A Modest Proposal: Biden FY 2023 Budget Request Proposes Slight Funding Increase for International Family Planning and Reproductive Health

The detailed appendix accompanying the proposal from the Biden-Harris administration rejected calls from advocates for robust changes in policy that could advance sexual and reproductive health and rights (SRHR). This includes declining, for the second year in a row, to recommend the elimination of the Helms amendment, which restricts U.S. foreign assistance funds from being used to provide abortion services overseas. Nevertheless, the request includes two important technical fixes, reiterated from last year, to improve the effectiveness of U.S. foreign assistance funds and ensure that FP/RH programs receive the same treatment as other global health sectors.

Addressing the demand for access to reproductive health services, including through the provision of a full range of effective contraceptive methods and accurate information about SRHR, along with integration with other health services, will reduce unintended pregnancies and unsafe abortions; improve maternal and child health; lower HIV-transmission rates; promote the rights, education and economic empowerment of women and girls; raise standards of living; and support more sustainable development.

As in Jonathan Swift’s time, there are many solutions the global community can pursue to combat widespread poverty, health disparities, and persistent inequality that are far more humane than the alternatives, real and satirical. Among them are dramatically improving access to contraception and SRHR. Throughout its first year in office, the Biden-Harris administration declared its strong commitment to expanding global SRHR. Yet this budget request lacks the same level of bold ambition. Reaching those goals will take much more than this modest proposal.

Funding Request

The president’s FY 2023 budget request proposes $597 million for bilateral FP/RH assistance, of which $572 million is allocated from within the Global Health Programs (GHP) account and $25 million from the Economic Support Fund (ESF) for FP/RH activities in a very small number of strategically important countries. While the total bilateral request represents a $22 million increase above the current FY 2022 enacted level, the $48 million increase requested within the GHP account, administered by the Office of Population and Reproductive Health (PRH) and country missions within the U.S. Agency for International Development (USAID), is a positive development. This increase in GHP was achieved by moving a portion of funds previously included in the allocation for ESF in past years.

Advocates have argued that investments in FP/RH projects through the GHP account are likely to be a more effective channel than ESF allocations to the governments of U.S. friends and allies, as one may question whether such plus ups of national health budgets are dictated more by political considerations than by programmatic need. Although the final FY 2022 spending package reverted to the breakdown between GHP and ESF that has persisted for more than a decade, it was noteworthy that both the House and Senate versions of the State Department foreign operations appropriations bill choose to allocate all bilateral FP/RH funding through the GHP account with no ESF designated for FP/RH activities. (In the FY 2022 budget proposal, ESF was requested for FP/RH activities in Afghanistan, Egypt and Jordan, but which countries and how much of the $25 million each will be recommended to receive in FY 2023 will not be available until detailed budget tables are released in the coming weeks.)

The budget request earmarks $56 million for a U.S. core contribution to UNFPA within the International Organization and Programs (IO&P) account managed by the State Department. If enacted, the amount requested for UNFPA would represent a $23.5 million — or more than 70% — increase above the enacted level. This amount is identical to that contained in President Biden’s first budget request when he made good on his pledge to resume funding to UNFPA after four years of U.S. contributions being withheld during the Trump-Pence administration.

As detailed in the State Department and USAID congressional budget justification (CBJ), FP/RH is again included in the “preventing maternal and child deaths” thematic area (p. 84), one of the three objectives of the GHP account, along with “controlling the HIV/AIDS epidemic” and “combatting infectious disease threats.” The text of the rationale for FP/RH programs is identical to that contained in last year’s CBJ, which represented a departure from the rationale for investments during the prior administration that was, as one might suspect, more deferential to governments’ religious and cultural sensitivities and less concerned about the rights of their citizens to essential health care.

The combined $653 million requested for bilateral and multilateral FP/RH assistance represents a $45.5 million — or 7.5% — increase above current levels and is slightly more than the amount appropriated in FY 2010, right before the downward slide in FP/RH funding to an average annual amount under $610 million for the last dozen fiscal years. Nevertheless, it is important to acknowledge the context for the modest proposed increase for FP/RH. SRHR advocates should perhaps consider themselves fortunate as the budget requests for many of the other global health sectors funded under the bilateral GHP account are either flat or cut, including the allocations for bilateral maternal and child health, nutrition, HIV/AIDS and tuberculosis. Likewise, reduced contributions are proposed for some of UNFPA’s multilateral counterparts like the World Health Organization, UNICEF and UNAIDS. Regardless, all of the proposed budget allocations for global health — whether up, down or level — fail to meet the moment in which humanity now finds itself and as the COVID-19 pandemic continues to ravage the globe.

