E105: The Financial Domain of Family Planning

Kirtly: "The rich get richer, and the poor get children." I've always thought about that when I think about family planning. That's a quote from "The Great Gatsby" by F. Scott Fitzgerald, and it reflects on social and financial inequality. It was published in 1925, probably written in the early '20s, in the U.S. at a time of great financial inequality in the U.S. And once again, it was a reflection on the excesses of the wealthy.

So is this true? In many ways, our children are our greatest wealth. But one of the biggest predictors of a young woman staying in poverty is whether she has children when she's young.

We're today going to talk about the financial domain of family planning. And I'm Dr. Kirtly Jones from Obstetrics and Gynecology. I'm a reproductive endocrinologist and spent my career working in clinics for family planning and contraception and clinics for infertility, and research in both areas. And both focused on helping people have the children they want, when they want, if they want.

And with me is Dr. Katie Ward, who has a doctorate in nursing practice and a PhD in anthropology, and she works in women's health. We met generations ago in a family planning clinic.

Katie, you've studied and visited cultures around the world. And through time, the concept of family planning is a new one in terms of human social evolution, meaning new one in the last 100 years. What are your thoughts about "the rich get richer and the poor get children"? What are your thoughts about that?

Katie: Well, I wish I'd visited cultures through time. I'd love to go back and see what it was really like. But the cultures I visit are contemporary, and I think the thing that's happening there is industrialization. But for most of human history, children were wealth. They were the labor, they were your Social Security, they were who was going to support you in old age. And so having children was not a financial burden. It was a financial strategy, which is not to say women weren't trying to control when they had children or how many. They have been for a very long time, and we've talked about that a bit before.

Well, one of the things I do see as an anthropologist is . . . and I wish I knew who to attribute this quote to, but whenever you build a road into a new place, so you're getting market forces in a new environment, the second thing after a road gets there is that people want access to family planning. So we do really see that. That is the next thing that they want.

Kirtly: I didn't know that, but that's a great . . . I'm going to put that in my little file to study.

Katie: But humans are slow reproducers. We have one baby at a time. We invest enormously in each child. That's kind of the unique thing about our species. And historically, many of our children did not survive.

So at the agricultural revolution, about 10,000 BC, there were maybe 5 million to 10 million people on the whole planet. That's the population of New York City spread out over the entire globe. And for the next 10,000 years, as we became more agrarian, the population still barely grew, less than half of 1% a year.

It was industrialization that really changed everything. Death rates dropped thanks to more sanitation, better medicine, reliable food, and birth remained at that same clip. So we went from 500 million to 1 billion in a 200-year space. And then we went from 1 billion to 2 billion in just another 100 years, and then up to 4 billion in 45 years.

So I don't disagree with Fitzgerald, but I think he was talking about industrialization, not something that's been the condition of our human ancestors throughout time. But it's a modern problem, and culture just hasn't quite caught up.

Kirtly: Yeah. Well, in a study from Columbia University's Center on Poverty and Social Policy, about a third of young women in urban areas experience poverty at age 22, and caring for a dependent child was strongly associated with higher poverty rates regardless of racial and ethnic groups.

The process of family planning begins with education. I don't know what comes first, meaning intention and then education, but I think some time when you're a teenager or in grade school, you have to know that you can plan your family, and then you have to choose whether you want to. So I think you have to know that you can have children by choice and not by chance.

And the next step is intention. Some people say, "I'll do whatever God gives me," and other people want to choose, they want to plan. And a person has to take that step. So they have to believe that they have agency in their life and they can control their life course, at least to some degree.

The last and most important is opportunity. You have to have access to contraception.

To help us think about access to family planning, we have Shireen Ghorbani in our virtual Scope studio. And Shireen has been active in county governance here in Salt Lake as a member of the Salt Lake County Council. She's been a longtime advocate for healthcare access. She's currently the president and CEO of Planned Parenthood of Utah.

Kirtly: Thank you so much, Shireen, for helping us think about access. So how did you come to Planned Parenthood, Shireen?

Shireen: Well, I actually have to say I think the way that I got there is at 17, walking into a Title X clinic. I grew up in the state of North Dakota and had a parent who was very open with me about education and understanding my own reproduction, knowing that I was going off to college soon and likely to become sexually active. We walked into a clinic that was able to provide low or no-cost care through the Title X program, the only domestically funded reproductive health program in the country. And I got on birth control at 18. And I genuinely believe that the ability to control my reproduction is what led me to this moment in a global way.

