Public H&alth Then and Now - NCBI

Public

H&alth

Then and Now

Fragmentation and Reproductive Freedom: Federally Subsidized Family Planning Services, 1960-80 NANCY ARIES, PHD Abstract: This paper analyzes the evolution of the federal family planning program from 1960 to 1980. Political pressure to offer family planning raised the question how best to organize services. Longstanding providers preferred a categorical approach in order to maintain a diverse political coalition for an historically invisible service. In addition, categorical funding meant financial support for non-traditional providers. A compelling argument was also made for service integration. Given an expanded definition of health and the

medicalization of contraceptive technology, the health delivery system presented itself as the appropriate service provider. Neither group prevailed. By 1980, federally supported family planning services were provided in autonomous clinics but also were integrated into existing maternal and child health programs. The debate continues but, under the Reagan Administration, terms and motivations differ from those of the past. (Am J Public Health 1987; 77:1465-1471.)

Introduction

family planning program has remained organized and financed independently of existing maternal and child health

The authorization for federally funded family planning services under Title X of the Public Health Service Act expires in 1987. As in the past, the Congressional hearings will provide an opportunity to debate not only the specific issue of federal funding for family planning, but also the broader one of women's reproductive rights. Pro-life advocates, who tend to take a narrow view of both funding for family planning and women's reproductive rights, oppose reauthorization. They prefer either a state-run block grant program or a more highly restricted piece of legislation. One suggested restriction is that funding be denied to agencies which counsel or refer women for abortion services. This strategy is an attempt to isolate family planning providers and minimize their effectiveness in the delivery of broadly defined reproductive health services. Thus far, the family planning programs have been able to prevent the imposition of such limitations on the legislation, but the issue has never been conclusively resolved. The upcoming reauthorization must be seen as the latest iteration in a century-long social and political debate over the intent and scope of birth control services. 1-3 Since the 1920s, when a federal legislative strategy to "relegalize" birth control got underway, Congress has been a major focal point of these debates. The issues have ranged from the legal status of family planning, to its appropriate location within federal and state agencies, to the actual content of service provision. While specific legislative issues have changed over time, the question of the degree to which family planning would be fragmented from other reproductive health services has remained unanswered. Despite arguments that can be made for integrating the delivery of all women's health services, the

programs.4

Address reprint requests to Nancy Aries, PhD, Assistant Professor, Department of Health Care Administration, Baruch College, Mt. Sinai School of Medicine, City University of New York, 17 Lexington Avenue, Box 313, New York, NY 10010. This paper, submitted to the Journal April 23, 1987, was revised and accepted for publication June 18, 1987. Editor's Note: See also related editorial p 1393 this issue.

© 1987 American Journal of Public Health 0090-0036/87$1.50

AJPH November 1987, Vol. 77, No. 11

Service fragmentation can be explained in three ways. First, there has been a lack of consensus regarding the exact nature of family planning.5 Because family planning involves both personal decision making and medical expertise, the definition leaves room for debate as to where and by whom the service is best provided. Moreover, a number of effective contraceptives can be obtained without medical intervention. The implication is that non-medical settings may be as appropriate for service delivery as medical ones. Second, most providers of reproductive health services-whether maternal health, family planning, or abortion-have chosen to remain independent in order to broaden their separate bases of support. For example, in the 1920s and 1930s when Congress considered the legalization of birth control, maternal health advocates remained silent.* Their child welfare orientation drew together a diverse coalition including the Catholic Church which they did not want to disrupt by supporting family planning. Similarly, family planning advocates allied themselves with the advocates of population control in the 1950s and 1960s to broaden their base of support.6 Both groups remained silent on the abortion question in the late 1960s and 1970s, again not wanting to jeopardize existing political alliances.** Finally, the fragmentation of services must be seen within the context of the ongoing debate concerning the government's social welfare function.7 With no consensus as to whether the federal government should finance or provide services and whether these functions should be carried out directly or through the states, special interest groups were able to exert greater influence on policy. During the expansive Kennedy-Johnson years, pressure mounted for the development of a separate family planning program. Once in *Interview with Lisabeth Schorr, Chair, Select Panel for the Promotion of Child Health, January 16, 1981. "*Interviews with Arthur Salisbury, Vice President for Medical Services, National Foundation-March of Dimes, May 5, 1981, and William White, Director, Office of Family Planning, DHHS, December 17, 1980.

