Key Findings

• While the first 2024 presidential primary is nine months away, several Republican hopefuls and President Biden have begun their messaging to voters, including staking out positions on controversial health issues like abortion. Looking ahead to 2024, three in ten voters say they will only vote for a candidate who shares their views on abortion. This includes nearly half of Democratic voters (46%) and more than one-third of women voters (35%). Another half of voters (53%) say abortion is just one of many important factors they will be weighing in their decisions during the 2024 election and 16% say abortion is not an important factor in their vote.
• Six months after abortion access was one of the major issues in the 2022 midterm elections, Democrats have a strong edge over Republicans on which political party the public believes best represents their views on abortion, with four in ten (42%) saying the Democratic Party best represents their own views on abortion, compared to about one fourth (26%) who say the Republican Party best represents their own views on abortion. The Democratic Party also has the advantage among women ages 18 to 49. About half (45%) of women ages 18 to 49 say their views on abortion are best represented by the Democratic Party, nearly twice the share (24%) who say their views align most with the Republican Party. A substantial share (32%) of the public says “neither party” represents their views on abortion, including three in ten women ages 18 to 49.
• It’s been nearly a year since the Supreme Court issued a decision in Dobbs v. Jackson Women’s Health Organization and with many states passing laws either restricting or protecting abortion access, the KFF Health Tracking Poll finds large majorities of the public are now aware that Roe v. Wade has been overturned, though many Hispanic and Black women under age 50 remain unsure of the status of Roe (43% and 32%, respectively).
• Awareness of mifepristone, the abortion pill that has been the focus of several ongoing lawsuits, has doubled since January 2023, with about two-thirds of adults now saying they have heard of the drug compared to about three in ten in January. The share of women ages 18 to 49 who have heard of mifepristone has increased 15 percentage points to 61%, up from 46% in January.
• As the legal landscape surrounding abortion and mifepristone continues to change, there is widespread confusion about whether the use of mifepristone for abortion is legal. About half (45%) of the public say they are “unsure” whether medication abortion is available in their state, and more than half of women ages 18 to 49 living in states with a full abortion ban either incorrectly believe they can access medication abortion (15%) or say they are unsure (46%).
• Most adults in the U.S. are aware medication abortion pills are safe but views towards the medication are largely partisan, and some confusion remains. Nearly three-fourths of Democrats say medication abortion is safe (72%), as do six in ten (58%) of independents. Less than half of Republicans agree (40%). Republicans are also twice as likely as Democrats to say they are “not sure” about the safety of mifepristone (22% v. 45%). When it comes to abortion procedures, majorities across partisans are aware they are safe, and fewer are unsure about their safety.
• With the recent court case challenging the U.S. Food and Drug Administration’s approval of mifepristone, the latest KFF Health Tracking Poll finds confidence is relatively high for the government agency, with around two-thirds of adults expressing “a lot” or “some” confidence in the FDA to ensure that medications sold in the U.S. are safe and effective (65%). The public doesn’t have as much confidence in the U.S. Supreme Court, especially when it comes to making the right decisions on cases regarding reproductive and sexual health. A majority of the public, including about seven in ten women (69%) say they trust the Court either “not too much” or “not at all” to make the right decision on this issue. This includes majorities of women across age groups and race and ethnicity, as well as majorities of Democrats and independents. Nearly six in ten (56%) Republicans, on the other hand, say they trust the Court to make decisions about reproductive and sexual health.

The Role Abortion May Play In The 2024 Election

With abortion playing an important role in voters’ decisions to turn out and who to vote for during the 2022 election, the KFF Health Tracking Poll examines how abortion may motivate voters in the upcoming 2024 election, the first presidential election since the overturning of Roe v. Wade. Three in ten voters say they will only vote for a candidate who shares their view on abortion and about half (53%) of voters saying a candidate’s stance on abortion will be just one of many factors they will be weighing. A smaller share (16%) say abortion will not be an important factor in their voting decision.

Similar to the 2022 midterms, the issue of abortion access is most salient for women voters and Democratic voters. About one-third (35%) of women and nearly half of Democratic voters (46%) say they will only vote for a candidate that shares their view on abortion, more than twice the share of Republican voters (20%) who say the same.

More than a third of women voters 18 to 49 (36%), say they will only vote for a candidate who shares their views on abortion. Partisan voters within this age group are similar to partisan voters overall, with half (48%) of Democratic women voters ages 18 to 49 saying they would only vote for a candidate who shares their views on abortion, compared to three in ten independent women and about one-fourth (23%) of Republican women voters in this age group. However, few women voters in this age group across party say it is abortion is not an important issue to their vote (8% of Democrats,13% of independents, 13% of Republicans).

Voters living in states where abortion is fully banned (29%) or legal, but with gestational limits (28%) are no more likely to say they will only vote for a candidate who shares their opinion than voters in states where abortion is legal (32%). Similar shares of voters who say abortion should be legal in all or most cases (31%) and those who say it should be illegal in all or most cases (28%) will only vote for a candidate that shares their views.

For the public overall, the Democratic Party holds a strong edge over the Republican Party on the issue of abortion. About four in ten (42%) say the Democratic Party best represents their own views on abortion, compared to about one fourth (26%) who say the Republican Party best represents their own views on abortion. A substantial share (32%) of the public says “neither party” represents their views on abortion.

While most partisans select their own party as the one that best represents their views on abortion, about one in five Republicans say “neither party” best represents their views (21%), and an additional 6% say the Democratic Party best represents their views on abortion. Half of independents say neither party represents their views on abortion, while four in ten (36%) say they are best represented by the Democratic Party, and 13% say their views on abortion best align with the Republican Party. Nine in ten Democrats say their views on abortion are best represented by the Democratic Party.

Women ages 18 to 49, the group most directly impacted by the Supreme Court decision in Dobbs v. Jackson Women’s Health Organization, are nearly twice as likely to say their views on abortion are best represented by the Democratic Party compared to the Republican Party. About half (45%) of women ages 18 to 49 say they are best represented by the Democratic Party, while one-fourth (24%) say they feel their views align most with the Republican Party. About three in ten (31%) say “neither party” best represents their views. The Democratic Party also holds an advantage on abortion among Black, Hispanic, and White women ages 18 to 49. The Democratic Party also holds a similar advantage among women ages 18 to 49 in states where abortion is currently banned and in states where it is legal. Partisan women in this age group look similar to partisans overall, as about three-fourths of Republican women ages 18 to 49 say their views best align with the Republican party, 17% say neither party represents their views, and few (6%) say the Democratic Party represents them.

One Year Since The Dobbs Decision

Nearly one year after the U.S. Supreme Court overturned Roe, about seven in ten (71%) U.S. adults are aware of the decision and only a small share (5%) incorrectly say Roe is still the law of the land. Still, about one in four (24%) U.S. adults say they are “not sure” whether the 1973 ruling that established a woman’s constitutional right to an abortion is still the law of the land, including a substantial share of women ages 18-49, the group most directly affected by the ruling.

Nearly seven in ten women ages 18 to 49 (68%) are aware Roe has been overturned, while one-fourth say they are not sure, and 7% incorrectly say Roe is still in effect, relatively unchanged from June 2022. Within this group, Black and Hispanic women are less likely to be aware that Roe has been overturned than White women. Four in ten (43%) Hispanic women, ages 18 to 49, and about one-third (32%) of Black women, ages 18-49, say they are “not sure” about the status of Roe, compared to about one in seven (16%) White women. About a third of women ages 18 to 49 without a college degree are also unsure of the status of Roe in the U.S.

