Over 1000 Family Planning Sites Closed after 2019 Title X Changes

Updated: Mar 25


Remember when the Trump administration changed the Title X rules and Planned Parenthood (and others) decided that they had to withdraw from the program? The revised rules, after surviving several court challenges, were implemented in July 2019. How have the changes affected the communities that were being served by the only Federal program dedicated solely to the provision of family planning and reproductive health care?


Here’s what I've learned: In the five months since the program was implemented…


…forty percent of Title X programs in 28 states withdrew completely from the program, closing over 1000 service sites and losing at least 1.5 million patients.[1]


The service sites included federally qualified health centers, local health departments, hospital clinics, nonprofit providers, and Planned Parenthood affiliates. What rule changes would cause 1000 clinics dedicated to the provision of family planning and reproductive health care to voluntarily withdraw from receiving the precious resources that fund their work?


Five changes in the new Title X rules that led to >1000 clinic closures


1. Requiring physical and financial separation from locations that provide abortion services

2. Removing the requirement to provide pregnancy options counseling

3. Prohibiting referrals for abortion and mandating referrals for prenatal care

4. Requiring that counseling be done by MDs or APPs (advanced practice professionals)

5. Removing the requirement to provide “medically approved” methods of contraception


Let’s unpack these new requirements to see what’s actually under the hood.


1. Requiring physical separation from locations that provide abortion services

With the new rules, if a program provides abortion services in one location, Title X funding is no longer available for family planning services in any location. If a state-wide family planning program offered abortion services at one of their clinics, none of the other clinics in the state program could obtain Title-X funding. This applies to all health care organizations, including Planned Parenthood clinics, state health departments, and physician’s offices in medical systems and health care complexes.


There is no medical or safety reason for this separation of services;

it is solely to limit the number of clinicians and reproductive health clinics

that offer abortion services.


2. Removing the requirement to provide pregnancy counseling

The rule changes eliminate Title X’s long-standing requirement that all pregnant patients be offered nondirective pregnancy options counseling, including information about parenting, adoption and abortion.[2] Title X funding recipients are no longer required to offer pregnancy counseling or information on abortion. They are allowed to offer pregnancy counseling “so long as this counsel in no way promotes or refers for abortion as a method of family planning.”


The revised rules repeatedly refer to “abortion as a method of family planning.” In my experience, women, health care providers in general, and abortion providers in particular do not consider abortion to be a method of family planning. In fact, women who choose to have an abortion are educated on contraceptive options and encouraged to adopt a method at the time of their abortion procedure. Most are actually provided with their chosen birth control method before they leave the clinic. But here is the Trump administration’s irrational rationale:


“the Department believes that, in most instances

when a referral is provided for abortion, that referral necessarily

treats abortion as a method of family planning.”


According to the new rules, the referral to an abortion provider and the abortion procedure itself “are so linked” that giving a woman a referral “makes the Title X project or clinic a program one where abortion is a method of family planning.” To them, getting a referral for an abortion is the same as getting an abortion, which I can say in complete confidence is not what the woman thinks.


3. Prohibiting referrals for abortion and mandating referrals for prenatal care

Aside from conflating an abortion referral with an abortion procedure, the new rule insists that any woman with a positive pregnancy test gets a referral for prenatal care whether she wants one or not. If the woman instead would like a referral to an abortion provider, she may be refused or she may be given a list of clinicians who are either primary care physicians or obstetricians, “some (but not the majority) of which may provide abortions.” Including abortion providers on the list is not required. And…, wait for it…,


“neither the list nor project staff may identify which

providers on the list perform abortion.”


Yes, you read that right. This is intentionally misleading, compromising the woman’s dignity, her autonomy to make the fully-informed health care decision that is right for her, and undermining her trust in her health care provider and in the health care system. I’d be furious to be treated that way. So is the American Medical Association whose president says…


“…our government has no place dictating the type of care physicians

can provide to patients or controlling what we can say to them.”


