The Trump administration is expected to continue its assault on Planned Parenthood by reportedly going after the provider’s federal family planning dollars — cutting the provider off to punish it for providing abortion services, even though Planned Parenthood doesn’t use any federal funds for abortion.
While various media reports have rightly focused on the fact that this would be the administration’s most drastic move yet in harming Planned Parenthood and its patients (its affiliates see 1.6 million of the 3.8 million clients whose contraceptive care is paid for by Title X dollars), the consequences of such policy could actually be more widespread.
The rumors come as the Trump administration seeks to change the existing Title X federal family program in other ways, saying already it would prioritize grant applications from organizations with religious backgrounds and those that counsel abstinence. For this, The National Family Planning and Reproductive Health Association (NFPRHA), represented by the American Civil Liberties Union (ACLU), filed a lawsuit in federal court on Wednesday to challenge the 60-page funding announcement — that makes no mention of contraception — released in February. Planned Parenthood of Wisconsin, Planned Parenthood of Greater Ohio, and Planned Parenthood Association of Utah filed separate, similar legal challenges.
Federal officials are aiming to cut off Planned Parenthood from Title X family planning funding to fulfill a campaign promise to anti-abortion advocates, but the way the Trump administration would go about excluding Planned Parenthood would affect how all Title X clinics provide care to patients. Think tank after think tank has found that thousands of other health care providers, namely community health centers, would struggle to handle the increase in patients should Planned Parenthood be excluded from the federal family program. Indeed, as Vox reported, in 105 counties in the United States, Planned Parenthood is the sole clinic offering comprehensive contraceptive services.
Another core tenet of the existing Title X family program is that all health care providers must tell patients about their options when pregnant. With Trump’s expected policy, this service — that is, an emphasis on unbiased noncoercive counseling — could change.
Federal officials are reportedly looking to reinstate a Reagan-era policy referred to as the domestic gag rule. Republicans in Congress have been pushing the Department of Health and Human Services (HHS) to reinstate the gag rule. A group of anti-abortion groups added pressure on Monday, saying in a letter to HHS that “t]he result of this policy is simply to separate the Title X network of family planning providers from abortionists like Planned Parenthood – the nation’s largest abortion chain.” And in a phone call to ThinkProgress and other reporters in February, the Office of Population Affairs, an office within HHS that administers this public fund, said changes to the program could be forthcoming.
“Even though that’s the frame that social conservatives in Congress and the administration and their allies might take, the real impact would certainty extend far beyond just Planned Parenthood,” said Guttmacher Institute Senior Policy Manager Kinsey Hasstedt.
The Reagan administration gag rule would call for abortion and Title X-funded services to be physically separated, in addition to the existing financial separation. It would also prohibit clinics from providing comprehensive pregnancy options counseling or abortion referrals, even at the request of the patient. Providers would also have to provide all pregnant patients information about prenatal care and social services, whether or not they want to go through with the pregnancy.
Trump’s version of the domestic gag rule could look different than Reagan’s, which carried over into the first Bush administration and was suspended by the Clinton administration — but the Trump administration is getting pressured to reinstate a similar policy.
Altogether — from the funding announcement to the rumored domestic gag rule — this undermines the integrity of the Title X federal family planning program, advocates told reporters on Wednesday. And they’ll do everything they can — “including legal action” — to make sure these policies don’t go into effect.
The practical effect of a domestic gag rule means low-income individuals will receive substandard reproductive health care compared to people with private insurance.
“If you limit pregnancy options, counseling, and referrals for folks who rely on publicly funded programs, this really disproportionately impacts individuals who are low-income, young, or otherwise under-served and further entrenches existing health disparities,” Hasstedt told ThinkProgress.
This policy would also erode the trust between a provider and patient, who is likely already on the margins of care because they face barriers to access, added Alissa Light with the Family Tree Clinic in Minneapolis. Family Tree Clinic is not a Title X clinic, but sees many of the same patients.
“Perhaps causing folks to retreat from the provider or from care in general — and this could be particularly true for individuals and groups who have historically experienced coercive treatment in the context of reproductive health care,” added Hasstedt when trust between the provider and patient weakens.
