Administering Title X: The States' Role.

Although Title X is a categorical program whose funds must be spent on the provision of family planning services, it is sufficiently flexible to accommodate the diverse ways in which states administer health care services. At the national level, the program is administered by the Office of Population Affairs, within the Department of Health and Human Services. Each year, Congress decides how much funding to appropriate for Title X, and the Office of Population Affairs allocates funds among the 10 federal regions.

Public and private, nonprofit agencies apply to their regional health coordinator for funds to provide contraceptive and related services and to undertake training, technical assistance and other support; the health coordinator awards grants on a competitive basis. Grantees are responsible for ensuring that the full range of services required by Title X are provided. Most distribute program funds to subgrantees (officially known as delegate agencies) on the basis of an assessment of state and local needs, including the number of women in need of subsidized contraceptive services, the prevalence of poverty and the availability of other public support for family planning.

Growth of the States' Role

Since Title X's inception, there have been two major waves of consolidations among grantees. The first wave occurred in the mid-1970s, when the number of family planning project grants declined from more than 400 to about 200. (29) The second occurred a decade later, during the Reagan administration, when the number of grantees fell below 100, where it remains today. (30)

The federal government helped spur these consolidations by actively encouraging the states (and territories) to assume responsibility for the administration of federally funded family planning programs. The current configuration of public and private, nonprofit family planning providers that receive funding through Title X is the result of the federal government's efforts to give states the opportunity to be involved in the provision of family planning services.

Most states and territories have chosen to play a central role. As Table 1 (pages 12-13) indicates, in 1994, the health department was the sole Title X grantee in 27 states and seven U.S. territories, and a grantee (usually the primary one) in another 10 states. The remaining 13 states, the District of Columbia and Puerto Rico chose not to apply for Title X grants; in these jurisdictions, Title X funds were awarded to private, nonprofit family planning agencies. (31) No state health agency has ever been turned down for a Title X grant. (32)

In 1994, a total of 85 primary grantees received Title X support; the number of grantees per state ranged from one to six. Fifty-one of these grantees were state, territorial, local or municipal health departments; 14 were independent family planning councils (regional, nonprofit umbrella agencies); seven were affiliates of the Planned Parenthood Federation of America; and 13 were other types of community agencies, such as hospitals.

State Administrative Structures

As is evident in Table 1, states and territories that receive Title X funds use a variety of administrative structures to deliver family planning services funded by the grant. States in which the health department is the sole grantee may choose to provide services directly, delegate funds to other providers or do both. For example:

* Mississippi, like many southern states, provides services exclusively through its own network of state health department clinics.

* Maryland operates its own clinics, but also delegates funds to public-sector providers, such as Baltimore's city health department, and to private agencies, such as Planned Parenthood of Maryland.

* Arkansas uses most of its grant to operate its own network of clinics, but delegates some Title X funds to community action agencies in isolated rural areas.

* North Dakota provides no services directly; instead, it funds county health departments and community action agencies to do so.

* Vermont also provides no direct services, instead choosing to subcontract all services to a single private agency (a Planned Parenthood affiliate).

States in which the health department is not the sole grantee delegate funds for service provision. For example:

* The Texas health department delegates its grant to county health departments and private providers.

* The Iowa health department allocates its funds to hospitals and community action agencies.

Local health departments typically use their Title X funds to provide direct health care services, leaving other Title X--supported services (such as data collection, bulk purchasing of supplies and coordination of services) to state agencies; only the largest local health departments have the resources and personnel to handle these additional functions. (33)

Twenty-nine state health departments delegate Title X funds to at least one private, nonprofit agency, including university medical centers, community action organizations, community health centers and nursing service organizations. Many of these agencies are located in areas that have no other reproductive health care provider. (34) Some 814 delegate agencies received Title X funds in 1991; together, grantees and their delegate agencies operated approximately 4,100 clinics. Of these clinics, 58% were administered by state and local health departments; 17% by Planned Parenthood affiliates; and the remaining 25% by hospitals, regional or local family planning councils, Indian nations and community organizations. (35)

As a result of the various ways in which Title X is administered, the more than four million women who receive services funded by the program rely on a variety of providers, depending on the state in which they live (Table 2, pages 16-17). Overall, close to half of these women obtain services in clinics operated by state and local health departments, and more than a fourth go to Planned Parenthood affiliates.

References

(29.) House Report 95-1191, 95th Congress, Second Session, 1978; and Subcommittee on Child and Human Development of the Senate Committee on Human Resources 95th Congress, Second Session, Family Planning Services and Population Research Act Extension of 1978: Hearing to Extend Appropriations Authorizations for Five Fiscal Years, Washington, D.C., 1978.

(30.) Office of Population Affairs, DHHS, "Family Planning Program FY 1988 Program Grants and Contracts by State," Washington, D.C., 1994.

(31.) ----, "Family Planning Grantees, Delegates, and Clinics: 1994-1995 Directory," Washington, D.C., 1994.

(32.) J. Bennett, Office of Population Affairs, personal communication, July 1995.

(33.) D. Chase, Hennepin County, Minnesota, Health Department, personal communication, Sept. 15, 1995.

(34.) S.K. Henshaw and A. Torres, 1994, op. cit. (see reference 8).

(35.) Ibid.

Table 1

The majority of states and territories are Title X grantees, but they administer their grants in diverse ways.

