For half a century, Title X has been the only national, publicly funded family planning program, and as such it acts as a critical safety net, providing patients with low- or no-cost services they may not be able to receive elsewhere. In addition to family planning services, including contraception counseling and provision and screening and treatment for sexually transmitted infections (STIs), Title X also covers key preventive services, such as cancer screenings and services related to substance use disorders. The Title X network is made up of public and private nonprofit providers, such as federally qualified health centers, community clinics, and clinics focused on sexual and reproductive health care.
This crucial program, though, was undermined by rules issued by the Trump administration. The regulations are known informally as the Domestic Gag Rule for their similarities to the Mexico City Policy—or Global Gag Rule—which was also reinstated and expanded under President Trump. Both policies use the issue of abortion as a guise to place restrictions family planning funding, despite the fact that federal funds are not used for abortion services (other than very narrow exceptions). In the case of the Domestic Gag Rule, onerous restrictions that place an unnecessary burden on recipients of Title X funding that also provide abortions with nongovernment or private funds—as well as rules that contradict the delivery of patient-centered care—have decimated the program’s network of sexual and reproductive health care providers.
The Biden–Harris administration has promised to undo this damage, and the Office of Population Affairs (OPA) within the Department of Health and Human Services (HHS) recently released proposed rules that would reverse the harms caused by the Trump-era regulations.
Trump Administration Rules and Their Impacts
In March 2019, the HHS finalized regulations that severely restrict the services that recipients of Title X funds can provide. These new rules use a different interpretation of Section 1008 of the Title X statute that states, “none of the funds appropriated under this title shall be used in programs where abortion is a method of family planning.” In the past, Title X grantees had abided by this section by having financial separation of Title X funding from funds used to provide abortion services. The broader interpretation from the Trump administration bans Title X grantees even from simply providing pregnant clients with referrals to an abortion provider—the “gag” in the Domestic Gag Rule—and places excessively stringent requirements for the complete physical and financial separation of Title X-funded services from abortion-related activites. These rules target Title X recipients that also provide abortion services even though they do so with funding streams that are entirely separate from federal dollars.
The Trump administration rules also removed the requirement that sites that receive Title X funding provide nondirective pregnancy options counseling, a change that directly opposes Centers for Disease Control (CDC) and OPA recommendations for the provision of quality care. In practice, this means that—in addition to being barred from actually providing abortion referrals—sites could now provide patients with received biased and incomplete information, such as resources on prenatal care only. Nondirective pregnancy counseling is critical to ensuring that pregnant people have full informed consent to make decisions free from coercion. This rule change was particularly worrisome when considering that the Trump regulations also opened up Title X funding to groups such as Obria, which does not provide any form of hormonal contraception and openly pushes an anti-abortion agenda. In addition, the rules prioritized providers with a focus on primary care over reproductive health care, and encouraged the participation of “non-traditional” providers that only offer one means of pregnancy prevention, such as fertility awareness methods.
The response to the Trump administration’s rules from the Title X network was immediate, as providers argued that they go against best practices of providing care, and place unnecessary burdens on grantees. A quarter of grantees withdrew from the program rather than abide by the new regulations, including six states leaving the program entirely—Hawaii, Maine, Oregon, Utah, Vermont, and Washington—and 410 Planned Parenthood clinics that left the program, as the organization as a whole withdrew from Title X as a result of the regulations. Rather than an unintended consequence, the withdrawal of Planned Parenthood affiliates reveals what the rules were designed to do. Prior to the Trump rules, Planned Parenthood provided care to 41 percent of clients receiving Title X services. The rules were part of targeted efforts to stop Planned Parenthood from participating in government programs.
New providers that have joined the program since the Trump rules were issued have not come close to making up for the gap in services caused by Planned Parenthood’s departure, causing a 21 percent reduction in clients served from 2018 to 2019. (For comparison, 2017 to 2018 saw only a 2 percent reduction in clients served.) Preliminary estimates of clients served in 2020, unpublished but cited in the Biden–Harris administration’s proposed rule, point to an even more dramatic reduction of nearly 50 percent. Although the COVID-19 pandemic clearly played a role in this drop in clients, this drastic change is also reflective of reduced capacity during the first full year of the Domestic Gag Rule being in effect.
Who Has Been Most Affected?
