Community Health Centers and Family Planning in an Era of Policy Uncertainty
Introduction. Community health centers play a major role in furnishing publicly funded reproductive health care, including family planning services, to women living in low-income and medically underserved communities. Community health center patients are overwhelmingly low-income, members of a racial or ethnic minority group, and disproportionately female. In 2016, nearly one-third of all low-income women of childbearing age obtained care at a community health center. Since the health centers program was first enacted into law in 1975, voluntary family planning has been a required service.
Study purpose and methods. Building on earlier research conducted by George Washington University in 2011, this study examines the current state of community health centers’ family planning services. Its purpose is to assess the scope and onsite availability of family planning services, how health centers are incorporating evidence-based recommended best practices into their activities, how participation in the Title X family planning program might affect the scope and quality of health center family planning services, and to document barriers to care. The study is based on a survey, conducted between May and July 2017, of health centers in all 50 states and the District of Columbia. Since health centers on average deliver care at over seven sites, the survey gave special focus to each respondent’s largest service site offering family planning services onsite. The survey yielded a 41 percent response rate.
Key findings. Virtually all health centers (97 percent) reported that their largest comprehensive medical sites offered family planning services. Among the study’s key findings:
Scope and comprehensiveness of care: About half the sites provide short-acting, effective methods onsite, including oral contraceptives (OCs), the contraceptive ring, and the contraceptive patch, and over half provide long-acting methods onsite, including hormone-releasing IUDs, the copper IUD, and implant. Between 2011 and 2017, the proportion of sites offering onsite long-acting contraception rose from 36 percent to 63 percent for the implant and 56 percent to 64 percent for hormonal IUDs. Over the same time period, however, the percentage offering onsite oral contraceptives declined from 61 percent to 51 percent. Fewer than half provide emergency contraception onsite, and many do not prescribe or refer for it at all. Onsite provision of Plan B (available without a prescription) has significantly decreased from 2011. One in four health centers offers all seven of the most effective family planning methods onsite, while nearly half (48 percent) provide all seven methods either onsite or by prescription.
Promoting access to services and counseling. Two-thirds of health centers offer access to initial contraceptive visits on a same-day and walk-in basis. In 2017, 68 percent of health center sites offered same-day/walk-in initial contraceptive visits for new patients and 89 percent for established patients. Most health centers follow current patient screening and counseling recommendations: 76 percent report that they ask about the childbearing plans for female patients of childbearing age, 85 percent routinely screen sexually active women age 25 or younger for chlamydia, and 80 percent routinely screen women of childbearing age for intimate partner violence.
Family planning staffing. Health centers are less reliant on physicians for family planning counseling than they were in 2011. Three quarters report that physicians provide family planning counseling, down from 85 percent in 2011.
Special population services. Sixty-three percent of health centers offer services for adolescents, up substantially from 47 percent in 2011, and are more likely today than previously to maintain special confidentiality protections for minors.
The role of Title X funding: Across virtually all measures of performance, the receipt of additional Title X funding lifted performance. Twenty-six percent of respondents report that their largest family planning sites also receive Title X funding. In keeping with the more dedicated mission of Title X grantees and detailed family planning requirements of Title X, Title X-funded sites consistently show a larger range of onsite contraceptive methods across all types of methods, including natural family planning instruction and emergency contraception. Title X-funded health center sites are substantially more likely – 48 percent compared to 15 percent of sites not receiving Title X funding – to offer all seven of the most effective methods onsite. Title X-funded sites also consistently show greater incorporation of evidence-based best practice methods, including prescribing oral contraceptives without requiring a pelvic exam and use of the “quick start” method for oral contraception that ensures that women who seek it have more rapid access to effective contraception. Title X-funded sites are also more likely to follow best practices related to screening and counseling. Title X-funded sites are also far more likely – 43 percent compared to 16 percent – to have health counselors or educators providing family planning counseling.
Expanded onsite services; limited additional capacity: As their services have grown – especially related to provision of long-acting contraceptives – health centers simultaneously are referring fewer patients to freestanding family planning clinics. Half of respondents reported increased demand for family planning services in the past five years, and the majority responded with staffing increases to support this demand. In 2011, 78 percent of health centers with family planning clinics in their service area reported referring patients to them; by 2017, this figure had declined to 36 percent. Sites without Title X funding more typically refer patients, whose care becomes their direct responsibility under Title X. Health centers reported limited capacity to accept new patients; 51 percent reported that they could increase patient capacity but only between 10 and 24 percent; only 6 percent reported that they could absorb a 50 percent or greater patient increase.
Expanded services; remaining barriers. Reported major barriers to meeting patients’ family planning and reproductive health needs focus on the challenges of affordability for patients and the financial resources needed to maintain a robust family planning practice. Nationally, 23 percent of health center patients remain uninsured, a percentage that is higher in non-ACA Medicaid expansion states (36 percent). Twenty-five percent reported the lack of insurance coverage among patients as a major barrier, 28 percent reported high patient out-of-pocket costs as a major barrier issue, and 19 percent reported inadequate insurance payments as a major barrier. One in four health centers (24 percent) reported the high cost of stocking contraceptives onsite as a major barrier, and twenty percent reported high patient demand for other primary care services at their largest site as a major barrier. Nineteen percent reported a lack of staff trained in IUD/implant procedures as a major barrier.
Implications. Community health centers are vital to low-income women’s access to primary and preventive healthcare services, including family planning services. Family planning has been a required service under the community health center program since its beginning and remains a crucial component of health care for women of reproductive age (15-44). This survey finds that since 2011, the share of health centers offering long acting contraceptive methods has grown. At the same time, health centers that also participate in the Title X program are more likely to offer a broad range of methods and engage in higher quality practices such as use of the quick start method for oral contraceptives and same day walk-in services. This suggests that targeted supplemental funding tied to clear performance expectations may yield positive, measurable results in preventive primary care. Expanding the availability of targeted family planning quality improvement funds as a direct part of the health centers program would be consistent with the Balanced Budget Act of 2018, which, in extending health center grant funding, explicitly allows HHS to spend funds on targeted primary care quality improvement. On February 23, 2018, the Trump Administration released the funding opportunity announcement (FOA) for Title X family planning grants. This funding announcement does not require that grantees adhere to evidence based standards for quality family planning that were promulgated by the Office of Population Affairs and Centers for Disease Control and Prevention. This study finds that health centers that participate in Title X are those that offer the highest quality family planning services. Any weakening of the evidence-based requirements for Title X grantees may result in a significant loss of access to the most effective contraceptive methods for low-income women, men, and teens.
A majority of health centers also reported in this study that they are unable to accept a major increase in new patients. This is particularly important to note in light of recent proposals to block Planned Parenthood from the Medicaid program and redirect funds to other providers, such as community health centers. The FOA for Title X funding released in February 2018 gives preference to clinics that provide primary health care and family planning services in the same location. In addition, as this survey suggests, these health centers may not have the capacity to fill the void if Planned Parenthood were excluded as a Medicaid or Title X provider.
Strategies that will elevate the standards of family planning services offered by health centers have the potential to have high impact on many of the challenges facing women’s health. Promoting the availability of high quality family planning services reduces unintended pregnancy and abortion rates, improves birth outcomes, and allows women to make informed and independent reproductive choices to improve their health and their future wellbeing.