For the first time since the launch of a federal grant to expand reproductive health care decades ago, the state health department won’t be running the program in Mississippi. Instead, a nonprofit will.
For years, Jamie Bardwell and Danielle Lampton worked at the Mississippi Department of Health, learning how the state’s family planning programs worked– or didn’t.
They left the Department in 2018 and founded Converge, a nonprofit focused on reproductive health. Their team conducted training for Mississippi health care providers and helped clinics learn how to affordably expand birth control offerings.
Then, earlier this year, Converge beat out the health department to win a critical $4.5 million federal grant, called Title X, to provide family planning services around the state.
Access to Title X-funded services in Mississippi has long been more theoretical than universal. Patients sometimes struggled to get through to clinics over the phone, even though the health department offered family planning services at almost every county health department. Wait times for appointments could be long. And most people wound up with less effective methods like the pill or male condoms, instead of long-acting IUDs or implants.
In Mississippi, a majority of Title X patients are at or below the poverty line, and a majority are uninsured, according to federal data.
The consequences of poor access to care are clear: The majority of pregnancies in Mississippi are unplanned. The state has the highest rates of chlamydia and gonorrhea of any state in the country, and the sixth-highest rate of HIV.
Over the last decade, Converge’s cofounders say, they have learned Title X’s complicated rules and regulations and built relationships with providers and patients they hope will enable them to ensure every Mississippian has real access to high quality care.
“It has taken us that long to be experts in this topic,” Bardwell said. “And it’s a topic and a subject area that there aren’t many people in Mississippi that are clamoring to be experts on.”
They plan to offer services at a smaller number of clinics than in the past, prioritizing areas with the highest need rather than the biggest population. Scott County, for example, is a target area because it has no federally qualified health center focused on serving people without health insurance.
They also want to add telemedicine so people can get birth control prescriptions without having to make a trip to a clinic.
“We see Converge as one of the primary drivers for change in how people get family planning care,” Lampton said. “And most importantly, in increasing how much family planning care is person-centered, by which we mean, care that is about the preferences, the desires, the values and needs of the patient.”
June Gipson, president and CEO of Open Arms Healthcare Center in Jackson, is cheering: Her clinic, which focuses on serving marginalized people, has been a Title X subgrantee for about five years, and she expects to see changes under Converge.
“They care,” Gipson said of Converge’s co-founders, whom she has known for years. “They actually care about women.”
In other states, nonprofits are already running Title X programs. Every Body Texas has overseen the state’s now-$15.4 million grant since 2013. In Georgia, an FQHC has administered Title X since it beat out the state health department in 2014.
Just after the change, the number of Georgians using Title X services fell from 115,000 to about 86,000. But by 2020, the program served 170,000 people–the largest number of patients in any year since 2006.
In Georgia, state leadership said it was “deeply concerned with the federal government’s decision” when it lost Title X funding. In Mississippi, the health department is striking a different tone.
State Health Officer Dr. Thomas Dobbs told Mississippi Today that reproductive health care has been transitioning away from county clinics for decades and that the department is “excited” that Converge will be able to expand partnerships with other providers.
“We are working with Converge to ensure a seamless transition in service delivery,” he said.
He added that the department received an extension on previously unused grant funds that will allow the state clinics to operate for at least a year while Converge sets up its network.
Many of the barriers to accessing reproductive health care in Mississippi are the same ones that limit access to all health care. Particularly in rural areas, there simply aren’t enough doctors and nurses. People without transportation may not be able to get to a pharmacy to pick up a birth control prescription.
And if providers don’t want certain patients to have birth control, they don’t have to give it to her.
“Title X alone is not going to solve all of the problems,” said Caroline Weinberg, the founder of Plan A, a mobile clinic focused on reproductive health care in the Delta. “But money helps everything.”
Since 1970, Title X has funded clinics around the country to ensure all Americans can access birth control and family planning services. Services can include birth control, sexually transmitted infection (STI) tests, breast and cervical cancer screening, basic infertility treatment and more. Patients with family incomes below the federal poverty line pay no fees for services, while others pay on a sliding scale.
The health department has administered the program in Mississippi at least since the late 1970s, if not earlier, offering some level of services at nearly every county health department. It also distributed funds to eight subgrantees in 2021, mostly federally qualified health centers.
But in 2018, even before the pandemic and Trump-era regulations battered Title X programs across the country, the program served only about 25,000 Mississippians, a small fraction of the state’s women of reproductive age.
The health department commissioned Converge to assess the quality of its family planning services in 2019. The report documented basic problems that had serious consequences for patients, as first reported by Erica Hensley for Rewire News Group and later obtained by Mississippi Today through a records request.
Referring to the landscape of family planning care in Mississippi, Lampton said the state has ended up “with a broken system that gets an F.”
When patients called during working hours, the phone could ring with no response. Or the patient could be put on hold until the line would cut off.
Staff gave incorrect information about service costs, saying things like “You will get a bill if you have no insurance” instead of explaining that fees vary by income and are waived for people below a certain income level.
At the time, the health department required patients to come in for an exam before receiving a full supply of birth control. But it could take months to get an appointment.
“In that time period a patient would go without birth control and possibly experience an unplanned pregnancy,” the report noted.