The practical effect of a domestic gag rule
Title X is the country’s only federal program dedicated to family planning. Organizations, like state health departments and reproductive health groups, compete for this Title X grant money so that health care providers they contract with can provide basic, preventative health care services to low-income individuals. Per existing federal law, these public dollars cannot pay for abortion services, and only go directly to services like birth control or cervical and breast cancer screenings. The Title X family planning program currently supports nearly 4,000 clinics that provide services to more than 4 million people each year.
The Reagan administration disrupted the Title X program in 1988 when it issued a regulation, promulgating the domestic gag rule. It was only in effect for one month because of various court challenges, according to the NFPRHA. But a divided Supreme Court did rule against reproductive rights groups, saying a government could bar abortion counseling.
The Clinton administration formally suspended the gag rule in an executive order, and later, in 2000, codified into federal law that Title X clinics must offer patients the opportunity to have “neutral, factual information and nondirective counseling” on “prenatal care and delivery; infant care, foster care, or adoption; and pregnancy termination.”
This has become standard practice at Title X clinics. Many clinics incorporate materials available on the Family Planning National Training Center into their training. There’s no requirement to use this material, but some Title X clinics do. And in this training, providers are guided on how to be noncoercive if a patient comes in and tests positive in a pregnancy test.
“Now that we talked about parenting and talked a little bit about adoption, your third option is pregnancy termination or abortion,” a provider says to a patient ambivalent about her options in the training video. This scenario wouldn’t play out under a gag rule.
“You are really forcing all providers to decide between Title X funding and providing high quality patient-centered family planning care and ensuring that their clients have all the information that they need to make informed decisions about their own reproductive health,” Hasstedt told ThinkProgress.
Many groups competing for Title X dollars would adjust, like the grantee in Indiana, said Kristin Adams, president and CEO of Indiana Family Health Council, which represents the 35 Title X clinics statewide.
“If awarded the funding, we have to follow guidance of the contract whether you like it or don’t like it — you are still obligated,” Adams told ThinkProgress. “It’s a contract I have with the federal government. We will make sure patients are served to the best of our capability and [that we’re] still following the letter of the law and contractual agreement with the federal government.”
Deadline for Title X applications is fast approaching
These reports come as organizations compete for Title X grants; applications are due May 24. Already, many groups who’ve successfully bid in other grant cycles have tailored applications to stay competitive and appease the abstinence-only emphasis in the Title X grant funding announcement, for which the NFPRHA is suing the Trump administration. Many providers are reworking their existing Title X network to include more primary care providers, like community health centers, instead of family planning providers, who specialize in reproductive care, a current Title X grantee told ThinkProgress. (They asked to not be named as they’re competing for funding.)
So, even without a domestic gag rule, the Title X family planning program will likely change to meet the Trump administration’s standards on reproductive care. (Legal action against the Title X funding announcement is trying to immediately block this; NFPRHA is hoping to continue to fund current Title X grantees until a court can rule on the lawsuit.) And even reports of a domestic gag rule exacerbate an ongoing threat reproductive health care providers feel.
The Title X Planned Parenthood clinic in Waco, Texas is always worried about funding, said the site’s nurse practitioner Melissa Lynn. It’s Waco’s only Title X clinic. It temporarily lost Title X funding in 2011, when the Texas health department effectively excluded the provider from the network. Then in 2013, the Obama administration awarded Title X funding to the Women’s Health and Family Planning Association of Texas, a coalition of women’s health providers that contracts with the Planned Parenthood of Greater Texas and by extension the Waco clinic. But this year, the Texas health department is bidding for Title X funds — unlike 2013 and 2015. And again, that funding is at risk.
“In the past when we didn’t have Title X, there are women who go without reproductive health care and that’s birth control — we do pap smears, STD testing, pregnancy testing,” Duncan told ThinkProgress. “Fortunately, we do have donors who have stepped up and many will hopefully — if we do lose funding — still be able to serve some women. But I don’t think it’ll be the number that we have right now.”