In 1994, nearly 6.6 million women received contraceptive services from the more than 7,000 clinics that make up the network of publicly funded family planning clinics in the United States.¹ Many of these women were low-income or poor but had neither public nor private insurance. Some were Medicaid recipients who found family planning clinics more willing than private physicians to accept Medicaid reimbursement.² Others had private insurance that either did not cover preventive gynecologic care or certain contraceptive methods or supplies, or did not provide women with care from familiar providers or with the level of confidentiality that they desired.³

Ensuring that all women have access to affordable and accessible contraceptive care is crucial for the prevention of unintended pregnancies. In 1994, the provision of contraceptive services by publicly funded family planning clinics led to the prevention of an estimated 1.5 million unintended pregnancies.⁴ Moreover, the low-income women who avoided pregnancy because of such services are those least likely to be able to afford any additional children and those most likely to rely on public sources for their support.

The funding to support subsidized family planning clinic services comes from a variety of sources, including the federal-state Medicaid program (Title XIX of the Social Security Act), the Title X family planning program of the Public Health Service Act, and the maternal and child health and social services block-grant programs, as well as allocations from state and local sources.

These public sources support the provision of contraceptive services through a diverse network that includes hospital outpatient clinics, health department clinics, Planned Parenthood clinics, community and migrant health centers and independent clinics.⁵ The majority of contraceptive clients served by publicly funded providers in 1994 obtained services from either health departments (33% of all clients) or Planned Parenthood affiliates (30%), with hospitals srving 16% of all contraceptive clients, community and migrant health centers serving 9% and independent agencies 13%.⁶

Agency types vary considerably in the number of clinics they operate and the number of clients they serve. For example, the more than 1,400 health departments operate, on average, 2.2 clinics each and serve, on average, an annual total of about 1,500 contraceptive clients per department (680 clients per clinic). In comparison, the 159 Planned Parenthood affiliates operate an average of nearly six clinics each and serve an annual average of more than 12,000 contraceptive clients each (2,000 clients per clinic).⁷

Although services and programs may vary from clinic to clinic, some commonalties exist. In particular, clinics funded through the Title X program follow certain federal guidelines and regulations regarding the provision of services, including the range of methods that must be made available and the range of fees that can be charged to women of different income levels. Previous studies have found, however, that the practices and policies of individual family planning agencies, and the mix of funding used to provide contraceptive services, often vary according to the type of sponsoring agency.⁸

In this article, we report on the findings of a new survey of a nationally representative sample of all publicly funded family planning agencies. We focus on the organization, practices, policies, programs and funding of those agencies. How do they use the public funds allocated to them to deliver contraceptive services to low-income women? What services and programs do they offer and what provisions do they make to ensure that low-income women can obtain those services? In most cases, we look at differences in the provision of services according to the type of sponsoring agency and according to whether or not the agency is funded through the Title X program.

Our findings are intended to assist policymakers, program administrators and others who will help design the future structure and level of public funding for family planning services. By outlining the services and programs that current levels of funding support, we show what might be affected by changes in either the level or the structure of future funding.

Methods

A sample of 995 family planning agencies was drawn from an Alan Guttmacher Institute (AGI) list of all publicly funded family planning agencies in the United States, including all 50 states, the District of Columbia and eight nonstate U.S. jurisdictions. The methodology used to compile this list has been described previously.⁹

The universe of publicly funded family planning agencies consists of 3,119 individual agencies—including hospitals (17%), health departments (45%), community and migrant health centers (16%), Planned Parenthood affiliates (5%) and independent agencies (16%)—that operate at least one publicly funded family planning clinic.* Agencies that provide services at more than one clinic site were asked to provide information for their entire agency, i.e., for all of the clinics as a group rather than for each site.

To accurately represent the full network of agencies providing publicly funded family planning services, we expanded the definition of hospital outpatient clinics and community and migrant health centers used in our earlier surveys, and changed the process for including them, resulting in more agencies of these types in the current universe than in previous AGI lists. In previous studies, we included community and migrant health centers only if they received Title X funding, but in this study, we include all agencies receiving community or migrant health center funding that reported providing contraceptive services. Likewise, we carried out a systematic investigation of the provision of contraceptive services through hospital outpatient clinics, resulting in the addition of many "new" hospital providers. In addition, the sample frame included for the first time the publicly funded family planning agencies located in eight nonstate U.S. jurisdictions (American Samoa, the Federated States of Micronesia, Guam, the Marshall Islands, the Mariana Islands, Puerto Rico, Palau and the Virgin Islands).