Health department receives 100% of Title X funds

 Exclusively funds      Operates clinics    Operates clinics
and operates clinics  and funds public and     and funds
                        private agencies    private agencies

      Florida               Georgia             Alabama
     Louisiana              Maryland            Arkansas
    Mississippi             Oklahoma            Delaware
   North Carolina                              New Mexico
   South Carolina
     Tennessee
      Virginia
   American Samoa
        Guam
  Mariana Islands
  Marshall Islands
     Micronesia
       Palau
   Virgin Islands

 Exclusively funds    Funds public and  Funds private agencies
and operates clinics  private agencies


      Florida              Idaho                Hawaii
     Louisiana            Illinois             Nebraska
    Mississippi           Kentucky           Rhode Island
   North Carolina         Michigan             Vermont
   South Carolina         Montana
     Tennessee         New Hampshire
      Virginia          North Dakota
   American Samoa       South Dakota
        Guam            West Virginia
  Mariana Islands
  Marshall Islands
     Micronesia
       Palau
   Virgin Islands
    Health department      Health department receives
receives 66-94% of Title X
          funds
                                           <65% of Title X funds

Funds public and  Funds private agencies
private agencies                           Funds public and private
                                           agencies

   Colorado               Iowa                        Nevada
    Kansas                                          New Jersey
   New York
    Ohio
   Oregon
    Texas
  Washington











                  Health department
                  receives no Title X funds

Funds public and
private agencies


   Colorado                  Alaska
    Kansas                   Arizona
   New York                 California
    Ohio                    Connecticut
   Oregon               District of Columbia
    Texas                    Indiana
  Washington                  Maine
                           Massachusetts
                             Minnesota
                             Missouri
                           Pennsylvania
                               Utah
                            Wisconsin
                             Wyoming

                           Puerto Rico


(*)Title X funds are granted to nonstate public or private,

Source: Office of Population Affairs, Department of Health and Service,
"Family Planning Grantees, Delegates, and Clinics: 1994-1995 Directory,"
Washington, D.C. 1994.

Table 2

Patients in most states receive services through a variety of Title X--funded clinics.

STATE                     PERCENTAGE DISTRIBUTION OF PATIENTS
                                      SERVED,1994
                      Health        Hospital          Planned
                      department                      Parenthood

Total                  44             8                  30
ALABAMA                98             0                   0
ALASKA                 80            20                   0
ARIZONA                30            22                  44
ARKANSAS               97             0                   0
CALIFORNIA             28            10                  41
COLORADO               44            27                  19
CONNECTICUT             7            13                  74
DISTRICT OF COLUMBIA   30             7                  35
DELAWARE               60             0                  40
FLORIDA                86             1                   6
GEORGIA                88             6                   6
HAWAII                 28            11                  14
IDAHO                  82             0                  18
ILLINOIS               46            10                  26
INDIANA                 0             2                  92
IOWA                    1            15                  52
KANSAS                 87             0                  13
KENTUCKY               84             2                   9
LOUISIANA              97             0                   2
MAINE                   0             0                  27
MARYLAND               65             4                  29
MASSACHUSETTS           0            10                   0
MICHIGAN               66             4                  28
MINNESOTA              23             0                  67
MISSISSIPPI           100             0                   0

STATE                      PERCENTAGE
                        DISTRIBUTION OF
                      PATIENTS SERVED,1994
                      Other     Total


Total                  18         100
ALABAMA                 2         100
ALASKA                  0         100
ARIZONA                 3         100
ARKANSAS                3         100
CALIFORNIA             21         100
COLORADO               10         100
CONNECTICUT             6         100
DISTRICT OF COLUMBIA   28         100
DELAWARE                0         100
FLORIDA                 6         100
GEORGIA                 1         100
HAWAII                 47         100
IDAHO                   0         100
ILLINOIS               18         100
INDIANA                 6         100
IOWA                   32         100
KANSAS                  0         100
KENTUCKY                4         100
LOUISIANA               1         100
MAINE                  73         100
MARYLAND                2         100
MASSACHUSETTS          90         100
MICHIGAN                2         100
MINNESOTA              10         100
MISSISSIPPI             0         100
MISSOURI         17   6   34  42  100
MONTANA          22   0   54  25  100
NEBRASKA          0   5   51  44  100
NEVADA           57   0   25  18  100
NEW HAMPSHIRE     0   9   48  43  100
NEW JERSEY        4   9   65  22  100
NEW MEXICO       38  21    5  36  100
NEWYORK          15  20   54  11  100
NORTH CAROLINA   96   0    0   4  100
NORTH DAKOTA     74   0    0  26  100
OHIO              5   8   64  23  100
OKLAHOMA         91   2    0   7  100
OREGON           63   0   37   1  100
PENNSYLVANIA      4  25   37  34  100
RHODE ISLAND      0  11    0  89  100
SOUTH CAROLINA   96   0    3   1  100
SOUTH DAKOTA     16   7    0  77  100
TENNESSEE        89   0    8   2  100
TEXAS             6  16   34  44  100
UTAH              0   0   92   8  100
VERMONT           0   0  100   0  100
VIRGINIA        100   0    0   0  100
WASHINGTON       31   0   63   6  100
WEST VIRGINIA    56   2    0  42  100
WISCONSIN         0   0   86  14  100
WYOMING          31   0    0  69  100

Source: The Alan Guttmacher Institute, special tabulations from 1995
survey of clinics providing family planning services.

Note: Percentages may not add to 100 because of rounding.