion in FY 2020 to support the work of this critical center.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutritional support to low-income pregnant persons and parents with children under five years of age through food packages, health education, and referrals to health and social services. The program, administered through grants distributed by state WIC agencies, complements the Title X program and the efforts of the health care safety net to ensure access to health services for low-income women and families. WIC has improved birth outcomes, reduced health care costs, improved nutrition-related health outcomes, increased access to medical care, and improved pre-pregnancy nutritional status.^xvi We oppose the cuts proposed in the FY 2019 budget and request that the administration recommends $6.37 billion for the WIC program in FY 2020.

Exclude Harmful Policy Riders

The budget should be free of any policy riders that seek to eliminate certain family planning and sexual health providers from accessing public funds. Such riders, including those that object to a provider’s scope of service beyond family planning and those that allow for exemptions for required services due to an entity’s religious or moral objections to that care, are to the detriment of patients and public health. For instance, the administration should abandon its repeated efforts, as evidenced by the president’s FY 2018 and 2019 budget plans, to bar “certain entities that provide abortions, including Planned Parenthood” health centers from serving patients that access care through federally funded health programs.^xvii Blocking patients from obtaining publicly funded reproductive health services from Planned Parenthood and other similar providers would reduce access to high-quality care and widen existing inequities.

We further urge the president to remove the Hyde Amendment and related restrictions from his FY 2020 budget request. That harmful language prevents people who qualify for Medicaid, work as federal employees, or otherwise receive health care coverage or services directly from the federal government from accessing abortion through those programs. Access to abortion should not be dependent on how someone receives health care or coverage.

Finally, the budget should remove language added in the FY 2019 budget that would bar any immigrant without “satisfactory status” from accessing emergency Medicaid, which provides coverage in life-threatening situations, including labor and delivery care.

Conclusion

The president’s FY 2020 budget request should strengthen the safety net to make certain that millions of current and future patients can obtain high-quality, affordable family planning and sexual health care from providers of their choice. Millions of Americans rely on publicly funded health care programs, including family planning, to make the best decisions for themselves and their families and to lead their best possible lives.

Thank you for considering these requests.