Family Planning & the Federal Budget Impasse

by by Erin Schikowski

illustration by by Annika Finne

As the Independent went to press, legislators on Capitol Hill were still struggling to agree on a budget for the remainder of Fiscal Year 2011. If Congressmen fail to do so by April 8, the government will shut down for the fifth time in US history—which, according to The Economist, would “be highly disruptive” given the current fragility of the economic recovery.

In negotiating a budget, legislators have been particularly torn over Title X, the only federal grant program devoted entirely to family planning and related preventative-health services like prenatal care, educational programs, contraceptive counseling, and cancer and STI screenings. In February, a Republican-controlled House passed a budget that would have eliminated Title X completely and drastically reduced funding for dozens of other programs. The Senate rejected this bill in early March.

As budget negotiations wore on last week, your correspondent joined physicians from across the country for Federal Advocacy Day, an event sponsored by the American Medical Women’s Association (AMWA) and Physicians for Reproductive Choice and Health (PRCH). On March 31, approximately 60 physicians, nurses, medical students, and other participants visited dozens of a offices to argue—not as lobbyists but as constituents—that cutting Title X would have devastating consequences for the poorest women and families nationwide. 

On the Ground Title X-funded services must be offered free of charge to those living at or below the poverty line; this, according to the Guttmacher Institute, describes two-thirds of all clients who receive care through Title X-funded providers. The National Family Planning & Reproductive Health Association (NFPRHA) reports that in 2009, Title X enabled providers to perform 2.2 million Pap tests, over 2.3 million breast exams, nearly six million STI screenings, and one million HIV tests. Despite recent and fallacious claims, no Title X money may be used for abortions.   Early Thursday morning during a training session, Advocacy Day leaders explained that medical professionals’ stories can illustrate the data so many legislators and their aides already know. Firsthand anecdotes, they said, make “these experiences come alive for legislators and others who don’t get to see what [medical professionals] see” on the ground. Many participants had stories to share about patients who benefit from Title X and other publicly funded family-planning programs.   Dr. Catherine McKegney B’76 told of a woman named Olivia who was from rural Minnesota and only marginally employed. Olivia was unable to support the fourth child with which she was pregnant and would ultimately choose to have an abortion. She would then seek affordable contraception to prevent subsequent unintended pregnancies. When McKegney placed her intrauterine device (IUD), which was covered by a state family-planning program designed for women who neither qualify for Medicaid nor have insurance, McKegney said Olivia “practically kissed [her] feet for putting that IUD in, she was so grateful.” The IUD would prevent Olivia from having further unintended pregnancies or abortions ever again.   Through contraceptive counseling and services, publicly-funded­­ family planning obviates a total of 800,000 abortions each year, according to the Guttmacher Institute. However, some who oppose Title X do so because providers may give an abortion referral upon the client’s request. This referral consists, according to National Abortion Federation, of “a name, address, telephone number, and other ‘relevant factual information,’ such as what insurance is accepted.” Although many organizations receive Title-X funding—the majority of which are state, county, and local health departments—Planned Parenthood has recently found itself at the center of the Title-X debate due to the fact that some Planned Parenthoods offer abortion services.   Even if a Congressman’s constituents are opposed to abortions—which, in any case, are not funded through Title X—the fact still remains: Title X saves money. In the Journal of Health Care for the Poor and Underserved, researchers reported that for every dollar spent on Title X, taxpayers saved four.   Christa Nordstrand, a second-year medical student, told a vivid anecdote about the cost-saving benefits of Title X. Ana was one of Nordstrand’s first patients, a mother of four who had been addicted to heroin between ages twelve and sixteen. Due to the prenatal care she received at a Title X-funded clinic, Ana gave birth to two healthy children despite being addicted to heroin. Following two uncomplicated deliveries, neither child required a stay in the neonatal intensive-care, which costs $3,500 per day according to a recent article published in the American Medical Association Journal of Ethics.