Every year, nearly 4 million people rely on the Title X family planning program for birth control, STI testing and treatment, and cancer screenings, among other things. For anyone unfamiliar, this federal grant program funds clinics to help guarantee access to a variety of family planning and preventive health services for primarily low-income people or those who are uninsured.
When people are able to get the birth control that best fits their needs, they’re less likely to have an unintended pregnancy. And Title X clinics and the health care providers they employ are more likely to offer a full range of contraceptive options than public clinics that don’t receive Title X funds, according to a 2017 report by the Guttmacher Institute. So it should come as little surprise that Title X clinics were estimated to help prevent over 800,000 unintended pregnancies a year.
Yet, last month, the Trump administration proposed dramatic rule changes to the Title X program, changes that could potentially restrict access to all of the services I just mentioned.
At this point you might wonder, “But why fix what isn’t broken?” Well, these rule changes represent yet another part of this administration’s wide-reaching strategy to dismantle access to reproductive health care, namely abortion services.
When reading through the proposed changes (which you can read in full here), many of the them sound harmless. Who wouldn’t want a program to “ensure a holistic and health-centered approach” to a person’s family planning needs, as the U.S. Department of Health & Human Services (HHS) announcement read? But as with so many of the devastating policies that have been promoted by the Trump-Pence administration, the devil is in the details.
Depending on how the rules are interpreted and enforced, the result could be the closure of family planning clinics or a greatly reduced ability for clinics to see low-income patients. This is especially worrisome because health centers like Planned Parenthood (which would almost certainly be barred from participating in Title X) are the sole providers of family planning services in 33 percent of the counties served by Title X clinics.
Because some of the rule changes appear to use intentionally vague language, it will be difficult to know exactly how they might affect access to reproductive health care until they are actually implemented. But the medical community is worried: Organizations like the American Medical Association (AMA) and the American Congress of Obstetricians and Gynecologists (ACOG) have issued statements condemning the proposed changes.
That’s why, as an abortion provider and women’s health advocate, I wanted to read between the lines to see what really might be at stake. Let’s unpack a few of the most troubling changes and what they could mean for people seeking reproductive health care.
One of the rule changes focuses on “Protecting Title X health providers so that they are not required to choose between the health of their patients and their own consciences, by eliminating the current requirement that they provide abortion counseling and referral.”
This sounds like a deceptive way of saying that your health care provider could withhold information about safe, legal, evidence-based treatment when you are seeking options and/or counseling for an unintended pregnancy.
While existing law already protects the conscience rights of health care providers to refuse to provide abortion, it is clearly unethical to refuse to give a referral so that people can get the care they need elsewhere, even if you as a physician cannot offer it.
This rule also prioritizes the conscience rights of the health care provider over the conscience rights of the patient. Every day in my clinic, I care for patients who choose abortion or contraception because of their moral and ethical beliefs, not in spite of them. Compassionate health care must always center the needs of the patient—not the beliefs of the provider.
The HHS statement goes on to say that the rule changes “would not bar non-directive counseling on abortion, but would prohibit referral for abortion as a method of family planning.”
Imagine any other situation in which your health care provider is required to withhold information about a legitimate procedure that could treat your health condition. The thing is, non-directive counseling is already the standard of care for health care providers. When we provide a patient with care, we review all treatment options, including the risks and benefits of each option, and give patients every piece of information they need in order to make an informed decision.
One line in the proposal argues that “referrals for abortion are, by definition, directive.” But simply offering referral information is not coercive and does not “promote” abortion. Rather, it meets basic standards of medical ethics, which require that referral information be provided so that patients are fully informed and can get safe health care elsewhere if they need to.
So what would non-directive counseling on abortion look like under these restrictions? If you specifically asked for a referral for abortion, you might be given a list that includes places that may or may not provide abortion care. In fact, the list must include facilities that do not provide abortion at all, according to the proposal, and health care providers would not be allowed to tell patients which facilities provide abortion and which ones do not.
Even a health care provider who strongly supports your right to decide what to do with your own body would apparently be barred from providing a referral for abortion.
Another aim of the new proposal is “requiring clear financial and physical separation between Title X funded projects and programs or facilities where abortion is a method of family planning.”
This specifically targets health centers like Planned Parenthood, which provide a wide range of reproductive health services in addition to abortion.
Even though Title X funds are already prohibited from being used for abortion services, this new regulation will prohibit any organization that provides abortion services at any of its locations, at any time, from receiving Title X grants at all, meaning it also no longer gets funding for non-abortion things like STI testing and cancer screenings.
The proposal states that the department wants to ensure “Title X funds are not being used to build infrastructure that supports, or may be used to support, the separate abortion business of a Title X grantee or subrecipient.” Based on this phrasing, this rule sounds like it could even exclude clinics that employ a doctor, nurse, or other health care professional who provides abortion elsewhere in their free time, even if those services are not offered at that Title X clinic, given that employing someone who also provides abortions might not be considered a clear financial separation.
When clinics lose funding, they are often forced to decrease the number of patients they can see. Sometimes those clinics close completely. And fewer clinics means decreased access to essential reproductive health care for people who need it the most.
Texas is a great example of what happens when family planning clinics are defunded. In the two years after the state legislature stripped funding from family planning clinics in 2011, Texas clinics served fewer than half the number of patients they had been able to see before the cuts. One study conducted a year after the legislation was enacted that enlisted focus groups of women in nine metropolitan areas of Texas also found that following the funding cuts, women reported paying more for routine care, experiencing unplanned pregnancies, and going without recommended follow up appointments. (The majority of the women were not aware of the legislative changes, the study authors point out.)
Another rule change would “require clinics to encourage meaningful parent/child communication and, as required by federal law, encourage family participation in a minor’s decision to seek family planning services, giving practical ways to begin—and maintain—such communication.”
Again, this sounds like a harmless idea. Who wouldn’t want to encourage young people to involve a parent or other trusted adult in their health care decisions, right? The issue is that the rule change is unnecessary: Title X clinics are already required to discuss parental involvement with their young patients. From what it sounds like, this new rule would increase oversight of exactly how Title X clinics talk to young people, which makes health care professionals worry that the government may soon be somehow inserting themselves into discussions between patients and providers.
Current Title X rules specifically allow young people to access care without parental involvement. While most adolescents involve a parent or trusted adult in their medical decision-making, some teens do not, sometimes because of abuse, neglect, or fear of severe punishment. This makes Title X clinics crucial resources for teens: If young people fear that their confidential medical information may be disclosed to a parent or guardian, they may decide to go without necessary care.
This rule change, and the increased surveillance it would require, raises suspicions that this administration will overstep their bounds when it comes to adolescents’ medical decision-making. It’s not a stretch to fear that the next rule change may require parental involvement. Several of the senior officials at HHS (which is the government agency that oversees Title X) have expressed anti-abortion and anti-contraception views, as well as inaccurate information about adolescent health that should cast doubt on their ability to administer the Title X program fairly, and without bias against young people.
Title X is a lifeline for millions of Americans and should be administered according to the best available medical evidence and standards of care.
The proposed rule changes threaten the effectiveness of the program and infringe upon the rights of the people who rely on it for basic reproductive health care. If you’re concerned about the proposed rule changes and want to get involved, you can submit public comments on this website until July 31, 2018.
Dr. Diane Horvath-Cosper is the medical director at Whole Woman’s Health of Baltimore. You can find her on Twitter @GynAndTonic.