She continues, “Anything short of complete openness and honesty inside the exam room undermines the critical patient-physician relationship and represents a fundamental threat to quality care.”[3]


4. Requiring that counseling be done by MDs or APPs (advanced practice professionals)

The new rule says that the nondirective pregnancy options counseling, if provided at all, must be provided by physicians or by other health care providers with at least a Masters’ degree -- nurse practitioners, midwives, physician’s assistants, etc. Up until now, the majority of such counseling has been provided by RNs, health educators, and social workers. These employees are highly- and specifically-trained individuals, unlike physicians and APPs who may never have had any training in pregnancy options counseling.


The use of MDs and APPs to provide in-depth counseling is inefficient, unnecessary, and most significantly cost-prohibitive to many cash-strapped family planning clinics.

Let the expensive and highly skilled practitioners provide the clinical care

and let the trained counselors do the counseling.


There is no legitimate reason for this rule except to add an additional financial burden to the clinics that provide health care to low income communities.


5. Removing the requirement to provide “medically approved” methods of contraception

The reason why Title X was previously mandated to include “medically approved” methods was two-fold: 1) to ensure that Title X sites kept pace with contraceptive advances and 2) to ensure that the program’s predominantly low-income patients had access to the same options available to individuals with greater resources.[2] Removing this mandate serves one purpose only: to allow programs that wish to offer only natural family planning methods and abstinence-only education to receive Title X funds. This is unnecessary. Prior to the implementation of these new rules, 74% of Title X clinics offered a full range of contraceptive methods onsite and 93% offered natural family planning instruction or supplies.[2] It is clear to me that:


…the new rules are intended to provide government funding

to anti-abortion, anti-contraception, faith-based clinics.


Conclusion:


Fifty years ago, Title X family planning program legislation was created with bipartisan support, was championed by Congressman George H.W. Bush, and was signed into law by President Richard Nixon.[4] Its mandate was, and still is, to help Americans, especially in low-income, uninsured, young women and men, and underserved communities, access high quality family planning and related reproductive health care. It is the only federal program that supports these goals.[4]


Unfortunately, the new rules disproportionately affect that

same population who have faced a

long history of reproductive coercion by federal government programs.[5]


The most common reason women say they go to Title X clinics is that they feel that the staff there treat them respectfully.[4] I’m afraid the Trump administration’s new Title X rules will interfere with health care providers’ ability to maintain that. Many clinicians say that following the new rules goes against their Hippocratic Oath. Behind exam room doors, some are choosing to abide by their medical ethics in defiance of these government restrictions. Others have had to shut their doors. The clinics that have closed have not been replaced depriving thousands of women and men from not only reproductive health care but from breast examinations, cervical and testicular cancer screening, blood pressure checks, STD testing, and other health screening and intervention services. This is occurring at the same time that reproductive health clinics are trying to deal with a global STD epidemic.


Though the new Title X rules went into effect in July 2019, supporters of family planning services unencumbered by ideological, religious, and partisan restrictions are awaiting further rulings from district court-level actions. While the legal battle continues, 1.5 million Americans search for new sources of reproductive health care.


REFERENCES

Unless otherwise marked, all wording within quotation marks is taken directly from the final rule published here: https://www.federalregister.gov/documents/2019/03/04/2019-03461/compliance-with-statutory-program-integrity-requirements

[1] Eikner D. What now? The New Reality of Title X and STDs. Slide presentation at STD Engage conference, November 20, 2019. Washington, DC.

[2]https://www.guttmacher.org/article/2019/03/what-trump-administrations-final-regulatory-changes-mean-title-x

[3] https://www.ama-assn.org/delivering-care/patient-support-advocacy/title-x-gag-rule-what-s-line-upcoming-oral-arguments

[4] https://www.guttmacher.org/gpr/2017/01/why-we-cannot-afford-undercut-title-x-national-family-planning-program.

[5] https://www.guttmacher.org/article/2019/03/what-trump-administrations-final-regulatory-changes-mean-title-x

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