But in a more specific way, in 2016, I lost my mom to pancreatic cancer, and that really spun me into a place around political activism really tied to access to healthcare.

That led to a couple of runs for office, ultimately the opportunity to serve Salt Lake County on the county council. That was heading into COVID, which was a really terrible and difficult time to be in county government, which is also the home of the health department for a county of a million people plus.

And similar to the experience of losing my mom, frankly, losing access across half this country to control our reproductive choices when it comes to abortion access, the fall of Roe and the Dobbs decision really sent me on a trajectory to understand how it is that I could spend my professional life and my energy ensuring that people have access to education, healthcare, to control and plan their families as they see fit, and into the world of Planned Parenthood.

So I feel just incredibly honored to carry forward work that I know many . . . that you both are involved in, that many people have carried in this state for many years, just ensuring that people have information and access to care.

Kirtly: Thank you. Well, Katie, maybe our listeners don't even know what Title X is, and you were going to talk a little bit about Title X. Can you do that now? Can you talk about Title X?

Katie: Sure. I mean, Title X is very different now than it is when I was first introduced to it, but I was feeling, in thinking about the financial domain of family planning, how much I wanted to pay homage to Title X.

It's a little bit of funding. In the scheme of our whole budget, or the federal budget, it's not very much. It's not a thing that people hear about as much as we hear about Medicare or Medicaid or Social Security or other big programs. But it's been an important thing in my life. And I wanted to go back a little bit to what that program was when I was introduced to it, because I think it's a really fascinating history and it's an example of when our government does something well, just how very well it can do it.

Kirtly: Oh, absolutely.

Katie: So we got the birth control pill in 1960. And like anything new, it . . . Actually, the uptake was pretty fast in 1960. But in the course of the '60s, you had a lot of interesting political things happening, the civil rights movement and this war on poverty, and we were developing social programs like Medicare and Medicaid and Social Security. This was all happening in the context of women having access to birth control pills for the first time.

When Title X was developed, it was just a decade after the pill became available. And it was a response to a problem that we still see today, where women with means have access, and women without means don't.

And so Title X was created with strong bipartisan support. It was actually President Nixon who called on Congress to ensure that family planning assistance became available regardless of your economic condition. And Title X had sponsors in both the House and the Senate on both sides of the aisle. So it was kind of things that almost seem inconceivable today.

Kirtly: Yeah, I think Former President, when he wasn't president, Bush, when he was in Congress, was very powerfully supportive of Title X.

Katie: He was. He was the House sponsor. George H.W. Bush was.

And so the scope of this was really ambitious. The idea was to provide low-cost contraception and family planning services broadly. So that included Pap smears and STI screening and pregnancy testing. And it's never been about abortion provision. It's been cancer screening, STI testing and treatment, pregnancy testing. It had an infertility component.

And so it had all this direct patient care, but it also had a training component. So they found nurses and sent them to training programs and then continued to provide ongoing education and research and support.

It was this top-to-bottom care provision, but also caring for the providers and continuing to educate them. And so it created this whole service, including . . . I think it was instrumental in establishing the Office of Population Affairs.

I was the beneficiary of some of this training, so this is why it's personal for me. Planned Parenthood recruited me and trained me through that Title X funding. I was one of the very last nurse practitioners from Utah to get sent to a Title X training program. I don't know how many people they trained across the country, but it was a lot. They'd run 2 or 3 cohorts of 15 or 20 people across 5 programs. So it was a lot of people that they were training for 20 years probably.

And those providers like me went on . . . part of our obligation was to work in those Title X clinics, but many of us have become educators and have gone on to build professional organizations. Title X did so much more than just pills and Paps. It built a profession.

That funding has been cut, education has moved into universities, people who are being trained now are not trained within a system. I came out of school, I did have an obligation to work in a Title X clinic, but I saw myself as part of a system and part of a solution, not just someone who got a diploma and was off to work for the highest bidder.

And so I just wanted to share my little story about how important Title X was, because I would not be here now, both probably because I would be an impoverished person with too many children not getting family planning services, but also, that's what set me on a path to get the job that I have now. I always introduce myself here as a professor and an anthropologist, but I started in a Title X training program.