Because the universe for this survey is different from that in earlier surveys, overall changes across time may reflect the greater representation of hospitals and community and migrant health centers in the current survey. Comparisons within agency types are therefore more likely to be reliable.

All 588 agencies that had responded to AGI's 1992 family planning agency survey and were still active in 1994 were included in this survey. To ensure adequate numbers of agencies of different types, we selected the remaining 407 agencies in the sample from separate strata according to agency type. All 159 Planned Parenthood affiliates were included. Of the agencies that had not participated in the 1992 survey, every third hospital, every fourth independent agency and every fifth health department and community and migrant health center were sampled.

In May of 1995, we mailed a 16-page questionnaire to the family planning director of each sampled agency. The questionnaire asked the agencies to provide information about their services, policies and practices and the numbers and characteristics of their contraceptive clients, as well as their funding sources and billing options. We sent two follow-up mailings in June and telephoned all nonrespondent agencies in July and August with additional requests to complete the survey. In the course of follow-up, we found that 110 of the sampled agencies were ineligible for this survey because they either had merged with other agencies, had closed or no longer provided family planning services, or did not fit the definition of a publicly funded agency.

We received 603 responses from the remaining 885 eligible agencies, for an overall response rate of 68%. A total of 97 hospitals (response rate of 51%), 241 health departments (80%), 138 Planned Parenthood affiliates (87%), 46 community or migrant health centers (46%) and 81 independent agencies (61%) responded.

We checked the data for consistency and completeness, and telephoned many agencies again to get additional information or to clarify certain responses. Most of the items pertaining to agency services, policies and practices were completed by all agencies. However, because agencies differ in the way they collect client data and allocate funds to programs, responses to the items pertaining to client characteristics and funding allocations were less completely reported.

For this analysis, we weighted the responses to represent the actual distribution of family planning agencies in the United States, according to the agencies' type and Title X-funding status. The weights used have been applied to all reported items. Except for the client characteristic items,^† we have not attempted to adjust for or use weights to compensate for item nonresponse. In each table, we report the unweighted number of agencies used to calculate percentages (or the smallest "n" for columns with multiple items).

Organization of Agencies

Focus on Contraception

Agencies of various organizational types differ in the extent to which they focus on providing contraceptive services and on serving the needs of contraceptive clients versus providing general care and serving the needs of a diverse clientele. Contraceptive clients make up the majority of clients served by Planned Parenthood affiliates and independent family planning agencies—80% and 65% of all clients, respectively. In contrast, clients receiving contraceptive services make up fewer than half of all clients served within the hospital outpatient departments (45%) and the public health department clinics (39%) that provide family planning services. Community and migrant health centers have the lowest percentage of contraceptive clients—17% of all clients served.

Client Characteristics2

Overall, 30% of all contraceptive clients served by publicly funded providers are younger than 20; 50% are aged 20-29 and 20% are aged 30 or older. A majority of clients are non-Hispanic white (61%), while 19% are black, 14% are Hispanic and 7% are Asian or of some other race. Most clients are poor—57% have family incomes below the federal poverty level and 33% have family incomes between 100% and 249% of the federal poverty level. However, only 25% of all clients served by publicly funded family planning agencies are Medicaid recipients.

Hospitals, health departments and community or migrant health centers serve larger proportions of minority and poor clients than do independent or Planned Parenthood agencies. Moreover, when compared with agencies without Title X funding, agencies receiving Title X funding serve more poor contraceptive clients (60% with incomes below the poverty level vs. 47%) and fewer Medicaid recipients (21% vs. 38%).

