Texas Family Planning Providers’ Difficulties Offering Adolescents Confidential Services Foreshadows Similar Problems Nationwide As New Title X Rules Go Into Effect

Kate Coleman-Minahan, Kristine Hopkins, and Kari White

Introduction

Texas is one of 24 states that does not explicitly allow minor teens to consent for their own contraceptive care. Adolescents who have concerns about confidentiality are less likely to use sexual and reproductive health (SRH) services and have lower contraceptive use. Leading medical organizations, including the Society for Adolescent Health and Medicine, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists, recommend that all adolescents, including teens under 18, receive confidential and low or no-cost SRH services.

The federal Title X family planning program has supported nearly 4,000 health centers nationwide and guaranteed confidential and low-cost SRH services for all patients, including minor teens. Because federal rules supersede state parental consent laws, adolescents who seek SRH services at Title X clinics can consent for their own contraceptive care. However, recent changes to the Title X program guidelines may deter minor teens from getting confidential services. Among other changes, the new rules impede organizations' abilities to provide comprehensive SRH care including counseling and referral for abortion. And while Title X recipients can still provide confidential services, they now require providers to document attempts to encourage family participation in teens’ healthcare.

Unclear guidance around these rules could lead to provider confusion and misinterpretation. These rule changes have reduced the network of participating organizations; eighteen states have already lost more than half of their Title X network. This reduced network also means fewer locations where minor teens can receive confidential services.

Policies enacted by the Texas legislature in 2011 and 2013 led to organizations losing their Title X funding; these organizations subsequently had to follow state parental consent requirements. Policy changes in Texas may offer some evidence about the potential impact of changes to the Title X family planning program on SRH services for adolescents nationwide.

The authors use data from three waves of in-depth interviews, conducted between February 2012 and February 2015, with program administrators at publicly funded family planning organizations in Texas about changes in service delivery. They conducted a thematic analysis of transcripts from 47 organizations with segments related to the provision of services to minor teens.

Key Findings

Overall, 34 of 47 (79%) organizations lost Title X funding during the study period. Respondents at these organizations frequently reported a decrease in teen clients, which they attributed to loss of confidential services previously guaranteed under Title X.
As the number of Title-X-funded sites decreased, the availability of confidential services varied across and within organizations. Organizations tried to ensure teens still had access to low-cost services. However, these strategies were not always successful.
- Some organizations that retained Title X funding allocated their reduced funding to limited clinics in their networks and referred adolescents to those locations.
- Other organizations without Title X funding referred teens to another Title-X-funded clinic in the community, if one existed.
- To mitigate cost barriers for their teen clients, some organizations sought funding from private donors and foundations; others relied more heavily on patient assistance funds; many developed or expanded sliding-fee scales with prices within reach of teen clients.
Different rules about parental consent according to services provided and funding used create an administrative burden on staff. Even without Title X, minor teens with Medicaid have access to all confidential services, including contraception. And since all teens can consent for pregnancy testing, sexually transmitted infection testing, and contraceptive counseling, staff at sites without Title X funding had to evaluate teens’ service needs and insurance coverage to determine whether parental consent was required.
Parental consent changes were abrupt and created confusion among staff, reducing organizational efficiency. Organizations that lost and then regained Title X funding experienced even more confusion and inefficiencies.

Requiring parental consent for contraceptive care in Texas negatively impacted adolescents and family planning clinic staff

This caption describes the image above.

This figure highlights representative quotations describing four key ways that changes to Title X funding and parental consent negatively impacted minor teens and clinic staff.

Policy Implications

As demonstrated in the Texas case, reduced points of access to confidential, low-cost SRH services may adversely affect teens by eliminating their access to SRH care or limiting where they can receive high-quality care. Health care quality for teens in Texas, and nationwide, would be improved with guaranteed access to a full range of confidential, affordable SRH services and the right to decide which people to involve in their care.

Reference

Coleman-Minahan, K., Hopkins, K., & White, K. (2020). Availability of confidential services for teens declined after the 2011-2013 changes to publicly funded family planning programs in Texas. Journal of Adolescent Health. Published online ahead of print.

Suggested Citation

Coleman-Minahan, K., Hopkins, K., & White, K. (2020). Texas family planning providers’ difficulties offering adolescents confidential services foreshadows similar problems nationwide as new Title X rules go into effect. PRC Research Brief 5(2). DOI: 10.26153/tsw/7108.

About the Authors

Kate Coleman-Minahan (kate.coleman-minahan@cuanschutz.edu) is an assistant professor in the College of Nursing at the Anschutz Medical Campus, University of Colorado Denver and co-investigator with the Texas Policy Evaluation Project (TxPEP) at The University of Texas at Austin; Kristine Hopkins is a research scientist and faculty research associate in the Population Research Center, UT Austin and investigator with TxPEP; Kari White is an associate professor of social work and sociology, a faculty research associate with the PRC, and the lead investigator of TxPEP.

Acknowledgements

This study was funded by the Susan Thompson Buffet Foundation. This work was also supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)-funded Population Research Center at The University of Texas at Austin (P2C HD042849), and University of Colorado Population Center funded by the NICHD (R24 HD066613). These funders played no role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Susan Thompson Buffett Foundation or the National Institutes of Health.