How the Tighter Restrictions on the Title X Program Impacted Family Planning Services for People Across the United States

by Brittney Ehlers

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The Title X program has been an essential federal program providing contraceptive and reproductive health services for over 50 years. It is the only federally funded family planning program in the United States and provides essential, low-cost contraceptive methods and reproductive health care to millions of people nationwide.

However, in recent years the Title X program has been under attack. The Trump Administration finalized the 2019 Final Rule initially promulgated under the Reagan Administration that placed tighter restrictions on all grantees under the program. This “gag rule” prohibited providers from offering resources or referrals to abortion-related services to their clients. Under these new restrictions, Title X grantees were barred from providing resources or referrals to abortion-related services and must be fully physically and financially separated from any abortion-related activities. These restrictions drastically undercut the existing network of providers and has impacted the ability of millions of Americans nationwide to receive essential reproductive health services.

The Disappearing Title X Network

Although the Title X program has provided essential services for decades, the program has continuously suffered funding cuts since its inception. Between 2010 and 2016, appropriations for the program fell from $317 million to $286 million- a nearly 25% decrease in funding over the 6 years. During the same time, unmet need for contraceptive services rose, with seventeen states seeing a greater than 15% increase in need for services. For the over 4 million people receiving low-cost reproductive health and family planning services through the program, this decrease in funding has been catastrophic.

The 2019 Final Rule - What Happened

To make matters worse, the Trump Administration finalized their 2019 Final Rule on the program which caused many grantees to pull out of the network because they were unable to abide by the tighter restrictions. To explain this further, I have included a table below with information taken from the Federal Registrar which outlines some of the major changes imposed under the new rule:

Source: Federal Registrar 2019;42(59):14312

Title X projects were required to provide an array of medically approved family planning methods (including natural ones) as well as services for adolescents.

Contraceptive methods do not need to be medically approved and can include natural family planning methods or other fertility awareness-based methods as well as information and referrals to adoption.

Physical and Financial Separation

Initial program stated that a grantee’s abortion services must be “separate and distinct” from Title X project activities. They could share a common facility, waiting room, staff, and record system as long as it is possible to distinguish between the two.

The rule requires Title X projects to be “physically and financially” separate from prohibited activities relating to abortion including providing abortion services, referrals, or advocacy. All facilities, waiting rooms, staff, and records must be completely separated and Title X funds cannot be used to build facilities that offer abortion services.

Services for Pregnant Clients

Projects were required to offer pregnant clients with information and nondirective counseling on the following: prenatal care, infant care, foster care services, adoption services, and abortion. They were required to offer referrals upon request of the client, including referrals to abortion providers.

All prior requirements were removed. Additionally, projects must refer pregnant clients to health providers that offer prenatal health care.

Under the new rule, service sites no longer had to provide an array of diverse contraceptive methods and could instead, select the methods they desired. This means that sites under the program don’t necessarily have to offer IUDs, implants, and contraceptive pills, and could instead choose to only offer non-medical, abstinence only, or fertility awareness-based methods which, if used incorrectly, have a higher failure rate than medical methods.

Most importantly, under the new rule all service sites were required to be physically and financially separate from programs offering abortion related services, and all pregnant women, regardless of their desired pregnancy outcome, MUST receive prenatal care services. This removes all reproductive autonomy from the pregnant person, as they are no longer able to receive nondirective care that fully meets their pregnancy needs and fertility intentions.

So, what exactly did this mean for the Title X network?

These tighter restrictions meant that many grantees could not continue to offer services and comply with the new requirements. As a result, over 1000 clinics pulled out of the Title X program. Over 400 of those clinics were Planned Parenthood Sites. The final rule reduced network capacity by almost half nationwide, and 6 states — Hawaii, Maine, Oregon, Utah, Vermont, and Washington - lost all Title X providers. The Guttmacher Institute estimates than in order to continue providing all clients in need of family planning services, other safety-net program will have to increase their caseloads by an average of 70%.

The departure of these clinics has left contraceptive deserts across the country, and of the nearly 20 million women nationwide in need of contraceptive services, over 1.6 million of them now live in a county without access to a single health center that offers a full range of contraceptive methods.