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PUBLIC HEALTH THEN AND NOW

place, however, the general retrenchment of the 1970s and 1980s did not affect the program. Understanding the two decades from 1960 to 1980 is particularly important to understanding the problems and options which we face now and in the future. It was during this 20 years that the arguments and strategies first evolved which are the basis of the contemporary debate. Historical Background A compromise existed prior to 1960 regarding the organization and delivery of family planning services. Legally, birth control was defined as a medical service. In 1936, the New York Circuit Court ruled that a physician could provide contraceptive services to "protect the health of his patients or to save them from infection."8 While the decision in the "One Package Case" removed legal barriers which had prevented physicians from dispensing contraceptives, most physicians were reluctant to do so.9 In 1937, the American Medical Association's Committee to Study Contraceptive Practices and Related Problems recommended that physicians be informed of their legal rights and that contraceptive education be promoted in medical schools.'0 The AMA, however, did not actively organize or promote such services. To a large extent, the vacuum in service delivery was filled by Planned Parenthood Federation of America. Within five years of the One Package decision, more than 70 affiliates were operating family planning clinics throughout the country.*** Several southern state health departments also organized family planning programs during the 1940s, but they served only a small number of women.'" Planned Parenthood was able to co-exist alongside of organized medicine because it emphasized the social significance of birth control.' The Federation's slogan was "every child, a wanted child". By down-playing the medical aspects of contraceptive care, the Federation could justify its system of freestanding clinics which operated under medical supervision but were not part of the medical care system. Proximate Causes for Change in the Sixties Several forces emerged in the 1950s and 1960s which disrupted the relation between existing providers such as Planned Parenthood and organized medicine. As a result, the issue of service delivery was reframed. Following World War II, family planning was presented as a viable response to the problem of over-population in less developed nations. President Dwight Eisenhower's Committee to Study the US Military Assistance Program, for example, argued that economic development could not succeed as long as birth rates exceeded death rates by a percentage greater than the rate of economic growth. The Committee's report concluded that population control was a necessary

condition for economic development.'2 The economic justification for population control was later dropped in favor of an ecological analysis. Environmentalists attributed the potential depletion of finite resources to rapid population growth. Limits on population growth were essential to prevent further environmental deterioration and to preserve existing resources.13 Over-population would affect the ecological balance as well as economic well-being. Insufficient natural resources would mean an ever decreasing standard of living for the world's population. ***Metropolitan Executive Director Council: Toward Continued Strengthening of the Planned Parenthood Federation, Mimeo, May 1975.

