The most incisive guide to issues facing the American family today . . . An invaluable resource for anyone wishing to stay on the cutting edge of research on family trends.
-W. Bradford Wilcox
Associate Professor of Sociology, University of Virginia
When Robert S. McNamara, the secretary of defense for Presidents John F. Kennedy and Lyndon B. Johnson, passed away in 2009, the media recounted achievements that few in his generation could match. While charting his rapid rise in the Ford Motor Company and his leadership of the World Bank, the news accounts directed most of their attention to McNamara’s seven years at the Pentagon in the 1960s, directing a military build-up in Southeast Asia during the early but critical years of the Vietnam War. A common theme of most obituaries was the irony of how the prosecution of a war in a tiny country by a talented, dedicated, and bright public servant ended in such a colossal defeat, at the cost of more than 58,000 American lives.
While the American misfortunes in Vietnam cannot be blamed on any one man, McNamara is nonetheless inextricably linked to that military failure. Less understood is how the contradictions of the former defense secretary are equally linked to another war of LBJ, one that became more of a quagmire than Vietnam ever was: the War on Poverty, including a related battle, the assault on American fertility declared by President Richard M. Nixon in 1969 and ushered in by the Family Planning Services and Population Research Act of 1970, also known as Title X of the Public Health Services Act. Granted, neither the War on Poverty nor Title X fell under McNamara’s purview. Yet both domestic undertakings were inconceivable apart from the mentality that the Whiz Kid from Ford personified, an attitude which presumes that there are no social, political, or economic problems that the discipline of public policy, when rationally pursued and applied by the best and brightest, cannot fix.
As George F. Will observed on McNamara’s death, the corporate titan’s service to two presidents coincided with the elevation of politics to an empirical science, driven by the mythology of behavioralism, which holds that things that can be quantified can be controlled and that everything can be quantified, including human behavior. Thinking social science is not all that different from the natural or physical sciences, McNamara applied the systems theory that he honed in private industry to matters of public life, creating the modern discipline of “policy analysis” in which every social-science major has since been trained.
When applied to domestic affairs, what Will calls the “McNamara mentality” reduced all the complexities of society to formulae. No longer were human behaviors governed by Adam Smith’s “invisible hand” of Providence. Rather these actions were interpreted as “crises” requiring the same kind of expert scrutiny, organization, and manipulation that yielded the mechanical precision and efficiency evident in Ford’s assembly lines, which in McNamara’s day built nearly 5,000 cars a day. Consequently, in a desire to control nearly everything in American life, the leadership class in Washington has for nearly fifty years accepted McNamara’s faith in case studies, survey research, and statistical analysis to unlock the mysteries of statecraft hidden from previous generations. Freed from the influence of cultural mores, religion, and the marketplace, that enlightened statecraft is supposed to deliver “rational” policies that will yield a better America, or in LBJ’s slogan, the Great Society.
The irony is that this industrial approach to public policy never delivered what the engineers promised. The extent of that policy fiasco is illustrated by the War on Poverty, which continues to be prosecuted at an annual cost of $953 billion, according to Robert Rector of the Heritage Foundation, and with little to show for itself. As Charles Murray, Lawrence Mead, and Thomas Sowell have documented, that massive social experiment has left America with an underclass that is more dysfunctional today, and far less capable of self-reliance—largely because of the perverse incentives built into all public welfare systems—than it was in 1964.
The Seeds of Title X
Researchers have given less attention, however, to a critical element of that social intervention for which Republicans are most responsible: the federal funding, promotion, and distribution of birth-control devices and “family-planning” services for which Title X remains the inspiration. Pursuing LBJ’s stated goal of attacking root causes and not simply tempering the consequences of poverty, prominent Republicans in the late 1960s—including President Richard M. Nixon, then-Congressman George H. W. Bush, and socialite John D. Rockefeller III—began to echo their Democratic counterparts in claiming that reducing fertility among the underclass was indispensable to alleviating poverty in America. Representing a formidable convergence of Margaret Sanger’s grass roots birth-control brigades with the elite Population Council of Rockefeller, these political figures believed that the most effective way to reduce poverty was by literally reducing the number of poor people by preventing them from reproducing.