The survey findings indicate some women ages 18 to 49 are changing their approach to contraception and reproductive health following the Dobbs decision. More than half (55%) of women ages 18 to 49 say they or someone they know has taken at least one of several steps aimed at reducing the likelihood of getting pregnant due to concerns about not being able to access an abortion. This includes roughly three in ten women in this age group who say they or someone they know has started using long-acting birth control such as an IUD or implant (32%), gotten a new prescription for an oral contraceptive (28%), or bought Plan B or emergency contraception in case it was needed in the future (28%).

State Abortion Laws

Over the past year, the U.S. has seen various state-level actions on abortion access with many states making abortion illegal, some states solidifying access to abortions, and in some states legal challenges to abortion bans are still being considered in in the state courts. Three in four U.S. adults say they understand the abortion laws in their own state either “very well” (30%) or “somewhat well” (45%), while one in four feel they understand them “not too well” (20%) or “not at all well” (5%).

With many states passing bans on abortion, nearly three-fourths (73%) of adults say these bans make it more difficult for doctors to safely take care of pregnant people who experience major complications. In addition, two-thirds of the public are either “very concerned” (42%) or “somewhat concerned” (23%) that bans on abortion may lead to unnecessary health problems. This includes eight in ten (82%) Democrats and seven in ten independents and about half (47%) of Republicans who are concerned these bans could lead to unnecessary health problems. Four in ten Republicans say bans on abortion do not make it more difficult for doctors to treat pregnant patients.

Medication Abortion In The Courts

The availability of mifepristone, used for medication abortion, has been the subject of several court cases following the Supreme Court’s Dobbs ruling which overturned Roe v. Wade and eliminated the federal standard regarding abortion access. On April 21st, the US Supreme Court blocked a lower court order that would have stopped the distribution and availability of the medication abortion drug, mifepristone, across the country. The high court’s ruling allows the current FDA rules to remain in effect, keeping mifepristone available for medication abortion where and when abortion is legal as the case proceeds through the courts.

Awareness Of Medication Abortion On The Rise, But Some View It As Unsafe

Awareness of the abortion pill has doubled since January 2023, with about two-thirds (64%) of adults now saying they have heard of the drug compared to about three in ten (31%) in January. The share of women ages 18 to 49 who have heard of mifepristone has increased 15 percentage points to 61%, up from 46% in January.

Public confused aBOUT legality AND SAFETY Of medication abortion

There continues to be widespread confusion on whether medication abortion is legal in certain states with about half (45%) of all adults say they are “unsure” whether medication abortion is available in their state.

Those who live in states where abortion is legal and available are much more likely to be aware of the legality of medication abortion in their state, while a larger share of those in states where abortion is limited or banned say they are “unsure.”

In the 25 states and D.C. where abortion is legal beyond 22 weeks gestation six in ten correctly say medication abortion is legal in their state, while four in ten either incorrectly say medication abortion is illegal (6%) or say they are “not sure” (34%). In the 14 states where all abortion methods, including medication abortion is banned, one-third are aware of this while 13% incorrectly believe the medication is legal, and more than half (54%) say they are unsure. In states where abortion is banned beyond a certain number of weeks of gestation, medication abortion is a legal option for early intervention. Six in ten of adults living in these states are “not sure” about the status of medication abortion, 15% incorrectly say it is illegal, and one-fourth are aware it is legal in their state.

Similarly, there is confusion among women of reproductive age over what is available to them. Nearly half (46%) of women ages 18 to 49 living in states where abortion is banned are unsure about whether medication abortion is legal, and 15% incorrectly say it is legal. In states where abortion is legal up to a certain point, more than half (53%) of women ages 18 to 49 are unsure about the status of medication abortion, and an additional one-fifth (18%) incorrectly say it is illegal. Women in states where abortion is legal and available are more aware, with six in ten correctly saying medication abortion is legal in their state.

Most U.S. adults (55%) say medication abortion pills are “very safe” (30%) or “somewhat safe” (25%) for the person taking them when taken as directed by a doctor, but a substantial share (35%) say they are “not sure” about the pills’ safety. Few adults believe the pills to be either “very unsafe” (3%) or “somewhat unsafe” (6%).

Similar to most questions about abortion, perceptions of safety divide by partisanship. Nearly three-fourths of Democrats say medication abortion pills are safe (72%), as do six in ten (58%) independents. Less than half of Republicans agree (40%). Republicans are also twice as likely as Democrats to say they are “not sure” about the safety of mifepristone (22% v. 45%). Views on the safety of medication abortion also slightly differ by gender with larger shares of women than men saying medication abortion is safe, but at least three in ten men and women are unsure about the safety of the medication.

In addition, very few U.S. adults are correctly aware that mifepristone is safer, when taken as directed, than Viagra (16%), Penicillin (8%) and Tylenol (7%). About four in ten say they are not sure about how the safety of these medications compare to mifepristone (Viagra: 44%, Penicillin: 41%, Tylenol: 40%).

While many are uncertain about the safety of medication abortion, larger majorities (74%) are aware abortion procedures are “very” (44%) or “somewhat safe” (30%), with few saying they are “somewhat” (8%) or “very unsafe” (4%). An additional 14% say they are unsure about the safety of abortion procedures. Majorities across partisans and gender say that abortion procedures are at least somewhat safe, though women and Democrats are more likely to say this compared to men and Republicans.

Mifepristone For Miscarriage Treatment

Besides the use for medication abortions, mifepristone as well as misoprostol (the other drug used for medication abortion) can also be used to treat miscarriages and to induce labor. While abortion bans do not explicitly ban the use of mifepristone or misoprostol for miscarriage management, the exceptions to abortion bans are limited and vague. In states with abortion bans or restrictions, many clinicians have delayed providing miscarriage management until the pregnant person’s health worsens. A large majority of adults are not aware that mifepristone can be used to treat a miscarriage, though women (22%) and Democrats (27%) are most likely to be aware that it can be used for this purpose.

Views Of The Supreme Court And The FDA

On the heels of these key legal battles, the latest KFF Health Tracking Poll finds most U.S. adults disapprove of the Supreme Court of the United States (SCOTUS) and a strong majority say they don’t trust the Court to make decisions about reproductive and sexual health.

Six in ten adults (58%) say they disapprove of the way SCOTUS is handling its job including majorities of adults across age groups, race and ethnic groups, and gender. Views of the Court are largely partisan with three in four Democrats (78%) and six in ten independents (61%) disapproving of the way the Court is handling its job, while two in three Republicans (66%) approve. One year after the Dobbs decision, two-thirds of women ages 18 to 49 (65%) say they disapprove of the way the Supreme Court is handling its job.

About half of the public say they trust the Supreme Court to make the right decision about cases related to science and technology (55%), cases related to the role of the federal government (53%), and cases related to the future of the Affordable Care Act (ACA) (49%). Yet less than four in ten (37%) say they trust the Court to make the right decisions about cases related to reproductive and sexual health including about three in ten (28%) women ages 18 to 49.

Large majorities of Republicans say they trust SCOTUS “a lot” or “somewhat” to make the right decisions about cases related to each of the issues asked about while fewer than half of Democrats agree. At least six in ten Republicans say they trust the Court on issues related to science and technology (74%), the role of the federal government (66%), and the future of the ACA (65%). More than half of Republicans (56%) say they trust the Court to make decisions about reproductive and sexual health. Among Democrats, about four in ten say they trust SCOTUS at least somewhat on the role of the federal government (45%), science and technology (44%), and the future of the ACA (37%). A large majority of Democrats (79%) say they do not trust the Court to make the right decisions on cases related to reproductive and sexual health. Independents’ trust of the Supreme Court varies with about half of them saying they trust the Court at least “somewhat” on issues related to science and technology (50%), role of federal government (51%), and the future of the ACA (48%), but fewer (34%) say they trust the Court to make the right decision when it comes to reproductive and sexual health.