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Domestically, the population question was discussed in behavioral terms. Poverty persisted despite rapid economic growth post World War II.' An explanation was found in the culture of poverty and its impact on the process of family formation.'5 The incidence ofpoverty was directly associated with family size. Poor women typically had more unintended births than higher income women. Moreover, poor women desired better access to family planning in order to limit family size and thus maximize their chances of escaping from poverty. Critiques of the economic and environmental analyses associating poverty and resources with population size have been made by several writers.16'17 Thus, federally subsidized family planning services were proposed as a technological solution to a complex social problemn. Family planning would provide poor women with the means to achieve smaller families, which in turn could enable these families to exit from poverty. Family planning's political viability was based on the voluntary nature of the service which could achieve multiple goals. There was also a major advance in contraceptive technology which had important implications for service organization. Prior to 1960, the diaphragm was the primary method of birth control dispensed by Planned Parenthood clinics. In 1960, the Food and Drug Administration (FDA) approved the sale of oral contraceptives and, starting in 1964, physicians at Planned Parenthood clinics began inserting intrauterine devices (IUDs). These methods required physicians to play a more active role in the provision of family planning services. The pill was a prescription drug and insertion of an IUD required a trained medical practitioner. While the technology alone may have resulted in a medicalized service, combined with these other factors, it clarified medicine's role in the organization and delivery of services. In 1964, the AMA House of Delegates clarified its policy on the relation between medicine and human reproduction. The statement read, "An intelligent recognition of the problems that relate to human reproduction . . . is more than a matter of responsible parenthood. It is a matter of responsible medical service . . . the prescription of child spacing measures should be available to all patients who require them, consistent with their creed and mores, whether they obtain their medical care through private physicians, or tax or community-supported health services."'8 The general framework outlined by the AMA was more fully articulated by the American College of Obstetricians and Gynecologists (ACOG). In 1963, the College had called upon obstetricians and gynecologists to offer women freedom of choice regarding methods to regulate family size. Recognizing that gynecologists were often women's primary care physicians and that the definition of medical care was expanding to include psycho-social health problems, this initial statement was later revised to include counseling and education. 19 The position of the medical profession was best summarized by Dr. Frank Lock in the College's 1964 Presidential Address. He commented that, "It is time for ACOG to recognize its responsibility for dealing with medical as well as social aspects of a woman's health.' 20

Congressional Action: Categorical Funding The Office of Economic Opportunity (OEO) was the first federal agency to publicly support family planning. In 1965, it funded a small family planning program in Corpus Christi, Texas. Given intense public scrutiny, planners in OEO sought broad-based support by establishing multiple objecAJPH November 1987, Vol. 77, No. 11


tives for the program.2' At the same time, OEO emphasized its significance as a social service program designed to reduce welfare dependency and minimized its function as a reproductive health service. The request for proposals began with a statement that family planning helped maintain the "economic well-being as well as the health of families".22 The remainder of the section, however, explained how unwanted children stood in the way of families who were trying to improve their economic status but ran "the greatest risk of forming a succeeding generation of poverty-stricken adults." The primary justification for family planning was that it would help eliminate "a major source of poverty." The OEO program used the service delivery model established by Planned Parenthood. Although family planning was considered "a basic element of personal health," the solicitation for grants asserted that the health care system had failed to meet the needs of the poor, especially women seeking reproductive health services. "The poor have had limited access to most health services. This has been especially true of family planning services, since public health departments and public hospitals-the main providers of health care for the poor-have frequently been slow to make such services available.' 22 Therefore, OEO did not want to mainstream the family planning program in Corpus Christi. Rather, it was administered by a community action agency which assumed responsibility for the organization and delivery of a health-related service. After OEO funded the family planning program in Corpus Christi, the issue of increased federal involvement was kept on the Congressional agenda. In late 1965, Senator Ernest Gruening (D-AK) began four years of hearings on the "Population Crisis". While primarily concerned with population growth in less developed countries, the hearings also provided an opportunity to discuss the need for domestic funding of family planning. Representative James Scheuer (D-NY), for example, spoke about the failure of the Department of Health, Education, and Welfare to implement effective service delivery models piloted by OEO. He described the agency as exhibiting almost a "total lack of effective leadership, drive, direction, and forward thrust in getting the services to where the action is, in the neighborhoods of America. "23 Remarks such as Scheuer's showed impatience with DHEW's actions and thus laid the foundation for the introduction in 1966 of a bill which called for the development and implementation of a comprehensive family planning program. Many members of Congress appeared to agree with Scheuer; separate legislative authority was deemed important because it would force DHEW to play a more active role in program development and would maximize the opportunity for providers other than medical schools and state health departments to apply for funding. Birth control advocates considered nonmedical providers essential to future program development because they would take the broadest approach to services. Dr. Alan F. Guttmacher, the President of Planned Parenthood Federation of America, asserted this position at the Senate hearings: "Our role has been the traditional one of the voluntary health organization-pioneering in new areas of service and preparing the ground for the eventual inclusion of our special field into routine medical care. "24 The family planning bill did not reach the floor, but birth control advocates continued to lobby Congress for the increased availability of services. In 1967, family planning was made a program priority in the amendments to the AJPH November 1987, Vol. 77, No.

