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Title X: The Nation’s Program for Affordable Birth Control and Reproductive Health Care

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For more than 40 years, Title X family planning clinics have played a critical role in ensuring access to a broad range of family planning and related preventive health services for low-income, uninsured individuals, and others.  According to Frost, Sonfield, Zolna, & Finer (2014), in the United States, half of all pregnancies are unintended, and unintended pregnancy is highly concentrated among low-income women.  In response to this disparity, the government created Title X.  Title X is the only federal grant program that is solely dedicated to providing individuals with comprehensive family planning and related preventive health services.  This funding has greatly decreased the number of unwanted pregnancies, and therefore, abortions (HHS, 2018).  Controversy has occurred lately with the Trump administration proposing that Title X family planning funds be prohibited from being awarded to clinics that provide abortion services.  Planned Parenthood clinics would greatly be affected if this funding were to be removed as they provide a substantial amount of other preventative services to patients.

Background

According to Sobel, Rosenzweig, Salganicoff, & Long (2018) current statues state that Title X funds must serve low-income populations at low or no cost, provide clients with a broad range of acceptable and effective family planning methods and services, and ensure that services are voluntary.  Stipulations also state that funds may only go to entities where abortion is not a method of family planning.  With current regulations, this is interpreted that Title X clinics are prohibited from using funds to pay for abortions and that any abortion related activities must be kept financially separate from Title X activities.  These projects are required to provide nondirective counseling to pregnant women on prenatal care and delivery, infant foster care, adoption, and abortion.  Those patients desiring an abortion, must currently be provided with a referral if asked, however, the provider cannot promote abortion, schedule an appointment, negotiate rates, or arrange transportation for women desiring abortions (Sobel et al., 2018).

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Title X serves over a million low-income, uninsured, and underserved clients.  Currently these clinics are required to offer a broad range of FDA-approved contraceptive methods onsite and follow both the CDC and OPA guidelines for Quality Family Planning  (Sobel et al., 2018).  According to the Guttmacher Institute (2016) Title X funded centers provided a higher average number of contraceptive methods and were more likely to have protocols to enable easy initiation and continuation of methods, compared with centers not receiving Title X funding.

Stakeholders

Stakeholders are essential to any proposed change.  Important stakeholders for this proposed policy change are low-income patients dependent upon funding, clinics receiving funding, politicians and the federal government, clinic staff, and healthcare providers.  Decision-makers for this proposed policy change are the politicians currently holding office in the federal government.  Nurses, healthcare professionals, and civilians can influence these stakeholders by contacting them directly and educating them on the proposal being discussed.  Ultimately, facilities that provide both abortion services and preventive healthcare services are going to be affected by this proposal.  All low-income individuals receiving care at these facilities would be affected if the clinics were to close due to not having adequate funding.  This proposal impacts the safety, quality, and values of those clients involved.  If Planned Parenthood clinics were to close, clients would have to travel greater distances to obtain services and possibly pay out of pocket for services rendered.  This is a step back from previous care provided and could potentially impact not only the rates of self-induced abortions, but unplanned pregnancies, as well.

Use of HMD (IOM)

In 2009, at the request of OPA’s (Office of Population Affairs), the Institute of Medicine (IOM), now the National Academy of Medicine, independently evaluated the Title X program and made recommendations in their publication, A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results.  This review found that family planning – “helping people have children when they want to and avoid conception when they do not –is a critical social and public health goal.”  It was argued that family planning can prevent unintended and high-risk pregnancies, therefore, reducing fetal, infant, and maternal mortality and morbidity.  The appropriate use of contraception can reduce abortion rates.  IOM cited ample evidence that family planning services are cost-effective (Napili, 2017).

According to Napili (2017) recommendations were made to increase program funding and to improve program management, administration, and evaluation.  The IOM recommended that the OPA review and update the Program Guidelines to ensure evidence-based practice.  In response, OPA created new program guidelines in 2014.  These guidelines followed existing recommendations from the CDC, U.S. Prevention Services Task Force, the American Congress of Obstetricians and Gynecologists, the American Academy of Pediatrics, the American Society for Reproductive Medicine, and the American Urological Association.  In response to the IOM report, HHS also contracted with IOM to convene a Standing Committee to advise the Title X program on issues raised by the 2009 report, including other family planning issues emerging (Napili, 2017).

