By Tracee Saunders, Rebecca J. Kreitzer, and Candis Watts Smith | August 14, 2018
Title X of the Public Health Service Act is the only federal program devoted exclusively to family planning and reproductive health care. Title X is symbolic of the mid-20th century’s widespread and bipartisan support for policies aimed at increasing access to affordable contraception.
More recently, the once-separate politics of abortion and contraception have converged. Just as we see a growing number of “abortion-free zones,” we are witnessing the growth of contraception deserts, or geographic areas with inequitable access to affordable family planning due to states’ broad discretion in Title X implementation. New and proposed reforms to Title X at the state and federal levels may expand contraception deserts.
More recently, the once-separate politics of abortion and contraception have converged.
This inequality isn’t trivial. Two-thirds of reproductive age women in the U.S. use contraception, and more than 20 million women require the assistance of public programs to afford that contraception. While many low-income people use Medicaid to access family planning, an additional 4 million rely on Title X each year. More than a third of this subset obtains their contraception at a Planned Parenthood clinic—the very clinics that have become the primary target of more than a dozen states’ new restrictions on the allocation of state and federal family planning funds.
Further, Title X clients are among the most vulnerable populations: two-thirds have incomes at or below the federal poverty level, roughly half are uninsured (even after expansions to the ACA), 35% have coverage through Medicaid or other public programs, and many receive lifesaving STI and cancer screenings at Title X clinics.
Yet despite the overwhelming evidence that affordable family planning reduces unintended pregnancy and abortion rates and decreases Medicaid expenses, at least a third of adult U.S. women who ever tried to obtain contraception reported barriers in accessing it.
Comparing Contraception Deserts in Two Red States
Title X funds are, for the most part, allocated at the state level, and the distribution of resources is influenced by state-level politics. With that in mind, we compared the equity of access to subsidized contraception through Title X in North Carolina and Texas (by “equity,” we mean resources are distributed in response to need). ‘
In North Carolina, the vast majority of Title X funds allocated in 2017 went to 112 county health departments as well as five Planned Parenthood locations. Although Texas has 5 times the landmass and nearly 3 times the population, it has only 94 service sites – just a smattering of federally qualified health centers, health departments, hospitals, Planned Parenthood, and a university health center.
Mapping Contraception Deserts
We identified two types of contraception deserts using a technique often used by applied geographers (the integrated two-step floating catchment area method). This method incorporates spatial barriers to access (e.g., minutes needed to drive to a clinic) with non-spatial ones (e.g., percent of an area’s inhabitants that are low-income).
When the federal government considers whether a given place is a “Health Professional Shortage Area,” the guideline is that clients should need to drive 30 or fewer minutes to a clinic; we adopt this standard. But we also assess access using a 15-minute driving distance, because contraceptive dispensing patterns vary by method (e.g., oral versus implantable contraceptive methods) and many patients must visit a clinic for their birth control several times a year. In the first type of desert, marked in dark blue, most residents do not live within a driving time of 30 (or 15) minutes. In the second type of desert, light blue in our maps, many people live outside a 30 (or 15) minute driving distance and the area has a “high needs” population.
Our analysis reveals a greater set of disparities in the Texas in comparison to North Carolina. In North Carolina, Title X is distributed through most county health departments, so affordable family planning is fairly accessible throughout the state. In Texas, most Title X providers are in urban areas, where most people live. However, this leaves broad swaths of Texas with very limited access to affordable family planning.
How Many People Live in Contraception Deserts?
Many people live in areas characterized by limited access to family planning. Based on a 15-minute driving designation, 24.7% of North Carolina’s population (estimated 10.4 million) lives in an area with poor access to affordable family planning (summing the 11.7% living in an area with very poor spatial access and the 13.0% living with somewhat poor spatial access and high needs). The severity of contraception deserts in Texas is much greater. More than half of the state’s population (estimated 28.7 million) lives in a contraception desert.