11

Economic Opportunity Act. In addition, the amendments to the Social Security Act required that a minimum of 6 per cent of the Maternal and Child Health appropriation for state aid be expended on family planning and that states offer family planning services to families receiving public assistance. While the goal of categorical funding had not been achieved, Congress had gone on record in support of family planning. Some even believed the amendments would pressure states into funding separately identifiable programs because it was the simplest way to meet the new federal requirements.t As the level of federal activity increased, birth control advocates identified the need for an organization that could articulate a federal strategy relative to family planning. In 1968, the Center for Family Planning Program Development was organized within Planned Parenthood for just that purpose. A contract with OEO led to the publication of the Needfor Subsidized Family Planning Services.25 The Center estimated that approximately 5.3 million women below the near poverty level were in need of family planning services but that only 773,000 had access to care. Laying to rest the question of need, the question became how best to close the gap. The numbers appeared to justify a separately identifiable family planning program whiich could fund multiple small scale projects, such as the one in Corpus Christi. This strategy was in keeping with the new vigor of special interest groups and the desire to circumvent state and local health departments in the organization and delivery of services. In 1970, birth control advocates achieved their goal. Congress passed Title X of the Public Health Services Act which established a program of categorical funding of grants for family planning services. The legislation was widely supported by population and ecology groups, and family planning service providers. It provided for grants-in-aid to both public and private providers. Thus state and local health departments, hospitals, and voluntary health agencies (including Planned Parenthood) became eligible to receive federal funds. President Richard Nixon's message to the Commission on Population summarized the multiplicity of the positions favoring the provision of family planning services: "Finally we must ask: how can we better assist American families so that they will have no more children than they wish to have? ... One of the ways ... is to provide assistance for more parents in effectively planning their families. We know that involuntary childbearing often results in poor physical and emotional health for all members of the family . .. Unwanted or untimely childbearing is one of several forces which are driving many families into poverty or keeping them in that condition ... And finally, of course, it needlessly adds to the burdens placed on all our resources by increasing population."18 Administrative Viewpoint: Program Integration While the arguments in support of a separately funded independently provided program were compelling, an equally forceful argument was made in favor of the integration of family planning into existing health services. The medical profession took the position that family planning was a reproductive health service and, therefore, best provided through the health care delivery system. 'Interview with Ralph Pardee, Deputy Director, Office of Maternal and

and

Child Health, US 1981.

Department of Health and Human Services, January 15,

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Following the development of the family planning project in Corpus Christi, the Administration's strategy aimed to legitimatize the medical profession's presentation of family planning as a health service. While OEO funded the Community Action Agency's family planning program in Corpus Christi, officials also contacted ACOG and requested that the College organize an "interconceptional" care program. The Project Director, Louise Tyrer, MD, wrote, "The particular emphasis that the ACOG wishes to place in regard to the goals of this program is to make certain that women participating in the program have quality care consisting of a complete history, physical examination, laboratory testing ... and family planning services."tt From the title of the program to its goals, ACOG emphasized the medical nature of birth control, noting it was one of many reproductive health services required by women during their childbearing years. DHEW was also concerned that family planning remain integrated in existing health and social services because a unified approach to services prevented unnecessary fragmentation and/or duplication. In 1966, Secretary of DHEW John Gardner had commented at the Senate hearings, "We believe that family planning services can on the whole be best and most suitably provided within the framework of a broader health service program, such as a program of maternal and child health care or of comprehensive public-health services, especially since in the plans and project applications submitted to us in this connection, the element of family planning services can be given appropriate emphasis."24 While not stated explicitly, such an approach minimized the Department's visibility in the funding of a politically controversial service. DHEW's point of view was reinforced by publicizing its longstanding support of family planning. A review of departmental activity indicated that funds from the Social Security Act and the Public Health Service Act had been available to support local family planning programs since 1942.2 At the time of the review, 17 states used federal funds to refer and pay for family planning services; 40 states used some portion of their Title V Maternal and Child Health grants to provide family planning services, and almost all Maternal and Infant Care projects offered contraceptive care.26 Following the review, DHEW issued a policy statement on family planning. The department's objective was to "provide families the freedom of choice to determine the spacing of their children and the size of their families."27 The intent of the review and the policy statement was to demonstrate that DHEW had already assumed a leadership position in the development of family planning services. The Administration was arguing that no further action was necessary, and an adequate mechanism existed whereby federal funds could be made available to state agencies for further program development. The department also hired a team of outside consultants led by Oscar Harkavy of the Ford Foundation to "undertake a wide ranging examination of progress made to date by DHEW in implementing Secretary Gardner's policy statement of January 24, 1966.' 28 The consultants, however, constrained by their mandate recommended ways that the department could strengthen existing service delivery mechanisms. Unable to call for a separately identifiable family planning program, better coordination of recommended family planning activities within DHEW was recommended, as ttTyrer L: The role of ACOG in family planning. ACOG Mimeo, no date.

