Community Health Centers and Family Planning in an Era of Policy Uncertainty
Family planning and related services are essential to the health of women and families. For this reason, provision of high quality family planning services ought to be central to community health centers’ mission, not only because family planning is a required service but because community health centers play such a central role in women’s health. Thirty percent of all low-income women of reproductive age rely on community health centers, and women of reproductive age represent one quarter (26 percent) of all community health center patients. As community health centers have grown, and as other sources of accessible, affordable family planning services have shrunk, community health centers’ role in family planning has become increasingly important.
In thousands of communities, residents continue to rely on independent family planning clinics, which remain an essential part of the primary care landscape. Indeed, as the referral findings in this report suggest, many community health centers depend on collaboration with independent family planning clinics to help meet the sexual and reproductive health needs of their communities.
This report shows some of the ways in which community health center family planning services have strengthened. Between 2011 and 2017, the proportion of community health centers offering highly effective contraceptive implants onsite increased significantly among both Title X and non-Title X funded community health centers. However, the evidence also shows wide variation in health centers’ ability to meet women’s reproductive health care needs. These findings suggest that while some health centers have strengthened their services and performance, others fall short of the broad range of contraceptive methods and simplified access to care that are considered essential to modern, high quality family practice performance.
It is clear from this survey that Title X participation makes a significant difference in community health center performance. Some of this difference can be attributable to the fact that Title X grantees are dedicated to providing family planning services and have access to additional resources targeted to upgrading and improving family planning care. One would expect more dedicated and specially trained staff to provide a wider array of onsite services commensurate with Title X requirements. In addition, unlike Title X, Section 330 of the Public Health Service Act leaves many of the key details of clinical practice to community health centers, which in turn may contribute to highly variable care. Given their obligations to patients of all ages and their limited operational resources, community health centers must continually balance resource allocation against the full scope of community need, but the result is that some clinics fall short in meeting current standards of family planning care. As suggested by the FOA for Title X funding, the Trump Administration is changing the evidence -based requirements for Title X clinics, which will have severe implications for the provision of quality family planning at Title X clinics.
Some of the differences between community health centers that do and do not receive Title X funding are striking. Some involve relatively low practice transformation strategies to update older and outdated practices; these strategies should be well within reach regardless of the availability of additional Title X funding. For example, it is not clear why only half or fewer than half of all community health centers offer onsite access to oral contraceptives (51 percent) or emergency contraception (40 percent for plan B or other OTC EC); indeed, between 2011 and 2017, onsite oral contraceptive dispensing dropped by 17 percent, and a sizable minority of clinics do not dispense, prescribe, or refer for EC (15 percent for Plan B and 28 percent for ella). Nor is it clear why only 62 percent of community health centers report that new patients can secure a prescription for oral contraceptives without a pelvic exam and only 31 percent of community health centers will dispense or prescribe emergency contraception ahead of time. These practices are now considered the standard in the field and are elements of high quality care that require the introduction of healthcare efficiencies rather than major new resources. The value of focusing on relatively modest efficiency changes in the provision of family planning services that can improve access and quality thus emerges as an important report conclusion.
Important differences remain with respect to community health center size and rural/suburban or urban location, but measurable improvements involving highly effective family planning services have occurred in recent years. Similarly, over three-quarters of community health centers report that they routinely screen young women for chlamydia, screen for intimate partner violence, and ask about pregnancy intention. These numbers suggest the beneficial effects of evidence-based quality performance measures and the systematic introduction of best practices and the extent to which careful focus on performance can translate into greater quality.
It is particularly important to note the finding that only half of community health centers say they can handle a modest (10 to 24 percent) increase in patient capacity, and almost three in ten say they can only accommodate a slight (less than 10 percent) increase in new patients. A common theme among proposals to block Planned Parenthood from the Medicaid program is the redirection of funds to other providers, such as community health centers, with the expectation that other clinics could meet the needs of those formerly served by Planned Parenthood. However, this survey suggests that these health centers may not have the capacity to fill the void if Planned Parenthood were excluded as a Medicaid or Title X provider. In addition, this survey shows that many health centers are not providing the full range of methods to which women need access. Other studies have found that Planned Parenthood clinics are more likely to offer women the full range of contraceptive and family planning services. This survey confirms that many health centers not only do not feel equipped to absorb many new patients; many also do not offer the broad scope of services that are part of the current standard of high quality family planning care.
Finally, this study shows the value of a program such as Title X – not only as a vital source of funding for clinics that focus on reproductive health and ensuring access to comprehensive contraceptive methods but also as means for leveraging performance improvement among health centers that focus more broadly on the provision of primary care. Given the limited amount appropriated to Title X and the ongoing need for Title X funding in communities across the nation, a possible approach to improve the scope of family planning offered by all community health centers would be to dedicate a specified proportion of 330 funding to assist health centers in achieving specific family planning performance improvement. A strategy that combines supplemental funding with clear family planning improvement performance expectations is a permissible activity under the health center program itself.
Section 50901 of the Balanced Budget Act of 2018 (Pub. L. 115-123), which extends the Affordable Care Act’s health center grant fund through the end of Fiscal Year 2019, explicitly authorizes HHS to use a portion of these additional funds to make targeted improvements in primary health care quality improvement. The health centers program has successfully used this targeted supplemental grant approach for other high community needs such as maternity care, substance use addiction treatment, mental health, and oral health. Based on this study’s findings regarding the impact of dedicated Title X funding, and in view of community health centers’ central role in the health of low income women of childbearing age, a well-designed family planning initiative as central part of the health center program itself can be expected to promote the availability and quality of health center family planning services.