Nearly one year since the Dobbs decision, most women say they don’t trust the Supreme Court to make the right decision when it comes to cases related to reproductive and sexual health. About seven in ten women (69%) say they trust the Court either “not too much” or “not at all” to make the right decision on this issue, while three in ten say they trust the Court either “somewhat” or “a lot.” This includes at least half of Hispanic women (55%), and two-thirds of Black (64%) and White (64%) women  who say they do not trust the Court on these issues.

Nearly three-fourths (72%) of women ages 18-49, the group most directly impacted by the Dobbs decision, say they do not trust the Court to make the right decision on cases related to reproductive and sexual health. This includes a majority of women in this age group (ages 18 to 49) across party lines, including 56% of Republican women ages 18 to 49, and at least three-fourths of independent (75%) and Democratic (81%) women of reproductive age.

The U.S. Food And Drug Administration

In light of the legal debate around the U.S. Food and Drug Administration’s (FDA) approval of mifepristone, the latest KFF Health Tracking Poll finds six in ten adults say it is “inappropriate” for a court to overturn the FDA’s approval of a medication, while four in ten (39%) say they think it is “appropriate.” Three-fourths of Democrats (73%) say they think the court overturning the FDA’s approval of a medication is “inappropriate,” as do nearly six in ten (57%) independents. Republicans are divided with similar shares saying the court overturning the FDA’s approval of a medication is “appropriate” (50%) and “inappropriate” (49%).

Overall confidence in the FDA is relatively high, with around two-thirds of adults having “a lot” or “some” confidence in the FDA to ensure that medications sold in the U.S. are safe and effective (65%), including a quarter (23%) who say they have “a lot” of confidence. About one-third (35%) of adults say they either have “a little confidence” (21%) or “no confidence at all” (14%) in the FDA to ensure medications sold in the U.S. are safe and effective.

Majorities across demographic groups, including partisanship and age, report having confidence in the FDA to ensure the safety of medications. However, larger shares of adults 65 and older (31%) and Democrats (34%) report having “a lot of confidence” in the FDA’s certification of medications, with fewer of those ages 18 to 29 (15%) and Republicans (15%) who say the same.

These findings were released on May 31, 2023.

Key Findings

• The 2010 Affordable Care Act (ACA) experienced its most recent legal challenge earlier this year in the ongoing Braidwood Management v. Becerra case. While the case challenges all ACA requirements for private health insurance to cover preventive services, the federal district court ruled that the ACA’s requirement for no cost coverage of preventive services recommended or updated by the U.S. Preventive Services Task Force (USPSTF) after March 2010 is unconstitutional and on a separate basis, the requirement to cover  PrEP medications for HIV prevention violated the plaintiffs’ religious rights. The latest KFF Health Tracking Poll finds the public largely unaware of the ongoing case, but after hearing about the case – substantial shares say it could lead to increased cost for preventive care for them and their families and a large majority say that if PrEP is no longer required to be covered by insurance, it will be more difficult to reduce HIV infections.
• Views of the ACA remain partisan with large shares of Democrats and independents holding positive views of the law while many Republicans view the law unfavorably. Yet, a majority of all partisans including most Democrats (92%), independents (87%), and Republicans (72%) say they have a favorable view of the part of the law that eliminates out-of-pocket costs for many preventive services. While many haven’t heard much about the ongoing lawsuit, about one-third of adults think they will have to pay more as a result of it. About half of adults say they aren’t sure if they will have to pay more for their health care because of this ruling.
• Eight in ten adults (82%) say that if PrEP is no longer required to be covered by insurance, it will make it more difficult to reduce the number of new HIV infections in the U.S., while 18% say it won’t have an impact on infections. The share who say PrEP no longer being covered will make it more difficult to reduce new HIV infections includes a majority across groups, including partisanship, those who are lesbian, gay, bisexual, or transgender, and whether they either know someone who has or personally has HIV. In addition, almost two-thirds of adults (63%) are not sure if people in the U.S. who need medication to prevent getting HIV are able to get it.
• While few adults overall are aware of PrEP, many still view HIV/AIDS as a serious issue. KFF has been conducting polling on the HIV/AIDS epidemic in this country for nearly three decades, and the latest poll finds that still three-quarters of adults (76%) say that HIV/AIDS is a serious issue for the U.S. today, with three in ten (29%) who say it is “very serious” and almost half (47%) who say it is “somewhat serious.” This includes large shares of Black adults, Hispanic adults, and Democrats who say HIV/AIDS is a “very serious” problem in the U.S. today.

The Legal Battle Around ACA’s Preventive Care Protections and PrEP

A U.S. district judge recently ruled the Affordable Care Act’s requirement for private insurers to cover the full cost of certain preventive services recommend by the U.S. Preventive Services Task Force (USPSTF) is unconstitutional and should not be in effect. The ruling does not apply to services that were recommended by USPSTF prior to when the ACA was signed into law in March 2010, Women’s Preventive Services recommended by Health Resources and Services Administration (HRSA), or vaccines recommended by the CDC’s Advisory Committee on Immunization Practices (ACIP). On May 15^th, 2023, the 5^th Circuit Court of Appeals issued a stay of the ruling which means that as of now, the entire preventive services requirement is still in effect. This survey was fielded while this legal debate was taking place and asked respondents about awareness and implications of the first ruling from the district court.

A KFF analysis of claims data found that in a typical year about 6 in 10 people with private insurance, or about 100 million people, receive at least one preventive service or medication under the Affordable Care Act. As the district court ruling applies to a narrower subset of these preventive services, about 1 in 20 people with private insurance, or about 10 million people, receive at least one of the preventive services or medications potentially affected by the district court’s remedy in the Braidwood case.

While this case could have implications for some, few have heard much about the ruling, with a quarter of adults who say they’ve heard “a lot” or “some” about this ruling. Almost four in ten (37%) say they have heard “not too much,” and a similar share (38%) have heard “nothing at all.”

With few knowing about this ongoing case, about half of U.S. adults (49%) are “not sure” if they personally will have to pay more for health care because of the ruling. Around a third (32%) think they will have to pay more because of the ruling, and one in five (19%) do not think the ruling will mean they have to pay more for health care.

Larger shares of women (53%), a group more likely to need access to preventive services, say they aren’t sure if they’ll have to pay more for their health care because of the ruling than men (45%). Similarly, 55% of young adults, ages 18-29, aren’t sure if they’ll need to pay more.

This case is the latest legal battle over the 2010 health reform law known as the Affordable Care Act (ACA) or Obamacare. Overall, around six in ten (59%) adults have a favorable opinion of the ACA, including large majorities of Democrats (89%) and independents (62%). Republicans continue to view the law unfavorably, with 42% saying they have a “very unfavorable” opinion of the ACA. Click here to see more than ten years of polling on the ACA.

The ACA’s requirement for no cost coverage of preventive services has long been one of the most popular aspects of the law. The latest KFF Health Tracking Poll finds eight in ten (82%) adults have a favorable opinion of the part of the ACA that made many preventive services free to people with health insurance, including half (52%) who have a “very favorable” view. The share who view this part of the law favorably is substantially higher than the share who hold favorable views generally about the ACA in general.