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was the inclusion of a section on family planning in all relevant state plans. Their report mentioned the Comprehensive State Health plan under the Public Health Service Act, and the Maternal and Child Health, Medical Assistance, and Public Assistance plans under the Social Security Act.28 The change of administration did not affect DHEW's position on family planning. President Nixon's appointees concurred with President Lyndon Johnson's that family planning could best be developed within existing health programs. At the Congressional hearings on what was to become Title X, DHEW Secretary Elliot Richardson commented that the Administration and birth control groups "have essentially the same goals." The department, however, opposed the section of the bill which "sets up a new categorical formula grant program of grants to States for

planning, establishing, maintaining, coordinating and evaluating family planning services."' 8 According to Richardson, DHEW already had the authority necessary to mandate the development of family planning components in relevant state plans; new legislation would result in unnecessary duplication of effort. Although community groups did not support the Administration when they realized they could gain direct funding for programs under their control, their representatives spoke to both sides of the issue. On the one hand, they opposed the concept of a separately identifiable program. Cary Nabinet from the Uptown Committee for Family Planning commented, "We feel in the New York City community that family planning alone or birth control is not the answer.. .. To bring a birth control pill or bring a family planning program into a community without considering the other kinds of services that they need clearly would be looked upon by them as a form of genocide."'8 Effective provision of family planning required that it be coupled with other health and social services. On the other hand, many community groups chose to support the legislation because they feared losing access to a vital service. As Bobby McMahan from the National Welfare Rights Organization commented, "The issue of birth control is one that most black people face with mixed emotions.... (m)any black people believe that some of the Senators and Congressmen and other government officials who support family planning services are doing it in hopes of reducing the number of poor, particularly the black poor. . . .(t)he poor are not going to cut off a nose to spite a face whatever the real motives of you legislators may be.. . . Therefore, we support this legislation."28 Their contention was that every woman should have freedom of choice regarding childbearing and this could only be achieved if family planning services were readily available in their communities. Because the Administration had not moved on this issue by making additional moneys available for the development of family planning within existing health programs, they supported the establishment of a categorical program. Ironically, the Administration's strategy might have succeeded if it had joined forces with the family planning constituency and requested additional funding for services. The AMA, which would have been expected to speak on behalf of the Administration, supported the proposed legislation. AMA was also critical of DHEW's efforts to make family planning widely available to women in need of services. From the prepared statement of AMA President Gerald Dorfman, MD, it appeared that AMA was less concerned with the organization of services at the federal level than with the content of services at the delivery level. In calling for AJPH November 1987, Vol. 77, No. 11


