PolicyLab

Access to sexual and reproductive health care is critical, especially in the current environment where sexually transmitted infection (STIs) rates have reached epidemic levels and unintended adolescent pregnancy remains an important issue.  

Adolescents are particularly vulnerable. 

• One in three high school students has been sexually active and over 20% report being currently sexually active.  
• Almost half of all STIs occur in teenagers and young adults, despite that age group accounting for only one-quarter of the population.
• Unintended adolescent pregnancy rates remain high, and use of condoms among high school students has decreased in recent years.   

Access to care is substantially shaped by public policy on funding, health care coverage and clinical service guidelines. As adolescent health researchers and practicing pediatricians, we recognize that recent federal policy changes, as well as the ongoing threat of additional changes, will have a large impact on adolescents—even as many of the details and implementation of these changes remain uncertain.  

Here, we outline the current sexual and reproductive health funding landscape and the potential for current changes to have downstream impacts on adolescent well-being.  

A volatile funding landscape creates uncertainty 

A shifting federal funding landscape creates uncertainty for those seeking sexual and reproductive health care as well as those providing the services. While the full impact is still unclear, existing and proposed funding changes will limit the capacity of the reproductive health care network at a time when federal policy is reducing access to public health coverage.  

H.R. 1, the congressional policy package passed in July, includes substantial cuts to Medicaid as well as a ban of Medicaid payments for one year for all services offered by nonprofit family planning clinics that provide abortion services and received over $800,000 in Medicaid reimbursements in 2023. These clinics are a key source of care for adolescents, providing reproductive health care for nearly a quarter of youth aged 15-17.  

The Medicaid payment ban included in H.R.1 will eliminate reimbursement for the full range of services offered at these clinics including well-woman exams, cancer screenings, vaccinations, birth control, and testing and treatment for STIs. The payment ban will also impact the clinics’ ability to stay open.  

In a related move, the federal administration froze funding for more than 1,000 Title X clinics this spring, which are important federally-funded providers of confidential and comprehensive family planning services (not including abortion) to low-income and uninsured individuals. While funding has been restored to some providers, including here in Philadelphia and other parts of Pennsylvania, the back-and-forth of funding and proposed cuts to the program in the next fiscal year creates uncertainty that complicates clinics’ ability to function smoothly. This will have disproportionate impacts on adolescents.  

These changes have an outsized impact on adolescents  

The impact of these types of policy changes is not new and we can look to research from related changes in the first Trump administration to understand their potential impact on adolescents.  

Our own prior work has highlighted the potential detrimental impact of disruptions or changes in Title X and Medicaid funding on adolescent health care, with a focus on three key elements further detailed below:  

• Confidential care
• Preventative care, including health education
• Comprehensive reproductive care 

Availability of confidential health care services for adolescents, particularly in states without explicit protections 

All minors seeking care at a Title X-funded clinic are legally allowed to access confidential services, including STI testing, contraception, and pregnancy counseling, without a parent or guardian. This is the case even in states where minors are not otherwise allowed to consent to these services. This confidentiality protection is a critical feature of the Title X program, as decades of research have reinforced that adolescents who are assured confidentiality during health care encounters are more likely to obtain appropriate health services.  

Prior PolicyLab work has demonstrated the impact of Title X cuts. When the Title X program was restricted in 2019, we identified that more than 1.8 million adolescents aged 15-17 were then living in areas without access to confidential care. These changes disproportionately impacted youth in rural areas and the Midwest.

Even though restrictions were lifted and funding reinstated in 2022,  we know that return to services takes time and may be incomplete. Many Title X funding recipients are small clinics or community organizations without adequate funding reserves to quickly reinstate programs or rehire staff, and adolescents may not be aware when services are again available.  

Given current restrictions and uncertainty in Title X funding, it is likely that we will see similar changes in access to confidential care and that youth living in states without minor consent and confidentiality laws will suffer most.  

Availability of high-quality preventative services 

Title X-funded clinics play a significant role in supporting free or low-cost STI testing, condom distribution, and sexual health education in clinical and community-based settings, including schools, teen centers and walk-in clinics.   

Our work with adolescents has highlighted the critical importance of these programs, particularly school-based sexual health care services, in supporting traditional classroom-based sexual health education. Underscoring findings from PolicyLab researchers, a recent national survey found that adolescents prefer to learn about sexual health from a clinician to other sources like social media, websites or peers.  

Ensuring that adolescents have access to patient-centered sexual health resources in easily accessible settings, particularly preventative services such as STI testing and condoms, is a critical tool in curbing high adolescent STI prevalence and the emergence of multi-drug resistant STIs. 

Equitable access to comprehensive reproductive health services 

It is critical that all adolescents have access to non-directive, comprehensive reproductive health care to allow them to make well-informed decisions that will impact their long-term health and well-being.  

Youth without private insurance, access to a primary care provider, and the financial means to pay out-of-pocket for preventative care or contraception will be disproportionately affected by any Medicaid and Title X funding cuts. The reproductive health clinics threatened by funding restrictions in H.R. 1 provide access to one third of all patients in publicly supported clinics.

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Same-day long-acting reversible contraception (LARC) provision is the most effective form of contraception. However, to be able to provide these services, clinics need to have clinicians trained in non-coercive, person-centered counseling approaches, as well as clinicians skilled in placement and removal. Critically, clinics can only offer same-day LARC when they have the funding support to stock these devices.

 

Large randomized studies have demonstrated that when LARC provision requires a return visit (e.g., for a device to be purchased and delivered specifically for that client), adolescents are more likely to experience unplanned pregnancy and to choose less effective contraceptive methods.  

 

Financial disruptions to the Title X program, even if temporary, will limit availability of same-day LARC, with the most significant impact most likely occurring in clinics with limited financial resources such as in rural or other underserved environments. 

Finally, comprehensive reproductive health care includes abortion services and the layering on of state abortion restrictions will have ripple effects on the overall well-being of adolescents, as our colleagues explored in 2022.   

Notably, Title X has never funded abortion services and federal Medicaid funding does not pay for abortions (with very limited exceptions). However, a reduction in services to prevent unintended pregnancies paired with a policy environment limiting access to abortions will have significant downstream impacts on the health of adolescents and families.   

How we can support adolescents' well-being   

Adolescents deserve access to reproductive health services that are confidential, accessible, and respect reproductive autonomy.    

There is a lot of work to be done to ensure adolescents have equitable access to confidential and comprehensive sexual and reproductive health care alongside consistent messaging.  

Creating more touch points for adolescents to access sexual and reproductive health care can help to improve access for youth who may not have other sources of health care. These touch points can be in primary care, the emergency department, and specialty care settings. This will require strengthening medical training so that all pediatric providers are able to deliver comprehensive, non-coercive sexual and reproductive health care and are equipped to maintain confidentiality within local legal requirements.  

Outside the health care setting, developing other funding streams to maintain community services such as sexual health education, STI testing and condom distribution will be critical.  

Public health messaging, targeting adolescents, that shares information on where confidential services are available at free or low-cost may help to clarify misconceptions in a shifting and unclear landscape. Adolescents should also be informed about crisis pregnancy centers, which claim to offer sexual health services but often do not have medical staff and do not offer comprehensive pregnancy options counseling.  

While these strategies may dampen the consequences of policy shifts, they will not undo their impact. Medicaid and Title X programs are linchpins in the adolescent health care landscape. Supportive funding and policy is crucial to ensuring that services are available and accessible.