As a battle over restrictions on federal dollars for reproductive health services unfolds on the national stage, state lawmakers are considering whether to include $6 million in new spending for family planning services in the budget recommended by Gov. Steve Sisolak.

A sixfold expansion over the family planning dollars included in the last two-year budget, the funding would allow the state to bolster care in rural Nevada, where the state is the provider of family planning services, and offer prenatal care education and disease prevention in urban Nevada, state officials told lawmakers during a budget hearing last week. Family planning advocates say the money will also give the state flexibility as the federal government imposes new restrictions on the reproductive health dollars it grants to states and generally has scaled back funding.

On Friday, the Trump administration released a final rule blocking groups that provide abortions or refer to abortion providers from receiving any federal dollars through Title X, a family planning grant program enacted in 1970.

Federal family planning dollars can be used for a broad swath of reproductive health services including contraception, pregnancy testing and counseling, breast and cervical cancer screenings, and testing for sexually transmitted diseases. Though Title X dollars can’t be used for abortions, providers can offer them through other financial means.

Though Planned Parenthood in Nevada does not receive any federal family planning dollars, the rule would prevent other Title X recipients from referring patients to abortion providers unless the patient has already decided to have an abortion and explicitly requests to be given a referral.

Opponents of the rule have promised to take legal action challenging the rule.

At the same time, a very different conversation is happening in Nevada, where the governor actually campaigned on the importance of family planning, including talking about his support for Planned Parenthood in an ad with his two daughters. In his State of the State speech, Sisolak announced a pledge to spend $3 million a year on family planning.

“Currently, Nevada ranks last in the nation in the number of women who have a dedicated health-care provider,” Sisolak said. “We don’t fare much better when it comes to cervical cancer screenings or other forms of family planning. That’s going to change.”

Longtime Planned Parenthood lobbyist Elisa Cafferata said those state family planning dollars will be all the more important in light of the new Trump administration rule, which she said would damage the network of safety net providers who currently direct their patients to Planned Parenthood for family planning services.

“It just it really gets in the way of this safety net referral system where we've kind of worked out where is the best place to provide this service,” Cafferata said. “So those state funds will kind of give us some room to make those referrals back and forth.”

Diminishing Title X dollars

Since 2010, the federal government has slowly reduced the dollars it provides to states to offer family planning services through Title X. The idea was that as more Americans gained insurance coverage under the Affordable Care Act and its associated Medicaid expansion, they would increasingly be able to get their family planning services covered through their insurance plans.

In the last couple of years, the state has seen a particularly sharp drop in the federal dollars it receives for its Community Health Services program, which provides family planning services through 12 community health nurses. In the 2016 fiscal year, the state received $585,000 in Title X funds, which dropped to a $180,000 grant for 2017, a $201,000 grant in 2018, and a $73,000 extension grant for 2018 and 2019.

For low-income residents in rural Nevada, community health nurses are often the only point of access for family planning services. Sometimes they’re the only resource for rural residents with private insurance to get those services, too.

“The Title X grant was significantly reduced and then re-allocated due to changing the federal priorities for those funds to the more urban areas, so we kind of got a twofold blow,” said Shaun Griffin, the co-founder of the nonprofit Community Chest based in Virginia City. “The priorities shifted so that the North and South urban centers received the lion’s share of the money and then the total grant was cut. It was a one-two punch to the rurals.”

In August, the federal government announced its latest round of Title X grants, including $140,000 for the state of Nevada, $695,000 for the Nevada Primary Care Association, $132,000 for Nevada Health Centers, $903,000 for the Southern Nevada Health District and $521,000 for Washoe County.

But family planning advocates say the state isn’t coming close to meeting the demand for services with the current funding levels. During the last legislative session, Planned Parenthood cited statistics showing that Nevada was meeting 43 percent of the need for publicly funded family planning services in 2001 and only 10 percent in 2014.

The Legislature took steps to bridge the funding gap in 2017 by establishing a dedicated family planning fund and allocating $1 million over the biennium for family planning services. Supporters of the measures believed the funds would be used as seed money for the family planning fund, with the hope that the state would then apply for other grants to grow the account.

However, because of some confusion in the legislative process, the state did not set up the family planning account under the belief that lawmakers did not intend for the $1 million to be inserted into the account. Instead, the Division of Public and Behavioral Health granted those funds to a dozen local agencies and community organizations through its normal grant-making process.

The Southern Nevada Health District used its $250,000 grant to offer mobile family planning services to underserved urban areas, while the Washoe County Health District used the $72,000 it received to offer family planning services to female inmates. The other 10 grantees used the dollars to generally increase access to family planning services in specific geographic areas, such as rural Nevada.

