How Publicly-Funded Family Planning Providers are Adapting in the COVID-19 Pandemic

Family planning providers, including community health centers, free-standing women’s health centers, health departments, and Planned Parenthood clinics are significant sources of care for contraceptive and STI services for low-income and uninsured individuals. Medicaid, the Title X Family Planning Program, and Section 330 of the Public Health Service Act (PHSA) provide support to more than 10,000 safety-net clinics across the country that provide reproductive health services to low-income women, men, and teens. These safety-net clinics have had to find ways to continue providing quality family planning services while also following the social distancing rules during the coronavirus pandemic. Some of the common changes reported by clinics and recommended by organizations (e.g., CDC, NFPRHA, FPNTC, ASCCP, UCSF’s Beyond the Pill, and the Reproductive Health Access Project) during this time apply throughout the delivery system, while others are specific to family planning care.

• Shift to telehealth – Many safety-net clinics are shifting to telehealth when possible. According to HRSA’s survey of health centers on April 24^th, more than half (54%) of health center visits were conducted virtually during the prior week. The range was considerable however, from clinics in Louisiana reporting that roughly two-thirds (64%) of visits were conducted virtually, compared to about one-third in neighboring Mississippi (38%). For many providers, this is a major new undertaking, as only a small fraction of family planning services were previously provided via telehealth. For example, Planned Parenthood announced that they will offer telehealth services in all states, including contraceptive counseling and prescriptions, sexually transmitted infections (STIs) and HIV care, emergency contraception, and other services. Telehealth services have required significant up front investment from providers for technology, training, and to ensure regulatory compliance. To make it easier for safety-net providers to offer telemedicine during the COVID-19 outbreak, however, many state Medicaid programs have issued guidance expanding coverage and access to telehealth services, and waiving potential penalties for HIPAA violations for the duration of the emergency.
• Contraception services – Many family planning clinics are trying to continue providing the full range of contraceptive services but must balance decisions about staffing, services, hours, and space with needs for care. This includes whether to initiate a new contraceptive method, how to address maintenance such as routine Depo-Provera injections, or support discontinuation when patients seek it, such as LARC removal. In several states, women can obtain oral contraceptive prescriptions for 12 months, which reduces the need for in-person visits.
• Extending use of LARCs – While most LARC products are FDA-approved for three to ten years, research has found that some are effective at preventing pregnancy for longer, up to 12 years in the case of the copper IUD. To reduce the need for in-person appointments, some clinicians are advising patients that they can continue with their current LARC method longer than the official recommendation without greatly risking unintended pregnancy.
• STI treatment – CDC has recommended prioritizing patients with STI symptoms, those reporting contact with STIs, and individuals at greater risk for complications. Some clinics are offering at-home chlamydia and gonorrhea tests through a telehealth appointment and then an at-home test kit using urine collection or a home swab, which can be returned to a clinic for testing.
• Self-administered injectable contraception – While a subcutaneous Depo-Provera injection has been available for years and was designed for self-injection, it is not formally approved by the FDA for at-home use, which is considered off label use. In light of the pandemic, rather than medical staff administering injections at the clinic every 12-15 weeks, which is usual clinical practice, NFPRHA has released guidance on offering subcutaneous Depo-Provera that individuals can self-inject at home.
• Deferral of non-urgent services – State orders have outlined that non-essential services be delayed until the emergency response is over, which could include a wide range of services such as preventive well woman visits but also certain follow up services for cervical cancer, as recommended by ASCCP.
• Curbside services – Some clinics are offering curbside services that may include a packet with condoms, at-home STI testing kits, medication pick-up, or drive-up injectable contraception administration.

Some of these changes may be temporary, but some, such as greater use of telemedicine, which can give patients more autonomy in their reproductive health care, may endure longer-term. Over time, we will gain a better understanding of the scope and scale of these changes as well as their impact on access and quality. Provider finances and the type of regulations the states adopt after the emergency eases will also have implications on how and whether clinics will continue to offer services like telemedicine care after the pandemic emergency subsides. In the recent past, some family planning providers have faced a unique set of funding challenges. The network of providers receiving federal Title X funds shrunk considerably in the past year, with 26% of clinics leaving the network, including all Planned Parenthood clinics. These departures were triggered by major changes to the program, issued by the Trump Administration in Spring 2019, that prohibited Title X -funded clinics from making abortion referrals and required complete physical separation of abortion services. Six states (WA, OR, UT, ME, VT, HI) no longer have any Title X-funded clinics. While many states were able to offset the loss with state funds, the looming fiscal crisis puts the continued availability of these dollars in question.

Now, during the pandemic emergency, many clinics are experiencing lower patient volume and staffing shortages. Rising unemployment means that safety-net clinics may see an increase in patients in the near future as people lose employer-sponsored insurance. This will likely be a combination of uninsured patients without a source of payment as well as some with Medicaid coverage, particularly in expansion states, which could bring in additional revenue.  In non-expansion states, Medicaid family planning programs could provide another revenue source for clinics by extending coverage for family planning services to individuals who do not qualify for full scope Medicaid coverage. While some providers will obtain short-term assistance from the recently enacted COVID-19 relief laws, this support will likely not be sufficient to meet long-term financial needs. For millions of low-income people, their need for timely sexual and reproductive health will continue, but the extent to which many of the providers that have been serving them will have access to resources they need to keep their doors open is not clear.