More than twice as many Democrats as Republicans say they feel “very favorable” towards this part of the law (75% Democrats vs. 29% Republicans), though a majority of Republicans (72%) have at least a “somewhat favorable” opinion of the no cost preventive service coverage from the ACA.

HIV Prevention and Access to PrEP

Another aspect of the ongoing Braidwood Management v. Becerra case focuses on PrEP, a medication to prevent people from getting HIV. PrEP was among the medications covered by the preventive services provision of the ACA, requiring private insurance companies to cover it with no cost-sharing, but the district court judge also ruled that the federal government cannot require the plaintiffs who have religious objections, to offer insurance with coverage for PrEP.

Very few adults have heard about PrEP, the medication to protect people from getting HIV, with half of adults saying they have heard “nothing at all” about the medication, and 15% saying they have heard “a lot” or “some” about it. Awareness of PrEP increases to 25% among adults ages 18-29, 21% among Black adults, 32% among those who have HIV or know someone who does, and 42% of LGBT adults.

Once made aware of the medication, eight in ten adults (82%) say that if PrEP is no longer required to be covered by insurance, it will make it more difficult to reduce the number of new HIV infections in the U.S., while 18% say it won’t have an impact on infections.

Majorities across demographic groups say that if PrEP is no longer required to be covered by insurance, it will make it more difficult to reduce the number of new HIV infections. This includes nine in ten people who have HIV or know someone who does (93%), Democrats (91%), and LGBT adults (87%). At least three in four Republicans (73%), those who don’t know anyone with HIV (80%), or non-LGBT adults (81%) agree that this ruling will make it more difficult to reduce the number of new HIV infections in the U.S.

Similar shares across racial and ethnic groups say that if PrEP is no longer required to be covered, it will make it more difficult to reduce the number of new HIV infections.

Overall Awareness of PrEP and Views of HIV Epidemic

While few adults overall are aware of PrEP, many still view HIV/AIDS as a serious issue. Three-quarters of adults (76%) say that HIV/AIDS is a serious issue for the U.S. today, with three in ten (29%) who say it is “very serious” and almost half (47%) who say it is “somewhat serious.” Fewer say that HIV/AIDS is a “very serious” issue (29%) in the U.S. today than said the same in March 2019 (34%).

Larger shares of Black adults (51%) say HIV/AIDS is a “very serious” problem in the U.S. today, as do Hispanic adults (39%), and Democrats (31%). This also includes 39% of adults who say they either have HIV/AIDS or know someone who does and 47% of LGBT adults.

Conversely, smaller shares of White adults (23%) and Republicans (22%) say HIV/AIDS is a “very serious” problem today, although still large majorities think it is at least somewhat serious.

Those who see HIV/AIDS as a “very serious” problem are also more likely to say they are worried about getting HIV. At least a third of Black adults (34%) and Hispanic adults (37%) say they are at least somewhat concerned about getting HIV, as do a quarter (24%) of LGBT adults. Overall, most adults are not worried about getting HIV, with around one in six who say they’re “very” or “somewhat” concerned.

ACCESS To HIV Medications

Almost two-thirds of adults (63%) are not sure if people in the U.S. who need medication to prevent getting HIV are able to get it. Around a quarter (27%) say the people who need HIV medication can get it, while one in ten say people are not able to get the medication they need.

Majorities across demographic groups say they’re not sure if those who need HIV medication in the U.S. are able to get it, including 67% of independents, 61% of Democrats, and 60% of Republicans.

Around half of LGBT adults (53%) and those who either have HIV or know someone who does (49%) are unsure of whether people with HIV can get medication, with 22% of LGBT adults and 37% of those who have HIV or know someone who does reporting that people with HIV are able to get medication for it.

Majorities across racial and ethnic groups aren’t sure whether people are able to get medication to prevent getting HIV, with 65% of White adults who say so, 63% of Black adults, and 60% of Hispanic adults.

This KFF Health Tracking Poll was designed and analyzed by public opinion researchers at KFF. The survey was conducted May 9-19, 2023, online and by telephone among a nationally representative sample of 1,674 U.S. adults in English (1,594) and in Spanish (80) including 799 women aged 18-49. The sample includes 1,393 adults reached through the SSRS Opinion Panel either online or over the phone (n=45 in Spanish). The SSRS Opinion Panel is a nationally representative probability-based panel where panel members are recruited randomly in one of two ways: (a) Through invitations mailed to respondents randomly sampled from an Address-Based Sample (ABS) provided by Marketing Systems Groups (MSG) through the U.S. Postal Service’s Computerized Delivery Sequence (CDS); (b) from a dual-frame random digit dial (RDD) sample provided by MSG. For the online panel component, invitations were sent to panel members by email followed by up to three reminder emails. 1,360 panel members completed the survey online and panel members who do not use the internet were reached by phone (33).

Another 281 (n=35 in Spanish) interviews were conducted from a random digit dial telephone sample of prepaid cell phone numbers obtained through MSG. Phone numbers used for the prepaid cell phone component were randomly generated from a cell phone sampling frame with disproportionate stratification aimed at reaching Hispanic and non-Hispanic Black respondents. Stratification was based on incidence of the race/ethnicity groups within each frame. Respondents in the phone samples received a $15 incentive via a check received by mail, and web respondents received a $5 electronic gift card incentive (some harder-to-reach groups received a $10 electronic gift card).

The online questionnaire included two questions designed to establish that respondents were paying attention. Cases that failed both attention check questions, those with over 30% item non-response, and cases with a length less than one quarter of the mean length by mode were flagged and reviewed. Cases were removed from the data if they failed two or more of these quality checks. Based on this criterion, 3 cases were removed.

The combined cell phone and panel samples were weighted to match the sample’s demographics to the national U.S. adult population using data from the Census Bureau’s 2021 Current Population Survey (CPS). The sample of female respondents 18-49 years old was weighted separately from other respondents to ensure representativeness of this group. Weighting parameters included sex, age, education, race/ethnicity, region, and education. The sample was weighted to match patterns of civic engagement from the September 2017 Volunteering and Civic Life Supplement data from the CPS and to match frequency of internet use from the National Public Opinion Reference Survey (NPORS) for Pew Research Center.  Finally, the sample was weighted to match patterns of political party identification based on a parameter derived from recent ABS polls conducted by SSRS polls. The weights take into account differences in the probability of selection for each sample type (prepaid cell phone and panel). This includes adjustment for the sample design and geographic stratification of the cell phone sample, within household probability of selection, and the design of the panel-recruitment procedure.

The margin of sampling error including the design effect for the full sample is plus or minus 3 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Sampling error is only one of many potential sources of error and there may be other unmeasured error in this or any other public opinion poll. KFF public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

Increasing mental health challenges and growing opioid overdose deaths have heightened the focus on behavioral health issues and the need for improved delivery of services. Behavioral health conditions, including mental health and substance use disorders, are particularly prevalent among Medicaid enrollees, with approximately 39% living with such a disorder. Federal initiatives have aimed to increase access by addressing workforce shortages, improving school-based care delivery, and launching and funding crisis services.

Medicaid is the single largest payer of behavioral health services in the country, so state programs can help leverage changes in the system by implementing a range of policies that enhance the delivery, quality, and effectiveness of these services. Despite state and federal efforts to improve accessibility and quality, 35% of Medicaid-covered individuals with significant mental health concerns report not receiving treatment. States maintain flexibility in determining the coverage, delivery, and payment of behavioral health services, leading to variations in these areas.

