Proposed Restrictions on Title X Funds Stirs Up Hornet's Nest

Alicia Ault

May 21, 2018

Although it has not yet been officially released, a Trump administration proposal that would prohibit federal Title X family planning funds from being awarded to clinics that provide abortion services is generating comments about its potential impact from clinician groups on both sides of the abortion debate.

Under current law, funds for Title X — a program established in 1970 to provide family planning and preventive healthcare to low-income Americans — cannot be used to provide abortion or promote abortion as a method of family planning. In practice, many clinics that receive the funds — such as Planned Parenthood facilities — provide abortion services. But those services are funded by private money.

The new rule — which is under review at the White House before being formally published — would block those clinics that receive Title X money from performing abortions.

The White House has not made the proposal available to the public. One media outlet — The Hill — reported on Friday that the White House unveiled the proposal in a telephone call to groups opposed to abortion rights. The Hill said that under the rule, Title X recipients could not be co-located with abortion clinics, and they would no longer be required to tell patients that abortion is an option.

"Gag Rule" Under Scrutiny

That last point is of concern to women's healthcare providers.

Hal Lawrence, MD, executive vice president and CEO of the American Congress of Obstetricians and Gynecologists, said in a statement emailed to Medscape Medical News, "The anticipated changes to Title X issue an ultimatum to qualified health care providers, forcing them to not only stop offering abortion in order to continue being eligible for Title X grants, but to altogether cease inclusion of abortion care in discussion of women's reproductive health choices, thereby turning back the clock on women's health."

Restricting access to Title X funding "is likely to shutter health centers or dramatically narrow the scope of care health centers are able to provide," he added.

"This 'gag rule' is not only unconscionable, but it undermines medical ethics by forcing health care professionals to withhold accurate and timely medical information from patients," said Jenn Conti, MD, a fellow with Physicians for Reproductive Health, in a statement.

"If I can't mention the word 'abortion,' then I am not providing my pregnant patients who want to know all of their options with complete, accurate, unbiased medical information," she said.

The White House said the rule would not include a strict prohibition on abortion discussions. "Contrary to recent media reports, [the US Department of Health and Human Services' (HHS')] proposal does not include the so-called 'gag rule' on counseling about abortion that was part of the Reagan Administration's Title X rule," said an unnamed White House press secretary in a statement.

The proposal "would ensure compliance with the program's existing statutory prohibition on funding programs in which abortion is a method of family planning. The new proposed rule would not cut funds from the Title X program. Instead, it would ensure that taxpayers do not indirectly fund abortions," said the statement.

Many groups that oppose abortion rights said they were pleased. "The American Association of Pro-Life Obstetricians and Gynecologists (AAPLOG) applauds President Trump's common sense clarification of the original purpose of Title X, which explicitly did not support pushing abortion as a method of family planning," said Donna Harrison, MD, executive director of AAPLOG, in a statement emailed to Medscape Medical News.

The Susan B. Anthony (SBA) List, an organization that had lobbied for the rule, called it a "major victory." SBA List President Marjorie Dannenfelser said in a statement, "President Trump has shown decisive leadership, delivering on a key promise to pro-life voters who worked so hard to elect him."

The rule "doesn't cut a single dime from family planning. It instead directs tax dollars to Title X centers that do not promote or perform abortions, such as the growing number of community and rural health centers that far outnumber Planned Parenthood facilities," she added.

The SBA List said that Planned Parenthood receives $50 million to $60 million a year from Title X. The Title X program was allocated $286 million in 2018, according to the group.

"Family planning at Planned Parenthood means access to abortion," said Christina Francis, MD, chairman of the AAPLOG board of directors, in the statement sent to Medscape Medical News. Francis added, "President Trump's proposed Protect Life rule recognizes that women don't need abortion. Title X dollars aren't being cut, but simply redirected to abortion-free providers."

Legal Challenges Expected

A group of Democratic senators who had urged against the rule estimated that Planned Parenthood serves 40% of Title X patients. About 4000 Title X–funded centers provide preventive healthcare — such as Pap smears, HIV testing, and breast examinations — to some 4 million men, women, and adolescents. Of those patients, two thirds have incomes below the federal poverty level, and 43% are uninsured, said the senators in a Politico article.

The concern is that the proposal will revive a rule issued by President Ronald Reagan's administration in 1988. At the time, multiple organizations filed suit the same day to block the rule, which kept it from going into effect. The case went to the US Supreme Court, which in 1991 determined that the so-called gag rule was legal. When HHS attempted to put the rule back into effect, physician organizations, including the National Family Planning and Reproductive Health Association, sued again. Eventually, the gag rule went into effect — for just a month, until President Bill Clinton rescinded it by executive order in 1993.

The rules governing Title X that have been in effect since 2000 require financial, but not physical, separation of Title X and non–Title X activities and allow healthcare providers to counsel patients about abortion.

Legal challenges to the new Trump rule — when issued — are expected.

In early May, Planned Parenthood of Wisconsin, Planned Parenthood of Greater Ohio, and Planned Parenthood Association of Utah filed suit, along with the National Family Planning & Reproductive Health Association, against the Trump administration in federal district court in Washington, DC, alleging that a February call for Title X grant applications was illegal because it was "changing the program so that it no longer focuses on either birth control or reproductive health care and instead pushes patients toward abstinence and tries to keep patients from coming to Planned Parenthood," said the group in a statement.

The Title X statute and regulations make it clear that the program "is meant to provide comprehensive, evidence-based contraception and reproductive health services," they said.

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