Measuring the Relationship Between the 2019 Title X Final Rule and Patients’ Sexual and Reproductive Health Care Access and Behavior in Iowa Using a Difference-in-Difference Approach

Abstract Introduction Previous research has documented how the implementation of the 2019 Title X Final Rule reduced the Title X network capacity and led to decreases in patient numbers. Our objective was to examine the relationship between the Rule and patients’ reproductive health care access and outcomes. Methods Our analysis draws on panel data from patients recruited when seeking publicly funded family planning care in Iowa between May 2018 and February 2019 who completed a baseline survey and agreed to be contacted for follow-up surveys at 6-, 12-, 18-, and/or 24-month intervals. We employ a difference-in-difference (DiD) approach, comparing reproductive health outcomes (access to care and contraceptive use) of respondents who had recently received care at sites that eventually left the Title X system following the Rule, the exposed group, to outcomes among those who had recently received care at sites that did not shift from being in the Title X system to exiting it, the control group, both before and after its implementation. Results After adjusting for respondents’ demographic characteristics in the DiD models, we found that those in the exposure group were 11% less likely to have received recent contraceptive care compared to respondents in the control group after the implementation of the Title X Final Rule when examining the full study period ( p < .01). When examining only the pre-COVID 19 time period, we found that respondents in the exposure group were 13% less likely to have been using a provider-involved method ( p < 0.01), 11% less likely to have been using a method that carries a cost ( p < 0.05), and 18% less likely to report being satisfied with their method ( p < 0.001) compared to respondents in the control group. Conclusions Using Iowa as a case study to understand how the 2019 Title X Final Rule may have changed family planning patients’ sexual and reproductive health outcomes, we found evidence of a negative association of the Rule with patients’ access to, and use of, contraception. Policy Implications These findings expand the evidence base of the influence of the 2019 Title X Final Rule on the Title X health care system and its capacity to provide SRH care by highlighting the trickle-down effects of the Rule on patients themselves. Policies that restrict access to any aspect of sexual and reproductive health care, including contraception and abortion, are in direct conflict with people’s realization of reproductive autonomy.