KFF surveyed state Medicaid officials about behavioral health policies related to administration, delivery systems, integrated care, and data analytics. These questions were part of KFF’s Behavioral Health Survey of state Medicaid programs, fielded as a supplement to the 22nd annual budget survey of Medicaid officials conducted by KFF and Health Management Associates (HMA). A total of 44 states (including the District of Columbia) responded to the survey by December 2022, but response rates varied by question. Further policy context is available in a series of behavioral health briefs that can be accessed in the “Behavioral Health Supplemental Survey” section on this page.

This issue brief utilizes this survey data to answer four key questions:

• How do states administer and finance their behavioral health programs?
• What managed care arrangements do states use to deliver behavioral health care?
• How are states promoting the delivery of integrated behavioral and physical health care?
• How do states monitor behavioral health data?

Behavioral Health Administration and Spending

Medicaid covers a disproportionate share of adults with mental illness and/or SUD (22% vs. 18% of all non-elderly adults). In recent years, state Medicaid and behavioral health authorities are increasingly collaborating to fund, provide oversight, and develop policy for publicly-funded behavioral health services and supports. We asked states to describe the current organizational structure of their Medicaid and behavioral health authorities and to indicate any planned changes to this structure. We also asked states about growth of behavioral health spending in Medicaid.

States’ behavioral health administration structures vary, but in most states Medicaid and behavioral health authorities are different divisions under a single agency (Table 1). Only two states reported that Medicaid and behavioral health authorities were in the same division under a single agency. About one-third of states reported that Medicaid and behavioral health authorities were in separate agencies—either separate cabinet level agencies, separate social service agencies, or separate agencies for each of Medicaid, mental health, and SUD. Three states reported “other” administrative structures.¹  While agency structure is not the only approach to coordination, operating Medicaid and behavioral health in a single agency may allow states to foster communication and data-sharing between these authorities. For example, one stated rationale for the 2015 merger of Arizona’s Medicaid and behavioral health authorities was to improve coordination of health care by integrating the management of health services for Medicaid enrollees.

Of the 44 responding states, two reported plans to change the state administrative structure in FY 2023: Iowa reported that its Department of Human Services and Department of Public Health have aligned to form a single Department of Health and Human Services and that behavioral health and Medicaid will both be divisions within this larger agency. Idaho reported plans to transition behavioral health and Medicaid from different divisions under a single agency to a joint division under the agency, and to manage both Medicaid and non-Medicaid behavioral health services through a managed care organization (MCO).

Most states report that Medicaid spending on behavioral health services is growing faster or about the same as overall Medicaid spending growth. In particular, a plurality of responding states (18 of 43) reported faster growth in behavioral health spending, while only four states reported slower growth in behavioral health spending; of the remaining states, seven reported that growth was about the same and fourteen reported they did not know. Reasons reported for faster rates of behavioral health spending included increased utilization and expansion of telehealth, increased utilization of behavioral health services, rate increases for behavioral health services, and new or expanded services or eligibility criteria for those with behavioral health.

Delivery System Models and Managed Care Arrangements for Behavioral Health Services

States use a combination of fee-for-service (FFS) and managed care arrangements to deliver behavioral health care to Medicaid beneficiaries, with these services increasingly being provided by managed care organizations (MCOs) in recent years. State movement toward managed care models has included carving behavioral health services into comprehensive, capitated MCO contracts or contracting with risk-based limited benefit prepaid health plans (PHPs). Other states have retained the FFS model but may contract with public or private Administrative Service Organizations (ASOs) to deliver behavioral services on a non-risk basis. We asked states to indicate behavioral health delivery system models in place and, if applicable, to report MCO provision of different behavioral health benefits. We also asked states to report any behavioral health quality incentives in place across delivery system models.

Nearly all responding states had multiple behavioral health delivery system models in place as of July 1, 2022; in particular, most states reported covering behavioral health services under both FFS and through MCOs (Figure 1 and Appendix Table 1). Almost all responding states (42 of 44) reported covering at least some behavioral health services under FFS; of these, 32 states also reported that some behavioral health services were included in a managed care arrangement (MCO and/or PHP). Only two states (Tennessee and Maryland) reported that they did not use any FFS arrangements to cover behavioral health services. Some states with FFS and/or managed care models reported that coverage of behavioral health services also included public or private behavioral health ASOs and/or county or government administered ASOs. While states may use different delivery models for certain behavioral health services, the increased complexity of the behavioral health delivery landscape could complicate access to needed care for enrollees.

Six states reported behavioral health delivery system changes planned for FY 2023:

• Three states (Missouri, North Carolina, and Oklahoma) reported plans to put in place new MCO arrangements for covering behavioral services.
• North Carolina and Arizona reported plans to eliminate their FFS models and transition all behavioral health benefits in to managed care.
• Iowa reported a plan to eliminate its county/government ASO model.
• Ohio implemented a new PHP model on July 1, 2022.

Most states continue to rely on MCOs to administer and manage inpatient and outpatient behavioral health services (Figure 2 and Appendix Table 2). States may carve specific services out of MCO contracts to FFS or PHPs; services frequently carved out include behavioral health, pharmacy, dental, and long-term services and supports (LTSS). However, significant movement has occurred across states to carve these services in to MCO contracts. Consistent with results from past years, the majority of MCO states reported that most specified behavioral health service types were always carved into their MCO contracts (i.e., virtually all services covered by the MCO); fewer states reported that services were always carved out (to PHP or FFS) or that carve-in status varies by geographic or other factors. Qualified Residential Treatment Programs (QRTPs)²  and mental health residential stays were the benefits most frequently carved-out. Some states reported that managed care coverage of specific behavioral health benefits varied by certain criterion, such as carve-outs for certain populations (see Appendix Table 2 for more information).

Nine responding states with MCO arrangements for acute care benefits reported changes to how behavioral health benefits were delivered under MCO contracts in FY 2022 or 2023. Changes to contracts fall into a few key policy domains, including:

• Revisions to support behavioral health integration. For example, North Carolina reported plans to launch integrated managed care plans.
• Changes to benefit design or coverage. For example, Ohio implemented a new prepaid inpatient health plan (PIHP) for youth with complex behavioral health needs
• Implementation of new payment models. For example, Massachusetts reported plans to implement prospective payments for participating primary care providers delivering integrated behavioral health care services.

See Appendix Table 3 for additional state-by-state detail on changes in MCO coverage of behavioral health services.

Three-quarters of responding states reported a financial quality incentive in place in FY 2022 or planned for FY 2023 to drive improvements in behavioral health care quality (Table 2). We asked states to report any financial incentives to promote behavioral health quality for MCOs, PHPs, and/or PCCMs or FFS. Of states with financial incentives in place or planned, states most commonly noted that they included behavioral health quality measures in an alternative or value-based payment program. States also reported withholding a percentage of managed care capitation payments or implementing performance bonuses or payments. Some states reported multiple kinds of financial incentives in place or planned. For example, Massachusetts noted that MCOs and Accountable Care Organizations (ACOs) participate in shared savings/losses programs tied to behavioral health quality performance indicators and that psychiatric and substance abuse treatment hospitals have a quality incentive payment structure.

Integrated Care

Many individuals receiving care for behavioral health conditions also have physical health conditions that require medical attention, and the inverse is also true. State Medicaid programs can adopt integrated care policies to address care fragmentation and better integrate physical and behavioral health care, such as by co-locating of both types of care at the same site or removing documentation requirements that may serve as barriers to integration. We asked states about whether they had implemented certain strategies to promote integrated care: Certified Community Behavioral Health Clinics, the psychiatric collaborative care model, and less extensive behavioral health documentation requirements.

