Wikipedia Deep Dive

Title X

12 min read

In 1977, Marie Sanchez, the chief tribal judge of the Northern Cheyenne Reservation, traveled to Geneva to address the United Nations Convention on Indigenous Rights. Her message was devastating: American Indian women were being targeted for what she called a "modern form" of genocide—forced sterilization. In the six years following the passage of a federal family planning law, physicians had sterilized perhaps a quarter of all Native American women of childbearing age. Some evidence suggests the actual numbers were even higher.

This dark chapter emerged from a program that was supposed to help people.

Title X—pronounced "Title Ten," not "Title Ex"—is a federal grant program created in 1970 to provide family planning services to Americans who couldn't otherwise afford them. It's the only such program the federal government has ever created. The program has helped millions of people access contraception, cancer screenings, and reproductive health care. It has also become one of the most politically contentious pieces of legislation in American history, dragged into culture wars over abortion despite the fact that it has never directly funded abortion services.

The story of Title X is really two stories. One is about expanding access to health care for poor and working-class Americans. The other is about how a bipartisan public health initiative became a political football, kicked back and forth between administrations with each change in the White House.

How We Got Here

The first federal funding for family planning came in 1965, tucked into President Lyndon Johnson's ambitious "War on Poverty." The idea was simple: poor families often couldn't afford to plan whether and when to have children, which perpetuated cycles of poverty. Giving them access to contraception and family planning counseling could help break that cycle.

By the late 1960s, both Congress and President Richard Nixon—a Republican, notably—agreed that the federal government should do more. In 1970, the Senate passed Title X unanimously. Not a single senator voted against it. The House followed with a vote of 298 to 32, and Nixon signed it into law on Christmas Eve.

That kind of bipartisan consensus seems almost unimaginable today.

The program grew quickly. In 1971, the federal budget for family planning was just six million dollars. By 1972, it had ballooned to almost 62 million—a tenfold increase in a single year. Two years later, Congress required state Medicaid programs to cover family planning services, with the federal government picking up 90 percent of the tab. By 1975, legislation authorized the construction of a nationwide network of family planning centers.

Today, that network includes nearly 4,000 service sites spread across the country and eight U.S. territories. The Office of Population Affairs, which administers the program, estimates that at least 75 percent of American counties have a clinic receiving Title X funding.

What Title X Actually Does

If you've never visited a Title X clinic, here's what happens there. The program funds contraception—everything from birth control pills to intrauterine devices, commonly called IUDs. But contraception is just the beginning.

These clinics provide pregnancy testing and counseling. They perform breast and pelvic examinations. They screen for breast and cervical cancer—in 2018 alone, Title X funding covered more than 600,000 cervical cancer tests and 800,000 breast cancer tests. They test for sexually transmitted infections, or STIs, and treat them when found. In 2018, the program funded almost five million STI tests. They also provide education about preventing the spread of HIV and offer counseling to patients who are affected.

The clinics serve a specific population. People who use Title X services are predominantly low-income—in 2009, 70 percent of patients were below the federal poverty line. About two-thirds had no health insurance. For many of these patients, the Title X clinic is their only source of health care. A 2006 survey found that over 60 percent of women receiving services at Title X clinics identified that clinic as their usual source of health care, not just for reproductive issues but for everything.

In 2018, the program served 3.9 million people, 87 percent of them women.

The Math That Politicians Love

Here's a number that appeals to fiscal conservatives and public health advocates alike: every dollar invested in helping women avoid unintended pregnancies saves $3.74 in Medicaid expenditures. That's the estimated return on investment, calculated by looking at the medical costs that would have been incurred without the program.

In 2008, services provided at publicly funded family planning clinics saved federal and state governments an estimated $5.1 billion in short-term medical costs alone. That doesn't count the longer-term economic benefits of allowing families to plan their children's births.

The impact on teenage pregnancy has been particularly dramatic. In 2015, the program helped reduce teenage pregnancies by 44 percent. According to estimates, without publicly funded family planning services, the number of unintended pregnancies and abortions in the United States would be nearly two-thirds higher among women overall. Among poor women specifically, the number of unintended pregnancies would nearly double.

That last statistic is worth pausing on. Title X has never directly funded abortion—that's been prohibited from the very beginning. Yet by preventing unintended pregnancies, the program has reduced the number of abortions in the United States.

The Abortion Question

From the moment Title X was enacted in 1970, the law specified that funds could not be used for programs that use abortion as a method of family planning. This was not an afterthought or a later amendment. It was built into the original legislation that passed the Senate unanimously.

Despite this, Title X has become inseparable from the abortion debate. The reason is organizational: about 40 percent of all Title X patients are served by Planned Parenthood clinics and their affiliates, which receive roughly 60 million dollars annually through the program. Planned Parenthood is also the nation's largest private abortion provider.

Abortion opponents argue that any money given to Planned Parenthood from Title X frees up other funds that can be used to perform abortions—even if the Title X money itself never touches abortion services. It's a fungibility argument: money is money, and giving an organization federal dollars for one purpose allows it to redirect private dollars to another purpose.

Supporters of the program counter that abortion services and family planning services are completely separate, with different funding streams and different regulatory requirements. They point out that defunding Title X doesn't eliminate abortion—it just makes contraception harder to access, leading to more unintended pregnancies, which actually increases demand for abortion.

The debate reached a fever pitch in 2011, when Representative Mike Pence of Indiana—later Vice President under Donald Trump—led an effort to prevent Planned Parenthood from receiving any Title X funds. House Republicans called for cuts of over 300 million dollars from Title X for fiscal year 2011.