Given these organizational differences and the characteristics of clients served, how do family planning agencies of different types actually deliver contraceptive care to the millions of low-income women who seek care from public-sector providers? First, we will look at the delivery of contraceptive care at these agencies and at specific services, policies and programs related to the delivery of contraceptive care. We will also look at the delivery of other, noncontraceptive services at family planning agencies. Finally, we will review the types of public and private funding used by these agencies to provide contraceptive care and the payment and fee options that publicly funded family planning agencies provide for low-income clients.

Delivery of Contraceptive Care

Timing of Care

On average, a new client seeking routine contraceptive care from a family planning agency waits 10 days from the time she schedules an initial exam until the day of her appointment. If she seeks care from a Planned Parenthood clinic, her wait is significantly shorter than that of a woman obtaining care from a hospital or health department clinic (four days vs. 11 days, on average). Overall, 9% of agencies provide same-day services for an initial contraceptive visit and an additional 37% provide services within a week. However, 32% of agencies report that women seeking routine care must wait two weeks or more for an initial visit; only 6% of Planned Parenthood affiliates report waits this long.

Nearly half of all family planning agencies increase access to their services through evening appointments; however, fewer than one in five have weekend hours. Planned Parenthood affiliates are the most likely to provide flexible appointment times, with 97% offering evening services and 73% offering weekend hours.

If a client misses a scheduled visit, 71% of agencies follow up by mail or telephone to reschedule the visit. Somewhat fewer contact clients who do not return for their annual visit (64%). Planned Parenthood affiliates are the least likely to provide follow-up for missed appointments; only 41% contact clients who miss a scheduled visit and 44% contact those who do not return for their annual visit. In contrast, 91% of community and migrant health centers report following up clients who miss a scheduled visit, and 85% report contacting those who do not return for an annual visit.

Who Provides Care?

At some agencies, physicians are the primary providers of routine contraceptive care, while at others, midlevel clinicians such as physician's assistants, nurse practitioners or midwives provide most such care. Overall, agencies employ an average of 3.1 physicians; together, these doctors provide patient care for an average of 6.8 hours per week. In comparison, agencies employ an average of 6.7 midlevel clinicians and registered nurses, who together provide a total of 70.9 hours of patient care per week.

The ratio of midlevel clinicians and nurses to physicians differs widely by type of provider. Overall, per agency, there are 2.1 midlevel clinicians per physician (data not shown). Health departments have the highest ratio (6.2 midlevel clinicians per physician), followed by Planned Parenthood affiliates (3.9), independent agencies (2.2), community and migrant health centers (1.9) and hospital agencies (0.7). When clients make appointments for contraceptive care, 85% of agencies attempt to schedule them with the same clinician they saw on previous visits.

Routine Services Provided

Most family planning agencies set specific policies regarding the range of services to be provided at initial or annual contraceptive visits, which make up the majority of medical visits made by contraceptive clients.¹⁰ All agencies routinely provide Pap smears, breast and pelvic exams, blood pressure measurement and education on effective method use and on breast self-examination at these visits. However, 53% of all family planning agencies have instituted a policy whereby some new clients obtaining oral contraceptives may be allowed to delay the pelvic exam until a later visit.

Ninety-four percent of agencies routinely obtain clients' sexual histories and 75% of agencies routinely provide hematocrit and hemoglobin testing. Testing for sexually transmitted diseases (STDs), urinary tract infection and pregnancy is done routinely during the initial and annual visit at some agencies; more often, however, these tests are provided only if the client requests them or has symptoms. Routine testing for gonorrhea, chlamydia and syphilis is provided by 64%, 54% and 42% of agencies, respectively. In addition, 96% of agencies routinely counsel clients regarding risk factors for STDs, including the human immunodeficiency virus (HIV), and 62% routinely provide education in condom negotiation skills.

All agencies report providing contraceptive education through individual counseling and printed materials distributed to clients. More than three-quarters of agencies (77%) now provide client education through videotapes, while about one-third (36%) conduct group education sessions. Overall, 87% of family planning agencies encourage counselors to spend more time with teenagers than with other clients; however, only 71% of hospitals do so.

