Return on investment: a fuller assessment of the benefits and cost savings of the US publicly funded family planning program.

In the United States, half of all pregnancies are unintended, and unintended pregnancy is highly concentrated among low-income women.1 In response to this disparity, the federal and state governments have worked for decades to expand access to family planning services for young and low-income women and men, channeling public funds for family planning services primarily through 2 programs. Title X of the Public Health Service Act, enacted by Congress in 1970, is the sole federal program devoted entirely to family planning. Medicaid is a joint federal-state public health insurance program, which provides the vast majority of public family planning dollars and covers millions of women and men of reproductive age. Since the mid-1990s, to further increase access to family planning services for low-income women not eligible for full-benefit Medicaid, 30 states have expanded eligibility under Medicaid specifically for family planning services.2 Decades of research have documented the reach and impact of publicly supported family planning services in the United States. Recently, Frost and colleagues found that 8.9 million poor and low-income women received publicly supported contraceptive services in 2010.3 Such services helped women prevent an estimated 2.2 million unintended pregnancies that year, of which 1.1 million would have resulted in an unplanned birth, 760,000 in an abortion, and 360,000 in a miscarriage. Moreover, publicly funded family planning services resulted in an estimated net public savings of $10.5 billion in 2010. Although compelling, these findings capture only a portion of the total health impact of and savings generated by public efforts. The analysis by Frost and colleagues and similar previous analyses by Guttmacher Institute researchers4–8 were limited to the numbers of unintended pregnancies, abortions, and unplanned births averted by clients’ increased contraceptive use. They also were limited to a portion of the public savings from averting unplanned births that would have been funded by Medicaid, including only prenatal care, labor and delivery, postpartum care, and 12 months of infant care. Other studies of the benefits and cost savings from publicly funded family planning services went beyond those by Guttmacher in several ways, such as accounting for the medical costs of care for up to 5 years of a child's life, estimating public savings from averted miscarriages and abortions, and including costs for social services for infants and young children.9–12 A sizable body of literature indicates that the health impact and public-sector savings of publicly supported family planning services in the United States extend well beyond the impact of preventing unintended pregnancies.13 Research indicates that by enabling women and couples to plan, delay, and space pregnancies, contraception is linked to improved maternal and child health outcomes.13–15 Appropriate pregnancy spacing is linked to better birth outcomes, including the reduced likelihood of babies born prematurely, at a low birth weight (LBW), or small for their gestational age.16,17 Moreover, the package of care delivered as part of a publicly supported family planning visit extends well beyond contraception. Clients routinely receive screenings for sexually transmitted infections (STIs), such as chlamydia, gonorrhea, syphilis, and HIV; cervical cancer prevention services, including Pap tests, and testing and vaccination for human papillomavirus (HPV); breast exams for early detection of breast cancer; and screenings for a variety of other health conditions and risks, such as diabetes, high blood pressure, and intimate partner violence. Screening services can lead to early detection, preventive behavior change, and prompt treatment. Some forms of treatment, such as for chlamydia and gonorrhea, are routinely provided on-site; others are facilitated through referrals to specialists. This broader package of preventive services has taken on heightened importance in recent years as policymakers, health care experts, providers, and insurers all have emphasized the importance of prevention, and indeed, the Affordable Care Act, which was enacted in March 2010, requires most private health plans to cover most of these preventive services without any out-of-pocket costs to enrollees. The impact on health and the cost savings of many of the individual preventive services delivered as part of a publicly supported family planning visit have been studied independently; for example, numerous studies have explored the benefits and costs of various HIV prevention strategies, including routine HIV screening.18–22 But no study has looked at these services together in the context of what care is delivered to publicly supported family planning clients in the United States. The analysis presented in this article expands on both Frost and colleagues’ research3 and earlier research at Guttmacher4–8 on the benefits and cost savings of publicly funded family planning services. First, we estimated the direct health benefits and cost savings from several services delivered during a publicly funded family planning visit: testing and treatment for chlamydia and gonorrhea, HIV testing, Pap and HPV testing, and HPV vaccination. Second, we estimated the numbers of averted unplanned births that would have been preterm or LBW and that would have been closely spaced (<18 months interpregnancy interval). Third, in line with other recent cost-benefit studies,9,10,12 we estimated the public savings from averted unplanned births to include the costs of medical care for children aged 13 to 60 months, factored in the medical costs from averted miscarriages and abortions, and readjusted to account for some averted births that were simply delayed and would not have contributed to public savings over the 5-year period. We concluded with a unified estimate of cost savings from publicly supported family planning care by combining the findings by Frost and colleagues3 with those from this analysis.