A collage of forms of birth control. The Title X program provides family planning services, like birth control, with federal dollars. Providers fear that amid cuts in Washington, their services may be at risk.
The Title X program provides family planning services, like birth control, with federal dollars. Providers fear that amid cuts in Washington, their services may be at risk. (Naomi O'Donnell/The Beacon)

In a lawsuit last year, Missouri Attorney General Andrew Bailey argued in favor of restricting access to abortion-inducing drugs. If they aren’t restricted, he said, the state could lose federal dollars due to a lack of teen pregnancies, leading to a decline in the state’s population. 

Now, amid funding cuts, executive orders and layoffs for federal employees coming from Washington, agencies in Missouri could be forced to alter how they provide family planning services through the federal Title X program. 

Health care providers worry that if cuts to their programs occur, Missouri could see an uptick in unintended pregnancies among low-income women and girls. The program served 2.8 million people nationwide in 2023. Of those patients, 60% had an income at or below the federal poverty level. 

Missouri receives $5 million annually to run its Title X services, which provide free or low-cost reproductive health care for young or low-income women regardless of their ability to pay. The state’s program sees about 40,000 patients a year, with many providers located in rural areas. 

Providers and reproductive health advocates remember President Donald Trump’s first term, when he instituted a new policy that limited which clinics could administer Title X care based on whether they referred patients to abortion providers. As clinics voluntarily removed themselves from the program or states pulled out altogether due to the rule, the number of patients dropped 60%. 

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“If there is a reduction in clinic sites, hours, access or an increase in cost barriers, we’re going to see a lot of negative health outcomes,” said Michelle Trupiano, executive director of the Missouri Family Health Council, which administers Missouri’s share of federal dollars to subrecipients.

“We’re going to see an increase in unintended pregnancy, which could also lead to an increase in maternal mortality rates. The health outcomes are going to be far-reaching,” she said. 

Family planning funding during Trump’s second term

Title X is part of the nation’s social safety net, programs that aim to help stabilize people living in poverty, and was established in 1970. 

Reproductive health care advocates argue that, like many federally funded programs, annual allocations from Congress aren’t enough to sufficiently care for patients across the country who rely on the program. 

Congress last year funded Title X to the tune of about $286 million, which hasn’t increased since 2015. 

Contractors with the Office of Population Affairs, which runs the program, found in December that to fully fund Title X, Congress would need to up its funding to about $1.86 billion annually to serve the estimated 2.9 million people who may need free or subsidized family planning care. 

Researchers found that about 1.9 million women who don’t have access to Medicaid or private insurance and adolescent girls who may need confidential care could lean on the program for their family planning needs, sexually transmitted infection testing or cancer screenings. 

“Title X has been chronically underfunded for several years,” said Amy Friedrich-Karnik, federal policy director at the Guttmacher Institute, a group that studies and advocates for reproductive health care access. “There’s been inflation and each year more folks may need care. Our implementers are really working with what is essentially a decrease in the amount of funding every single year.” 

Those funding struggles were exacerbated in 2019, when the Trump administration put in place its new policy. After the rule, Planned Parenthood clinics across the country and seven states dropped out of the program.   

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The states that dropped from the program made up for the lost funds through their own budgets. 

“I don’t think that will be the case here in Missouri, which leaves us in a really bad place,” Trupiano said. 

As Trump’s second term begins, agencies that rely on the funds are holding their breath. 

“We’ve been having one-on-one conversations with the agencies that we work with,” said Trupiano. “For so many of them, they’re not just funded by one federal stream, they have a lot of different federal streams. So it’s a lot of what-ifs.” 

Who relies on Title X for birth control in Missouri? 

Those who use Title X clinics for their family planning care are more likely to be uninsured than those at other health care providers. In 2023, 27% of Title X patients were uninsured, compared to just 8% of the U.S. adult population that is uninsured. The program plays a bigger role for people in states that have not expanded Medicaid through the Affordable Care Act. 

“Women who are not eligible for federal Medicaid due to the rather narrow eligibility requirements and do not have private insurance can access services at Title X clinics, free of charge and out-of-pocket costs,” said Blair Darney, a reproductive health researcher at Oregon Health and Science University. 

Of those who paid for their services with health insurance, 67% relied on public insurance. In states with expanded Medicaid under the Affordable Care Act, 78% of Title X patients were insured through the program. 

Over 35,000 people used Missouri Title X clinics in 2023. About 10,600 Missourians were on public insurance, while 13,000 were on private insurance and about 12,000 were uninsured. 

Providers that are part of the Title X program are required to provide a broad range of reproductive health services, like offering all forms of birth control. Darney and other researchers looked into the types of care people received in Title X clinics from 2016 to 2018. 

“So because of that requirement for becoming a Title X clinic, we found in our research, and others have found as well, that patients have better access to long-acting, reversible contraception like IUDs and implants in Title X clinics than in non-Title X community health clinics,” Darney said. 

Her research found that Title X clinics provided 52% more of the most effective contraceptives, such as long-acting reversible contraceptives, to women at risk of pregnancy than clinics not funded by Title X. For adolescents, that number rose to 58%. 

The clinics are also key providers for sexually transmitted infection and cancer screenings. 

“For many of these patients, accessing care through a Title X agency is the only way that they are getting health care,” Trupiano said. 

For now, the clinics are waiting until the beginning of April — when grant funds are disbursed annually. If Congress changes how much money flows into the program or policy changes bring funding and provider cuts, Trupiano fears what it will mean for Missouri patients. 

“In a word, it will be devastating, because there will be health centers that will close their doors,” she said. “That will not only reduce access to reproductive and sexual health care, but other care that those health centers may provide, and is going to leave a safety net that is already very strained, if not broken, completely collapsed.” 

Meg Cunningham is The Beacon’s rural health reporter. She graduated from the Missouri School of Journalism, where she covered state government and health. She spent roughly three years covering national...