Provision of Contraceptives

Methods Available

Few family planning agencies provide a full range of contraceptive methods. Oral contraceptives are the only method that is universally available at family planning agencies of all types (Table 1). The hormonal injectable is available at 96% of agencies, up from 22% in 1992.¹¹ Other methods that are offered at at least 90% of agencies include the male condom, spermicide and the diaphragm. In addition, 78% of agencies offer periodic abstinence. The hormonal implant is provided at 59% of agencies, up from 46% in 1992.¹²

The remaining six methods are offered at fewer than 50% of all family planning agencies. Some 47% of agencies offer the IUD, 30% provide the female condom and 20% the cervical cap. Tubal sterilization and vasectomy are offered at small proportions of agencies—28% and 23%, respectively. Oral contraceptive pills are provided for emergency postcoital use at 38% of agencies.

Most agencies that do not provide a specific method on site do refer interested women to other providers. For example, nearly 70% of agencies provide referrals for both vasectomy and tubal sterilization, 41% say they refer clients for the IUD and 28% provide referrals for emergency hormonal contraception.

The range of contraceptive methods offered varies widely according to the type of agency, with Planned Parenthood affiliates offering an average of 10 methods per agency, compared with eight methods at hospitals and seven methods at health departments, community and migrant health centers and independent agencies. No health departments, community health centers or independent agencies provide all 13 methods of contraception, and only 6% of hospitals and 5% of Planned Parenthood affiliates do so.

Planned Parenthood affiliates are much more likely to offer all 11 reversible contraceptive methods than are any of the other four agency types (38% vs. 1-10%). Thirty-nine percent of agencies either provide or offer referral for all 11 reversible methods; that proportion is 84% for Planned Parenthood affiliates, compared with 27-48% of other types of agencies.

The largest difference in the proportion of agencies offering a specific method is for emergency hormonal contraception, an option provided by 97% of Planned Parenthood affiliates, 52% of hospitals and 20% of health departments. The implant is offered at the majority of Planned Parenthood affiliates and hospitals (91% and 76%, respectively), but only 51-57% of other agencies. Likewise, the IUD is offered at 88% of Planned Parenthood affiliates and 73% of hospitals, but only 36-47% of other agencies.

The proportion of agencies offering the female condom also varies widely, from 80% of Planned Parenthood affiliates to 22-39% of other agencies. The cervical cap is available at 59% of Planned Parenthood affiliates, compared with 11% of health departments. In addition, hospitals are 3-4 times as likely as any other agency type to offer tubal sterilization and at least one and a half times as likely to offer vasectomy.

The mix of available methods varies according to whether the agency receives Title X funding. Nearly all Title X-funded agencies offer spermicide, the condom and the diaphragm as well as oral contraceptives and the injectable, yet only 86% of agencies that do not receive Title X funding provide the condom, 81% the diaphragm and 79% spermicide. On the other hand, clinics not receiving Title X funds are more likely to offer emergency contraceptive pills and the cervical cap; this pattern reflects, in part, the small number of health departments (the agency type most likely to receive Title X funding) that offer these methods. Agencies not funded by Title X are also more likely than other agencies to provide sterilization services. Even among hospitals, which tend to offer sterilization services, Title X-funded hospitals are less likely to provide sterilization services than are hospitals not receiving Title X funds (data not shown).

The availability of some methods varies by agency location and by region (data not shown). All contraceptive methods, except oral contraceptives and periodic abstinence, are offered at a higher percentage of agencies in metropolitan counties than of agencies in nonmetropolitan counties. The implant, the IUD, emergency contraceptive pills, the cervical cap and the female condom are more than 50% more likely to be offered at metropolitan agencies than at rural agencies. The implant, the IUD and emergency contraceptive pills are more widely available in the Northeast and the West than in the Midwest or the South. For example, the implant is offered at 74% of family planning agencies in the Northeast and 63% of agencies in the West, but only 47% of those in the Midwest. Similarly, the IUD is provided at 68% of agencies in the Northeast and 58% of those in the West, but at only 31% of those in the Midwest and 45% of those in the South. Tubal sterilization is offered by 57% of agencies in the Northeast, compared with 14-27% of those in other regions (data not shown).