Contraception Deserts in NC and TX, 15 minute driving distance
| Contraception Desert Type | # of Tracts (%) | Area miles squared (%) | Population (%) | |
|---|---|---|---|---|
| North Carolina | Spatial Access Very Poor | 293 (13.5%) | 6,224.27 (11.6%) | 1,245,975 (11.7%) |
| Spatial Access Somewhat Poor + High Needs Population | 268 (12.3%) | 588.04 (1.1%) | 1,202,199 (13.0%) | |
| Texas | Spatial Access Very Poor | 1,966 (35.2%) | 215,041.9 (80.1%) | 9,662,682 (34.2%) |
| Spatial Access Somewhat Poor + High Needs Population | 1069 (19.1%) | 13,734.9 (5.1%) | 5,127,532 (18.1%) |
Even if we rely on the more conservative 30-minute driving distance standard, the number of people living in a contraception desert is remarkable: More than 2 million people or nearly 20% of North Carolinians and more than 10 million people or 35.4% of Texans lives in a contraception desert. And these are but two states.
Contraception Deserts in NC and TX, 30 minute driving distance
| Contraception Desert Type | # of Tracts (%) | Area miles squared (%) | Population (%) | |
|---|---|---|---|---|
| North Carolina | Spatial Access Very Poor | 74 (3.4%) | 224.11 (0.4%) | 356,334 (3.4%) |
| Spatial Access Somewhat Poor + High Needs Population | 393 (18.1%) | 2,805.08 (5.2%) | 1,662,027 (16.3%) | |
| Texas | Spatial Access Very Poor | 1,087 (19.5%) | 173,876.5 (64.7%) | 4,642,172 (16.4%) |
| Spatial Access Somewhat Poor + High Needs Population | 1,129 (20.2%) | 20,411.9 (7.6%) | 5,377,523 (19.0%) |
The Future of Title X
We find that contraception deserts exist in both of these “red” states, but the severity varies. While more research is needed to better understand the different ways in which states implement Title X, including how those decisions are made, and which racial or ethnic groups across the U.S. are most likely to live in a contraception desert, it is clear that there are large inequities and that residents of some states are much worse off than others.
Title X was created to provide evidenced-based, effective contraceptive and reproductive healthcare to Americans in need. When people have access to affordable family planning, unintended pregnancy rates and abortion rates drop. Ongoing efforts to defund family planning resources have an impact on American fertility and perpetuate inequalities in unintended pregnancy rates across racial and socioeconomic classifications.
Title X’s funding has decreased over five decades, and the Trump administration has now revised the criteria for awarding Title X grants to emphasize natural family planning (abstinence and the “rhythm” method) and eliminate emphasis on all forms of evidence-based contraception. The administration has also proposed a new rule that, if implemented, would prohibit clinics that provide abortions or abortion referrals from receiving federal family planning funds. In response, organizations like the American College of Obstetricians and Gynecologists (ACOG) have launched campaigns to oppose these changes and #SaveTitleX.
To mitigate inequitable access, policy advocates should fight for increased funding for Title X at the state and federal levels and for the establishment of additional clinics, especially in rural areas. Many social conservatives advocating to prohibit Title X funds going to Planned Parenthood and other similar clinics assert that the role of these clinics in providing low-cost contraception can be replaced with community health centers. Community health centers do play an increasingly critical role in the family planning safety net, but not all community health clinics offer a range of family planning options directly.
Policy advocates must also continue to fight for Title X’s mission at the federal level. If funding for Title X continues to decline in the federal budget, state governments that fail to raise their funding for family planning risk an increase in abortion rates, unintended pregnancies, and Medicaid expenditures.
— Tracee Saunders is a Ph.D. student in political science at the University of Iowa studying social inequality, spatial politics, health policy and gender.
— Rebecca J. Kreitzer is an Assistant Professor of Public Policy at the University of North Carolina at Chapel Hill studying reproductive health, policy inequality, and women’s political representation in the U.S. states.
— Candis Watts Smith is an Assistant Professor of Public Policy at the University of North Carolina at Chapel Hill studying racial and ethnic politics and policy inequality. She is the author of Black Mosaic: The Politics of Black Pan-Ethnic Diversity.
— Photo by Surija/”Sray”