About one-third of responding states reported recognizing Certified Community Behavioral Health Clinics (CCBHCs) as a provider type for reimbursement in FY 2022 or FY 2023 (Figure 3). The CCBHC demonstration, established by Congress in 2014 and expanded in 2022, aims to improve the availability and quality of ambulatory behavioral health services and to provide coordinated care across behavioral and physical health.³  We asked states to report information on CCBHC coverage and experiences:

• CCBHC coverage: Nine states reported that they recognized CCBHCs as a specific enrolled provider type for Medicaid reimbursement in FY 2022, with an additional six states planning to do so in FY 2023. Most of the remaining states (17) reported no plans to recognize CCBHCs in FY 2023, while 12 states were undetermined.⁴  A few states reported reasons they did not currently plan to recognize CCBHCs, including concerns about payment methodology, budgetary impacts, or that the state had existing providers that served a similar function.
• CCBHC challenges: Among states that do or plan to reimburse CCBHCs, challenges to their adoption included cost efficiency, implementation of payment structure, and workforce challenges.
• CCBHC reimbursement structure: The most commonly reported CCBHC reimbursement methodology was a daily or monthly prospective payment system (PPS) (10 states). A handful of states reported using FFS, outlier/bonus payment, or another methodology.⁵  Finally, where applicable, states reported a range of approaches to managed care payment requirements for CCBHCs; some states require managed care entities (MCEs) to pay rates set by the state while others allow MCEs to negotiate rates

About one-third of responding states reimbursed psychiatric collaborative care model (CoCM) codes in FY 2022, with many states undetermined as to whether they will open such codes in the future (Figure 3). CoCM is a behavioral health integration model that enhances primary care by adding two services (and providers) to a primary care team: care management for patients receiving behavioral health treatment, and regular psychiatric inter-specialty consultation. CMS has developed specific CPT billing codes for COCM services. Fifteen states reported reimbursing these codes in FY 2022, with two more states planning to reimburse in FY 2023. An additional one-third of states (15) were undetermined about whether to reimburse these codes in the future,⁶  while the remaining 12 states reported no plans to open these codes.

A small number of states reported promoting integrated care by adopting less extensive documentation requirements for primary care settings as compared to specialty behavioral health settings. Four states reported they had less extensive requirements in place in FY 2022 (Arizona, California, Maryland, and Texas) and one state planned to adopt less extensive requirements in FY 2023 (Arkansas). For example, Arizona formally recognizes accredited patient centered medical homes with behavioral health distinction as meeting documentation requirements without the need for additional auditing and is working to do the same for behavioral health homes.

Behavioral Health Data and Health Information Exchanges

Data on behavioral health utilization can be used to understand areas such as care utilization patterns, access gaps, population trends, and health disparities. Health information exchanges (HIEs) can facilitate communication, which may result in more effective and timely linkages to behavioral health and other care, as well as improved coordination and quality. We asked states about initiatives to encourage and support behavioral health provider participation in HIEs, as well as any challenges encountered. In addition, we asked states whether they collected or analyzed data to better understand behavioral health utilization patterns, needs, or disparities.

About half of responding states reported a state initiative to encourage or support Medicaid behavioral health provider network participation in health information exchanges (HIEs) (Table 3). Leadership buy-in, financial incentives, infrastructure assistance, and quality incentives are some of the methods states use to encourage behavioral health providers to utilize HIEs. Most states report HIEs are used to manage admission, discharge, and to transfer data during acute care or crisis situations. Behavioral health providers may also utilize HIEs for care coordination, referral services, and in some instances, social services referrals.

States reported that technology limitations, costs, and confidentiality concerns were primary barriers to use of HIEs in behavioral health. Some states point to a lack of trust among behavioral health providers regarding entering sensitive data into the HIE due to concerns about violating enhanced confidentiality requirements for some behavioral health populations. States report several financial barriers that may prevent behavioral health providers from participating in HIE, including limited access to technology, upgrades to existing IT infrastructure, integration costs across data systems, and changes in billing and administrative processes.

Nearly all responding states (40 of 44) reported using state-level data to better understand the needs of Medicaid behavioral health populations. States report analysis of claims data, newly collected data, or other data sources. These include data analyses conducted within state Medicaid agencies, often through demonstrations or waivers, and within MCO contracts.

Looking Ahead

As states continue to expand behavioral health services coverage to close access gaps and address the pandemic’s impact on mental health and substance use disorders, they may face continued upward budget pressures in behavioral health services spending due to increased utilization. Improved data quality and access may prompt states and analysts to further examine the complex Medicaid behavioral health delivery system, examining access and outcomes associated with various delivery and financing mechanisms. While states are increasingly adopting integrated care initiatives and making efforts to reduce fragmentation across physical and mental health, behavioral health providers’ difficulty participating in health information exchanges may hinder progress.

In addition, current discussions over proposed federal rule changes, such as privacy regulations for people with substance use disorders and telehealth prescribing for controlled substances, may affect how behavioral health systems and providers deliver and coordinate care. Numerous existing and proposed federal initiatives aim to employ strategic policies to enhance the accessibility, quality, and availability of behavioral health care. For example, the Consolidated Appropriations Act (CAA) passed workforce requirements that aim to increase the accessibility and availability of behavioral health care, including requirements for Medicaid provider network directories and funding for new psychiatry residency positions. Finally, recognizing Medicaid’s importance in covering and financing behavioral health care for children, recent legislation has utilized Medicaid as one pathway to expand school-based behavioral health services and additional federal and state efforts in this area are ongoing.

1. The three states are KY, MA, and MI: KY reported that both the State Medicaid Services (Department for Medicaid Services, DMS) and Behavioral Health (Department for Behavioral Health, Developmental and Intellectual Disabilities, DBHDID) are under the Kentucky Cabinet for Health and Family Services. MA reported that Medicaid and behavioral health were within the same executive office, under different agencies/programs. MI reported that adult behavioral health and Medicaid are in the same administration (the Behavioral and Physical Health and Aging Services Administration) within the Michigan Department of Health and Human Services (MDHHS), while children’s behavioral health policy is administered by a separate area of MDHHS. ↩︎
2. Qualified residential treatment programs (QRTPs) are child care institutions that provide trauma-informed therapeutic programming designed to address the needs, including clinical needs, of children with serious emotional or behavioral disorders or disturbances. QRTPs may receive federal foster care maintenance payments, but may be subject to the IMD exclusion for federal Medicaid payment. On KFF’s Behavioral Health survey, of 43 states responding, 16 states reported reimbursing for QRTPs in FY 2022 and an additional 5 states planned to add reimbursement in FY 2023. Two states reported a Section 1115 waiver in place to allow coverage of services provided to enrollees in QRTPs that meet IMD criteria, while 5 states planned to seek such a waiver. Of these 5 states, all planned to seek Section 1115 authority to exempt the limitations on lengths of stays under the waiver for foster care children residing in QRTPs. ↩︎
3. The Protecting Access to Medicare Act of 2014 established a demonstration program to improve community mental health services by funding planning grants for states to implement Certified Community Behavioral Health Clinics (CCBHCs), and the 2022 Safer Communities Act expanded this program. In addition to setting requirements for CCBHCs, the 2014 Act directed CMS to issue guidance on a prospective payment system for mental health services furnished by CCBHCs to account for the total cost of comprehensive services they provide. The CCBHC demonstration aims to improve the availability and quality of ambulatory behavioral health services and to provide coordinated care across behavioral and physical health. CCBHCs provide nine types of services: crisis mental health services; screening, assessment, and diagnosis; patient-centered treatment planning; outpatient mental health and substance use services; outpatient clinic primary care screening and monitoring; targeted case management; psychiatric rehabilitation; peer support and counselor services and family supports; and intensive, community-based mental health care for members of the armed forces and veterans. CCBHCs may partner with designated collaborating organizations to provide some of these services. ↩︎
4. Including CT (which reported it is analyzing the CCBHC model and may implement a modified version in the future), ME (which reported that its goal is to cover CCBHCs by July 1, 2024), and WA (which reported it is currently conducting a research study for the adoption of CCBHCs with a target of FY 2024). ↩︎
5. Of the 15 states that reported recognizing CCBHCs in FY 2022 or 2023, 12 provided information on their current CCBHC reimbursement structure(s). Some of these states reported the use of multiple reimbursement strategies. PPS methodologies: On May 20, 2015, the Centers for Medicare and Medicaid Services (CMS) issued guidance to states specific to the development of a PPS to be tested under the Section 223 Demonstration Program for CCBHCs, and required in Section 223 of the Protecting Access to Medicare Act of 2014. CMS released proposed updates to that CCBHC PPS Guidance in May 2023 to coincide with an additional round of state CCBHC grantees. CMS developed two PPS methodologies for reimbursing CCBHCs: one that pays a fixed daily rate for all service rendered to a Medicaid enrollee (similar to the methodology used by Federally Qualified Health Centers) and one that pays a fixed monthly rate. 8 states reported using the daily PPS model (ID, KS, KY, MI, MO, NV, NY, and OR) and 2 states reported a monthly PPS model (NJ and OK). Other methodologies: 3 states reported using FFS (NJ, NM, and NV), 3 states reported using outlier or bonus payments (MI, NJ, and NV), and 2 states reported using another methodology (AK reported that CCBHs are grant-funded; NY reported using a PPS methodology but carved out of managed care and paid using a CCBHC-specific code with a provider-specific rate based on each agency’s total cost of operations divided by total visits). ↩︎
6. Including SC, which reported that it intended to cover these codes and hoped to do so in FY 2023, but a firm date had not been established. ↩︎