Provision of New Methods

In the last few years, three new methods of contraception have been introduced in the United States—the hormonal implant, the hormonal injection and the female condom. We estimated the prevalence of these methods among family planning clients by comp aring the number of clients using each method to the total number of contraceptive clients served at the agency.^‡

At agencies that provide the hormonal implant, an average of 2% of contraceptive clients received implant insertions in 1994 and 1% obtained removals.^§ At agencies that provide the hormonal injection, 12% of clients received injections in 1994. Finally, 1% of the contraceptive clients at agencies that offer the female condom were provided with that method (data not shown).

Condom Availability and Distribution

Agencies were asked a series of questions regarding their condom distribution policies (see Table 2). In coding the responses, we assigned agencies to categories according to their most liberal distribution policy. For example, if an agency responded that clients could obtain a limited number of free condoms and also indicated that condoms were available for sale, it was assigned to the former policy category. More than half of all agencies (55%) offer clients an unlimited number of free condoms, either from an open display or by request, and another 32% provide free condoms but limit the number that can be obtained by each client. Condoms are available only for sale at 3% of agencies; the remaining 10% of agencies do not provide condoms.

Distribution policies differ by agency type. Unlimited free condoms are offered at 66% of health departments, compared with 32% of hospitals. Planned Parenthood affiliates are the agency type most likely to sell condoms (12%); community health centers are least likely to do so (0%). While virtually all health departments, Planned Parenthood affiliates and independent agencies either distribute or sell condoms, 37% of hospitals and 21% of community health centers do neither.

The availability of condoms is also related to whether or not an agency receives Title X funding. Title X-funded agencies are much more likely than other agencies to offer free condoms to their clients (97% vs. 71%). All Title X agencies either give away or sell condoms, compared with 75% of agencies without Title X funding.

Related Programs

Services for Hard-to-Reach Groups

Family planning agencies are often the only source of reproductive health care for such hard-to-reach groups as substance abusers, prison inmates, disabled women, homeless women, and men.¹³ Forty-three percent of all agencies report routinely offering programs tailored to at least one such group, and 31% report doing so occasionally (data not shown).

Twenty-nine percent report routinely offering programs for substance abusers, and 37% report doing so occasionally. Fewer than half of family planning agencies routinely serve men (39%), disabled women (40%) or homeless women (35%), and smaller proportions do so occasionally (21%, 19% and 20%, respectively). Finally, 11% of all agencies routinely provide programs for prison inmates, and 30% occasionally do so.

Hard-to-reach groups are more likely to be served by Planned Parenthood affiliates and independent agencies than by other types of agencies; agencies receiving Title X funding are more likely to serve such groups than are agencies not funded by Title X.

Services for Teenagers

Overall, 69% of family planning agencies have at least one special program that serves the needs of adolescent clients (Table 3). Almost half of all agencies (49%) provide contraceptive outreach or education in schools or youth centers. Programs that emphasize postponement of sexual activity are implemented at 43% of agencies and more specific programs that provide high-risk teenagers with incentives not to become pregnant are offered by 15% of all agencies.

Planned Parenthood affiliates are the agency type most likely to provide programs specifically for teenagers (94%), followed by independent agencies (83%). Compared with other agency types, hospitals are more likely to run special clinics that provide con traceptive services for teenagers, but are less likely to provide other special adolescent programs. The great majority (87%) of Planned Parenthood affiliates routinely provide contraceptive outreach or education in schools or youth centers, compared with 34% of hospitals and community and migrant health centers.

More than half of Planned Parenthood affiliates and independent agencies include male partners in education and counseling, while fewer than one-third of hospitals and community health centers do so. Only one in 10 hospitals and health departments routinely offer programs for the parents of teenagers, whereas six in 10 Planned Parenthood affiliates do so.

All types of programs for teenagers are offered by a higher proportion of Title X-funded agencies than of agencies without Title X funding. The greatest difference between the two groups appears in the percentage of agencies that teach teenagers communication or negotiation skills (45% vs. 24%) and the percentage that train other organizations' staff to provide sexuality education to teenagers (30% vs. 14%).

School-Based and School-Linked Clinics

Nearly one-third (31%) of all family planning agencies reported that one or more school-based or school-linked clinics are located in their service area (Table 3). Of these agencies, about half (16% of all agencies) operate at least one such clinic, while staff from 12% of agencies provide services at these clinics. In all, 16% of agencies report receiving client referrals from school-based clinics and 7% report maintaining a formal relationship with school-based clinics that they do not operate.

