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By Adam Sonfield
Senior Policy Manager
In February 2018, the Trump administration took the first of several expected steps to reshape the Title X national family planning program to advance a socially conservative agenda. After a months-long delay, the Office of Population Affairs (OPA) released a funding opportunity announcement (FOA) for Title X service providers that, according to my Guttmacher Institute colleague Kinsey Hasstedt, has the potential to undercut the program’s mission in multiple ways.1,2
First, the FOA is designed to steer Title X funding away from providers that specialize in reproductive healthcare and toward providers that offer family planning services in the context of primary care, such as federally qualified health centers (FQHCs). This shift in the provider network would be in line with a common talking point of social conservatives, who incorrectly argue that FQHCs could readily take on the clients of Planned Parenthood affiliates and other specialized providers.3 In reality, the reach of the Title X program depends heavily on reproductive health-focused providers. Patients choose those providers because of their high-quality, respectful, and confidential care, and FQHCs already are struggling to meet their current demands for care.
Second, the Title X FOA focuses on fertility awareness methods (FAMs) while ignoring patients’ need for a true choice of contraceptive methods. The vast majority (93%) of Title X sites already offer FAM instruction and supplies, but less than 0.5% of Title X clients choose these methods.2 Nevertheless, the FOA repeatedly emphasizes FAMs and promotes the inclusion of sites that offer a single “family planning approach or method”; that may open the door to anti-abortion counseling centers and other sites that would undermine Title X’s commitment to ensuring patients’ contraceptive choices are free from coercion. Notably, the FOA does not ever use the words “contraception” or “birth control.” Nor does it reference the Quality Family Planning guidelines, which OPA developed with the Centers for Disease Control and Prevention and which have served as standards for Title X.4
Third, the FOA promotes abstinence-only-until-marriage messaging in Title X, and does so using coded language such as “avoiding sexual risk” and “returning to a sexually risk-free status.” OPA’s current politically appointed head, Valerie Huber, is a long-time abstinence-only advocate who helped develop that language in an attempt to rebrand the approach, after its reputation had been tarnished by research indicating that abstinence-only programs have been ineffective and harmful for adolescents.5 This abstinence-only emphasis is another departure from the Quality Family Planning guidelines, under which adolescents should be given comprehensive information about how to prevent pregnancy and sexually transmitted infections (STIs), including but not limited to information on abstinence.
Finally, the Title X FOA seems to promote family participation over the right to confidential family planning care. In a departure from previous FOAs, this year’s announcement prioritizes the involvement of parents, guardians, and even spouses, while failing to mention Title X’s long-standing commitment to confidential care and its prohibition on requiring parental consent or notice. In addition, the FOA would have providers subject a minor who has an STI or who is pregnant to “preliminary screening to rule out victimization.” Screening adolescent clients in this way is a step beyond previous Title X requirements to adhere to federal and state notification and reporting requirements and could discourage sexually active adolescents from seeking needed care.
The Trump administration’s funding opportunity announcement has been challenged in court by the National Family Planning and Reproductive Health Association and three Planned Parenthood affiliates.6 As of mid-May 2018, the groups were seeking to block the federal government from using the fiscal year 2018 FOA as the criteria on which to award the next rounds of Title X service grants, and to continue funding current grantees in the meantime. If the administration is permitted to move forward using the FY 2018 funding opportunity announcement, new projects are slated to be funded starting on September 1.
Meanwhile, the Trump administration has signaled that additional attacks on Title X are in the works. The administration’s budget request to Congress included language that would prohibit Planned Parenthood health centers nationwide from participating in all federal programs funded through the U.S. Departments of Labor and Health and Human Services.7 This would include not only Title X grants, but also reimbursement for serving Medicaid clients and participation in funding streams to promote maternal and child health, prevent HIV and other STIs, and provide breast and cervical cancer screenings.
So far, Congress has failed to enact such a prohibition, but anti-abortion lawmakers and advocacy groups have been pressuring the administration to act on its own, and leaks from within the administration indicate that something may be imminent.8 One possibility is imposing a so-called domestic gag rule within Title X. That policy was advanced initially by the Reagan administration in 1988 but was held up in court and eventually rescinded by the Clinton administration.9 The domestic gag rule would force Title X providers to withhold information about and referral for abortion, in a reversal of the program’s long-standing requirement that providers offer nondirective counseling on and referral for the full range of pregnancy options.10 It also would impose unnecessary and onerous requirements that Title X sites be physically separate from sites that offer abortion care with non-federal money, going well beyond the statutory ban on Title X dollars being used for abortion care.
Editor’s Note: On May 22, the Trump administration issued a notice of proposed rulemaking to further restrict and reshape the Title X program. The next Washington Watch column will provide details and analysis.
Financial Disclosure: Consulting Editor Robert A. Hatcher, MD, MPH, Nurse Planner Melanie Deal, MS, WHNP-BC, FNP-BC, Author Rebecca Bowers, Washington Watch Author Adam Sonfield, Executive Editor Shelly Morrow Mark, Copy Editor Savannah Zeches, and Editorial Group Manager Terrey L. Hatcher report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.