Kirtly: I used to go out into rural parts of the West, because we were part of a Title X district, and do those education programs. And I remember training nurse practitioners in tiny little clinics in Montana and northern Idaho. I thought, "This is where the rubber meets the road. This is where . . ." And in fact, I gave a national talk on Title X when it turned 40. I think it's 50 years old or something like that now. Title X clinics, those were where we took care of women and men and their reproductive health right in small towns, in small places.

Shireen, getting back to us, can you talk about access in Utah, the Intermountain West? Not necessarily Title X, but how do women get reproductive health access in the West?

Shireen: Yeah, I can. So reproductive health access is a challenge, and it's a challenge nationwide. We do not have really the workforce that we need to meet demand.

I was just looking at some Utah stats. This is a little outdated. I think this report came out in 2021, but at that time, it was a 21-day average wait time for new patients at OB/GYN practices. And a number of our OB/GYNs in Utah were over the age of 55.

And so when we just think about the kind of expertise and sort of the professional environment . . . And actually, I hear wait times a lot longer than that these days, that people are waiting three months or more.

I'll kind separate out a little bit. At Planned Parenthood, our expertise is really around birth control, around forms of contraception, certainly education, STI testing and treatment, as was mentioned. We do some cancer screening and can do some basic care. But for us, we're able to help people who maybe have a long-acting . . . so maybe folks that have an IUD that are ready to get pregnant, we can help kind of get them on that journey. But we do not provide prenatal care.

So for us, I will say the thing that we can offer is that we still have really rapid access to appointments. Within a week, you could come in and see someone, usually within three days. But everything from urinary tract infections to yeast infections to access to contraception, we're able to do that really quickly.

What I'm really proud of, and both of you have contributed to this, but we are the experts in reproductive healthcare. And so you are going to find people who place more IUDs, who have deeper knowledge, who've really seen it all if you come into one of our clinics, and we're really proud of that.

But in the greater context of access to care, we know that Utah still remains a little bit lucky in terms of kind of the national landscape around access when it comes to being able to access healthcare, whether it's in a community health center, so an FQHC, a federally qualified health clinic, which we still have many across the state. Our hospital system is stronger than it is in many other Western or more rural places.

But it is still difficult. We are under-resourced when it comes to access to primary care. It can be very difficult for folks to understand how to navigate these systems. And unfortunately, Utah is part of that as well.

So what I would say when it comes to access, one of the things that we're proud of is that we're able to serve . . . last year, it was, I think, 36,000 patients over 55,000 appointments. But we know that there's greater demand and there's greater need, and we know that there's a big impact on communities when really their center of excellence for reproductive healthcare goes away.

Kirtly: Well, when I think about baby planning, if you want to have your IUD removed and get a little family planning, you can wait three months to get into a gynecologist or your primary care, and you don't want to wait three months, whereas you could get into Planned Parenthood, and it's not necessarily terribly expensive. They will tell you about getting on vitamins and what you can expect and how to help you get pregnant. And you can see them usually in a week or so, and it's not three months.

Katie: I was just thinking of another thing that you mentioned, Shireen, is UTIs. In my system, if somebody messages me and says, "I think I have a bladder infection," and we can't get them in, our fallback is the urgent care, which leaves you with a big bill. And so I'm just going to put in a plug for if you need to be seen today for a UTI, Planned Parenthood.

Shireen: Well, I'll just say we are, just like FQHCs, so federally qualified health clinics, community health clinics, and then some of our free clinics are all part of a public health safety net across this state.

And I would just say, in the West, there are a lot of challenges. When I think about what's happening in places like where I grew up . . . North Dakota, South Dakota have now taken over and are ahead of Utah in terms of birth rate, and that is unfortunately being driven by teen pregnancy in those places. Nebraska as well.

When I think about places like Wyoming, the infrastructure of healthcare is much more sparse. It's much more difficult to get access to high-quality care and high-quality education around your reproduction.

Idaho, because of incredibly restrictive laws, has seen a decrease of about . . . I believe now it's up to 32% of the OB/GYNs in that state have left or stopped practicing.

So the landscape of reproductive healthcare is really changing in the West. And I think it's going to be harder and harder as it becomes a more hostile environment for people to be able to provide the full scope of care that we know is necessary for people to have healthy reproductive lives.

Kirtly: How do you get your funding? I know that there are restrictions now for Title X funding and that there's always been an effort to go on a sliding fee scale so people can pay what they can afford. So how are you able to continue to do outreach into rural areas and take care of people in a short period of time? How's that working? I mean, this is a big part of your job as CEO.