Planned Parenthood affiliates are the least likely to operate a school-based or school-linked clinic: Two percent of all affiliates reported that they have such a clinic as one of their sites, compared with 12-20% of other agencies. In addition, Title X-funded agencies are 50% more likely than agencies not receiving Title X funds to operate a school-based or school-linked clinic in their area.

Planned Parenthood affiliates are the agency type most likely to receive referral from such clinics (31%), followed by hospitals, community health centers and independent agencies (20-26%) and health departments (7%). Health departments are the agency type least likely to send clinic staff to provide services at school-based or school-linked clinics (6%); staff from 15-19% of all other agency types provide such services.

Noncontraceptive Services

Most family planning agencies offer reproductive and family care health services in addition to family planning (Table 4). A majority offer nutritional counseling (86%), immunizations (84%), postpartum care (75%), well-baby care (74%), a women's, infant and child (WIC) nutritional supplement program (67%), prenatal care (64%), sports or work physicals for women (58%) or infertility counseling (57%). Moreover, 48% provide primary health care for their female clients.

Fewer agencies offer such services as colposcopy (41%), cryotherapy (40%), genetic counseling (23%) or mammography (20%). Only 9% provide abortion services (5% of Title X-funded agencies** and 14% of other agencies). A large percentage of family planning agencies (68%) also offer noncontraceptive services for men; the most common male services are sports or work physicals, testicular cancer screening and primary health care.

Hospitals, health departments and community health centers are much more likely than either Planned Parenthood affiliates or independent agencies to provide a broad range of noncontraceptive services. Hospitals are more likely to offer such services as genetic counseling, mammography and infertility treatment. Community health centers are more likely to provide a range of noncontraceptive services for men as well as women. With the exception of infertility counseling and WIC programs, Title X-funded agencies are less likely than other agencies to provide specific noncontraceptive services.

To assess whether or not family planning agencies are more likely to offer noncontraceptive services now than they were in the past, we compared the percentage offering each type of service in 1992¹⁴ with the percentage doing so in 1995. Because of changes in the proportional distribution of agency types within our sampling frame, the overall differences in percentages would be difficult to interpret. However, differences between 1992 and 1995 within agency types, particularly health departments and Planned Parenthood affiliates, can be assessed.

In general, the percentages of health departments offering specific noncontraceptive services varied little between the two survey years. However, Planned Parenthood affiliates were much more likely to offer certain services in 1995 than they were in 1992. In particular, the percentages of affiliates offering postpartum care, colposcopy, cryotherapy and sports or work physicals were 19-21 percentage points higher in 1995 than in 1992, and the percentage offering midlife women's health programs was 34 percentage points higher (data not shown). In addition, the percentages of affiliates offering genetic counseling, mammography, infertility treatment and primary health care at least doubled between 1992 and 1995, although the absolute numbers are small.

Funding Public-Sector Services

Sources of Funding

By definition, virtually all family planning agencies analyzed here receive funding from at least one public source (federal, state or local).*^† Ninety-six percent of all agencies received at least one form of federal funding in 1994, with 91% of agencies receiving funds through the federal-state Medicaid program (Table 5). Sixty percent of agencies received Title X funding for their family planning program, 35% received maternal and child health block-grant funds and 15% each received social services block-grant or community or migrant health center funding. More than 60% of family planning agencies received funding from state sources in 1994 and 40% received support from local sources.

Eighty-eight percent of all agencies derive revenue from fees charged to at least some clients. However, only 43% obtain any revenue from the private insurance plans of clients. One in five agencies receive revenue from contributions made by the private sector and 16% obtain free contraceptive implants from the Norplant Foundation to provide the method to low-income women who do not qualify for Medicaid.