Where we go from here.

Immediately after inauguration, President Biden has taken steps to reverse the domestic gag rule and ordered the immediate review by the Department of Health and Human Services (HHS) of the 2019 Final Rule. The U.S. Supreme Court has also agreed to review a lawsuit filed by several organizations that state the tighter restrictions directly violate federal law and the Affordable Care Act (ACA). A provision in the ACA prohibits the HHS with interfering with communications about a full range of treatment options between a patient and provider. Under the current ACA, the HHS cannot violate ethical standards of health care professionals and does not have the authority to restrict providers from disclosing all information to patients, even in seeking abortion related care and services.

There is no doubt that the restrictions issued on the Title X program in 2019 increased barriers to affordable and accessible reproductive health services for millions of women. The true implications of these restrictions have yet to be seen as provider networks capacities were cut and states with the highest reduction of the Title X program will feel the greatest impacts. Steps must be taken to prevent another gag rule from being imposed on the program in order to ensure that every person has the right to fully informed reproductive health care.

Sources:

1. Gold RB. Title X: three decades of accomplishment. Issues Brief (Alan Guttmacher Inst). 2001;(1):1–4.

2. Frost JJ et al., Publicly Supported Family Planning Services in the United States: Likely Need, Availability and Impact, 2016, New York: Guttmacher Institute, 2019, https://www.guttmacher.org/report/publiclysupported-FP-services-us-2016.

3. Congressional Research Service. Title X (Public Health Service Act) Family Planning Program. Washington DC: Congressional Research Service; 2017:1–17.

4. Compliance with statutory program integrity requirements. The Federal Register / FIND. 2019;42(59):14312. https://www.federalregister.gov/documents/2019/03/04/2019-03461/compliance-with-statutory-program-integrity-requirements

5. NFPRHA-Interactive Map — National Family Planning & Reproductive Health Association. Nationalfamilyplanning.org. https://www.nationalfamilyplanning.org/pages/issues/nfprha-interactive-map. Published 2020. Accessed May 2, 2021.

6. Key Information About West Virginia. Powertodecide.org. https://powertodecide.org/sites/default/files/2019-12/Key%20Information%20West%20Virginia.pdf. Published 2019. Accessed May 2, 2021.

7. Frederiksen B, Salganicoff A, Gomez I, Sobel L. Data Note: Impact Of New Title X Regulations On Network Participation. Kaiser Family Foundation; 2019. https://www.kff.org/womens-health-policy/issue-brief/data-note-impact-of-new-title-x-regulations-on-network-participation/#:~:text=Data%20Note%3A%20Impact%20of%20New%20Title%20X%20Regulations%20on%20Network%20Participation,-Brittni%20Frederiksen%20%2C%20Alina&text=These%20new%20regulations%20prohibit%20any,physical%20separation%20from%20abortion%20services. Accessed May 1, 2021.

8. Dawson R. Trump Administration’s Domestic Gag Rule Has Slashed The Title X Network’s Capacity By Half. Guttmacher Institute; 2020. https://www.guttmacher.org/article/2020/02/trump-administrations-domestic-gag-rule-has-slashed-title-x-networks-capacity-half. Accessed May 1, 2021.

9. Hasstedt K. Beyond The Rhetoric: The Real-World Impact Of Attacks On Planned Parenthood And Title X. The Guttmacher Institute; 2017:Vol 20. https://www.guttmacher.org/gpr/2017/08/beyond-rhetoric-real-world-impact-attacks-planned-parenthood-and-title-x. Accessed May 1, 2021.

10. Birth Control Access. Powertodecide.org. https://powertodecide.org/what-we-do/access/birth-control-access. Published 2021. Accessed May 1, 2021.

11. Robeznieks A. Why the Supreme Court should take up Title X gag rule case. American Medical Association: Patient Support & Advocacy. 2020. https://www.ama-assn.org/delivering-care/patient-support-advocacy/why-supreme-court-should-take-title-x-gag-rule-case. Accessed May 1, 2021.

12. Federal Registrar. Federal Register/Vol. 86, №71/Thursday, April 15, 2021/Proposed Rules. Office of the Federal Registrar, National Archives and Records Administration; 2021.

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