In April, the U.S. Department of Health and Human Services (HHS) proposed a new Title X rule to ensure access to quality family planning services. The proposed changes would revise the Trump administration’s 2019 rules that Title X advocates say are harmful to women served by these public health services.

“Those rules have undermined the public health of the population the program is meant to serve,” HHS wrote. “The department proposes to revise the 2019 rules by readopting the 2000 regulations (65 FR 41270) with several modifications needed to strengthen the program and ensure access to equitable, affordable, client-centered, quality family planning services for all clients, especially for low-income clients.”1

The Trump administration changed Title X, prohibiting program clinicians and staff from giving patients any information about abortion services. It also made it logistically impossible for Title X clinics to offer abortion services at the same site, even though those services were not funded by Title X. (For more information, see the story in the October 2020 issue of Contraceptive Technology Update.)

The 2019 gag rule affected 4 million patients, including 40% who received care at Planned Parenthood facilities. After the gag rule, patients who received Title X services had to find new providers or stop receiving care.2

President Biden’s administration is beginning to return integrity to Title X, says Julie Rabinovitz, MPH, president and chief executive officer of Essential Access Health in Berkeley, CA.

“Even the wording in the proposal truly reflects the administration’s strong dedication to ensuring access to affordable, quality family planning services throughout the country,” she says. “We believe they are committed to making this a program about access, quality, and equity.”

The National Family Planning & Reproductive Health Association (NFPRHA) said it is relieved by the proposed rule for Title X. “Across the country, at least 1,300 health centers have withdrawn from the program since July 2019, leaving more than 1.5 million people without access to Title X-funded care,” said Clare Coleman, president and chief executive officer of NFPRHA.3

Planned Parenthood Federation of America also applauded President Biden for moving to end the Title X gag rule. “In less than two years, the gag rule has forced providers out of the program and decimated patients’ access to affordable birth control, STI testing, cancer screenings, and more,” said Alexis McGill Johnson, president and chief executive officer of Planned Parenthood.2

In the proposed rule, HHS cited some of the negative effects of the 2019 rule:

  • After the 2019 final rule was implemented, 19 Title X grantees out of 90 grantees, along with 231 subrecipients and 945 service sites, withdrew from the Title X program. This meant that one in four Title X-funded sites were no longer available, and six states no longer offered these services.
  • In California, the largest Title X project nationally, 36% of Title X service sites withdrew from the program, leaving more than 700,000 patients without access to this care.
  • While close to 4 million clients were served by Title X programs in 2018, that number plummeted to 3 million clients served in 2019.
  • The 2019 rule also decreased access for low-income, uninsured, and racial and ethnic minorities’ access to Title X family planning services, increasing health inequities.
  • Because of the 2019 rule, 225,688 fewer clients received oral contraceptives, 49,803 fewer clients received hormonal implants, and 86,008 fewer clients received intrauterine devices.
  • There also were 90,386 fewer Pap tests, and 188,920 fewer clinical breast exams. Sexually transmitted infection (STI) testing decreased by 625,802 for gonorrhea, 256,523 for chlamydia, and 77,524 for syphilis.4

According to HHS, the 2019 rule undermined the mission of the Title X program by helping fewer individuals in planning and spacing births, providing fewer preventive services, and delivering fewer STI screenings. The new rule will reverse these trends. “This will remove the 2019 Final Rule requirements for strict physical and financial separation, allow Title X providers to provide nondirective options counseling, and allow Title X providers to refer their patients for all family planning-related services desired by the client, including abortion services,” the rule stated.4

But the proposed rule — with its 30-day comment period that ended in mid-May — still did not go far enough, according to both Coleman and Rabinovitz.

“Unfortunately, the administration’s proposal lacks a true sense of urgency, and it fails to make the promise of greater access a reality for the millions who rely on this,” Rabinovitz says. “Title X patients need immediate relief.”

Every day the Trump-era regulations remain in effect, millions of low-income and rural women and people of color receive a lower level of care. “They’re denying them complete and unbiased information about their pregnancy options, and this leaves a lot of gaps nationwide,” she adds. “We’re calling on the Biden administration to do what the Clinton administration did in 1993 and call for the suspension of the Trump rules, while they go through the proposed rulemaking [process].”

NFPRHA implored HHS to suspend the 2019 Title X rule through separate rulemaking, Coleman says. “Unlike the Clinton administration actions suspending the domestic gag rule while proposing new rules, this proposed rulemaking leaves more than 2,600 health centers subject to program rules that the Biden administration and the provider network find untenable. Our field deserves relief now.”

Waiting for the proposed rule to be made final could take months or years. “We’re thrilled about the new regulations, which take us back to the 2000 regulations and adds meat around access, quality, equity, and team-friendly services, which are all critical components of the Title X Family Planning Program,” Rabinovitz says. “But at the same time, the administration needs to suspend the Trump regulations right now, while they’re going through the rulemaking process.”


  1. Department of Health and Human Services. Fact sheet: Notice of proposed rulemaking ensuring access to equitable, affordable, client-centered, quality family planning services. April 14, 2021.
  2. Planned Parenthood Federation of America. Planned Parenthood applauds HHS proposed regulations to end Title X gag rule. April 14, 2021.
  3. National Family Planning & Reproductive Health Association. HHS releases proposed updates to Title X regulations. April 14, 2021.
  4. Ensuring access to equitable, affordable, client-centered, quality family planning services. A proposed rule by the Health and Human Services Department. Fed Reg. April 15, 2021.