Compared with other agency types, health department agencies receive support from a larger number of public sources. Overall, 98% of health departments receive some federal funding and 42% receive at least three types of federal funding (data not shown). Likewise, 80% of health departments receive state funds and nearly 70% receive local funding for the provision of family planning services. Planned Parenthood affiliates also receive a variety of state and federal funding; for example, 33% receive social service block- grant funding, a percentage significantly higher than that for any other agency type. Moreover, these agencies are much more likely than any other type of agency to receive private-sector contributions. Community and migrant health centers are least likely to obtain revenue from client fees or private contributions, but they, along with hospitals, are the most likely to be reimbursed for their services through their clients' private insurance plans.

Most agencies that receive Title X funding also receive funds from a constellation of other public sources. More than half (51%) of these agencies receive revenues from three or more federal sources, including Title X, and 48% receive both state and local funds. In contrast, only 4% of agencies not funded by Title X receive revenue from three or more federal sources, and only 14% receive both state and local funds (data not shown).

Using Public Funding to Subsidize Care

Family planning agencies have a variety of strategies for using these public-sector dollars to provide contraceptive services to low-income clients. Since the majority of clients are poor and most are not Medicaid recipients, family planning agencies use non-Medicaid federal funding, such as Title X funds, as well as state and local funds to support a general program of services, thereby enabling them to serve some clients without charge or at a reduced fee.

At most agencies, the determination of who receives free or reduced-fee services is based on the financial status of the client. According to the regulations followed by Title X-funded agencies, clients whose family income is below the federal poverty threshold are served without charge, while those whose income is between 100% and 250% of the federal poverty level are charged a reduced fee based on a sliding scale.

Overall, 93% of all agencies report serving at least some non-Medicaid clients free or at a reduced fee, including 3% that serve specific populations, such as Indian Health Service clients, at no charge; the remaining 6% primarily serve Medicaid clients and report no reduced-fee options for non-Medicaid clients. Almost all family planning agencies (93%) allow the client to pay in installments if she is unable to pay the required fee at the time of her visit, and 54% waive charges for Medicaid-eligible clients who have not yet formally established their eligibility.

Community health centers are the most likely to reduce their fees, while hospitals are the least likely to do so. Agencies with Title X funding are more likely to allow installment payments and to waive fees for women eligible for Medicaid.

Fees Charged

Agencies were requested to provide information about the fees charged for routine first-visit services (initial exam, including the pelvic exam) and for a three-month supply of oral contraceptives to clients of different income levels.

For the initial exam, 89% of agencies with Title X funding do not charge clients whose income is 75% of the federal poverty level, compared with 33% of other agencies. Few agencies provide free exams to clients whose family income is more than 250% of the poverty level—4% of agencies with Title X funding and 10% of other agencies. Similarly, 87% of Title X-funded agencies do not charge women for oral contraceptives if their income is less than 75% of poverty, compared with 55% of other agencies.

The median fee charged to the few low-income women who are asked to pay for an initial exam at agencies with Title X funding (those with incomes at 75% or 125% of the poverty level) was about $20, compared with $26-$30 at agencies without Title X funding. For women with higher incomes (250% or more of the poverty level), the median fee for an exam is similar at the two types of agencies ($60 vs. $64). The median fee charged to low-income paying clients for pill supplies is about $10 at Title X-funded agencies and $15 at other agencies. Women with higher incomes are charged a median of $22 for oral contraceptives at agencies with Title X funding and $24 at those without Title X funding.

Discussion

The network of publicly funded family planning agencies and clinics in the United States continues to be an important source of reproductive and contraceptive health care for millions of low-income women. In this article, we have reviewed the delivery of contraceptive care by these providers, comparing the characteristics, programs and policies of agencies according to their sponsoring organization and funding status. Such an exercise is important in understanding how and to whom publicly funded contraceptive care is being provided. As the structure and financing of health care change, moving more and more toward a managed care model, it is critical to recognize the role that publicly funded family planning providers currently play in delivering care and to speculate about their future role.

Accessible, affordable and comprehensive contraceptive care is necessary for the prevention of unintended pregnancies. In addition, there is evidence that women who receive the method that they believe will be best for them are more likely to use that method effectively than are women who receive another method.¹⁵ It is also thought that more comprehensive education and counseling regarding method use lead to better compliance and more effective use. Moreover, it has been shown that satisfaction with gynecologic services contributes to greater and more consistent use of contraceptives.¹⁶ Providers can help women use contraceptives effectively by providing a full range of methods and by taking the time to explain the different methods available and to find out which methods best fit individual women's needs and desires.