Key Takeaways

• The federal Title X family planning program has undergone substantial changes in the number of participating clinics in response to shifting program priorities and rules that vacillate widely between different administrations, particularly about how counseling and referral to abortion services are handled by grant recipients.
• The Trump Administration regulations that prohibited grantees from referring clients for abortion services or having co-located family planning and abortion services led to a withdrawal of almost a third of the sites from the Title X network. The reduction of the provider network and limits to in person care during the COVID-19 pandemic translated to a major reduction in the number of people served by the program from 3.9 million people in 2018 to 1.5 million in 2020, a 60% drop.
• The Biden Administration issued regulations to reverse the Trump Administration policies banning abortion referrals and the participation of family planning providers that also offer abortion services in the program. Today, the Title X network has even more sites than the number participating prior to initiation of the Trump Administration regulations.
• The Title X family planning program has been level funded at $286 million for nearly a decade, and as a result, has not been able to keep up with medical price inflation or the growing demand for family planning services.
• While the size of the family planning network has largely recovered, ongoing litigation challenging the Biden Administration regulations and the program’s provision allowing minors to get contraception without parental consent could result in limits to the availability of federally supported family planning services in some states.
• In states with abortion bans, continued participation in the Title X program may be impeded by state laws that prohibit pregnancy options counseling that includes abortion and referrals, a current requirement of the Title X program. The state of Tennessee (a Title X grantee) has already been disqualified because of their refusal to provide comprehensive pregnancy options counseling and abortion referral for those who seek it. In six of the states where abortion is banned (AL, AR, LA, OK, WI, and WV), the health department is the only Title X grantee.

Introduction

The federal Title X program, which has been in existence since 1970, has historically provided family planning services to nearly four million individuals a year through a network of approximately 4,000 clinic sites. The program is part of the U.S. public health safety net that is designed to serve individuals with lower incomes and those without insurance who otherwise may not be able to afford family planning services. Over the past number of years, the program has undergone substantial changes in the number of participating clinics and individuals it has been able to serve due to regulation changes and the COVID-19 pandemic.

The Title X program is led by a Deputy Assistant Secretary for Population Affairs who is appointed by the president, with program priorities and rules vacillating widely between different administrations. In particular, a provision of the Title X statute, Section 1008, that specifies that no federal funds appropriated under the program “shall be used in programs where abortion is a method of family planning” has been interpreted differently depending on who is in leadership. Throughout most of the history of the program, the ban has generally been understood to mean that Title X funds cannot be used to pay for or support abortion. However, the Trump and Reagan Administrations interpreted this more expansively as meaning that in addition to not paying for abortions, grantees were not permitted to use federal funds to promote, counsel, or refer clients for abortion or have co-located family planning services and abortion activities.

This interpretation, referred to as the Domestic Gag Rule by its opponents, is similar to the Mexico City Policy that requires foreign nongovernmental organizations to certify that they will not “perform or actively promote abortion as a method of family planning” using funds from any source (including non-U.S. funds) as a condition of receiving U.S. global family planning assistance. This policy has been reinstated and rescinded with the changing administrations for many years, which could be the future of the Title X regulations.

Title X Regulation Changes

In 2019, the Trump Administration made significant changes to the Title X regulations, which prohibited participating family planning clinics from providing abortion referrals and having co-located abortion services. This allowed grantees that had not previously participated in the program due to the requirement to provide nondirective pregnancy options counseling to begin receiving funding, such as the Obria Group, Inc., a Christian organization based in Southern California. Two other grantees joined the program under the Trump Administration, City of El Paso in Texas and Osceola Community Health Services in Florida. The new program regulations most notably resulted in a mass exodus of clinics from the Title X network, including over 400 Planned Parenthood clinics and almost 900 other Title X sites. From June 2019 to August 2021, almost a third of the Title X sites left the program (Figure 1).

Not long after the clinics started leaving the program, the COVID-19 pandemic began, where fewer people were seeking in-person care. In 2018, the Title X program served 3.9 million clients, which decreased to 1.5 million by 2020, over a 60% reduction, due to the decrease in size of the network and the COVID-19 pandemic. After President Biden was elected in November 2020, the Department of Health and Human Services (HHS) issued proposed regulations in April 2021 reversing the Trump Administration’s regulations and again requiring comprehensive pregnancy options counseling and abortion referrals when desired, as well as allowing co-located abortion services. These regulations were finalized and became effective in November 2021 (Figure 2).

In January 2022 as part of the American Rescue Plan HHS awarded $6.6 million to 8 grantees to address “dire family planning needs” as part of a series of actions HHS took in response to Texas Law SB 8, which banned abortions in Texas after 6 weeks of pregnancy (Table 1).

Title X Service Grants

In March 2022, HHS released a new funding announcement under the new regulations, which resulted in funding for 16 of the 18 grantees that had left the program under the Trump regulations. The two grantees that did not return as FY2022 grantees were Planned Parenthood of Illinois and Health Imperatives, Inc. in Massachusetts, although the network of clinics for these grantees stayed in the program, returning as sites under the Illinois Dept. of Public Health Family Planning Program and Massachusetts Department of Public Health grants, respectively. (Individual grantees can encompass multiple sites and clinics.) FY2022 grants were awarded to 76 grantees for a total of $256.6 million. The program has been level funded at $286 million for the past nine years despite inflation (Figure 3).

