In a move being lauded by anti-abortion advocates and criticized by abortion rights supporters, the Trump administration plans to withhold federal funding from health clinics and departments that provide abortion services or referrals.
The new rules, finalized last month, will apply to Title X, a historically bipartisan program that represents the federal government’s only funding stream exclusively for family planning. They will shift the program's funding away from reproductive health clinics and toward faith-based clinics that emphasize fertility awareness and abstinence education.
Title X money largely benefits low-income patients and is spent on women's health services, such as birth control, pregnancy testing, STI treatment and cancer screenings -- but not abortions. The 1976 Hyde Amendment prevents federal dollars from directly funding abortions. The Trump administration's rules take Hyde to the next level, banning Title X from funding providers for, at a minimum, letting patients know abortion is an option even if they do not perform the procedure themselves.
Title X is estimated to serve 4 million Americans and 4,000 clinics. On average, it makes up about 19 percent of grantees' revenue, according to the Kaiser Family Foundation.
The changes at the federal level mirror policies that some conservative states have been pursuing for years. For a glimpse into this new era of Title X, experts suggest looking to Texas. In 2011, Texas passed a law that cut state family planning dollars by 66 percent and redirected state family planning funding away from reproductive health clinics and toward general primary-care providers.
In response, the Obama administration cut all of the state's Title X funding because the state law did not follow the program's guidelines at the time.
“Texas was very instructive,” says Jessica Marcella, vice president of advocacy and communications for the National Family Planning and Reproductive Health Association, an organization that opposes the new cuts. “If the [Trump] administration is successful, health outcomes could be severely impacted. The fact is, when you move away from science, you’re ignoring public health.”
As a result of the 2011 law in Texas, the state's Health and Human Services Department, which served around 244,000 women, lost Title X funding. Within a year, 82 clinics across the state closed -- a third of which were run by Planned Parenthood.
According to a 2016 study by the New England Journal of Medicine, births among Texas women covered by Medicaid increased 27 percent, and there was a 36 percent drop in claims for long-acting reversible contraceptives, such as IUDs. There was also anecdotal evidence of STD upticks in areas where clinics closed. Another New England Journal of Medicine study in 2015 found that teenagers had to travel further to receive confidential care.
"The exclusion of Planned Parenthood affiliates from a state-funded replacement for a Medicaid fee-for-service program in Texas was associated with adverse changes in the provision of contraception," the 2016 study noted.
There’s been some recovery of Title X funding in recent years. In 2013, the nonprofit Women’s Health and Family Planning Association of Texas received a Title X grant, which it disperses to reproductive health clinics and organizations across the state, including those run by Planned Parenthood as well as city- and county-run clinics.
In an attempt to make up for the loss of clinics, the state launched the Healthy Texas Women program in 2016. At participating providers, it covers pregnancy testing and counseling, family planning, breast and cervical cancer screenings and immunizations at no cost to low-income women. But it excludes abortion services.
While these are positive developments, “the reality is the number of women receiving services through the state in 2018 still falls below the number of women served in 2011,” says Kami Geoffrey, CEO of the Women’s Health and Family Planning Association of Texas.
The Future of Title X
On Tuesday, the American Medical Association announced it was filing suit against the changes to the federal program. The day before, California Attorney General Xavier Becerra announced his own lawsuit to block Trump's Title X changes. Separately, 20 other state attorneys general plan to sue.
Pending legal challenges, the Trump administration's new rules are set to go into effect in May. It’s too soon to know how many Title X-funded clinics will lose funding or face potential closure as a result.
Supporters of the new Title X rule argue that women can still receive the care they need at federally qualified health centers and other community health clinics that traditionally don't offer abortion services.
But if Texas serves as an example, the future for low-income women seeking health care is more complicated than that.
“Eliminating providers and assuming others can pick up the slack is erroneous thinking," says Geoffrey. "Just because you give money to a clinic doesn’t mean overnight they’ll have the space and the staff to offer those services to more clients.”