Title X, the government-supported family planning service that has helped low-income Americans access reproductive health services since 1970, served 193.5 million people during its first 50 years.

But funding for the program has been flat at $286.5 million for nine straight years, including in fiscal 2023, despite a growing population, inflation and unmet need for family planning services in many parts of the country. That’s led to uncertainty for individual Title X service providers, some of whom have had to seek outside support, and calls from Democratic lawmakers and the White House for a major increase in federal spending.

According to the nonprofit National Family Planning and Reproductive Health Association, the demand on the program led the federal government to tell 11 grantees last year that while they met the credentials for a full five-year grant, the program did not have enough money to provide them with one. The grantees, which include local health departments, nonprofits, jurisdictions and health facilities, were given funds to phase down from the Title X program by March 31, 2023.

The letters drove those grantees — who operate clinics in Florida, Georgia, Maryland, Massachusetts, Texas and West Virginia, as well as three in Nevada and two in Oklahoma — to coordinate on contingency planning and brainstorm how to continue services without Title X funds.

But on March 20, the Office of Population Affairs, which administers Title X, wrote to some grantees that their funding would be continued for a full-five year period and that they should stop any closeout activities. HHS would not comment on how many or which of the 11 grantees received such letters.

“We were sitting on a ledge not knowing what was going to happen,” said Sonya Bruton, CEO and president of the Maryland-based CCI Health and Wellness Services, one of the 11 grantees who’d been told that funding would be cut off.

She said the March 20 announcement assured the program “that we will receive support through the Title X program directly from the federal government without the need to find another partner through 2027.”

Uncertainty remains

Title X, which provides birth control, fertility services and treatment for sexually transmitted infections among other services, has long had bipartisan support as a safety net health provider, with pushback largely centered on whether grantees should be able to use nonfederal money for abortion services. The program’s funding cannot be used for abortions.

Planned Parenthood affiliates are some of the program’s biggest grantees, and Republicans have sought to bar them from the program.

About one-quarter of grantees left the program altogether after the Trump administration implemented a rule barring abortion providers from participating in the program. When the Biden administration rescinded that change, the program saw an increase in interested applicants without a funding increase.

Still, the flat funding has led to uncertainty, particularly for the 11 grantees who received warnings.

Yeraldin Deavila, a spokesperson for Washoe County Health District in Nevada, another one of the 11, confirmed the county also received a letter and would not run out of funds on March 31, 2023.

Not all grantees opted to continue with the program.

Laura A. Cruz-Acosta, a spokesperson for the City of El Paso, said the city did not reapply for funding after the phase-down funds.

The city has already begun to wind down from the program and is no longer providing family planning services but will refer patients to other facilities that provide these services — though these clinics might not accept free or sliding scale payments for care.

A spokesperson for HHS said the Office of Population Affairs said the continuation grants will begin in April 2023 but would not disclose how many grantees were leaving the program.

Bruton, of Maryland, said the news was a “welcome surprise,” a sentiment echoed by other grantees.

Bruton said over the past year, they had been encouraged to look for other partners without success. The state of Maryland said it would not make any emergency funding redistributions, she said, without a state survey, research and new data showing the current unmet need. But that process or other grant programs would not have come together before the end of March.

Federal journey

This year, the Biden administration has kicked off a push to increase the program’s funding by asking Congress for a 79 percent increase over the enacted level — or $512 million.

Sen. Maggie Hassan, D-N.H., announced last week at a Senate Finance Committee hearing that she and Sen. Elizabeth Warren, D-Mass., plan to send a letter to appropriators echoing the White House request.

“It’s historically been a program that’s been underfunded. But we all know that in light of the Supreme Court’s decision last year to restrict women’s reproductive freedom, this is a program that’s more essential than ever,” Hassan said.

It will be challenging to find bipartisan support for a large increase for Title X, given the divided government and House Republicans’ pledge to lower domestic spending to fiscal year 2022 levels.

The Office of Population Affairs saw the same level of flat funding appropriated for Title X when Democrats had control of both chambers for two years and the White House as when Republicans held a trifecta for two years of the Trump administration.

The program saw its funding peak in fiscal 2010, when it received $317 million in annual appropriations. Advocates have tried unsuccessfully to exceed or even match that number since it dropped to $286.5 million in fiscal 2011.

“The thing that limits this program is the federal appropriation and the ability to to have control over the resources once they are allocated,” said Bruton, adding that the Office of Population Affairs has been supportive despite its limitations. “I cannot stress enough that they have been in the trenches with us this entire year, trying us figure it out. And if they could have more resources, they would do more in more communities.”

Rising need

The clinics that faced a funding cliff had explored different ways to compensate for a lack of funding. They’re hopeful that increased funds could allow them to serve more patients.

J.R. Richards, CEO of the Georgia-based Medical Associates Plus, which receives a grant through the Neighborhood Improvement Project, said they already had to make changes because of funding changes.

The state has a high teen pregnancy rate, especially in Burke and Richmond counties, he said.

Medical Associates Plus originally received $600,000 for the program, but that dropped to $300,000 during the phaseout period, leading them to eliminate Title X services in rural Burke County, lay off their Title X program coordinator and health educator and end its weekly teen clinic.

Had they not received the letter, they would have looked at cutting more services and ordering fewer supplies.

The new funding level is $300,000, meaning it still won’t be able to serve the Burke County population. Increased funding would allow them to offer Title X services at their other clinics, which are not part of the program.

In Massachusetts, Action for Boston Community Development President and CEO Sharon Scott-Chandler said her organization was working to secure bridge funding from the state that would have kicked in July 1 as a backup plan after getting some supplemental state funding over the past year.

“Nationwide and even in Massachusetts, the demand outstrips the resources that we have,” Scott-Chandler said. “Even if we were fully funded, and all the grantees were fully funded, that still leaves a lot of people and a lot of unmet need.”

She acknowledged it was an anomaly that they “would have been okay for a few more months.”

Her region has been combating an uptick in chlamydia and other sexually transmitted diseases and seen an increased interest in long-acting reversible contraceptives. Additional funds would allow them to build partnerships to reach more specialized populations such as young adults, homeless individuals and those with substance use disorders.

Bruton said had they not been approved for more funds, their contingency plan would have reduced access to more expensive contraceptives.

“We had committed that we were still going to serve them in whatever capacity we could through our own resources,” Bruton said. “But that was not going to be the full breadth of services that we are able to provide with federal support.”