Investing in America's Adolescents: Why the Distribution of Title X Funds Matters

Yesterday, the White House proposed a policy change that would dramatically reduce adolescents’ access to appropriate reproductive health care services, placing their health at risk and increasing the likelihood of unintended teen pregnancies. Current law – in place for decades – already prohibits any federal funding administered through the Title X Family Planning Program from covering abortion services except in rare and extraordinary circumstances. But this proposed policy change would prevent any health care provider who offers patients medically and legally accurate information about the availability of abortion services from receiving much needed Title X funding – even if they don’t provide abortion services at all or use separate resources to provide abortions.

If enacted, this policy shift will severely impact the availability of medically necessary, proven-effective reproductive health care for young people across the country by shuttering the doors of providers who need this financial support to ensure access to services like contraception, cancer screenings and sexually transmitted infection (STI) and HIV testing and treatment.

We have already seen the effects of such a policy in Texas where Planned Parenthood affiliates are barred from using public funds to provide health care services; a 2016 New England Journal of Medicine study found that this policy change negatively impacted continuous contraception use and was associated with an increase in the state’s rate of childbirth among Medicaid-enrolled women. While the intentions behind this policy change were ostensibly to restrict access to abortions, the actual economic and health care impact fell onto women and families who could no longer access safe, low-cost contraceptive services.

Troubling Trend of Limiting Access to Evidence-Based, Needed Care

Yesterday’s news aligns with and amplifies the impact of a number of policy changes from the past year that restrict adolescents’ access to appropriate sexual health prevention and treatment services, such as rollbacks of both the Teen Pregnancy Prevention program and the federal mandate that employer insurance plans cover contraceptive services. While both of these rulings are subject to legal challenges, they still represent the steep uphill battle we face in ensuring that all adolescents have access to the care they need to successfully transition into healthy, productive adults.

Furthermore, several senior U.S. Department of Health and Human Services (HHS) officials have touted their preference for abstinence-only education, despite the well-documented inefficacy of these programs and the likelihood they cause harm. When abstinence is adhered to fully, it is certainly an excellent method for prevention of pregnancy or STIs. However, numerous studies have demonstrated that abstinence-only education and "abstinence pledges" do not delay the onset of sexual activity, reduce the risk of pregnancy, or increase use of - risk-reduction behaviors like condom and contraceptive use - among adolescents once they choose to become sexually active.

Yet, in February, HHS issued guidance that recipients of Title X funding focus on abstinence and “fertility awareness,” otherwise known as natural family planning (this is also emphasized in yesterday’s proposed rule). Instead of supporting funding for and education regarding highly effective forms of birth control such as long-acting reversible contraception, this new guidance places priority on the proven-ineffective practice of preventing pregnancy by timing sexual activity around a woman's fertility cycle. This represents a dramatic and harmful shift from the long-standing tradition of distributing Title X funds to programs that support evidence-based sexual education and health services.

The reality is that many teenagers will choose to be sexually active, regardless of what any adult or program encourages them to do. While abstinence can be an effective tool for some youth, it should be presented as part of comprehensive sex education programming that includes contraceptive services, condom promotion, HIV and STI testing and partner communication. Some have suggested that increasing access to these pillars of comprehensive sexual health education will increase sexual activity – that claim is simply unfounded.

Evidence-based Family Planning Programs Help Teens Become Self Sustainable  

In addition to promoting the health and well-being of young people across the country, Title X’s emphasis on preventive services saves the federal government billions of dollars. A 2010 estimate showed that for every $1 spent on family planning programs and providers, the government saved about $7 in Medicaid-related costs, totaling net government savings near $13.6 billion.

This number does not include the indirect savings of these preventive services by improving the health and well-being outcomes for adolescents as they become adults. For example, reducing missed days of school for teens with symptomatic untreated STIs or preventing teen pregnancy's long-term negative impact on academic and earning potential means that they’ll be better prepared to take care of their own health and achieve greater success in their education and future employment. Together, these improved outcomes will lead today’s adolescents to greater self-sustainability and make it less likely that they will need to rely on public benefits like health care, food and income assistance to care for themselves and their families in the future.

Ensuring Policy Changes are in the Best Interest of the Youth They Impact

As physicians, we have front-row seats to the real-world impacts of these policy changes. In Children’s Hospital of Philadelphia (CHOP) primary care practices that receive Title X funds, we work hard to ensure our region’s most vulnerable youth have access to comprehensive sex education and services. Philadelphia’s younger adolescents have some of the highest rates of STIs in the country. These new policies and restrictions would decrease our ability to provide no-cost, appropriate, timely STI prevention and treatment and contraception to the young people in our area who need these services the most, leaving them with few other options to turn to for evidence-based, effective services.

Many of these conversations are fraught with political contention, but the facts all point to the same solution: if our nation’s leaders want to reduce unintended teen pregnancies and prevent conditions such as chlamydia, cervical cancer and HIV, then they must support evidence-based programs that achieve that goal and administer Title X funds accordingly.

The one thing that will remain constant throughout all of the policy proposals, headlines and debates is this: teenagers will continue to have sex. It is up to us to decide if we will invest in the evidence-based tools they need to achieve a safe and healthy path to adulthood.

Public comment on this proposal will be accepted until July 31, 2018, and can be submitted electronically here.