But the requested amount for FP/RH in particular falls far short of the marker laid down by SRHR advocates recommending expenditure of $1.736 billion as the U.S. fair share of the total financial investment necessary to address the current unmet need for modern contraception of 218 million women in low- and middle-income countries (LMICs).

Even at the current level of U.S. investments in FP/RH programs, however, funding appropriated by Congress in FY 2021 delivered measurable results and made the following possible:

• 27.2 million women and couples received contraceptive services and supplies;
• 12.0 million unintended pregnancies, including 4.5 million unplanned births, averted;
• 4.0 million unsafe abortions averted; and
• 19,000 maternal deaths prevented.

Strategic investments in sexual and reproductive health save lives. The Guttmacher Institute’s analysis Adding It Up, upon which the calculation of the U.S. fair share of these investments is based, found that meeting the current unmet need for modern contraception in LMICs would result in a decline of about two-thirds in unintended pregnancies (from the current 111 million to 35 million per year), unplanned births (from 30 million to nine million per year) and unsafe abortions (from 35 million to 10 million per year). Furthermore, for every additional $1 spent on contraceptive care, $3 is saved on maternal and newborn care because of declines in the number of unintended pregnancies.

Policy Recommendations

Accompanying the main volume of the president’s budget request each year is a massive appendix which outlines in exacting detail the executive branch’s recommendations for changes to the text of the current appropriations legislation — additions, deletions and revisions. It is important to read the fine print.

• Deleting the Hyde amendment but retaining the Helms amendment

For the second year, the Biden budget request does not contain the infamous Hyde amendment, a provision in the annual Labor, Health and Human Services, Education appropriations bill that has barred states from using federal Medicaid funds to provide abortion, except in cases of life endangerment, rape or incest, since 1976. Important progress in the campaign to remove the Hyde amendment from annual appropriations legislation was made last year in Congress as neither the House-passed nor Senate “chairman’s mark” contained the provision. Unfortunately, the removal of the Hyde amendment was sacrificed in the final FY 2022 omnibus bill as part of the bad deal with Senate Republicans that led to all policy “riders” on domestic and international reproductive health and rights being reinstated to reach agreement on the massive spending package.

Like last year, global SRHR advocates were disappointed that the Biden budget request did not move to strike the Helms amendment included in the appropriations bill that restricts the use of foreign assistance to provide “abortion as a method of family planning.” Unlike the Hyde amendment, however, the Helms amendment is also part of the permanent authorizing statute for overseas aid programs — the Foreign Assistance Act of 1961 — and not just an appropriations “rider” like Hyde. Deletion of the superfluous reiterations of Helms included in foreign aid appropriations bills since FY 1980 would not end its enforcement, absent it being struck from the Foreign Assistance Act. That fact did not prevent House appropriations champions from removing the two repetitions of Helms from their version of the FY 2022 spending bill and attempting a clever workaround for appropriated funds, which, like the Hyde amendment, were reinstated in the final omnibus bill. A bill to accomplish the objective of amending the permanent law, the Abortion is Health Care Everywhere Act (H.R. 1670), has attracted an impressive 177 cosponsors in the House.

• Inserting technical fixes to allow for contraceptive procurement using the HIV/AIDS Working Capital Fund and for FP/RH programs to continue in countries where U.S. foreign aid has been cut off

Like last year, the Biden budget request proposes to reword two boilerplate provisions in the annual State Department and foreign operations appropriations bill to expand their application to funding for bilateral FP/RH programs and contraceptive commodities.