Even as birth rates among all income groups, ages, and races had been declining since the height of the baby boom in 1957, these Republicans nonetheless fell hard for the Malthusian sky-is-falling fears fostered by the privileged classes who declared “overpopulation” public enemy number one, fears that matched the panic over “global warming” today. Therefore, when the Social Security Amendments of 1967 were being marked up, George H. W. Bush, a father of six, crafted a section of the bill to require states to make contraception available to all welfare recipients. But that was only the warm up. Three years later, the future president marshaled overwhelming congressional approval for Title X, the first federal program to boldly and exclusively focus on promoting birth control and reducing fertility. The lodestar program would fund—through a new Office of Population Affairs at what is now called the U.S. Department of Health and Human Services (HHS)—more than 4,500 centers in 75 percent of the nation’s counties, dispensing birth-control paraphernalia to “low-income” women and girls, ages 15 to 44. Allan C. Carlson notes the irony that President Nixon signed the bill on Christmas Eve 1970, just when the country was preparing to celebrate the “unplanned” birth of a baby born in poverty 2,000 years before.
Title X officially expired in 1985, yet Congress has continued to appropriate money for the program every year since, including $317 million in 2010, bringing the total amount of federal expenditures for the program since 1970 to an inflation-adjusted $12.4 billion. Only under President Ronald Reagan was spending on Title X significantly scaled back. While Title X is the only federal program dedicated exclusively to promoting and distributing birth control, it inspired a number of other federal programs to dispense contraceptives as part of their larger agenda. Those programs include Temporary Assistance for Needy Families (TANF), the Indian Health Service, Social Services Block Grants, and the Centers for Disease Control and Prevention (CDC). As if this weren’t enough, President Barack Obama has thrown another grant program into the mix, one limited to controlling pregnancy among women under 20 years of age, and set up yet another bureaucracy, the Office of Adolescent Health at HHS, complete with a $115 million budget.
Even though Title X remains the model program, the cash cow is Title XIX of the Social Security Act (Medicaid), an entitlement that does not depend on annual appropriations by Congress. Medicaid began to pay for contraceptives when Title XIX was drafted into the federal birth-control campaign in 1972. At the behest of Planned Parenthood, Congress not only made contraceptive devices and “services” a mandatory part of state Medicaid programs but also promised to reimburse states 90 percent of the costs of dispensing and actively promoting birth control, even to minors without parental notification. Given the favored reimbursement status afforded no other mandated health service, it comes at no surprise that Title XIX outpaced Title X as the biggest spender of federal family-planning dollars by the early 1980s. The “means-tested” nature of Medicaid means this component of the federal family-planning behemoth is also supposedly directed to low-income populations, yet HHS has since 1993 granted waivers to twenty-seven states to relax income limits for eligibility purposes in order to supply free birth control for girls and women with incomes up to 200 percent of the official poverty level.
Tracking public expenditures of all these related programs is tricky, but the Heritage Foundation calculates that federal and state governments spent $1.73 billion in 2002 on a wide range of programs promoting birth control or pregnancy avoidance. Heritage also estimates that more than a third of that money ($653 million) was directed at birth control for young women ages 15 to 19. A more recent study by former Heritage analyst Daniel Patrick Moloney concludes that birth-control funding through Medicaid alone accounted for more than $1.3 billion in 2006, representing a more than doubling of Medicaid funding in constant dollars since the Clinton administration introduced the waiver program. Moreover, just as HHS has liberalized Medicaid eligibility levels for receiving free birth control, so Title X eligibility regulations require that “income levels” of dependent children be determined independent of their parents—on the basis of a child’s part-time job or allowance—dramatically expanding the program’s market beyond the low-income population, according to researcher Charlotte Allen. In calculations that are consistent with the Heritage Foundation figures, she estimates that at least one-third of all Title X recipients are teenagers, including minors receiving free contraceptives without their parents’ knowledge or consent.