A study published in December 2021 by the Mississippi Reproductive Health Access Project at the University of Texas at Austin summarized findings from 498 “mystery client calls” to health department sites, federally qualified health centers and private practices. Sometimes clinic staff said patients couldn’t choose the type of birth control they’d receive.
“It is up to what the doctor wants,” one caller was told.
The Converge report found some clinics were running out of condoms.
“Within any operation there will be anecdotal issues and opportunities to improve on standardization and customer service,” Dobbs said. “Staffing shortages have exacerbated issues no doubt. Having Converge as a partner will allow us to better focus our resources of specific need. We are also restructuring our oversight structure in counties to ensure better quality.”
The COVID-19 pandemic caused family planning visits to health department sites to drop somewhat, but it was state policy that pushed a broken system closer to collapse.
Hensley reported for Rewire that Mississippi was one of at least four states to use an emergency rule to get federal authorization to divert Title X staff to COVID-19 response. Data provided by the health department shows the steepest decline in visits came nearly a year into the pandemic: Hensley reported the department had shifted staff to the vaccination rollout.
From December 2020 to January 2021, total visits to health department sites fell 33%. The next month, they dropped another 45%.
Visits ticked up again the rest of the year, but by the end of 2021, the number of family planning visits to county health departments had fallen by about 30% from 2020.
Dobbs said the state’s “severely depleted” health workforce had been tasked with extraordinary duties, particularly early in the vaccine distribution effort.
“These public health heroes worked countless overtime AND ensured TB, STIs and other challenges were addressed,” he said. “Although follow-up appointments were delayed, refills were maintained to ensure continuity of treatment.”
Wyconda Thomas opened Healthy Living Family Medical Center in Gunnison, a town of a few hundred people in Bolivar County, in 2018. The nurse practitioner grew up in Rosedale, eight miles away, and wanted to serve the community that raised her.
She calls herself a one-stop shop, and her clinic motto is “Delivering quality care where it’s needed most.” The nearest hospital is 30 minutes away.
“The ambulance service, it used to come to Rosedale two days a week,” she said. “So you had to pick which day you had a heart attack.”
These days, she doesn’t see the ambulance stationed in Rosedale at all.
Thomas became a Title X subgrantee in 2021. In her first year, health department data shows, her clinic reported 426 family planning visits– more than all but two other sub-grantees and five county health departments that year. The $40,000 grant enabled her to add family planning services for the patients she was already seeing regularly.
She also sees a lot of teenagers, and during their well child exams, she takes the opportunity to offer some basic information.
“We also include the family planning of just education about their bodies, changes in their bodies, what their bodies are capable of, which is getting pregnant,” she said. “We discuss the different types of birth control if they’re interested in that. We talk about how to avoid pregnancy.”
Lack of access to care and lack of information are related. “People can’t know a lot about what they don’t have access to to begin with,” Tyler Harden, Mississippi state director at Planned Parenthood Southeast, said.
Thomas sees that link every day with her patients, who rely on her for information about their options, the potential side effects of different contraceptive methods, and her thoughts on what might work best for them.
“If they don’t know something, it falls on me,” she said.
Converge leaders say they plan to actively promote services, rather than waiting for patients to find them. And they want to give patients information, too.
On Personally, the website Converge built to help patients find a clinic, users can search by services offered and payment types accepted.
“We wanted patients to be able to see things before they even get to their visit,” said Jitoria Hunter, director of external affairs. “Like how to talk to your providers and looking at the different methods that they have access to.”
Nonprofits, community health clinics, hospital-based clinics and county health departments can apply to join the Title X network online, on a rolling basis.
Current and prospective subgrantees are waiting to see what changes under Converge.
Thomas said she would like to see more opportunities to attend trainings and conferences.
“Just like resources where I could go and learn more to take back to my patients,” she said.
Gipson expects Converge to be more responsive to subgrantees’ questions and suggestions. She hopes the program will offer less red tape and more support for innovations.
Before joining Plan A as program coordinator, Desiree Norwood served as mayor of Sunflower in the Delta, and saw firsthand how people living in communities with few options for health care reacted to a visit from the mobile clinic. Plan A hopes to apply for and receive funding under Converge.
Norwood said her understanding is that Converge “would fund small, innovative programs, such as Plan A, those programs that are rooted in the community.”
Converge is taking over Title X administration just as the Supreme Court looks set to overturn or substantially weaken Roe via a ruling in a Mississippi case, Dobbs v. Jackson Women’s Health Organization.
But in Mississippi, Roe didn’t fully protect abortion access anyway. Just one clinic remains open, down from 13 in 1982.
Now, reproductive health advocates see an effort to blur the line between abortion and contraceptives: In Missouri, some Republicans have argued that IUDs are “abortifacients.”
And the Title X program has already been a target in the past. In 2019, a Trump administration regulation prohibited grant recipients from referring patients for abortions, causing about a quarter of all sites to leave the Title X network.
To be effective in the future, Converge may have to do more than expand access to good health care. The organization may also have to defend Mississippians’ right to birth control.
“I think it’s really important that everyone knows that seeking family planning care at a Title X site is legal,” Lampton said.
“If Roe is overturned, family planning care is probably next on the agenda,” Bardwell added. “It’s about reproductive autonomy. It’s not lost on us that we have to make sure people know, like Danielle said, this is health care. This is basic health care.”