Policy Options

In June 2018, the Trump administration issued a new proposed regulation that would restore Reagan-era restrictions regarding abortion and Title X.  Specifically, these changes would ban federal Title X funds from being distribute to any provider that also provides abortion services.  The regulation would also prohibit Title X grantees from providing, promoting, referring for, supporting, or presenting abortion services to patients.  A referral could only be made if the pregnant patient had already decided to have an abortion.  This proposal would also eliminate the requirement for nondirective pregnancy options counseling which includes discussing abortion as an option.  The projects would be required to offer comprehensive primary health services onsite or have a referral process to primary health care providers in proximity.  Increased federal oversight, enforcement, and recordkeeping as part of the proposal, as well.  The proposal eliminates the requirement that a full range of family planning methods be offered, stating that only a broad range of methods need to be offered.  Lastly, the definition of “low-income” would be expanded to women who do not meet income guidelines but do not have contraceptive coverage.

These policy changes have many implications, both for and against the proposed changes.  If this proposed regulation would take effect, the impact would be far reaching and would change the network of providers that is eligible to participate, therefore, limiting, rather than expanding access.  Providers that also perform abortions would no longer be eligible to participate in Title X.  This dramatically reduces the network of family planning providers.  The new provisions that require both physical and financial separation of family planning and abortion services would make it impossible for clinics, such as Planned Parenthood, to comply with the new requirements of the program.

The restriction on referrals for abortions would compromise the quality of family planning care women receive.  With these restrictions, care is not patient-centered and could lead to a delayed in care.  Restricting the ability to counsel and refer patients can also place providers at risk for medical liability.  This regulation forces providers to offer patients poor quality care by restricting their ability to offer counseling and referral that includes abortions.  Stand-alone clinics in rural communities may not be in close enough proximity to other primary health providers, therefore, disqualifying them for funding.  Eliminating the requirement that a full range of family planning services be offered restricts access to contraceptives for low-income women.  This new regulation also channels new federal family planning funds to faith-based and other organizations that may not provide contraceptives services.  If these clinics are the only clinic within reach of these patients, there access to services is further restricted.  Others applaud the proposed change, stating it guarantees compliance, ensuring that taxpayers do not indirectly fund abortions (Ault, 2018).  These funds, under the proposal, would be redirected to abortion-free providers.  Minimal pros regarding provision of healthcare services were found regarding this legislative proposal.

Nurse as Change Agent

Nurses, especially advanced practice registered nurses, play a pivotal role in the proposed change to Title X.  Nurse midwives, nurse practitioners, and registered nurses all may provide services at clinics receiving funding from Title X.  The American Nurses association (ANA) condemns the Trump administration’s proposal to change how Title X family planning funds are allocated.  This proposal would be a major setback to previous progress made that ensures individuals have access to the services and care that they strive for.  As a result of this proposal, millions of Americans could lose basic, preventative reproductive healthcare.  Nurses have been deemed the most honest and ethical profession.  Nurses must stand up for and guard against any policy that hinders patients from making informed decision about their own health and which hinders access to care.  The Code of Ethics for Nurses determines that the primary commitment is to the patient and this proposed rule interferes with that relationship and violates basic ethics of the profession.

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A nurse’s role, therefore, is to be active in policy change and at the polls.  Nurses must proactively voice their concerns to policy makers.  Influencing policy can occur at the local, state, or federal level.  Locally, nurses can be politically active by assuming a leadership position in the health system or contacting elected officials about legislation.  Nurses can also obtain training in politics, become inovolved on committees, or even run for office.  Simply exercising one’s right to vote can impact healthcare policy.  Being active and jointing a professional nursing organization, such s the ANA, is essential as these organizations have lobbyists that discuss nursing issues at Capital hill.  As the largest medical profession in the world, nurses have the potential to profoundly influence policy and politics on a global scale.