For instance, with the $78,000 it received, Planned Parenthood Reno was able to offer 1,373 additional family planning visits over the previous year, while Nevada Health Centers saw an additional 1,180 patients in Las Vegas with its $103,000 grant, according to data provided by the state. Outside of the urban centers, Carson City Health and Human Services saw 497 Hispanic clients through a bilingual public health nurse funded through a $67,000 award, and Douglas County added 155 new patients, a 35 percent increase, with a $89,000 grant.

“A million dollars is a lot of money,” Cafferata said. “I know it doesn't sound like it here, but still if you're in a rural Nevada community, it's a lot of money.”

Cafferata, who was involved in the creation of the family planning account last session, said that though $1 million didn’t flow through the new account, the money still ended up where it was supposed to.

“I don't have any problem with where the funding went,” Cafferata said. “It all went to family planning programs.”

There was additional confusion about whether the state could grant funds to community health nurses, despite significant testimony specific to that need during the 2017 session. The legislation that created the family planning account had specifically said that its funds could be used to pay for community health nurses, while the legislation that made the $1 million appropriation did not.

“Because [the state hires] the community health nurses, it was almost like they were granting money to themselves, which, there's a rule against that, which is totally understandable but we very explicitly spent a lot of time saying, ‘You are the health care provider in rural Nevada. We have to figure out a way to really specifically replace the money you lost because we lost so much Title X money,’” Cafferata said.

In the end, some funds made their way down to the community health nurses by way of the local community organizations. For instance, Griffin said that the funding was used in northern Nye County to purchase adequate birth control supplies and keep other family planning supplies stocked in the office.

“I’m still working in Tonopah and, while things have improved with the health care delivery —and I say that generally — we still have a lot of work to do. A ton,” Griffin said. “I still think that people are under the misperception that everything is hunky dory, and it’s absolutely not.”

New funding, new solutions

Family planning advocates are optimistic about the $3 million a year Sisolak has included in the state budget for family planning. State officials say most of it will be granted out to local government agencies and community organizations — as the $1 million last session was — with a small portion reserved for administrative expenses.

During a recent budget hearing, Assembly Ways and Means Chair Maggie Carlton said she thought it was good that the Legislature started out small with its appropriation for family planning services two years ago before turning to a bigger sum this session. Family planning advocates had initially asked for $4 million over the two-year budget period in 2017.

“That was the reason why those dollar were picked last time because it was the first time. We didn’t want to drown you. We wanted you to succeed,” Carlton said. “You’re showing your success.”

But Carlton still had questions for state officials about the family planning dollars the state currently receives and what services they fund.

“I think in order to have a real discussion about the dollars that are being proposed here, we need to know what other dollars are coming into the state because, yes, it’s great to be able to fund things, but you have to be able to actually get the money on the ground and be able to spend it appropriately and address the issues that need to be done,” Carlton said.

Division of Public and Behavioral Health administrator Julie Kotchevar told lawmakers that the goal of the additional funding is not to duplicate what Title X is paying for but fill in gaps.

Kotchevar said that the state hopes to use some of the additional family planning dollars to conduct targeted outreach on prenatal care in urban Nevada. Some of the funding may also be used to mitigate the state’s high syphilis rates and ensure that pregnant women are screened to reduce the number of babies born with congenital syphilis.

The funding could also be used to promote the use of long acting reversible contraception (LARC), like the IUD. Kotchevar said that the state hopes to look at ways to make it easier for hospitals to pair the insertion of an IUD with delivery and focus on helping sheriff’s offices offer long acting reversible contraception to women in prisons.

Kotchevar said offering IUDs could give women in prison a chance to “take some control over your life and have a LARC if you’re in that vulnerable area and you’re here in the jail.”

“That’s one area where we’re looking at is to try and provide access to women where that may make a big difference in their life,” Kotchevar said.

It is not entirely clear what will happen with a bill created out of the interim health committee's conversations on family planning. That bill, SB94, recommends allocating $12 million for family planning services — Cafferata’s initial ask of the interim committee — and clarifies that the money can be used to pay for family planning services offered by community health nurses.

Cafferata said the $12 million ask will likely be amended out of the bill and that a separate provision on long acting reversible contraceptives will be clarified.

“I think $3 million a year is a good next step and really our hope is that it just becomes a regular part of the HHS budget and a program that we have and then we're not every year trying to submit a bill to do this,” Cafferata said.

As far as the rurals, Griffin is hopeful that funding for community health nurses can be separated from the rest of the family planning funding pool and directly allocated instead of forcing them to go through the grant application process.

“I’m just grateful that we’re in the running and there’s some funding available and we have a strong chance of it being allocated for this purpose,” Griffin said. “If we find ourselves on the other side of the fence — meaning not adequate funds for birth control or family planning — we’re going to find ourselves a situation we don’t want with increased pregnancies and increased STDs. No one wants that, so let’s prevent this.”