Title X Family Planning Clients Face Economic Challenges and Health Disparities
The Title X Family Planning program, administered by the U.S. Department of Health & Human Services (HHS) Office of Population Affairs (OPA), is the only federal program designed explicitly to provide comprehensive family planning and related preventive health services for uninsured individuals and those with low incomes. Title X clinics serve as a point of entry into the broader health care system for many individuals—particularly those who are young, have lower incomes, and are traditionally underserved by the private health care system. Recent data from the Family Planning Annual Report indicate that, nationwide, 88 percent of family planning clients at Title X clinics had a family income at or below 250 percent of the federal poverty line ($65,500 for a family of four in 2020).
Individuals’ social, economic, and physical environments (their social determinants of health) impact a wide variety of health outcomes. Poverty and discrimination have strong direct and indirect influences on health, and the social conditions to which these factors lead are some of the fundamental causes of health inequality. Child Trends’ analysis of data from the National Survey of Family Growth (NSFG) shows important differences between the socioeconomic challenges and health outcomes for women who receive care at Title X clinics and those who can afford to receive care from private doctors (see Methods for definitions). These disparities highlight the importance of the Title X program for individuals with low incomes and those who have been historically marginalized as they seek family planning services and related care. Additionally, a more in-depth understanding of the sociodemographic characteristics of Title X clients and their health care needs will enable Title X grantees and providers to better target their outreach and services.
Women receiving care at Title X clinics and those receiving care from private doctors are similar across several sociodemographic measures:
- Title X clients and women receiving care from private doctors are predominantly heterosexual. Eighty-five percent of Title X clients and 89 percent of private doctor clients report being heterosexual.
- The majority of family planning clients report being sexually active and not pregnant or seeking to become pregnant. Among Title X clients, 90 percent had an opposite sex partner in the past year, compared to 86 percent among women seeking services from private doctors. Ninety-one percent of women in both groups were not pregnant or seeking pregnancy.
- Approximately half of Title X clients and women receiving care from private doctors are parents. Fifty-one percent of Title X clients are parents, as are 57 percent of women seeking care from private doctors.
However, these two groups of women differ across other sociodemographic characteristics. Compared to women receiving care from private doctors:
- Title X clients are younger and less likely to be married. Sixty-six percent of Title X clients are under 30, compared to 44 percent of women visiting private doctors. Seventeen percent of Title X clients are married, versus 44 percent of women visiting private doctors.
- Title X clients are more likely to be Hispanic or Black. Twenty-seven percent of Title X clients are Hispanic and 26 percent are non-Hispanic Black. Meanwhile, 16 percent of private doctors’ clients are Hispanic and 13 percent are non-Hispanic Black.
- Title X clients are more likely to speak a primary language other than English. Eighteen percent of Title X clients report not speaking English “very well,” compared to 9 percent of women receiving services from private doctors.
Among these findings, it is especially important to highlight that many Title X clients are women of color. Research suggests that unconscious biases may impact family planning care among all types of providers; for example, providers are more likely to recommend intrauterine contraception to low-income Black and Latina women than to low-income White women, and low-income women of color are more likely than middle-class White women to report feeling that their provider had advised them to limit their childbearing. The Reproductive Health National Training Center provides resources—including training on client-centered contraceptive counseling and guidance on guarding against coercion while ensuring access to contraception—to help Title X grantees meet the program’s goals of voluntary and non-coervice services.
Our analyses of the NSFG data provide information about socioeconomic challenges that impact the health of Title X clients, such as food insecurity, housing insecurity, and lack of access to affordable health care. These challenges are closely tied to living with poverty, as well as to structural inequalities and discrimination faced, in particular, by low-income women of color.
Compared to women receiving care from private doctors:
- Title X clients are more likely to lack health insurance. Thirty-eight percent of Title X clients reported lacking health insurance in the past year, compared to 12 percent of women receiving family planning services from private doctors.
- Title X clients are more likely to report cost as a barrier to seeking health care. Nearly one in five Title X clients (18%) reported that they or a family member did not seek medical services in the past year due to cost, compared to 8 percent of women visiting private doctors.
- Title X clients are more likely to struggle with food and housing insecurity. Title X clients were approximately three times as likely to report that they or their family members experienced hunger because they could not afford enough food (13%) or that they had lacked a permanent place to stay for at least one night (15%) in the past year, compared to women receiving services from private doctors (5% and 6%, respectively).
- Title X clients have lower education levels. Approximately one in five Title X clients ages 25 and older (21%) reported having no high school degree, compared to 6 percent of women visiting private doctors.
Our findings from the NSFG align with Family Planning Annual Report data, which show that Title X providers primarily serve individuals with low incomes and those lacking health insurance. Our results also reveal economic hardships experienced by Title X clients that highlight the necessity of the no- or low-cost services provided by Title X for clients’ overall health, in addition to reproductive health. Previous research has found that 61 percent of Title X clients report their clinic as their primary source of health care. Title X regulations encourage providers to offer comprehensive primary care services onsite or be able to refer clients to primary health providers that are located nearby.
As previously described, social factors (e.g., economic resources, education, racial discrimination) can impact and create disparities in health outcomes. To better understand how the socioeconomic challenges highlighted earlier in this brief may accompany poorer health outcomes for Title X clients, we analyzed responses to questions related to family planning clients’ overall health and health behaviors. We found health disparities between Title X clients and women receiving family planning services from private doctors on some measures but not on others.
Compared to women receiving services from private doctors:
- Title X clients have lower self-reported health. Forty-two percent of Title X clients rated their overall health as less than “excellent” or “very good,” compared to 33 percent of women receiving family planning services from private doctors.
