Association for Public Policy Analysis & Management

The Title X program provides comprehensive reproductive and preventative health care services, regardless of ability to pay. The federal program issues grants to local service providers who in turn provide a set of essential safety-net health services. Previous quasi-experimental work has estimated that the program has helped low-income women reduce their fertility rates by up to 30%.

Because the program serves predominately uninsured and publicly insured women, states’ decisions regarding Medicaid expansion under the Affordable Care Act may have had important effects on Title X patient volumes and payer mix. Indeed, some local Title X administrators have argued that the recent declines in Title X patient volumes are attributable to newly insured patients seeking other sources of care. Such dynamics would have important implications for the financial viability of individual clinics. In this paper we examined the effects of Medicaid expansion on Title X patient volumes and the share of patients that were uninsured or had Medicaid.

State-by-year level aggregate data on Title X patient volumes and health insurance coverage characteristics came from the 2012-2016 Family Planning Annual Reports (FPAR). These data were merged with socio-demographic state-by-year characteristics from the American Community Survey and Medicaid expansion information from the Kaiser Family Foundation. In total, we observed n=255 state-by-year cells. Our three outcomes were the (1) the female specific clinic utilization rate defined as the number of unique female Title X patients divided by the number of women in a state-year that had family incomes under 250% of the poverty line; (2) the share of Title X patients in a state-year that were uninsured; and (3) the share of patients that had Medicaid. The effect of Medicaid expansion was estimated in a difference-in-differences model that included state fixed effects, year fixed effects, and other state-by-year socio-demographic controls. Standard errors were clustered at the state-level.

The clinic utilization rate declined at the same rate in expansion and non-expansion states prior to the implementation of the ACA in 2014. Difference-in-differences results suggest that expansion led to a small 0.48 percentage point decline in patient volumes. While the point estimate was not statistically significant (p=0.4), we can rule out effects larger than a 1.5 percentage point decline. However, results do suggest that Medicaid expansion reduced the share of patients that were uninsured by 8.5 percentage points (p<0.01) and increased the share of patients covered by Medicaid by 9.0 percentage points (p<0.01). All results were robust to excluding early and late Medicaid expansion states and to the set of included covariates.

While declining Title X patient volumes have important implications on Title X operations and financing, our results suggest that the ACA’s Medicaid expansion may have had a net-positive effect. The expansion decreased the share uninsured and increased the share of Medicaid covered patients, while having no discernable impact on overall patient volumes. Our results have important implications in light of the current Administration’s desire to re-shape the Title X program.