­­ Nordstrand said Ana currently has four children and, though “healthy now, Ana is still far below the poverty line and continues to receive care at similar clinics.”   The Deficit Still, there is no escaping the fact that many programs will need to be cut if Congress is to reduce the nation’s $1.3 trillion deficit. Last Thursday, the halls of Congressional office buildings were filled with various interest groups, from insurance-company representatives to park advocates to religious groups to the AMWA/PRCH physicians, all of them hoping to leave an impression on lawmakers.   According to the nonpartisan, nonprofit Congressional Management Foundation, in-person issue visits from constituents are most likely to influence an undecided legislator’s decision; constituents’ individualized letters and emails, phone calls, and comments during telephoned town-hall meetings are each at least ten percent less likely to have “a lot of positive influence.”   During Advocacy Day, Dr. Neelum Aggarwal, a Chicago-based neurologist specializing in Alzheimer’s Disease, explained to a Congressional aide that cutting funding for Title X—while better than eliminating it altogether—would be extremely damaging for the communities that rely on it. “With cuts,” Dr. Aggarwall said, “trust is lost. That’s extremely hard to rebuild and repair. People expect to come to these clinics and be able to get the care they need.”   When they can’t—when, for example, one clinic can no longer offer reduced-cost STI screenings—a patient may forgo screenings and other preventative-care services for years at a time. Or if a cervical cancer test result is inconclusive, a doctor may not be able to repeat it due to lack of funding. Dr. Aggarwal said that “normally, when funding gets cut the biggest hit is in the hours that the clinic stays open, the hours that someone is handling the phone calls—and, if cuts are severe, it limits access to physicians. A clinic may have three to five physicians and with cuts it goes down to two physicians. This causes overload for everyone, long waits, and with long wait times, people leave.”   While visiting Alzheimer’s patients in their homes, Dr. Aggarwal meets women who care for loved ones with Alzheimer’s. She said they quite often rely on Title X-funded clinics for free cancer screenings, contraceptive services, and other preventative health-care measures. One of these women told Dr. Aggarwal, “I need to keep me strong so that I can take care of Mom.  Mom can’t go in a nursing home; I promised I wouldn’t do that to her.” Most physicians attending Advocacy Day agreed that entire families—not just women—benefit from Title X.   Politics as Usual Unfortunately, some Representatives are firmly opposed to compromise. On Monday, The Hill reported a House aide as saying that the Republican leadership was “preparing for a shutdown. Instead of coming to the table to work with Democrats and the White House, who have offered $33 billion in cuts, Speaker Boehner is taking his marching orders from the Tea Party, who want to ‘cut it or shut it.’”   In digging their heels in, some Republicans have framed the elimination of Title X as being more than just a budget-reduction measure. In reference to health-care reform and Planned Parenthood, Roll Call recently reported Representative Jack Kingston (R-Ga) as saying, “There are some things that we have to be able to go back to our base and say we got a victory, not just a mathematical accomplishment.” For politicians like Kingston, cutting Title X would seem to be as much about political leverage as reducing the deficit. According to The Wall Street Journal, President Obama said that “there can be some negotiations about composition” of the budget cuts, but that he would not compromise on ideological matters like abortion at a time when the priority should be preventing a shutdown. The same article quotes Obama as saying, “We don’t have time for games, not on this.”   If the government shutdown of 1995-1996 can provide any political lesson, it’s that no party wins when a government shutdown occurs; the public loses faith in the government as a whole. Mark Hetherington argued in The American Political Science Review that voters’ declining political trust can actually contribute to future voter dissatisfaction by “creating an environment in which it is difficult for those in government to succeed.”   So much is at stake, both politically and in terms of affordable health care, but as it stands now, the future of Title X is unclear; it may be cut entirely, partially, or not at all. The bottom line, however, is that reproductive-health services should not be a matter of politics. All Americans--poor or not--deserve access to the basic health-care services Title X makes possible.   ERIN SCHIKOWSKI B’11.5 wonders whether the zoo will need volunteers during a shutdown.