EXECUTIVE SUMMARY

Family planning providers anticipate positive changes to the Title X program as President Biden announced his administration would roll back the Trump rules that forced hundreds of family planning clinics out of the program.

  • In 2019, the Trump administration issued a final rule for Title X that required strict physical and financial separation of Title X services from abortion services, going further than had occurred anytime previously.
  • The new rules led to hundreds of family planning centers withdrawing from Title X, leaving more than 1 million women without access to Title X programs for their reproductive healthcare.
  • If the Biden administration rescinds the rules, the Title X program can expand and the family planning centers that pulled out could rejoin.

Reproductive health advocates and Title X providers have reason to be both optimistic and concerned in 2021 as the new Biden administration made a promising — but not yet decisive — move to improve Title X and reproductive healthcare for American women.

The Biden administration immediately included Title X changes on the president’s list of early executive orders. The intended goal appeared to be to turn back the Trump-era rules that forced hundreds of family planning clinics to leave Title X, leaving more than a million women without access to Title X services.

President Biden released a memorandum on Jan. 28, 2021, saying the Secretary of Health and Human Services (HHS) “shall review the Title X Rule and any other regulations governing the Title X program that impose undue restrictions on the use of federal funds or women’s access to complete medical information and shall consider, as soon as practicable, whether to suspend, revise, or rescind” the final rules that severely impacted Title X programs.1

The consequences of the Trump administration’s new regulations for Title X funding have been devastating to Title X programs, says Julie Rabinovitz, MPH, president and chief executive officer of Essential Access Health in Berkeley, CA.

While the memorandum is a good first step, it does not go far enough to undo the previous administration’s damage to Title X, she says.

“Reversal of Trump’s regulations cannot come soon enough for the millions of low-income patients who rely on Title X for time-sensitive health services like birth control, STD testing, and treatment,” Rabinovitz says. “The Trump-era regulations are the most extreme rules implemented since Title X was established with strong bipartisan support and signed into law by President Richard Nixon in 1970.”

Effects of the Gag Rule

The Trump administration’s final rule for the Title X program, released in early 2019, required strict physical and financial separation of Title X services from abortion services. It further stated Title X providers could not refer patients for abortion care or offer any information and counseling that includes abortion information, referred to as a “gag rule.” Historically, Title X does not pay for abortion services.1

Since many family planning centers could not come into compliance with the new rule, they withdrew from Title X. This left many women with less access to reproductive health and contraceptive services.

“One in four Title X providers have had to withdraw from the program,” Rabinovitz says. “A report from Trump’s HHS [Department of Health and Human Services] show that the number of Title X patients affected by the change was 21% in 2019.”

The report from the Congressional Research Service revealed that Title X in 2019 served 3.1 million clients, 21% fewer than in 2018. Of these clients, 64% reported incomes at or below the federal poverty guidelines. Sixty percent had no other source of healthcare.2

In 2020, that percentage of people no longer receiving Title X services was expected to be even more devastating, although updated numbers were not yet available, Rabinovitz adds.

“Our healthcare providers in California cannot wait to rejoin the program,” she says. “As soon as the Biden administration takes action, we will welcome them with open arms.”

In Missouri, only one provider (Planned Parenthood of Missouri) chose to leave the Title X network because of the Trump administration’s gag rule, says Michelle Trupiano, MSW, executive director of the Missouri Family Health Council. “We’re working with them so that once the rules are rescinded, we can bring them back in because we were not able to fill the gap that was left when they pulled out of the network,” Trupiano explains.

“Although we’re disappointed the Biden administration did not suspend the dangerous Title X gag rule, we’re encouraged that the president has placed such an emphasis on access to quality, affordable healthcare so early in his term,” Trupiano adds.

Planned Parenthood of Missouri served 14% of the Title X patient base in Missouri. The state was unable to bring in a new provider with that much capacity. “I think we’re all looking forward to rescinding the Trump rules and going back to providing quality care,” Trupiano says.

Missouri’s Title X program might be able to bring in Planned Parenthood before its budget year starts in March 2021 because there already is some funding available, she adds.

Efforts to Reverse Damage ‘Encouraging’

Title X organizations have a lot of work ahead to restore the network to pre-2018 levels, but President Biden’s interest in repairing the damage is encouraging. “President Biden has vowed to rescind the rule, rebuild Title X, and make it right for millions of people who rely on the program for care,” says Audrey Sandusky, MPH, senior director of advocacy and communications with the National Family Planning and Reproductive Health Association in Washington, DC. “We are working very closely with the White House and our national partners to ensure the administration acts swiftly to repair damage done under the Title X rule and to restore critical health services to communities that are currently without Title X support. To date, 33 states had entities leave the program due to the rule, and six states are without any Title X funding whatsoever right now.”

Underfunding Is an Issue

About 1.5 million people lost access to Title X-funded care. “Both providers and patients are in desperate need of Title X support again,” Sandusky says. “Reversing the damage done under the rule cannot happen overnight. It’s going to be a long road ahead to rebuild the provider network — to bring back health centers, restore services, reinstate quality standards. That’s what we’ll be focused on this year.”

Title X also has suffered for years because of underfunding. “The program has experienced eight straight years of stagnant funding, despite a growing need for publicly funded care,” Sandusky explains. “At current funding, the program can serve one-fifth of the needs among women in the United States.”

Funding is a little more than one-third of the $800 million that is needed, Trupiano says. The year 2020 was one of the Title X program’s most challenging periods not only because of the Trump rule change, but also because of the COVID-19 pandemic.

“The rules and COVID on top if it have put a lot of stress on our network throughout the state,” Trupiano adds. “Now, we’re excited that providers can go back and not worry about compliance and what they can and cannot say to patients.”

Instead, Title X providers can get back to focusing solely on what they always have: providing the highest-quality care possible.

“Providers have a sense of relief,” Trupiano explains. “They’re most excited that they don’t have to concentrate on administrative burdens and policies and procedures that don’t benefit patients. Instead, they can spend time and energy on increasing access.”

REFERENCES

  1. The White House. Memorandum on Protecting Women’s Health at Home and Abroad. Jan. 28, 2021. https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/28/memorandum-on-protecting-womens-health-at-home-and-abroad/
  2. Congressional Research Service. Title X Family Planning Program. Oct. 28, 2020. https://crsreports.congress.gov/product/pdf/IF/IF10051