What Title X Sowed in the Real World
Richard M. Nixon and George H. W. Bush sold Title X to the public on the theory that “advance planning” called for dispensing heavy doses of contraception to those “who want them but cannot afford them” in order to reduce “unwanted and untimely childbearing” and enhance the “effective planning” of families. A similar argument was set forth when Congress tapped the resources of Medicaid for family-planning purposes in 1972. Would this untested theory deliver on its hype, or would the McNamara school of public policy—with its fixation on abstract rational planning—backfire in the real world just as it did with the War on Poverty? Keep in mind that in 1970, 10.7 percent of all U.S. births were to unmarried women, an objective measure reflecting hard Census data that are indispensable to assessing the efficacy of programs like Title X. While births to unmarried women may not necessarily be “unwanted,” the prevalence of a subjective characterization of some babies as “unwanted” is nonetheless significantly greater among the unmarried than the married. Moreover,
Percent of Births to Unwed Mothers
Source: Statistical Abstract of the United States, 1986 edition, Table 94; 2003 edition, Table HS-14; 2010 edition, Table 86; “Births: Preliminary Data for 2006,” National Vital Statistics Reports, Vol. 56, No. 7, December 5, 2007, Table 7; “Births: Preliminary Data for 2009,” National Vital Statistics Reports, Vol. 59, No. 3, December 21, 2010, Tables 1 and 7.
births to unmarried women are by definition “untimely” as births outside the protective bonds of marriage yield significantly problematic outcomes for the mother, the child, and society.
It would, therefore, not be unreasonable to expect Title X and its related programs at the very least to prevent the out-of-wedlock birth ratio from climbing or perhaps contribute to a shift from unmarried childbearing to married childbearing. That would represent “family planning” as a center-right country might understand the phrase. But what actually transpired? The out-of-wedlock birth ratio did not moderate, but continued to rise year after year. By 2009, some 41.0 percent of all babies were born to unwed mothers, a three-fold increase from 1970. Among African Americans, the ratio increased from 34.9 percent to 72.8 percent; among young women between the ages of 15 and 19, it jumped from 29.5 percent to 87.2 percent.
Composition of U.S. Households
(Number in millions)
Source: Statistical Abstract of the United States, 1986 edition, Tables 54 and 65; 2000 edition, Table 60; and 2010 edition, Table 59.
A center-right country might also have expected to see some measure of success in the “effective planning” of families. Here again, Census Bureau data are not encouraging. Since 1970, the country has not experienced any net increase in the number of families that represent the social ideal—married parents with children—but has in fact witnessed a more than tripling of single-parent households (from 3.3 million in 1970 to 10.5 million in 2008) and the near disappearance of marriage and intact families from the inner city. According to the 2000 census, the entire City of Baltimore, for example, has more households represented by single mothers with children (34,329) than married parents with children (25,717), as does the District of Columbia and the City of New Orleans. Another way of putting this is that, under Title X, the country has experienced less family planning but more disordering of families. This may explain in part why the official rate of poverty in the United States has declined very little since 1970, even though it had dropped significantly during the 1960s, before the passage of Title X.
Of course, correlation does not prove causation; the fact that commonly accepted family and social indicators worsened—and the poverty rate remained largely unchanged—during the life of Title X does not mean that the latter is entirely responsible for the former. Title X is not the only federal program promoting or dispensing contraception. Yet the fact that the percentages of births to unwed mothers are highest among the vulnerable populations that Title X and Medicaid target (teenagers and minorities) does indeed suggest that federal family-planning programs are far more implicated in the decline of the family than its promoters and defenders are willing to acknowledge.
On the other hand, the architects of Title X may be pleased—and may even take credit for the fact—that U.S. birth rates continued to decline after 1970, especially among African Americans. These outcomes were, in fact, ones the rational planners had anticipated. Based on data in the charts on the next page, the General Fertility Rate declined 24.1 percent from 87.9 births per 1,000 women in 1970 to 66.7 births in 2009. The birth rate declined 28.3 percent for married women during the same period; 40.3 percent for African-American women; and 42.8 percent for women 15 to 19 years of age. As measured by the Total Fertility Rate, the average American woman in 1970 would likely bear 2.48 children over her lifetime but only 2.01 children by 2009; for the African-American woman those numbers are 3.10 and 2.03. However, birth rates for unmarried women went in the opposite direction, nearly doubling between 1970 and 2008, another confirmation of the ironies of federal family planning. In any case, it is not clear that lower birth rates in general have been good for the country, or even an effective strategy for combating poverty.