increased federal support for family planning, Dorfman criticized existing federal programs: "Despite these programs, the United States population continues to grow at a rapid rate, and an estimated five million women are still without access to family planning services. This situation would seem to indicate that the existing programs have not achieved maximum effectiveness."18 He concluded that funds for family planning should be made available through a separately identifiable program. Program Implementation and Administrative Strategy Passage of Title X in 1970 did not resolve the conflict. At stake had been the approach to services.29 The Administration rejected the notion of categorical funding for family planning because it would legitimize a new approach to services which would by-pass state agencies and result in the funding of autonomous family planning programs. Therefore, the Administration's version of the bill, the version that became law, made no provision for centralized program administration and called for a five-year authorization without attaching spending levels. It would put Congress on record as supporting family planning without changing DHEW's modus operandi. Although Congress authorized funds for a categorical program of family planning services, the legislation did not consolidate existing DHEW family planning programs which meant existing programs would operate as they had in the past. Lacking a consensus, the legislation carried unresolved problems into the implementation process. Administrative Structure

Implementation of Title X compromised the position of the birth control lobby. The legislation stipulated that the Deputy Assistant Secretary of Population Affairs (DASPA) be given line authority over the agencies responsible for family planning programs. This provision was meant to assure a unified approach to service and a more innovative approach than had been taken by program directors which made family planning available through state health and social service programs. The DASPA's authority and location in the Secretary's office appeared to put birth control organizations in a powerful policy-making position. Implementation did not have the desired results. The first DASPA, Louis Hellman, MD, was a long-standing advocate of family planning. The implementation problem he faced was the degree to which program policy would be set in his office and therefore reflect a more innovative approach to services or would continue to be controlled by local and state program directors, some of whom had no particular committment to the program. Dr. Hellman chose to delegate line authority for family planning to the responsible directors. As a result, each director could act independently when it came to the issues of policy and program development. Dr. Hellman commented, "The legislature empowers the Secretary. The Secretary delegates to the Assistant Secretary for Health. The Assistant Secretary for Health delegates to the DASPA, and now the DASPA delegates to the Directors of the National Institutes of Health and the Public Health Service."ttt By delegating his authority, Hellman undermined the intent of this office. Dr. Hellman resigned as DASPA in 1977, and a new DASPA, Irvin Cushner, MD, was appointed in 1978. Dr. ...Interview with Louis Hellman, former Deputy Assistant Secretary for Population Affairs, DHEW, May 12, 1981.


Cushner who was also a family planning advocate took the position fully aware that the DASPA's policy-making authority had been delegated to program administrators. He assumed, however, that he could strengthen the DASPA's position and thus use his authority to guide the development of federal policy programs.* When Dr. Cushner tried to recentralize decision-making in the DASPA office, the Secretary of DHEW countered by establishing the Public Health Service and Family Planning Policy Board which was given responsibility for policy matters related to population and family planning. The Secretary thus formally reduced a congressionally mandated policy position to one of advocacy.

Summarizing his experience at DHEW, Dr. Cushner commented, "The Office of Population Affairs and the DASPA ... are impotent in relation to the law. There's no question about what authority exists in the law. . . (t)he working DASPA, not the one on paper, does not have that authority.... That was delegated out in 1971." The DASPA was no more than the advocate for an unpopular program. (In contrast to earlier administrations, the Reagan Administration has chosen to administer the Family Planning program through the DASPA's office. This reorganization can also be interpreted as a way for a non-supportive administration to control the program.) Having a limited presence in the Secretary's office, the Family Planning program was in an organizationally weak position. The lack of explicit support in DHEW was evidenced in the 1973 debates surrounding re-authorization. The critical issue before Congress again was categorical versus block funding. The Administration used the program's success to justify its contention that special authorization was no longer necessary. Title X had met the objectives set by Congress, they said, therefore, family planning could be successfully consolidated into existing health programs, and DHEW could assume responsibility for program monitoring as opposed to service provision. At the hearings, Deputy Assistant Secretary for Health Henry Simmons spoke in favor of consolidation. He commented that ". . . the administration believes that the proper Federal role, in family planning as in other health areas, is one of support, not domination.... The principal resources for accomplishing this will be the Medicaid program and the administration's proposals for national health insurance."30 The Administration sought to enhance the availability of services through '6equitable financing programs". As in other areas, it did not support the strategy of categorical funding. Paradoxically, the success of the Family Planning program was also used by its supporters to justify the reauthorization of Title X. Since its passage in 1970, over 75 per cent of the counties in the United States had at least one family planning clinic, and the majority of the clinics specialized in family planning.3' Given the organization of clinical services in smaller units, consolidation was practically impossible. A further concern was that existing block grants and financing mechanisms were not capable of providing family planning services. Joyce Henderson, Executive Director of the Los Angeles Regional Family Planning Council, commented that a majority of the states had already allocated social service money to other areas such as day care and protective services and could not make money available to family planning. More important, family planning provid*Interview with Irvin Cushner, former Deputy Assistant Secretary for Population Affairs, DHHS, October 20, 1980.