While these 76 grantees received 5-year awards to support their family planning networks, 13 grantees only received a one-year grant for FY2022 due to funding constraints. This resulted in 89 grantees funded at $265 million in FY2022 (Table 2). Additionally, in May 2022, HHS awarded supplemental funds totaling $16.3 million to 31 grantees to enhance and expand their telehealth infrastructure and capacity after the increase in the use of telehealth due to the pandemic. These funds were also made available through the American Rescue Plan for a 12-month project period.

For FY2023, HHS funded 87 grantees with $256 million. Eleven of the grantees that only received a one-year grant for FY2022 were re-funded in FY2023 with six receiving level funding and five receiving a decrease in funding. The City of El Paso did not reapply for FY2023 funding, and the State of Tennessee lost their Title X grant due to non-compliance with Title X regulations by not providing comprehensive pregnancy options counseling that includes referrals for abortion when desired.

Rebuilding the Title X Network

The Title X network has been rebuilding under the new regulations and funding. Of the 411 Planned Parenthood sites that left the program, 286 sites (70%) have rejoined.

Of the 869 other sites that left the program, 531 (61%) have returned. At the same time, there are 777 new sites that were previously not part of the program. This brings the current Title X network back to 4,108 sites, which is 2% more than the original 4,010 sites prior to the Trump regulations.

All six states that left the Title X network (HI, ME, OR, UT, VT, WA) under the Trump Administration’s regulations have returned with most of their sites or they have expanded their networks to new sites.

While most states had small increases in funding amounts from FY2019 to FY2022, California had a 42% decrease in funding from $21 million to $13.2 million. The state still managed to expand the number of Title X sites in their network and the grantee, Essential Access Health, recently received $60 million in state funding to expand reproductive health care for low-income individuals.

Nevada, which has five grantees, lost over a quarter of its funding from FY2019 to FY2022. Two of the grantees received larger grants (Nevada Primary Care Association and Southern Nevada Health District) and three of the grantees received less (Washoe County Health District, State of Nevada Division of Public & Behavioral Health, City of Carson City DBA Carson City Health & Human Services). Iowa has had a slight decrease in funding and the number of Title X clinics in Iowa has decreased by over 40%, largely due to the loss of the Planned Parenthood clinics in their network.

Impact of State Restrictions on Title X Funding

Two new grantees to the program, Bridgercare in Montana and Converge, Inc. in Mississippi, took over the Title X grants in their respective states in March 2022 after the state health departments had been the grantees for decades. Both grantees received slight increases in funding and Converge, Inc has been able to maintain Mississippi’s previous Title X network. However, the size of Montana’s Title X network has decreased slightly in response to a law passed by the Montana Legislature (House Bill 620), which prohibited the state from funding any organization that provides abortions, effectively excluding Planned Parenthood clinics from their Title X program.

In March 2023, Tennessee lost their Title X funding because of a state policy that required Title X clinics to only provide pregnancy options counseling for the options legal in the state, which excluded abortion, which is in violation of the federal requirements to provide comprehensive pregnancy options counseling. While Tennessee’s governor has said that the state will fund the health department for their lost Title X funding with $7.5 million in recurring annual state funding, it is unclear how long the state will maintain this funding. In Idaho, the Attorney General has clarified that the Idaho law banning abortion also prohibits Idaho medical providers from referring a woman across states lines to access abortion services, which would also be in violation of the Title X regulations requiring pregnancy options counseling. Planned Parenthood Great Northwest, Hawai’i, Alaska, Indiana, Kentucky, which is one of two Title X grantees in Idaho, is suing the Attorney General of the State of Idaho over their inability to provide comprehensive pregnancy options counseling to their clients.

This could become an issue in other states where abortion is banned and state laws or policies may be in direct conflict of Title X federal requirements, disqualifying a state health department from being a Title X grantee. There are currently 34 states with grantees that are state health departments and in 16 states the health department is the only Title X grantee, six of these are states where abortion is banned (AL, AR, LA, ND, SD, WI).

Current Title X Litigation

There are currently two lawsuits filed against HHS challenging aspects of the current Title X regulations. In a case filed in United States District Court for the Northern District of Texas, Amarillo Division in April 2020, Deanda v. Becerra, a father of three minor girls contends that the Title X provisions allowing minors to seek contraception without parental consent violates his rights as a parent under Texas law, and the due process clause of the fourteenth amendment. Judge Matthew Kacsmaryk, the only judge in the Amarillo division (and the same federal judge overseeing a case challenging approval of the abortion medication Mifepristone) ruled in favor of the plaintiff, stating that Title X does not preempt state laws requiring parental consent or notification before distributing contraception to minors, and that the Biden Administration Title X requirement violates the plaintiff’s fundamental right to control and direct the upbringing of his minor children. On December 20, 2022, the Court struck down as unlawful the provision of the regulations requiring Title X projects to provide minors services without requiring consent or notification of their parents or guardians. This ruling is not limited to the plaintiff or to Texas. In states that require parental consent or notification, minors may no longer be able to obtain contraceptive services without consent or notification. In February 2023, the Biden Administration appealed this decision to the Fifth Circuit Court of Appeals. The case is pending at the Fifth Circuit Court of Appeals, and the Biden Administration has requested oral argument.

On October 25, 2021, the state of Ohio, joined by 11 other states (AL, AZ, AK, FL, KS, KY, MO, NE, OK, SC, WV), filed a lawsuit in the US District Court for the Southern District of Ohio against HHS to block the implementation of the Biden Administration’s regulations. These states claim the final regulations violate Section 1008 of the Public Health Service Act that says none of the funds appropriated under Title X can be used in programs where abortion is a method of family planning. The litigants claim that by reinstating the regulations that allow co-located abortion services and require participating providers to offer referrals for abortions to clients who seek them, that HHS is not in compliance with the intent of the law. On December 29, 2021, the district court denied the plaintiffs’ motion for a preliminary injunction to block the Department of Health and Human Services from implementing or enforcing the final rule. The plaintiff states appealed this ruling to the Sixth Circuit Court of Appeals and the court heard oral arguments on October 27, 2022. In April 2023, the state of Arizona dropped out of the case (as the new governor and attorney general shifted to a Democratic administration). While this case is pending, the Biden Administration regulations, except for the parental consent provisions affected by the Deanda case discussed below, are in effect.

Looking Forward

The Biden Administration’s reversal of the Trump Administration’s Title X regulations has enabled grantees that left the program under the Trump regulations to rejoin. Many states have been able to rebuild their networks to where they were in 2019, and in some cases, have been able to increase the number of clinics in their networks. However, funding for Title X has not increased for the past nine years and some states are operating larger Title X networks with significantly less federal funding (e.g., California and Nevada).

With abortion banned or restricted in many states, access to Title X sexual and reproductive health services becomes even more important. While Tennessee is the first state to lose their Title X funding due to non-compliance around pregnancy options counseling after abortion has been banned in their state, other states may have similar conflicts. States with abortion bans may refuse to comply with the Title X regulations that require offering pregnancy options counseling that includes prenatal care and delivery; infant care, foster care, or adoption; and pregnancy termination, as well as abortion referrals upon request. In states where abortion is banned or restricted, this would require out-of-state referrals for those desiring abortion services.

HHS has released a grant opportunity forecast for $1.5 million designed to fund a currently funded Title X grantee to establish the Title X Nondirective Options Information, Counseling, and Referrals Hotline that will provide pregnant people with neutral and factual information, as well as nondirective counseling and referrals for those seeking this information. This hotline could help give people access to comprehensive information about pregnancy options regardless of where they live.

While there may be gaps in some states, HHS anticipated that the number of clients served by the program would return to around 4 million nationally by 2023, and with the Title X networks back to capacity in many states, it seems on track to reach that projection.