Last month’s “Washington Watch” column walked through the Trump administration’s first major step to reshape the Title X national family planning program, and noted that even bigger dangers were on the horizon.1 And indeed, on June 1, 2018, the administration published a series of proposed changes to Title X regulations.2,3 Most notably, the administration is proposing a new version of the Reagan administration’s “domestic gag rule” (a policy that was never fully implemented and later reversed by President Clinton) by barring abortion referral, undermining patients’ right to comprehensive pregnancy options counseling, and excluding from Title X organizations that provide abortion using non-federal dollars. In addition, the rule would alter the services and providers that could be supported by Title X in ways that would shift the program away from its mission of providing comprehensive, high-quality family planning care.

The move to bar clinicians from referring pregnant patients for abortion services would be a 180-degree reversal from Title X’s long-standing policy of requiring programs to offer referrals upon request for any of a pregnant patient’s options, including abortion. Offering referrals promotes continuity of care and helps prevent delays that can make care riskier and more expensive. Moreover, the proposed regulations would require Title X providers to refer all pregnant patients for prenatal care and social services such as foster care or adoption, regardless of the patient’s wishes.

Removing the guarantee that all pregnant patients receive unbiased, factual counseling on all of their options would be another major reversal for Title X. Denying this information would constitute a clear violation of the principle of informed consent and run contrary to clinical guidelines established by leading medical organizations and the federal government itself.4 The shift would reinforce the Trump administration’s efforts to promote religious and moral objections over patients’ rights and health.5

The proposed rule also would impose extensive new requirements for Title X–supported entities to be physically and financially separate from any entity that provides abortion using non-federal funds. That would include separate accounting records, physical spaces, staff, phone numbers, email addresses, patient health records, signs, and more. The clear intent is to exclude Planned Parenthood and other health centers that offer abortion care from Title X. Excluding those providers would severely damage the Title X network, strain the capacity of other providers, and make it harder for patients to obtain the care they need.6

Reshaping Title X Services and Providers

As described in last month’s column, a February 2018 funding opportunity announcement contained multiple requirements designed to shift the Title X program’s services and provider network along conservative ideological lines.7 The proposed regulations advance many of those same goals and, by entrenching them in the program’s regulations, would make them more difficult to undo.

First, the proposed rule continues the push away from Title X’s traditional focus on offering patients a broad range of contraceptive methods. It uses a definition of “family planning” that eliminates the requirement that providers offer “medically approved” family planning methods, and instead emphasizes natural family planning, other fertility awareness-based methods, abstinence, and adoption.

Second, the proposed rule echoes the funding announcement in how it is designed to reshape the Title X provider network. It disadvantages specialized reproductive health providers by favoring sites that offer primary care services. Moreover, it encourages the inclusion in Title X of entities “that refuse to provide abortion counseling and referrals,” those that serve “patients who seek providers who share their religious or moral convictions,” and “specialized, single-method [natural family planning] service sites.”2

In addition, the proposed rule continues to threaten adolescent patients’ confidentiality. For example, it imposes new requirements for clinicians to document their efforts to encourage parental involvement in minors’ decisions, and it codifies the funding announcement’s policy that providers must screen any teen who has a sexually transmitted infection or is pregnant to “rule out victimization.” These requirements go beyond what is needed to adhere to federal and state notification and reporting requirements and could discourage adolescents from seeking needed care.

Finally, the Trump administration is proposing to use Title X to provide free family planning services to people whose employer-based insurance excludes contraceptive coverage because of the employer’s religious or moral objections. Essentially, the administration is proposing to redirect scarce Title X funds to fix a problem it created with its October 2017 contraceptive coverage regulations.8

Public comments on the proposed rule are due on July 31, 2018, after which the administration must consider and respond to comments before finalizing the rule. Overseeing that process will be Diane Foley, who was tapped to head the Office of Population Affairs on May 29. Foley is the former president of Life Network, which operates anti-abortion counseling centers and abstinence-only-until-marriage programs in Colorado.9

REFERENCES

  1. Sonfield A. With funding announcement, Trump begins reshaping Title X. Contraceptive Technology Update 2018. Available at: https://bit.ly/2teuymi. Accessed June 22, 2018.
  2. U.S. Department of Health and Human Services. Compliance with statutory program integrity requirements. Fed Reg 2018; 83 FR 25502: 25502-25533. Available at: https://bit.ly/2xHjnrQ. Accessed June 22, 2018.
  3. Hasstedt K. A domestic gag rule and more: The Trump administration’s proposed changes to Title X. Health Affairs Blog, June 18, 2018. Available at: https://bit.ly/2lhkAwX. Accessed June 22, 2018.
  4. Hasstedt K. Unbiased information on and referral for all pregnancy options are essential to informed consent in reproductive health care, Guttmacher Policy Review, Jan. 10, 2018. Available at: https://bit.ly/2taIQFl. Accessed June 22, 2018.
  5. Sonfield A. Proposed ‘conscience’ rule could interfere with patient care. Contraceptive Technology Update 2018. Available at: https://bit.ly/2yu7jdE. Accessed June 22, 2018.
  6. Hasstedt K. Beyond the rhetoric: The real-world impact of attacks on Planned Parenthood and Title X. Guttmacher Policy Review, Aug. 3, 2017. Available at: https://bit.ly/2v7m68i. Accessed June 22, 2018.
  7. U.S. Department of Health and Human Services. FY 2018 Announcement of Anticipated Availability of Funds for Family Planning Services Grants, PA-FPH-18-001. Available at: https://bit.ly/2Iw3l8m. Accessed June 22, 2018.
  8. Sonfield A. Despite leaving key questions unanswered, new contraceptive coverage exemptions will do clear harm. Health Affairs Blog Oct. 17, 2017. Available at: https://bit.ly/2lfWBOC. Accessed June 22, 2018.
  9. Boguhn A. Trump’s HHS installs fake clinic leader to oversee family planning funds. Rewire News May 30, 2018. Available at: https://bit.ly/2kGJR3k. Accessed June 22, 2018.