Birth Rates by Marital Status
Source: Vital Statistics of the United States: 1969, Vol. 1—Natality, National Center for Health Statistics, 1974, Table 1-31; Statistical Abstract of the United States, 1960 edition, Table 57; 1978 edition, Table 81; 2000 edition, Table 82; 2003 edition, Table HS-14; 2009 edition, Tables 79 and 83; “Estimated Pregnancy Rates for the United States, 1990-2005: An Update,” National Vital Statistics Reports, Vol. 58, No. 4, October 14, 2009, Table 5; “Births: Preliminary Data for 2009,” National Vital Statistics Reports, Vol. 59, No. 3, December 21, 2010, Tables 1 & 7; and unpublished NCHS data on fertility rates of married and unmarried women.
Total Fertility Rates
(The TFR is the average number of children that a woman would
bear in her lifetime, based upon fertility patterns in a given year.)
Source: Unpublished NCHS data; Statistical Abstract of the United States, 1980 edition, Table 86; 2004-05 edition, Table 75; 2010 edition, Table 83, and “Births: Preliminary Data for 2009,” National Vital Statistics Reports, Vol. 59, No. 3, December 21, 2010, Table 1.
Parroted Estimates of Estimates
The apparatchiks of the Title X family-planning complex, from the researchers at the Guttmacher Institute and the CDC to practitioners associated with Planned Parenthood and the National Family Planning and Reproductive Health Association (NFPRHA), a trade group, would likely object to the foregoing assessment. They would prefer to judge the efficacy of Title X and its Medicaid version not on the basis of objective Census data but rather on the basis of a subjective rubric of their own making, the so-called “unintended pregnancies” and abortions and births that federally funded birth control allegedly precludes. For example, in 1999 the CDC identified “family planning” as one of the “ten great public health achievements” of the twentieth century, claiming in a later report that “publicly supported family planning services prevent an estimated 1.3 million unintended pregnancies annually.” In a more recent tribute to Title X on the NRPRHA website, those estimated numbers turn into “family planning facts,” claiming that “publicly supported family planning services help to prevent 1.4 million unplanned pregnancies each year,” and claiming that had those pregnancies materialized, they would have resulted in “600,000 abortions.”
The source of these parroted numbers is neither the Census Bureau nor independent research but analysts affiliated with the Guttmacher Institute, an organization founded by the Planned Parenthood Federation of America, a publicly funded advocacy organization whose affiliates are key grantees of the Title X and whose representatives aggressively lobby for the expansion of the Medicaid waiver program. That fact raises a number of red flags. First, having Guttmacher researchers assess the effectiveness of the federal birth-control system is comparable to having economists of Wall Street investment firms evaluate the effectiveness of the Troubled Assets Relief Program that has poured billions of dollars into the depleted coffers of these firms. This incestuous relationship linking the public-health establishment with the Guttmacher Institute and activist groups such as Planned Parenthood looks suspiciously similar to the collusion between the public agencies and private financial-services firms that helped bring on the current economic crisis. Acting on the same sort of raw self-interest that guided both investment brokers and the officials nominally responsible for overseeing their activities, public-health officials have for some time worked closely with Planned Parenthood and Guttmacher to feather each other’s nests at taxpayers’ expense.
Second, many of the “findings” of Guttmacher researchers do not represent hard data but rather estimates based upon estimates—estimates that seem to grow more favorable to their interests with every new study. Moreover, these estimates depend upon researchers divining the private thoughts behind the measurable and empirical behavior of American women. A 1990 Guttmacher paper claims, for example, that publicly supported family planning in the early 1980s averted an “estimated” 1.2 million “unplanned pregnancies,” an estimate which it in turn uses to estimate the number of abortions averted (516,000) had those “unplanned” pregnancies not been averted. A 1996 paper by the same researchers, based upon 1994 data, raised the baseline estimate, claiming that if Title X centers or Medicaid coverage for birth-control devices were not available, “women who currently use them would have an estimated 1.3 additional unplanned pregnancies annually.” Likewise, this estimated number of annually “prevented” pregnancies is used to make another guestimate of 632,000 abortions, 165,000 miscarriages, and 534,000 “unintended” births that would occur annually if those estimated pregnancies were not averted. A 2008 paper by Guttmacher researchers boosts the base estimate even higher: “In 2004, women who received care from family-planning clinics were able to avoid over 1.4 million unplanned pregnancies.”