First, appropriations legislation currently only allows “child survival, malaria and tuberculosis and emerging infectious disease” programs to use the HIV/AIDS Working Capital Fund to procure and distribute pharmaceutical commodities for use in U.S. government-funded health programs “to the same extent as HIV/AIDS pharmaceuticals and other products.” However, the HIV/AIDS Working Capital Fund cannot be utilized for procurement or distribution of contraceptives and other reproductive health supplies. A simple wording change — adding “other global health” — to the existing statute had been requested in the appendix to the president’s FY 2022 budget request and inserted in both the House-passed bill and its companion Senate version. This would broaden the fund’s eligibility to allow USAID the option of procuring contraceptive commodities using this mechanism if it chooses and eliminated another instance in which FP/RH programs are subjected to discriminatory treatment in appropriations legislation without legitimate programmatic justification. Unfortunately, the FY 2022 omnibus reverted to existing law.

Second, recent coup d’etats in Mali and Guinea and the resulting cutoff of U.S. foreign assistance to these countries’ governments in 2021 was just the latest illustration of the fact that only one global health program — FP/RH — is not exempt from a variety of prohibitions on assistance that can and have been enforced against governments that launch coups, engage in nuclear proliferation, default on loans from the U.S. government, expropriate U.S. assets and commit other serious misdeeds. In contrast, child survival and HIV/AIDS and other disease-specific programs have long been exempted from these country assistance prohibitions, as well as many other provisions of law. What should be a noncontroversial technical change to enable FP/RH to be covered under the exemption from country aid restrictions involves simply changing a few words so that the provision in the annual appropriations bill reads “global health programs,” rather than “child survival activities or disease programs.” Although included in both the House and Senate versions of the FY 2022 bill and requested by the president in the FY 2022 budget appendix, like the minor adjustment to the language governing the HIV/AIDS Working Capital Fund, the change did not survive the decision to not deviate from the legislative status quo in the negotiations over the final omnibus spending bill. Advocates will be working to break the political stalemate and finally succeed in persuading congressional appropriators to make these two small — but significant — technical language fixes for FY 2023.

• Conditions applied to the UNFPA contribution

The Biden budget appendix does not include the entire section of the bill containing all of the long-standing boilerplate restrictions on the U.S. voluntary contribution to UNFPA including: the requirement that UNFPA maintain U.S. funds in a segregated account, none of which may be spent in China; no funding for abortion; dollar-for-dollar reduction in the U.S. contribution by the amount of funds UNFPA furnishes to China; and reprogramming of any funds withheld from UNFPA due to the “operation of any provision of law” to bilateral family planning, maternal and reproductive health programs. However, the Biden budget appendix does contain the 1985 Kemp-Kasten amendment, unjustifiably interpreted during Republican administration to cut off U.S. financial contributions to UNFPA, but it does not propose any modifications to the language.

In not including the entire UNFPA section of the bill, the Biden budget appendix removed the existing statutory earmark of $32.5 million for UNFPA from the IO&P account. As a result, the FY 2023 contribution level of $56 million only appears in the State Department-USAID CBJ, accompanied by a forceful justification for the 72% increase being proposed by the administration. The CBJ states that UNFPA “advances the U.S. government’s strategic foreign policy goals to empower women, build democracy, and encourage broad-based economic growth through advancing global health and human rights and expanding access to voluntary family planning, reducing global maternal and child mortality, and preventing gender-based violence.”

What’s Next

The arrival of the president’s budget request on Capitol Hill will kickstart the FY 2023 appropriations process just two weeks after the finalization of the one for the current fiscal year that ends just six months from now on September 30. Renewed squabbling has already resumed over the appropriate split between defense and non-defense discretionary spending increases, the issue that delayed agreement on the just-enacted omnibus spending package for months. There will be no rest for the weary.

Cabinet secretaries and agency heads will soon fan out to defend the details of the budget requests proposed for their departments and agencies in congressional oversight hearings. Meanwhile, members of the House and Senate will be submitting their own proposals for funding of favored programs and state and district pet projects to appropriations subcommittees for their consideration. But the looming mid-term elections will reduce the number of days that Congress will be in legislative session in Washington, complicating the task of completing the 12 subcommittee spending bills in a timely fashion. With extremely narrow Democratic majorities in both chambers, combined with a seeming lack of incentive for Republicans to cooperate — sensing the possibility of electoral gains — avoiding a partisan stalemate may prove difficult.

Regardless of the challenges, going forward, the Biden-Harris administration must push Congress to approve not only the vital financial resources it has requested but also the policy changes that will be needed to fulfill its commitments to advancing and protecting SRHR around the world.