Title X Policy Shifts and Michigan's Reproductive Health Safety Net.

Importance: The Title X Family Planning Program is a US federal grant program designed to offer comprehensive and confidential family planning and preventive health services to individuals in the US, regardless of their ability to pay. In 2019, a major change to the program-called the Final Rule-led to about 25% of participating clinics, including all Planned Parenthood affiliates, leaving the Title X program. Because Planned Parenthood of Michigan (PPMI) had served about 70% of Michigan's Title X clients, its withdrawal from Michigan's Title X program was anticipated to significantly alter the service coverage provided by the Title X program in the state. Objective: To examine the changes in geographic distribution, organizational profiles, and service delivery volumes of Title X health centers in Michigan-including those that left the program and then rejoined-before and after the implementation of the Final Rule. Design, Setting, and Participants: This cohort study included Title X-funded health centers in Michigan's 83 counties from January 1, 2017, to December 31, 2023. Exposure: The enactment and reversal of the Title X Final Rule. Main Outcomes and Measures: Changes in service delivery volume, seen in (1) Title X penetration rate (number of unique females served at Title X-funded health centers), (2) PPMI penetration rate (number of unique females served by PPMI), and (3) reproductive health safety net penetration rate (sum of the females served by the Title X program and PPMI during the years it was excluded from Title X). Results: Title X service delivery counts decreased from 92 clinics before the implementation of the Final Rule in 2019 to 76 clinics during the Final Rule and increased to 92 after reversal of the Final Rule. Penetration rates were significantly higher before implementation of the Final Rule (incidence rate ratio [IRR], 3.98; 95% CI, 3.93-4.02) and after the Final Rule period (IRR, 2.96; 95% CI, 2.93-3.00). However, when PPMI service counts were included during the Final Rule period when PPMI was not formally part of Title X, there was considerably more stability in service delivery rates across the 3 periods (preperiod vs Final Rule period: IRR, 1.33; 95% CI 1.32-1.34; and postperiod vs Final Rule period: IRR, 0.99; 95% CI, 0.98-1.00). The mean PPMI penetration rate was only 1.41 times higher in the preperiod than in the Final Rule period (IRR, 1.41; 95% CI, 1.40-1.43). Conclusions and Relevance: This cohort study highlights PPMI's role in the state's Title X program and overall reproductive health safety net. During the relatively short time the Final Rule was in place, PPMI was able to maintain service delivery, protecting the public's health against these regulations. It is not clear if PPMI, or similar organizations, could maintain service delivery over a longer period.