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ers could not depend on Medicaid to cover the cost of clinic operations, since: 1) a large number of clients were women without children who were not Medicaid eligible; 2) Medicaid did not pay for ancillary services such as outreach and education which were considered a vital component of the Family Planning program.30 Thus consolidation would establish financial barriers for patients already in the system. Congress rejected the Administration's proposal for consolidation and reauthorized Title X with the stipulation that coordination be improved between the Family Planning program and related health services. The Battle over Consolidation Continues

In addition to the administrative structure of DHEW, Title X was undermined by the Administration's general policy of consolidation. In order to limit expenditures, the Administration was attempting to eliminate categorical programs or return these activities to the states. This policy constantly jeopardized independent service providers who had no institutional affiliation. A turning point in this regard was the transfer of family planning grants from OEO to DHEW in 1973. Eight years after OEO funded the Corpus Christi Family Planning Program, the agency was administering more than 500 family planning project grants for a total of $24 million. DHEW managed 300 grants for three times the dollar amount. The National Center for Family Planning Services which administered the Title X program opposed the transfer of OEO grants to DHEW unless the number of projects was reduced. The Center's resources were not considered adequate to manage a large number of small, independent grantees. Their proposal, which was in keeping with the Administration's overall policy, was to have the OEO projects administered by state health agencies.32 Birth control organizations opposed the department's plan for consolidation. They felt that the family planning projects funded by OEO were autonomous and therefore able to act independently on the issues of reproductive freedom; if incorporated into state health departments, they might become vulnerable to the policies of conservative state governments.* Although family planning providers had Congressional support for their position, 36 states were named Title X grantees before a compromise was reached. While the Title X legislation had been written to assure independent service providers access to federal funds, DHEW succeeded in integrating a large number of programs into existing health agencies. Efforts to consolidate projects were not limited to the transfer of OEO grants. The Ford Administration's proposal for national health insurance was based on the premise that consolidation and integration of services were essential to the development of a rational system of primary health care. DHEW's 1976 Forward Plan for Health concluded that programs such as family planning successfully addressed unmet needs within the health care system, but had resulted in a fragmented system of care which was often estranged from the mainstream of medicine. The document stated that "4such situations lead to duplication of administrative and delivery costs, and often to unnecessary fragmentation of

care."33 As an interim measure, it was proposed that the Bureau of Community Health Services which then had administrative responsibility for family planning, maternal and child health, and the community health centers organize a number ttInterview with Emily Jenkins-Reed, former Executive Director, Arizona Family Planning Committee, October 19, 1980. 1 470