Clinics structured primarily for the provision of family planning services, such as those operated by independent agencies and Planned Parenthood affiliates, provide contraceptive care that is somewhat more accessible (flexible clinic hours and shorter waits for appointments) and more comprehensive (more methods available) than the care delivered at clinics run by agencies that deliver a wide range of services, such as health departments and community and migrant health centers. In addition, such clinics are more likely to provide additional contraceptive services for hard-to-reach populations and to provide outreach programs and special services for teenagers.

However, clinics operated by health departments, hospitals, and community and migrant health centers are more likely to offer a broad range of health care services in addition to contraceptive care. Although many women say they prefer to obtain contraceptive services from providers that offer other types of health care services,¹⁷ such providers are less likely to offer a wide selection of contraceptive methods and are less likely to provide special outreach and educational programs for hard-to-reach populations or for teenagers.

Superficially, therefore, the current network of publicly supported facilities and programs providing family planning services appears to be diverse, but complementary. Women can obtain care from providers that offer both contraceptive care and general health care, if they desire and if their contraceptive needs can be met by such providers. At the same time, other women can be served by providers that focus primarily on the provision of contraceptive services and are better equipped to serve the needs of hard-to-reach populations and teenagers and to provide the full range of methods available.

In reality, many women do not have such a choice, but instead are served by the clinics that are geographically most accessible to them. Thus, access to the full range of contraceptive methods or to specific services or programs may be limited to the women who live nearest the clinics delivering such services. For example, women in nonmetropolitan counties or in some regions of the country are much less likely than other women to live near a family planning clinic that provides such methods as the implant, the IUD, emergency contraceptive pills, the female condom, tubal sterilization or the cervical cap.

Moreover, in some regions of the country, all publicly funded contraceptive services are provided by health department clinics, while in other regions such services are provided mainly by one or two of the other agency types.¹⁸ Insofar as we have shown that the provision of contraceptive services varies according to the type of sponsoring agency, women who reside in areas without much provider choice may not have access to a full complement of contraceptive services.

This analysis of the services, policies and programs of publicly funded family planning agencies has demonstrated that one of the primary factors that holds this diverse network of providers and varied sources of funding together and accounts for some of the commonalties in the provision of services is the Title X family planning program. Because agencies that receive Title X funding must follow certain federal regulations regarding the provision of services, these agencies generally provide a wider range of reversible methods than do other agencies, regardless of the type of operating organization.

In addition, because Title X is a grant program that provides funding for both contraceptive services and related program activities (unlike Medicaid, which reimburses providers only for the delivery of specific medical services), the agencies that receive Title X funds have more flexibility in designing program activities. Compared with agencies that do not receive Title X funding, those that do are more likely to provide free condoms, to serve hard-to-reach populations and to have a variety of special services and educational or counseling programs that are directed at the prevention of unintended pregnancies among teenage clients.

Changes in the structure and financing of health care, particularly large shifts in the Medicaid population toward receipt of services through managed care networks, are unlikely to eliminate the need for publicly funded family planning clinics. Most of the women who currently receive contraceptive care from publicly funded family planning clinics are not Medicaid recipients. However, many of them do not have insurance coverage for contraceptive care and are poor enough that the cost of paying out-of-pocket for contraceptive care and methods is more than they can afford. Teenagers wanting to avoid unintended pregnancy seek accessible and confidential contraceptive services from publicly funded family planning clinics and are likely to continue to need readily accessible, confidential services. Finally, many of the women served by publicly funded family planning clinics keep returning because they are able to receive familiar, confidential services and they are usually able to obtain the methods of contraception that they desire.

As health care services, financing and needs change, it is important that family planning services be readily available to all, especially to low-income women and men who are often outside the mainstream health care delivery system. A key source of funding for these family planning services is Title X. As the level and structure of future public funding for contraceptive services are considered, it will be important to keep in mind the advantages and limitations of current agency programs, policies and services. Continued funding for these services will remain critical to the prevention of unintended pregnancy among low-income women.