- Title X clients are more likely to be obese. Thirty-eight percent of Title X clients had a BMI that was classified as obese, compared to 32 percent of women receiving services from private doctors.
- Title X clients are more likely to report substance use. Forty-two percent of Title X clients reported binge drinking (four or more drinks within a couple of hours) at least several times a year, smoking tobacco daily, and/or daily marijuana use in the past year, compared to 32 percent of women receiving services from private doctors.
On other health-related measures, however, Title X clients were similar to women receiving family planning services from private doctors:
- Although obesity is a risk factor for diabetes and high blood pressure, Title X clients were no more likely to report being diabetic or pre-diabetic or have high blood pressure (6% and 11%), compared to women receiving services from private doctors (7% and 11%; results not shown).
- Title X clients had similar rates of disability as women receiving care from private doctors. Twenty four percent of Title X clients reported having a disability, including limitations in hearing, vision, cognition, mobility, and independent living, compared to 20 percent of women receiving services from private doctors (results not shown). Respondents were considered to have a disability if they responded yes to one of the six disability-related questions in the NSFG, based on the U.S. Department of Health and Human Services data standards.
Title X clients’ health challenges, often resulting from the daily stresses of living in economically disadvantaged circumstances, highlight how Title X is an important source of services to those in need. Findings also point to the necessity of screenings during family planning visits and referrals for additional services outside of Title X. The Centers for Disease Control and Prevention (CDC) and OPA recommend that Title X providers include screenings and referrals for health challenges such as substance abuse, obesity, depression, and intimate partner violence as part of their services. Previous research indicates that both providers and clients have positive perceptions of these efforts. In one study of a program that provided comprehensive preventive services during family planning visits, clients reported that they received health care services they otherwise would not have accessed, and the majority of providers reported that providing these additional services did not interfere with the delivery of family planning care.
Changes in the characteristics of Title X clients over time
Through analyses of the 2002 and 2015-2019 NSFG, we found that most of the studied characteristics (demographics, economic challenges, and health care needs) of Title X clients have remained constant over time. One observed trend was that a smaller proportion of Title X clients in recent years (2015-2019) are White or married, compared to 2002. From 2002 to 2015-2019, the proportion of married clients fell from 29 percent to 17 percent, and the proportion of White clients fell from 50 percent to 36 percent. However, these trends match demographic shifts for women receiving services from private doctors (and for the U.S. population more generally). Among these women, the proportion of married clients fell from 58 percent to 44 percent, and the proportion of White clients fell from 73 percent to 61 percent.
Another trend common to both Title X clients and women receiving care from private doctors was a reduction in the proportion of women who were daily smokers (34% to 18% and 24% to 15%, respectively).
Interestingly, there was also a decline in the proportion of adolescents (ages 15 to 19) served by Title X clinics from 2002 to 2015-2019 (23% to 12%) that was not found among women attending private doctors (7% in 2002 and 9% in 2015-2019).
We analyzed a sample of women from the 2015-2019 NSFG who received at least one family planning or related service in the past year and examined the sociodemographic characteristics and health care needs of women receiving services from a Title X clinic, compared to women receiving these services from a private doctor. In our initial analysis, we also compared Title X clients to the clients of non-Title X clinics but found that they were similar in their sociodemographic characteristics and health needs; as a result, we did not include the results of these analyses. Family planning and related preventive health services included birth control method or prescription, checkup for birth control, counseling about birth control, sterilizing operation or counseling regarding sterilization, emergency contraception or counseling regarding emergency contraception, pregnancy test, pap smear, pelvic exam, prenatal care, post-pregnancy care, and STI/HIV testing. Women who did not receive any family planning services in the year prior to their interview were not considered in our analyses.
The NSFG, conducted by the CDC’s National Center for Health Statistics, is an ongoing nationally representative survey designed to collect information on family life, childbearing, contraception, and the health of women and men ages 15 to 49. Although Title X clinics also serve males (approximately 13% of clients), the NSFG does not have information on the type of family planning provider men used (i.e., Title X clinic, non-Title X clinic or private doctor), so we limited our analysis to women. Additionally, we excluded women ages 45 to 49 from the 2015-2019 sample to be consistent with the 2002 data, which did not include women over age 44.
When weighted, data from the 2015-2019 NSFG are representative of the 62 million women ages 15 to 44 in the United States in 2017. Overall, 70 percent of women ages 15 to 44 received family planning or related services in the year prior to their interview (43 million). We identified three groups of women: 1) those who received at least one family planning or related service at a Title X clinic (n=686, representing 3.2 million women), 2) women who did not receive any of these services at a Title X clinic but received at least one at a non-Title X clinic (n=845, representing 4.4 million women), and 3) women who only received services from a private doctor or HMO (referred to as simply “private doctors” (n=5,165, representing 33 million women). Women who received services from a provider outside the three studied provider types were not included in the analysis. In the 2002 dataset, we identified 760 women who received at least one service from a Title X clinic (representing 5.4 million women).
All analyses were weighted and accounted for the survey design effects. Although many of the characteristics studied are interrelated (e.g., educational attainment and health insurance status), we analyzed each separately without controlling for other factors. We tested for significant differences between Title X clients and women receiving services from private doctors through logistic regression models where provider type predicted the characteristic of interest. We tested for significant changes over time in Title X client characteristics through logistic regression models with time period (2002, 2015-2019) as the independent variable of interest. Reported differences are significant at p<.05 unless otherwise noted.
This research was supported by Grant Number 1 FPRPA006070-01-00 from the U.S. Department of Health and Human Services Office of Population Affairs. The authors would like to thank Gladys Martinez at the National Survey of Family Growth, and Esther Gross and Elizabeth Karberg at Child Trends, for their thoughtful reviews.