All three studies also claim, based upon estimates of estimates—and the percentage of recipients of federal birth-control who are on welfare or Medicaid—that every dollar spent on federal family planning saves the taxpayers between $3.00 and $4.40 in health-care costs associated with “unplanned” births and abortions. According to Daniel Moloney, these claims of “reduced costs” were cited by former House Speaker Nancy Pelosi, who attempted to add hundreds of millions of dollars for family planning to President Barack Obama’s 2009 stimulus package—as well as state bureaucrats in applying for Medicaid waivers from HHS—on the basis of the old Nixon theory that increases in federal birth-control spending on the poor will yield declines in welfare spending.
The Construct of ‘Unintended Pregnancy’
The lack of empirical evidence in the record since 1970 to support such wishful thinking is not surprising. As Allan C. Carlson observes, claims about the number of pregnancies or abortions or births “prevented” or “averted” “are wholly imaginary numbers” that rest on “astonishing assumptions.” Borrowing an analogy from the investment world, the federal birth-control industry has created a statistical Ponzi scheme. At the heart of these phantom numbers are not only questionable estimates but also the ambiguous notion of “unintended pregnancy,” a theoretical construct that requires the researcher to accurately capture the subjective and often fluid feelings of individuals that may vary before conception, during pregnancy, and even years after birth. Moreover, it is assumed that the intentions being measured are those of the woman. What about the intentions or feelings of the father, or the couple as a whole?
On the other hand, the Guttmacher researchers may not be interested in discerning the feelings of the immediate players but instead are projecting the intentions of the rational planners, the architects of Title X who were seeking a reduction in American fertility in general; in their world, any more than perhaps two children per woman is considered “unwanted.” Whatever the case, the very construct reflects a bias against fertility and childbearing; indeed, the cronies of Title X consider “unintended pregnancy” a disease or illness that needs to be avoided. They would never frame induced abortion as something that is “unwanted” and, therefore, something to be avoided or restricted by law. Accordingly, childbearing is not considered a gift entrusted to women to be celebrated or encouraged. Consequently, “unintended pregnancy”—not unwed births, abortions, or family disorder—represents a grave public health risk that requires Title X, Medicaid, and billions of dollars to combat. But as Anthony Esolen of Providence College points out, the whole premise is rooted not in reality but a figment of the liberal imagination:
Except in case of rape, there are no “unintended” pregnancies, none. There are plenty of women who do not want to be pregnant, and plenty of men who do want them to be pregnant, but in all those cases the pregnancies are the results of intentional actions that have pregnancy as their perfectly natural and perfectly predictable consequences.
This does not mean that men and women may not have conflicted feelings when they first learn that their actions have resulted in what biology surely intends: conception. Conceptions are partly wanted and partly unwanted, yet more often than not, the “wantedness” of a pregnancy increases in the course of nine months so that once the baby is born, the parents are far less conflicted. But attempting to measure the notion of “wantedness” statistically as a basis for public policy is fraught with problems. Indeed, the way the Statistical Abstract of the United States defines “unwanted births” reflects the imprecise nature of the measure. As reflected in various editions of the Statistical Abstract that report the findings of the National Survey of Family Growth (NSFG), the variable means “all births in which mothers report as ‘not wanted’ or ‘probably not wanted’ at time of becoming pregnant.”