The Gag Rule and Its Aftermath

In February 2019, the Trump administration fundamentally changed how Title X operates. The Department of Health and Human Services issued what critics called a "gag rule"—regulations prohibiting the use of Title X funds to "perform, promote, refer for, or support abortion as a method of family planning."

The key word there is "refer." Under the previous rules, if a woman came to a Title X clinic and decided she wanted an abortion, clinic staff could tell her where to get one. Under the new rules, they couldn't.

Clinics could still provide what the regulations called "nondirective pregnancy counseling," including counseling about abortion as an option. But they could no longer say, "Here's the name and address of an abortion provider." The distinction between discussing abortion as an option and referring someone to an abortion provider might seem like splitting hairs, but it had real consequences.

The response was immediate. In August 2019, several major organizations withdrew from the Title X program entirely rather than comply with the new rules. Maine Family Planning pulled out. More significantly, Planned Parenthood—which had been serving 1.5 million women through Title X—announced it would no longer participate.

This wasn't a small adjustment. It meant that 40 percent of Title X patients suddenly lost access to their providers.

The Pendulum Swings Back

On January 28, 2021, eight days after taking office, President Joe Biden signed a presidential memorandum directing the Department of Health and Human Services to review "undue restrictions" to Title X. The memo instructed the department to "suspend, revise, or rescind" the Trump-era rules.

By April, the department had released its proposed revisions. By October, it had issued a regulation formally repealing the gag rule. The repeal took effect on November 8, 2021.

This back-and-forth illustrates something important about Title X: it's governed primarily by executive branch regulations, not by legislation. Congress sets the budget and establishes broad prohibitions—like the prohibition on funding abortion—but the detailed rules about what clinics can and cannot do are written by the administration in power.

This means each new administration can substantially change how the program operates without passing any new laws. It also means those changes can be undone by the next administration just as easily.

The Shadow History

Return now to Marie Sanchez and her testimony in Geneva. How did a family planning program lead to the sterilization of Native American women?

The answer lies in the complicated relationship between federal health programs and the Indian Health Service, the agency responsible for providing health care to Native Americans. Title X was not designed for coerced sterilization—quite the opposite, it was designed to give women control over their reproductive choices. But the infrastructure it helped create was used, in some cases, for purposes that violated its fundamental principles.

Studies have documented that during the 1970s, the Indian Health Service sterilized thousands of Native American women, often without proper informed consent. Some women were told their births would be dangerous when they wouldn't have been. Some were not informed that the procedure was permanent. Some were pressured into signing consent forms they didn't understand.

This wasn't unique to Native American communities. Similar patterns of coerced sterilization affected Black women, Latina women, and poor women of all races. The eugenics movement—the idea that society should actively prevent "undesirable" people from reproducing—didn't end with World War II. It continued in subtler forms well into the 1970s.

The story of Title X cannot be told honestly without acknowledging this history. A program designed to expand reproductive freedom was, in some implementations, used to restrict it in the most permanent way possible.

Where Things Stand

Today, Title X operates with a budget of around 286 million dollars per year in Congressional appropriations—less than it received in 2010, when appropriations topped 317 million. Additional funding comes from Medicaid reimbursements, state and local contributions, private insurance, and patient fees.

The program serves nearly four million people annually through a network of clinics operated by state and local health departments, tribal organizations, hospitals, university health centers, community health centers, faith-based organizations, and various nonprofit entities. Roughly 99 agencies receive Title X funding directly, and they in turn support the nearly 4,000 service sites across the country.

Whether Planned Parenthood will fully return to the program remains to be seen. The organization withdrew under protest during the Trump administration, and the Biden administration's repeal of the gag rule removed the immediate cause of that withdrawal. But the political landscape has changed. Any organization participating in Title X knows that the next Republican administration could reimpose restrictions—or go further.

This uncertainty affects not just Planned Parenthood but every Title X provider. How do you plan a clinic's operations when the rules might change dramatically every four or eight years? How do you hire staff, sign leases, and make long-term commitments when your funding model might be upended by the next election?

The Paradox at the Heart of Title X

Here is the strange paradox of Title X: it is one of the most effective programs ever created for reducing abortion rates, yet it is perpetually targeted by abortion opponents. The program has never funded abortion. It has prevented millions of unintended pregnancies, each of which might have ended in abortion. By any reasonable accounting, Title X has prevented far more abortions than it could ever have theoretically caused.

Yet the program remains politically toxic, caught up in debates about organizations it funds rather than the services it provides. The same law that passed the Senate unanimously in 1970 now passes on party-line votes when it passes at all.

Something fundamental has changed in American politics between then and now. A program that Richard Nixon signed into law on Christmas Eve, that expanded under both Republican and Democratic administrations, that saved taxpayers billions of dollars while improving health outcomes for millions of people—that program has become a partisan battleground.

The four million Americans who rely on Title X services each year probably don't think much about these political battles. They're just trying to see a doctor, get their birth control, or find out why they're feeling sick. The clinic with the Title X grant might be their only option.

For them, the abstract debates about abortion politics have very concrete consequences. When Planned Parenthood withdrew from Title X, 1.5 million patients lost their provider. Many of them lived in areas with no other Title X clinic within reasonable distance. Some found alternative care. Some did not.

That's the reality behind the acronyms and the appropriations numbers and the regulatory disputes. Real people, trying to access basic health care, caught in the crossfire of a culture war they didn't start and can't escape.