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Federal Register / Vol. 86, No. 192 / Thursday, October 7, 2021 / Rules and Regulations
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cervical cancer. One report estimates that each dollar spent on these services results in a net government saving of $7.09.21 We do not replicate the calculations, but note that they are derived from cost savings associated with averting unintended pregnancy and complications such as pre-term and low birth weight births. These cost savings are also derived from detecting and treating STIs that would have resulted in more serious outcomes, including infertility, cancer, and death.
In addition to the effects described above, the final rule will also enhance the equity and dignity associated with access to family planning services provided by Title X. A recent research brief summarized interviews with 30
women sharing their experiences with contraceptive access, providing suggestive evidence that birth control has an important positive impact on womens lives. Interviewees noted that birth control allowed women to to pursue academic and professional goals, achieve financial stability, and maintain their mental and physical health. 22
These recent interviews are consistent with the historical experience of the importance of birth control. For example, one econometric study identifies a causal relationship between the introduction and diffusion of the birth control pill and the increase in women enrolling in professional degree programs and increasing the age at first marriage.23 As of a result of the Affordable Care Acts contraceptive coverage requirement, Title X can play a critical role, helping provide insured clients with access to contraception without cost-sharing alongside its longstanding role supporting contraceptive access without costsharing for Medicaid beneficiaries and those whose incomes are equal to or less than 100 percent of the federal poverty level FPL, which allows these clients to experience these and other positive outcomes associated with access to contraception.
Researchers have identified other economic, social, and health impacts of increased access to family planning, 21 Jennifer J. Frost, Adam Sonfield, Mia R. Zolna, and Lawrence B. Finer 2014. Return on Investment: a fuller assessment of the benefits and costs of the US publicly funded family planning program. Milbank Quarterly 2014 Dec; 924: 696
749.
22 Rebecca Peters, Sarah Benetar, Brigette Courtot, and Sophia Yin 2019. Birth Control is Transformative. Urban Institute. https
www.urban.org/sites/default/files/publication/
99912/birth_control_is_transformative_1.pdf.
Accessed April 6, 2021.
23 Goldin, Claudia and Lawrence F. Katz 2002.
The power of the pill: Oral contraceptives and womens career and marriage decisions. Journal of Political Economy 1104: 730770.

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contraception, and treatment. For example, Bailey et al. 2019 finds that children born after the introduction of federal family planning programs were seven percent less likely to live in poverty and 12 percent less likely to live in households receiving public assistance. They perform an additional bounding analysis, which suggests that about two thirds of the estimated gains are due to increases in the incomes of parents.24 A recent summary discusses other impacts of access to family planning services in the United States and in other countries, which extends beyond women and girls, to their children and wider communities.25
The tables above present observable metrics of the effect of the Title X
program, which is important for evaluating the direct effect of the program. For this reason, the scope of the analysis initially focuses on clients served and services provided by Title Xfunded sites. To properly account for the net effect of the final rule when comparing the baseline scenario to the policy scenario, the Department would need to assess the extent to which clients and services continue to be provided through other channels than Title X-funded sites without the proposed rule. As a general matter, the impacts of this final rule may include:
Transfers between grantees and prospective grantees within the Title X
program;
other transfers for example, if Title X newly funds medical services that would, in the absence of the proposed rule, be provided by charitable organizations or other private payers;
and societal benefits and costs to the extent that the volume or characteristics such as location, which determines travel costs of medical services would differ with and without the final rule.
As noted earlier in this preamble, all Planned Parenthood affiliateswhich, in 2015, served 41 percent of all contraceptive clients at Title X-funded service siteswithdrew from Title X, citing the 2019 rule. However, a comparison of Planned Parenthoods two most recent annual financial reports indicates no subsequent decrease in the number of patients served and an increase, from 9.8 million to 10.4
million, in the number of services 24 Bailey, Martha J., Olga Malkova, Zoe M.
McLaren 2019. Does Access to Family Planning Increase Childrens Opportunities? Evidence from the War on Poverty and the Early Years of Title X.
Journal of Human Resources 54:4 pp. 825856.
doi:10.3368/jhr.54.4.12168401R1.
25 Emily Sohn 2020. Strengthening society with contraception. Nature 588, S162S164.

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provided per annum pre-pandemic.26
Although such year-to-year comparisons are simplistic and a focus on just one organization even a prominent one, with extensive activities has obvious limitations, this evidence may suggest that the Title X program impacts quantified elsewhere in this regulatory impact analysis may largely be associated with transfers.
The Department received a number of public comments drawing connections between the short-term effects of the 2019 rule and long-term potential for a reduction in total family planning clients served, not limited to the Title X
program. For example, two states NY, WA reported receiving emergency reserve funds through state funding in order to sustain the level of care that they provided under Title X; however, both noted that this funding is not reliable and sustainable from year to year. One grantee in Maine reported keeping all clinics open and operating with the use of the associations reserve funds and through private fundraising, which was an unsustainable and impractical task to continue. Another provider also reported fundraising to maintain care while also noting the administrative burden; however, many health centers were forced to close or reduce hours due to the lack of Title X
funding. The same organization also reported the need to scale back or eliminate education and outreach programs in many states. These public comments suggest that the long-term effect of the 2019 rule would have been to reduce clients served and family planning services provided beyond the Title X program.
In addition to the effects on the quantity of services, several comments discussed the effects on the quality of services provided. One organization and the Attorneys General of 22 states and the District of Columbia noted that losing Title X providers had a negative effect on patients that sought care. They argued that it was more difficult for patients to obtain culturally competent care and that the requirements of the 2019 rule placed a burden on providers and their method of pregnancy counseling, as they were inconsistent with the standards of care and required incomplete and confusing lists and referrals for pregnant clients. Finally, several states reported that while their efforts were refocused to recruiting and 26 Please see https www.planned parenthood.org/uploads/filer_public/2e/da/
2eda3f50-82aa-4ddb-acce-c2854c4ea80b/20182019_annual_report.pdf and https www.planned parenthood.org/uploads/filer_public/67/30/
67305ea1-8da2-4cee-9191-19228c1d6f70/210219annual-report-2019-2020-web-final.pdf.

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