To determine the feelings of mothers regarding the birth of their children in the previous five years, the NSFG asks a series of questions about the respondent’s contraceptive use, some of which could be interpreted as leading questions. Among the questions are those about her attitude not just at the time of conception of each child but also afterwards. No questions, however, inquire about the impact of an ultrasound examination on the respondent’s feelings. Perhaps because of these shortcomings, some reports on the NSFG urge caution in interpreting the measure: “An unwanted or unintended pregnancy [at conception] does not necessarily mean an unwanted child.”
Nonetheless, the NSFG data reveal a declining ratio of “unwanted births:” 13.1 of all births to respondents were “unwanted” in the 1973 cycle; 12.0 percent in the 1976 cycle; 10.5 percent in the 1982 cycle; and 9.1 in the 1995 cycle. Only in the 2002 cycle does the proportion increase (to 14.1 percent). Even with the 2002 outlier, the “unwanted births” of the NSFG are far less prevalent than the estimate of “unintended births” by Stanley K. Henshaw, a widely cited Guttmacher researcher. He looks at the same NSFG data (along with other sources), but claims that 30.8 percent of all births in 1994 were “unintended.” He also goes beyond the NSFG birth data: he estimates that 49 percent of all pregnancies in 1994 were “unintended,” of which 54 percent ended in abortion. For 2001, he estimates the same ratio of “unintended pregnancies” as he did in 1994 (49 percent) but estimates that the portion of such pregnancies that ended in abortion declined to 48 percent. Cited by the public authorities such as those at the CDC, these estimates—which have come to lay at the heart of the raison d’être of federal family planning as well as spurious claims of its effectiveness—need to be interpreted in light of the sobering realities of the past forty years, including the dramatic increase in unwed childbearing and declines in actual family formation, not to mention the slaughter of roughly 50 million babies through induced abortion.
Making Lies Sound Truthful
Americans need to wake up to the disingenuousness of the public-health/family-planning complex. After forty years of federal birth control that has helped to significantly increase contraceptive use to the point at which contraception is nearly universal among American women, it is not at all clear why “unintended pregnancies” remain a problem that requires federal intervention. The entire enterprise represents a classic illustration of the law of unintended consequences, an imprudent policy that emerged out of an unwarranted panic and that fueled the very pathologies that it was intended to contain.
Even the vocabulary that was created to sell, explain, and defend the system reflects intellectual dishonesty. The fact that the nation’s fertility rates have struggled to rise to replacement levels since the mid-1970s, that inexpensive birth-control is available at every neighborhood grocery store without a prescription, and that young women—relative to 1970—face significantly greater risks of sexually transmitted diseases, unwed childbearing, and infertility make it clear that this component of the War on Poverty is not really about “family planning,” serving “low-income populations,” reducing “unintended pregnancies,” or the latest euphemism, “increasing access to sexual and reproductive health-care services.” The policy rhetoric, as George Orwell warned about political language, “is designed to make lies sound truthful and murder respectable, and to give an appearance of solidity to pure wind.”
If the public-health establishment were genuinely concerned about promoting women’s and children’s health, it would be upholding monogamy and the institutional framework that best achieves that: life-long marriage. The public-health establishment would also be more open to the insights of Theodore Roosevelt, who a century ago saw the absurdity of pushing birth control when fertility rates were declining. Thinking the country would “die out unless the average family contains at least three children,” the twenty-sixth president called for public policies that welcome and favor the birth of children in marriage. Or to the insights of the late Robert Kennedy, who prompted laughter from reporters when the father of ten reportedly made it clear he would not welcome a government-funded birth-control program. As Carlson notes, “In an era of below-replacement birth rates, seen especially in Europe, Japan, and among married Americans, the country needs more—not fewer children; and larger—not smaller families.”
As a new Congress looks to find ways to bring the nation back to responsible government after decades of misguided policy systems that have contributed to the social and fiscal crisis of our time, Title X and related programs—especially Medicaid’s preferential funding and promotion of elective “health” options like birth control—ought to be among the first on the chopping block. It’s not the only thing that needs to go, but the Title X empire should be dismantled as the first step of sober policymakers trying to devise an exit strategy for the War on Poverty. Laying it to rest alongside of McNamara, whose mentality has done enough damage, would offer a needed reprieve for families, for children, and for America.
Mr. Patterson is editor of The Family in America.