Shireen: Yeah, it is. So our funding is made . . . I should say traditionally the funding for Planned Parenthood has been made up by a mix of federal grants, and that is Title X, again, used specifically for family planning, STI testing and treatment, cancer screenings, access to contraception. And then we are also able to accept most major forms of insurance. We accept insurance, and so we're able to see insured patients.

And then, as you also mentioned, we have a sliding fee scale. We used to be able to slide that down to zero. With some of the changes at the federal level and restrictions around Title X, in fact, the withholding of Title X, that is in flux, I'll say. It's quite in flux at the moment.

We're hoping that we're able to go back to that very soon, because we know that last year 26,000 Utahns accessed low or no-cost care because of a program like Title X. That's a big pot for us. So insurance, self-pay patients . . .

Kirtly: Twenty-six thousand Utahns.

Shireen: Yeah. And then some federal programs, like I mentioned, Title X.

The only other real federal program that we're a part of is Medicaid. We also, until recently, have been able to accept Medicaid, but there was a provision in HR1 that was passed that was called the Planned Parenthood Defund. And really, what that meant is telling Medicaid patients, some who have relied on us as their primary form of care for years, that they can no longer use their Medicaid at a Planned Parenthood. So that's another recent change that is concerning for many reasons.

But I guess I would just say then a huge part of our efforts at Planned Parenthood are centered around fundraising. We do have some community foundations and partnerships that come into play as well.

What's happening to us when we think about the decrease in funding that is coming from the federal government is particularly grim because we also don't have a state that invests heavily in family planning services or reproductive healthcare.

So in other states where they've been impacted by these federal cuts, often the state is stepping in to backfill or to ensure that people can still get low or no-cost birth control. Unfortunately, that is not what Utah has decided to do.

So it's a challenging landscape for sure, but I'll just say that it's one where I feel more committed than ever to figuring out ways that we continue to drive costs down and increase access to care.

One way that we're doing that is increasing our access to care through telehealth. We're able to still send oral contraception through the mail, so we're able to get people pills across the entire state. We are able to partner to do STI testing and screening. We can do quite a bit of that virtually as well, which is kind of surprising to folks, but we're able to help people connect to care.

And so we're really committed to, again, finding ways to keep costs low, to be really transparent about what the costs are, and really try to ensure that people can get the care that they need.

Kirtly: I think a lot about our clients, and they wouldn't consider themselves poor. They are working and making ends meet, but just. And with expanded costs for their health insurance with the Affordable Care Act subsidies going away, they are probably going to have to cut. I mean, either they'll cut their health insurance completely or they'll start cutting in other places.

Can we talk about more expensive healthcare or an unplanned pregnancy? I think I mentioned to Katie that there's data from Title X funding to suggest that every dollar spent on Title X funds saves the American healthcare system $7. So it ends up being enormously cost-effective from a national and local perspective.

So can we talk about what people are going to do in the year coming up as things are going to get very tight for them?

Shireen: Yeah, things are going to get really tight. And I'm concerned because when I talk to colleagues across some of our free clinics, or certainly folks in our community health centers, or even folks who are in public health in, for example, a county health department, the defunding of Planned Parenthood frankly was just the start and really, in some ways, I think has drawn attention away from a massive disinvestment in our public health infrastructure across this entire country.

County health departments, state health departments, community health centers, restrictions are making it more difficult to provide care or for folks to access care. And then as you mentioned, the exploding costs that people are starting to see on the marketplace as they're going out and looking at their premiums.

All of this, I think, is going to contribute to incredible strain on a healthcare system that is already strapped and challenged to provide care for the folks that have been able to get access.

So I'm very worried about what's happening, and I would just continue to say that we're going to do everything that we can to, again, keep costs very low and to try to keep access really abundant, to make sure that we have the staff that we need. But a lot of that is done through community collaborations, fundraising, and just making sure that we are here to ensure that people get the care that they need.

Katie: One thing I was thinking of that has been a change, and I think that it opens up some freedom . . . Kirtly, we've talked about this on our 7 Domains of Pap Smears. But not holding women hostage to their Pap smear in order to get birth control and being able to be a little more creative about, "Let's meet the needs you have today," and not link those two services. And that's been a shift over the course of my career.

