Massachusetts study: High demand for publicly funded family planning services, despite near universal insurance

Higher insurance rates don’t mean people stop seeking care at publically funded health centers, found a recent study of family planning clinics in Massachusetts. The findings speak to serious concerns within public health circles that policy-makers may point to higher insurance rates as a justification to cut critical public health funding.

Published in the Jan. 24 issue of Morbidity and Mortality Weekly Report, the study examines trends among uninsured patients seeking care at Massachusetts health centers that receive Title X Family Planning Program funds. (The federal Title X program supports access to high-quality family planning and related preventive services for low-income women and men.) In Massachusetts, which passed health reform legislation in 2006 and is often cited when trying to predict future impacts of the Affordable Care Act, researchers found that higher rates of people with health insurance had little effect on patient numbers at Title X-funded clinics. The study also found that the clinics continue to serve as a critical safety net for uninsured residents.

In addition to family planning and contraceptive services, Title X-funded clinics provide breast and cervical cancer screening, pregnancy testing and counseling, education and referrals, and testing for HIV and other sexually transmitted diseases.

“As more people get insurance, some might think that there’s no longer a need for safety net programs, but we just haven’t found that to be true,” said Jill Clark, a co-author of the study and assistant director of the Family Planning Program at the Massachusetts Department of Public Health. “From the other research we’ve done, people say they feel like they receive quality care (at these clinics), that their services are kept private and their confidentiality is respected. These are organizations that people are familiar with.”

Clark and her colleagues found that between 2005 and 2012, patient volume at Title X-funded clinics remained high. In 2012, the state’s five Title X-funded health care organizations served 66,227 patients, which translates to 90 percent of their 2005 patient volume. Also from 2005–2012, the overall percentage of Massachusetts residents served by Title X-funded organizations and who did not have insurance dropped from 59 percent to 36 percent. In 2005 and among different clinic sites, the percentage of clients who did not have insurance ranged from 77 percent to 46 percent; in 2012, those without coverage ranged from 52 percent to 24 percent. All age groups experienced declines in uninsurance, with the greatest declines among teens and adults ages 20 to 29 years old.

The overall message? Despite Massachusetts’ near universal coverage rate — 97 percent of residents had insurance as of 2011 — Title X-funded clinics continue to be critical access points for both insured and uninsured residents seeking family planning care. Authors Clark, Marion Carter, Kathleen Desilets, Lorrie Gavin and Sue Moskosky write:

The results of this study indicate that in the six years following health care reform in Massachusetts, publicly funded providers continued to be used as providers of choice for many clients with health care coverage and remained as a "safety net" for uninsured persons in need of family planning services. …The continued provision of safety net family planning services is important not just for the individual clients accessing services at these organizations but for broader health equity goals as well. Adults aged 20–29 years experience the most unintended pregnancies of any age group in the United States, and these clients constitute a large proportion of clients seen by these health centers. Yet insurance coverage among these young adults lagged behind that of other age groups.

In addition to direct clinical services, Clark told me that Title X-funded clinics are also key to effective community outreach and prevention education. Because such clinics spend years cultivating relationships with the communities they serve and have reputations for providing confidential care, they’re often better equipped to reach vulnerable and at-risk populations.

“There’s always going to be people who are not comfortable going to primary care for these services,” Clark said.

William Smith, executive director of the National Coalition of STD Directors, agreed, adding that many people simply don’t want to use their primary care doctors for sensitive health problems, such as STD screening. Plus, he said, Title X providers are often sexual health specialists who can catch diseases other providers might not. For example, lots of private providers are probably familiar with common STDs such as chlamydia, but many have probably never seen a case of syphilis in their careers.

“People really do want confidential care when it comes to sexual health issues,” Smith told me. “They want competent care and publicly funded family planning clinics and STD clinics really are centers of excellence and people know it. They know they’re going to get quality care and have providers who know what they’re doing.”

Smith said Title X funding is essential to reaching at-risk populations and preventing STD infections — “this is what public health does,” he says. And while he can’t cite an exact cause-and-effect relationship, he did note that as Title X funding has declined, rates of STDs have gone up. According to the National Family Planning & Reproductive Health Association, between fiscal years 2010 and 2013, Title X family planning funds were cut by more than $39 million. As a result, Title X clients declined from 5.22 million to 4.76 million, with no indication that they found other sources of care. Ironically, the budget cut — like many public health budget cuts — won’t save money in the long run: Research shows that every $1 invested in publicly funded family planning saves $5.68 in Medicaid costs related to unplanned births.

Even if demands for clinical services do change, Clark said that public health’s role as a trusted source of information, education and support remains the same. For example, a large portion of CDC funds for breast and cervical cancer screening must go toward direct clinical services for the uninsured. But as insurance coverage rose in Massachusetts, fewer and fewer residents qualified for the screening program. However, there was still an “incredible need” for related services, Clark said, such as patient care navigation, insurance enrollment and case management. In response, public health workers applied for a waiver and were able to use the funds to support services that help women stay in care and manage their health.

As the Affordable Care Act ushers in higher insurance numbers nationwide, Clark said that the Massachusetts study offers real lessons for public health workers and policy-makers across the country.

“We really do think it’s useful for other states as they’re figuring out what health reform means to them,” she said.

To read the full Massachusetts study, click here.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.