Factors of Influence

For this policy proposal to become effective, more resources are not necessarily needed as the proposal merely redirects funding to clinics that are deemed acceptable according to the provisions of the proposal.  For this proposal to be passed, nursing and medical professionals would need to promote the proposal and advocate for its passage.  There are many factors that hinder the passage of this proposal.  Many clients have low income status and rely on services from funded clinics.  Clinics that would be within regulation may not be located within the parameters of these clients.  More clinics would need to be built that provided the same services currently being provided to these patients so that care is not hindered.  Patients would need to be ensured that their care would not be jeopardized.  Data related to the current population serviced would need to be valued to determine if this is a feasible and just proposal.  Instead of taking a step back and decreasing services, the government would need to ensure that each clinic that is removed from service has an adequate replacement facility that provides the same preventative healthcare services to ensure continuity of care for patients.  If preventative health care services are not readily available, the rate of unplanned pregnancies could increase, instead of decrease, as is the intention of Title X.

Most resources and impacts would take place if the proposal was passed.  For instance, facilities would be required to have separate accounting records, electronic, and paper health records.  Separate treatment, consultation, examinational and waiting rooms, office entrances and exits, workstations, signs, phone numbers, email addresses, educational services, and websites are also a provision of the proposal.  Staff can not be shared between the clinics, either.  Facilities, such as Planned Parenthood, would have to find other financial resources to build separate facilities or declines Title X funds, removing preventative healthcare services from patients.

Conclusion

In conclusion, the proposal to change Title X has many implications on the future healthcare of our nation.  Title X family planning clinics have played a critical role in ensuring access to a broad range of family planning and related preventive health services for low-income, uninsured individuals, and others.  The proposal to emend Title X has been met with much controversy.  Arguments for and against his proposal have been discussed and numerous healthcare organizations have voiced their concerns with this proposal.  Multiple resources and factors need to be assessed before this proposal is implemented as it affects the provision of healthcare to those who otherwise cannot afford it.  To date, this proposal has not been approved.  It is imperative that stakeholders, such as nurses and other healthcare providers become involved in healthcare policy as they are in one of the greatest positions to promote change.

References

  • American Nurses Association (ANA). (2018). American Nurses Association Condemns Title X Funding Cuts Proposed by the Trump Administration. Retrieved December 1, 2018, from https://www.nursingworld.org/news/newsreleases/2018/ANA-condemns-title-x-funding-cuts–proposed-by-the-trump-administration/
  • Ault, A. (2018). Proposed restrictions on Title X funds stirs up hornet’s nest. Retrieved November 23, 2018, from https://www.medscape.com/viewarticle/896989#vp_2
  • Brokaw, J. (2016). The nursing profession’s potential impact on policy and politics. Retrieved December 1, 2018, from https://www.americannursetoday.com/blog/nursing-professions potentialimpact-policy-politics/
  • Frost, J. J., Sonfield, A., Zolna, M. R., & Finer, L. B. (2014). Return on investment: A fuller assessment of the benefits and cost savings of the US publicly funded Family Planning Program. Milbank Quarterly,92(4), 696-749. doi:10.1111/1468-0009.12080
  • Guttmacher Institute. (2016). Publicly funded family planning services in the United States. (2016, October 10). Retrieved November 23, 2018, from https://www.guttmacher.org/fact-sheet/publicly-funded-family-planning-services-unitedstates
  • Health & Human Services (HHS). (2018). Title X family planning. Retrieved November 23, 2018, from https://www.hhs.gov/opa/title-x-family-planning/index.html
  • Institute of Medicine of the National Academies (IOM). (2009). A Review of the HHS Family PlanningProgram: Mission, Management, and Measurement of Results. Retrieved December 1, 2018,fromhttp://nationalacademies.org/hmd/~/media/Files/Report Files/2009/A-Review-of-theHHS-Family-Planning-Program-Mission-Management-and-Measurement-of-Results/Review-ofHHS-report-brief.pdf
  • Napili, A. (2017). Title X (Public Health Service Act) Family Planning Program. Retrieved December 1, 2018, from https://fas.org/sgp/crs/misc/RL33644.pdf
  • Sobel, L., Rosenzweig, C., Salganicoff, A., & Long, M. (2018, November 21). Proposed Changes to Title X: Implications for Women and Family Planning Providers. Retrieved December 1, 2018, from https://www.kff.org/womens-health-policy/issue-brief/proposedchanges-to-title-x-implications-for-women-and-family-planning-providers/

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