Kirtly: Oh, when people, particularly young women, decide that they need birth control, they probably needed it last night. And they come to the conclusion today and wait three months for an appointment, or more.

Now, you don't necessarily have to have a physical exam to get some birth control methods, and being able to call and maybe even doing a telehealth discussion more rapidly helps someone probably not have the pregnancy that might happen if it didn't happen last night. We know, for young people, many times they've already been sexually active before they finally click to the fact that they don't want to plan a family right now and they need to take the next steps.

Shireen: And I'll just say that there's another . . . I just want to make a plug for Opill. So at Planned Parenthood, we firmly believe that the best birth control is the one that works for you. We understand that oral contraception might not be for everyone, IUDs or other long-actings may not be for everyone, but we really value the opportunity to help folks on that journey and really understand what's working best for them and their body and their lifestyle.

But still, over-the-counter oral contraception exists in the United States. It's called Opill, and you can get it in a number of places, including CVS. So I think it's good for people to know that that's a resource that's out there, especially as we see these exploding healthcare costs and how it might feel less and less attainable for folks to be able to get on the kind of birth control that they want. Just knowing that that's available in the public is important.

Kirtly: And that's why when you said that you are the experts, indeed you are, because I'd say many family docs or OB/GYNs don't know that it's available over-the-counter. They don't really counsel people regarding their options and try to fix in their mind what is the best for the patient, not which is best for your prescription pad.

I think it's a longer conversation that a lot of people want to have in their clinic, but that's something that we've always been very good at. Public health clinics have been very good at helping people make decisions based on their own needs.

I want to take a shift a little bit and talk about another kind of access to family planning. And that's the access to infertility care.

Some time ago, when I was the medical director of Planned Parenthood of Utah, under Title X funding, this is Title X again, we had infertility services. They were simple education about fertile periods in a woman's cycle, access to getting a semen analysis. So we got the eggs and the sperm. And simple fertility pills for people who had irregular cycles if that was appropriate for the problem.

Infertility is common. About one in eight couples will not conceive in a year. And after preliminary work, which we could do under Title X funding, and some simple therapies, the most successful treatments, including IVF, are very expensive.

Some insurance plans cover infertility, but many don't. And of course, people without insurance plans that cover treatment or without insurance at all, which is what we're going to be facing here, they have to pay out of pocket. An IVF cycle can be $10,000 or much more, and the evaluations to assess whether a couple is candidates for IVF can be about $1,000. This gives rise to what I consider serious health disparities in family planning.

And the quote we started with, that the rich get richer and the poor get children, doesn't really work in the IVF world. The rich get children through IVF, and the poor don't get babies.

There are some IVF programs that have payment plans for IVF cycles. And there are some that have resources for free cycles, but those are rare. I've had couples come to pay for their IVF cycle with bundles of tens and twenties that they have saved up in bits and pieces from working two jobs each.

So for some people, having children is the only major goal of adulthood. It is culturally or personally their number one goal.

And a national advocacy group for infertile people called RESOLVE, which has been around for 50 years, has a list of resources for funding fertility care in the U.S., and they can be found at resolve.org.

So there are some resources for people who say, "I want to plan my family. We're ready to have a family, it's not happening, we need IVF, but how can we afford it?" And luckily, there are some donors and there are some people who can help with that. You can find that list at resolve.org.

I want to thank Shireen Ghorbani for helping us out with the financial domain of family planning and for her advocacy for access to reproductive healthcare. Shireen, your voice is going to be so important as we go forward, and this next couple of years helping people get access is going to be critical, I think.

The important thing for our listeners to know, that someone who needs family planning services, either with contraception or fertility services, is that there are sources out there. And you can get birth control pills over the counter at the grocery store. Not in the grocery store, at CVS. So there are things, and we hope to keep them available so people can have the family that they want, when they want, if they want.

If this is your first listen to the 7 Domains of Family Planning, check out our other domains, the physical, emotional, social, intellectual, environmental, and spiritual, because it has a spiritual side, how you make your babies.

You can find us and all of our "7 Domains" podcasts wherever you get your podcasts, or at womens7.com.

Thanks for listening. Thanks, Shireen, for being with us. And Katie, you're my Title X hero.

Katie: Well, you two are my family planning heroes, Title X or not.

Kirtly: We're all here because we want people to have the lives that they plan as best they can.

Shireen: That's right. Thank you for having me.