Title X and Trump’s Domestic Gag Rule

The United States introduced its first official domestic family planning program for low-income Americans in 1970: the Family Planning Services and Population Research Act, Title X of the Public Health Service Act (known by the shorthand Title X, which is pronounced “ten”). Republican President Richard Nixon oversaw the program’s development and implementation, demonstrating just how bipartisan U.S. support for family planning once was.

How Title X Works

Clinics in the United States that provide family planning can apply for Title X grants, which allow them to offer services to patients on a sliding, income-based scale. In 2017, 3.6 million people were financially assisted by Title X subsidies. A total of 4 million Americans obtained services at clinics receiving Title X grants (this number is higher than the number who received subsidies because people with Medicaid and other forms of public and private insurance also visit Title X clinics).

Title X grants cover a broad array of services that fall under the umbrella of family planning: contraceptive services, supplies, and information; breast and cervical cancer screenings; and STI prevention, testing, and treatment. In keeping with federal law (the Hyde Amendment), Title X funds are not permitted to be used for abortion services.

Title X Budget

Total appropriations for 2019 are $286.5 million, down from a high of $317.5 million in 2010 (when there were 1.5 million fewer women of reproductive age in the United States, and when the value of a dollar was higher).

The $286.5 million appropriated for 2017 (the enacted amount has been identical every year since 2014, and Trump has requested the same amount in his Fiscal Year 2020 budget) was distributed as 89 grants to 47 state and local health departments and 42 NGOs, covering all 50 states, the District of Columbia, and 8 U.S. territories. A total of 3,858 service sites received funds.

New Funding Rule

The Department of Health and Human Services (HHS) introduced a new funding rule to the Federal Register on March 4, 2019. Barring successful legal challenges, which immediately started mounting, the rule will go into effect on May 3, 2019. Some aspects of the rule won’t require compliance until March 4, 2020, but most stipulations would require immediate compliance. The draft rule was proposed on June 1, 2018, and garnered hundreds of thousands of comments during the 60-day public comment period.

The Funding Changes, Explained

The politically motivated funding changes to Title X will amount to a domestic gag rule if implemented. In addition to twice referring to a fetus as an “unborn child,” which is not a medical term, the new rule prioritizes natural family planning and abstinence, especially for adolescents, and imposes new barriers to abortion access.

Currently, Title X clinics must offer all FDA-approved methods of contraception. Under the new rule, clinics that only offer natural family planning—and not a single FDA-approved method of contraception—will be eligible for grants.

Currently, all options must be discussed with patients during pregnancy counseling, including the option to terminate. The new rule will prohibit clinics from referring patients to abortion providers unless patients state a desire to terminate their pregnancies, unprompted by clinic staff. Clinic staff will also, however, be able to refuse to refer patients to abortion providers if they personally object to the procedure on “moral” grounds.

Currently, clinics that receive Title X grants for family planning services are able to offer abortion services with separate, non-federal funding. Under the new rule, clinics will have to draw a “bright line” between the two services: separate accounting, physical spaces, staff, contact info, patient health records, etc.

Currently, minors’ privacy is protected when seeking family planning services from Title X providers. Under the new rule, clinic staff will be required to document that they attempted to involve family members in the family planning decisions of minors. This will be disastrous for minors who are being sexually abused by family members, or who would rather not seek family planning services than have their parents or guardians know they are engaging in sexual activity.

Targeted Attack on Planned Parenthood

This new funding rule is an obvious attack on Planned Parenthood, whose clinics make up only 13 percent of Title X grantees, but cover the family planning needs of 41 percent of women who rely on Title X. Planned Parenthood provides comprehensive reproductive health care, including birth control, STI screenings and treatment, breast and cervical cancer screenings, sex education, and, yes, abortion.

Because it has been illegal to use federal funds for abortion since before Title X was introduced, Title X grants have never been used to pay for abortion. Requiring Title X clinics to have a separate physical space, separate accounting, separate staff, etc. places an insurmountable—or undue—burden on family planning clinics that also provide abortion. Of course, the intention of the Trump administration is for the new rule to be an insurmountable burden: Opponents of Planned Parenthood want to see all federal funding to the organization cease. This new rule will give them the justification they need to stop considering Planned Parenthood for Title X grants.

According to the Guttmacher Institute, excluding Planned Parenthood from Title X will require other Title X clinics to increase their client caseloads by 70 percent, on average.

This domestic gag rule will have innumerable consequences for the patients who rely on Planned Parenthood and other abortion-providing family planning clinics for their subsidized health care services.

Although the new rule was set to go into effect on in early May 2019, it was quickly challenged across the country by multiple state attorneys general, as well as patient and provider advocacy groups. In late April, a federal court in Washington state granted an injunction, ordering the rule delayed nationwide. The Trump administration has already promised to appeal the ruling, and the long term outcome remains unclear. But at least for the time being, Title X patients can breathe a sigh of relief.

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