Washington Watch: Costs rise for Title X clinics, but not funds

By Cynthia Dailard
Senior Public Policy Associate
The Alan Guttmacher Institute
Washington, DC

Mounting federal deficits coupled with an administration that favors abstinence promotion over contraception means that funding for the Title X family planning program is likely to remain stagnant in the coming years. President Bush sought no additional funding for the program during his first two years in office, and funding increases during the late 1990s did little more than keep pace with inflation.

During this period, however, the cost of doing business for Title X providers skyrocketed. In 2002, the Alan Guttmacher Institute (AGI) conducted a small scale investigation designed to identify the key factors responsible for these rising costs.1 The results will help guide future AGI research, and offer providers, advocates, and policy-makers a unique glimpse into some of the major financial pressures weighing on publicly funded family planning clinics.

Family planning providers routinely bemoan the rising cost of contraceptives, and with good reason: For Title X projects participating in AGI’s investigation, the per client cost of purchasing contraceptive supplies rose from an average of less than $8 in 1995 to $12.50 in 2001, an increase of 58%.

Increasingly, clients are shifting from oral contraceptives, which clinics can purchase at deep discounts, to newer, longer-lasting methods that are more expensive for clinics to provide. For example, clinics can provide three women with an annual supply of oral contraceptives for less than the cost of providing one woman with Depo-Provera (Pharmacia Corp., Peapack, NJ).2 Yet between 1995 and 2001, the proportion of contraceptive clients in Title X projects nationwide who used oral contraceptives fell from 62% to 52%, while the proportion of using Depo-Provera rose from 12% to 20%.3 This trend is only likely to continue now that a monthly contraceptive injection, a vaginal ring, a new intrauterine device, and a contraceptive transdermal patch have come on the market.

Diagnostic tests increase

Title X clinics are major providers of sexually transmitted disease (STD) tests and Pap smears: In 2001, Title X funded clinics provided 5.1 million STD tests, 600,000 HIV tests and 3 million Pap tests, according to The Alan Guttmacher Institute.

The costs of STD and HIV tests, however, also are rising. The Title X projects providing data to AGI for 1998 and 2001 reported that the average purchase price for STD and HIV tests almost doubled, from $3.50 to almost $7 per test. For chlamydia specifically, the average cost per test rose from slightly more than $4 in 1998 to nearly $6 in 2001. Compounding the situation, the Atlanta-based Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force are calling for even more chlamydia screening among populations of women likely to rely on clinics.

The same is true for Pap test costs: The projects reporting data said that the average purchase price for a Pap test increased from slightly more than $6 in 1998 to about $8 in 2001. These cost increases are likely to continue as clinics move to Thin Prep (Cytyc Corp., Boxborough, MA), which is rapidly becoming the standard of care in American gynecology but can cost family planning providers as much as triple what they pay for conventional tests.

Together, the average per client cost to these Title-X-funded projects to purchase contraceptive supplies and STD and Pap tests rose from $18 in 1998 to $21 in 2001, an increase of 19% in a three-year period. While Medicaid provides up to half of all public dollars used to fund family planning services in this country, Medicaid does not pay the full cost of serving clients in Title X programs. The Title X projects studied indicated that, on average, 28% of their clients are Medicaid recipients. Nonetheless, only 22% of their revenues came from Medicaid reimbursements.

This disparity is even more evident when viewed at the individual client level. It cost the Title X projects studied an average of $118 to provide an initial client visit. These same projects reported, however, that Medicaid reimburses them an average of only $62. Title X funds, according to these clinics, often are used to fill this gap, effectively subsidizing the care of clients enrolled in Medicaid.

Check Medicaid's impact

Title X projects in the AGI investigation also reported two other major sources of financial pressure: the increasing demand for assistance to clients in a multiplicity of languages, and the rising cost of staffing. Additionally, states are going through their worst fiscal crisis since World War II, meaning that state contributions for subsidized family planning services may be slashed. With a major infusion of new cash unlikely at the federal level, Title X projects will be hard-pressed in the coming years to continue to provide the high-quality services that have been the hallmark of the program for more than three decades.


1. Gold RB. Nowhere but up: Rising costs for Title X clinics. Guttmacher Report on Public Policy 2002; 5:6-9. [AGI’s investigation included information from 12 publicly funded family planning agencies that met four key criteria: They had been in existence for at least 10 years; served at least 1,000 contraceptive clients annually; had budget and funding data going back to the mid-1990s; and had at least one contract with a managed care plan (an arrangement that generally involves a high level of sophistication in the agency’s data and financial system.)]

2. Dailard C. Title X family planning clinics confront escalating costs, increasing needs. Guttmacher Report on Public Policy 1999; 2:1-3.

3. Alan Guttmacher Institute. Family Planning Annual Report, 2001 Summary; August 2002.