Implementing Title X: policy design, administration, and geographic access to care.

Background: Title X of the Public Health Service Act is a critical federal program-the only one dedicated exclusively to providing affordable, confidential, evidence-based reproductive health care to low-income populations, yet its capacity to fulfill this mandate depends on political, administrative, and fiscal decisions made across multiple levels of governance-from Congress and federal regulators to state and regional grantees and their sub-grantee clinic networks. Methods: This study assesses geographic access to Title X-funded clinics across all 50 states and the District of Columbia in 2024, a period with significant program and regulatory disruption. Using the Integrated Two-Step Floating Catchment Area (I2SFCA) method-which employs road-network-based drive time thresholds calibrated to urban-rural context-applied to 2024 clinic locations and census-tract-level demographic data, we identify a confluence of spatial and nonspatial barriers to Title X. Results: Findings reveal widespread and substantial gaps in geographic access, a challenge faced by people across all racial groups, rural and urban residents, and individuals with low incomes. Conclusion: These findings offer a precise geographic account of where Title X's reach falls shortest-documenting the ramifications of policy retrenchment and establishing a baseline against which future policy changes can be measured.