Title X organizations and other groups praised the Biden administration for reversing the draconian changes to the Title X family planning program that were enacted in 2019 under the Trump administration.

The 2019 changes, including a gag rule that prohibited Title X providers from discussing or referring patients to abortion services, resulted in one-fourth of Title X providers exiting the program. The number of patients served by Title X was cut in half nationwide. This left 1.6 million patients without care under the program that was designed to improve access to family planning services for low income and vulnerable women.1

“This is a very important development. We want to be clear that the Biden administration did the right thing by moving very rapidly to restore the Title X program and return it to its purpose of providing high-quality family planning care all across the country,” says Ruth Harlow, senior staff attorney for the ACLU Reproductive Freedom Project in New York City.

In some states, the 2019 changes decimated the Title X program. “California’s Title X network served nearly 1 million patients at 366 clinic sites across 38 California counties. But after the Trump rules took effect, the number of patients in California served by Title X dropped by 80%,” says Amy Moy, chief external affairs officer for Essential Access Health in Berkeley, CA.

The Department of Health and Human Services (HHS) published the Title X final rule, “Ensuring Access to Equitable, Affordable, Client-Centered, Quality Family Planning Services,” on Oct. 7, effective Nov. 8.2

“We are thrilled and relieved that with the release of the final rule, the Trump era regulations have been rescinded and replaced, and that opens the door for organizations that made the difficult decision to exit the program under the Trump rules to return,” Moy says. “We are ready and eager to welcome those organizations and rebuild our Title X network in California.”

The American Medical Association (AMA) also praised the latest action on Title X.

“The Biden administration’s final rule reversing drastic changes to the Title X family planning program is a major victory for physicians, healthcare professionals, and the millions of patients across the country who depend on Title X for access to essential reproductive care,” AMA President Gerald E. Harmon, MD, said in a statement.3 The AMA had challenged the Title X gag rule’s inappropriate interference into the patient-physician relationship and physicians’ ethical obligations, he added.

Before the Trump administration, Title X had widespread political support.

“What’s been amazing about Title X up until the 2019 disaster is that it had bipartisan support, and it functioned everywhere across the country — red states and blue states,” Harlow says. “Title X providers have healthcare uppermost in their minds and have worked very hard to implement the program and keep their eye on that rather than litigation and politics. I would expect that to continue.”

When the rule takes effect Nov. 8, most family planning centers that left the program are expected to return and resume Title X care for patients.

“Initial conversations with [California] organizations that withdrew from the program show eagerness and excitement to come back into the program,” Moy says. “Now, we can look forward to harmful restrictions being removed.”

This is true of Title X programs in all parts of the country. For example, Planned Parenthood of the St. Louis Region and Southwest Missouri, which served 14% of all Title X clients in Missouri before 2019, had pulled out under the Trump era rule. It is expected to return, thanks to the Biden administration’s reversal, says Michelle Trupiano, MSW, executive director of the Missouri Family Health Council, Inc.

“Planned Parenthood of St. Louis is the only abortion provider in the state,” she notes. “We have one clinic in the entire state of Missouri.”

Missouri Family Health Council will update its internal policies and work with Title X sites to update their policies and provide training and education in preparation for the 2021 final rule’s changes.

“We want to ensure all providers know what they now are allowed to do vs. what they couldn’t do over the past two years, and that’s the majority of our work over the upcoming months,” Trupiano explains.

In addition to eliminating the gag rule, the 2021 final rule includes these changes:

  • It ends the requirement that providers maintain strict physical and financial separation of abortion services.
  • It requires Title X-funded sites to offer a broad range of contraceptive methods or provide a prescription to clients for their method of choice.
  • It clarifies that the program’s income verification requirement should not burden patients or prevent them from accessing care.
  • It provides adolescent confidentiality protections, including a prohibition on requiring consent or notification of parents or guardians for services.
  • It allows more clinical service providers to direct Title X services and provide medical services consultation.
  • It allows telehealth for Title X planning services.
  • It advances the cause of health equity and requires family planning services to be client-centered, culturally and linguistically appropriate, inclusive, and trauma-informed.4

It is possible the 2021 Title X final rule could face a lawsuit from an anti-abortion organization. Any such legal challenge would run into problems because of solid data on how much the 2019 rule damaged the program and reduced access to family planning services.

“If any suits are filed for rescinding the final rule, they would have an extraordinarily difficult path because the agency has documented how damaging the rule was to this program,” Harlow explains. “The agency also has well-articulated reasoning for new changes, so any lawsuit will have a difficult time.”

Many lawsuits were filed to challenge the 2019 rule, stating the Trump administration had not followed the procedure act and made sweeping amendments that were detrimental to the Title X program.

“These lawsuits had mixed results — in some places successful and in others, not,” Harlow adds. “A number of the cases were on appeal to the Supreme Court by the time the Biden administration came in.”

The Biden administration voluntarily withdrew the cases, Harlow says.

It is unlikely the 2021 rule would face similar legal challenges because the Biden administration followed a standard rulemaking process.

“The Trump administration’s Title X regulations were in direct conflict with federal statute and medical ethics standards, and there is extensive evidence that they were harmful to the family planning safety net,” Moy explains. “The Biden administration’s final rule largely mirrors the regulatory framework that successfully governed the program for more than 20 years before the Trump-era regulations took effect in 2019. The rules are a reset, with important updates to advance health access and equity.”

Regardless of possible challenges, Title X programs are celebrating the new final rule and the end of the Trump administration’s rule.

“We are excited to able to once again offer the highest-quality care possible,” Trupiano says. “It’s been a long two years for our providers to operate under these onerous rules, and it will provide much needed relief not only to the network, but also to all Missourians seeking care.”

REFERENCES

  1. Dawson R. Trump administration’s domestic gag rule has slashed the Title X network’s capacity by half. The Guttmacher Institute. Updated April 15, 2021.
  2. Department of Health and Human Services. Ensuring access to equitable, affordable, client-centered, quality family planning services. Federal Register. Oct. 7, 2021.
  3. American Medical Association. AMA applauds Biden administration’s final Title X rule. Oct. 5, 2021.
  4. Department of Health and Human Services Office of Population Affairs. 2021 Title X Final Rule Summary. October 2021.