of "comprehensive ambulatory health care projects".3 The Administration defended the proposal on the basis of increased service demand and current budget constraints. In the short run, the comprehensive ambulatory health care projects were designed to maximize the coordination of categorical projects and better integrate their services with financing programs that also addressed the problem of access. In the long run, these projects were considered a model of primary care to be more fully developed under a program of national health insurance. The proposed ambulatory care projects appeared to provide the Administration with a mechanism to limit expenditures without decreasing service availability. They also responded to the demands of health professionals who argued for the development of comprehensive care networks. Congress failed to pass a national health insurance bill. The proposed termination of categorical grants gave way to administrative actions. The Carter Administration (1977-81) worked to improve coordination between family planning and other ambulatory health programs. Better coordination, however, could not change the reality of service delivery. Family planning services were being provided in more freestanding clinics than there were primary health care units. As of 1978, it was estimated that over 4.2 million women received family planning services at more that 2,523 sites.34 That same year there were only 778 Community Health Centers and 88 Maternal and Infant Care Projects.3s In 1978, DHEW conceded this point to Congress and birth control advocates. At the Title X reauthorization hearings, the Assistant Secretary for Health, Julius Richmond, MD, publicly supported the categorical approach to family planning services, commenting that, "the unique psychological and social aspects of family planning services require a diverse delivery system with participation of many and varied types of providers."36 Dr. Richmond's comments recognized that family planning was more than a medical service; it was a unique combination of social and medical services for women. He concluded, therefore, that the health care system alone was not capable of providing such services. Family planning required the involvement of providers with a broad perspective on the delivery of a health-related service. This perspective was best achieved through a cate-

gorical approach

to

services.36

Summary The 20 years from 1960 to 1980 are an important period in the history of family planning. It is the time when broad-based, but latent, popular support for family planning was finally translated into overt, political and programmatic support. On the liberal side, the so-called "sexual revolution" meant an increased demand for more and better contraceptives at the same time as the technical know-how to economically permit the wide availability of women-controlled methods of birth control became a reality. On the conservative side, traditional concerns over population growth in the third world were joined with concerns over domestic poverty. These social forces coalesced to make family planning services more readily available. Broad-based support for birth control was further reinforced by the expansive political climate of the era. It was a time when interest group politics were especially effective. Policy and program development for family planning was reflective of this political strategy. The question which confronted the policymakers in Washington, DC was not AJPH November 1987, Vol. 77, No. 11


whether to support the development of family planning programs but the form that such programs should take. Congress chose a strategy that underscored the diverse social nature of the support for the service. It acknowledged women's arguments for reproductive freedom, the concerns of ecology groups over decreasing resources and increasing populations, and the economic assumptions behind the war on poverty. In addition, it protected the role of the medical profession in service delivery. The strategy did not exclude anyone. Public health departments, medical schools, and other community-based providers were all eligible to apply for funding. This was important to the political viability of the program. Rather than forcing a consensus regarding the purpose of family planning, where there may have been none, fragmentation was used to build a coalition among those whose concern for family planning spanned a number of issues. Fragmentation facilitated the development of programs, many of which used innovative service delivery models. In contrast to the congressional strategy of coalition building, the Administration's strategy as embodied in DHEW's action sought to medicalize the program and thus possibly minimize its political and social content. It was argued that family planning services could best be developed as part of a broad-based plan for improved health care: * This would permit the Department to maintain a low profile in service provision; not knowing what the public response to federal activity would be. * Family planning could be considered one component of a larger program of primary health care and thus folded into existing services. * And finally, a stronger a priori case could be made for service integration in terms of effectiveness and efficiency as opposed to one of service fragmentation. The 1980s have brought an abrupt change in the course of government policy-making. The Reagan Administration represents both a continuation and a reversal on two important fronts. As a matter of general policy, the present Administration has sought to strengthen the state role in service delivery more strongly than did the three Administrations that preceded it. Despite these attempts the Family Planning program is one of the few categorical programs of the 1960s and 1970s which has not yet been incorporated into a block grant. Unlike preceding Administrations, the Reagan Administration not only adamantly opposes legal abortions but ranges from ambiguous to negative on the question of support for family planning services. Having failed to incorporate the Family Planning program into a block grant, the Administration has utilized the potential always inherent in the DASPA's position to control the program's administration. If the tacit question of the past two decades was how to fund, the Reagan Administration is questioning whether the federal government should fund such services at all. To date, political support for publicly funded family planning services has withstood six years of attack. The actions of the Reagan Administration raise the old questions of categorical funding versus service integration within a different political context. ACKNOWLEDGMENTS

I would like to thank Elliott Sclar, and the anonymous reviewers for their insightful readings of this paper. Ilena Greene assisted with production.


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