By design, the Title X program funds providers that serve patients with low incomes, so any damage to the program will impact availability most for vulnerable populations. In 2019, 64 percent of Title X patients had incomes under 100 percent of the federal poverty level (FPL) and received no-cost services, while an additional 24 percent of clients were between 101 percent and 250 percent of the FPL and received subsidized services.
Black and Hispanic women are also overrepresented among these providers’ clients, and thus disproportionately impacted by attacks on the Title X program. The racial and ethnic disparities in patient demographics seen between publicly funded and privately funded reproductive health care provision are reflective of greater overall trends in economic status, health access, and outcomes resulting from structural racism and racist policies, as well as inequitable distribution of resources and other structural and social determinants. Title X’s very purpose is to expand access to family planning services for individuals that have historically been denied access to high-quality health care and thus reduce health inequities, yet the Trump administration’s rules have exacerbated barriers to access for these same individuals.
Along with reducing access in terms of numbers of grantees, the 2019 rules’ implications for quality of care are particularly problematic given the population served by Title X. Women of color—particularly Black, Latina, and Native women—-and low-income women have been subjected to reproductive coercion throughout the history of the United States. By reducing the availability of Title X–funded providers and allowing directive patient counseling, the Trump regulations threaten the reproductive autonomy of Title X patients and individuals in need of publicly funded family planning services.
The Biden–Harris Administration’s Proposed Rule
On April 15 of this year, HHS officially issued a notice of proposed rulemaking (NPRM) to make good on the Biden–Harris promise to eliminate the domestic gag rule. The new rule would largely rescind the 2019 regulations altogether and put back in place the regulations established in 2000. In addition, new language would require HHS to focus on equity in awarding Title X funds and would introduce requirements to ensure that care is patient-centered, affordable, trauma-informed, and high-quality for all clients, particularly those with low incomes. The regulations also propose increased consideration for clients’ confidentiality and use more inclusive language than previous rules.
Implementation of this rule would restore greater equity to the Title X program, and ensure that patients have access to quality, patient-centered care based on their ability to pay. The return to nondirective counseling will allow grantees to provide care that aligns with best practices and meets the needs of individual clients. These new regulations will allow Planned Parenthood affiliates and other providers to rejoin the program, and return to providing Title X-funded, high-quality care. Rebuilding this network will expand access to sexual and reproductive health care for low-income individuals.
The Biden–Harris Administration had two options in fulfilling their promise to rescind the Domestic Gag Rule: the NPRM, which has been issued, and an interim final rule. The key distinction is the timeline, as the NPRM leaves the Trump-era rules in place until the regulations are finalized and implemented—which will likely be at least five months after the comment period closes on May 17. An interim final rule would allow for immediate implementation of new regulations, which would provide immediate relief to the Title X network and its recipients. It is still possible for the administration to issue an interim final rule while the process for the NPRM is ongoing, and doing so would be beneficial to the program and individuals in need of publicly funded family planning services.
The proposed rule is currently in its thirty-day comment period, meaning that individuals and organizations can submit public comments via the Federal Register until May 17. (Public comments by Dr. Jamila Taylor, TCF’s director of health care reform and senior fellow can be found here.)
HHS should move forward with this proposed rule so that Title X can restore funding to the key providers forced to withdraw from the program. Implementation of these regulations will allow Title X grantees to return to serving clients in patient-centered, nondirective, and equitable manner—fulfilling the program’s goal. All individuals, regardless of income, geography, race, or gender, deserve access to affordable and convenient family planning and preventative services. The rule issued in April would represent critical steps to ensuring this reality, and should be taken up by the agency immediately.
Additionally, HHS should go further to ensure that states do not undermine the Title X program, as eight states currently restrict allocation of Title X funds to exclude certain providers. These state-level policies, like the Domestic Gag Rule, damage the Title X network and access to family planning services. Final regulations should include language that prohibit states from interfering with funding allocation for reasons not related to recipients’ ability to provide Title X services.
The swift implementation of these regulations is critical to restoring the Title X network and ensuring access to family planning services for individuals with low incomes. HHS should finalize the rule as soon as possible so that providers can provide patient-centered, culturally congruent, and high-quality services—as the Title X program should.
header photo: Clinic escort volunteers stand outside of the Planned Parenthood in the Financial District neighborhood of Manhattan in New York City. Source: Michael M. Santiago/Getty Images