Family Planning Providers Struggled with Restrictions, Funding After Title X Gag Rule
Post-Roe landscape also leads to gag rules
Providers at more than 50 family planning facilities in three states reported disruptions and challenges after the 2019 Trump-era rule that changed the federal Title X program.1
“We did the study after [what’s called] the 2019 Trump domestic gag rule,” says Alicia VandeVusse, PhD, a senior research scientist with the Guttmacher Institute in New York City.
The rule prohibited Title X recipients from referring patients for abortion care. It required physical and financial separation of Title X grant recipients from any abortion-related activities, including referrals and counseling. It redefined family planning to include abstinence, adoption, and fertility awareness-based methods, causing more than 900 healthcare centers to leave the program.
“The rule mandated that all pregnant patients be referred for prenatal care,” VandeVusse says.
Researchers included respondents who joined Title X, those who left, those who stayed in the program after the rule, and some who had never joined. “We found the rule’s effects undermined family planning providers from providing patient-centered care, in particular,” VandeVusse says. “We asked about contraceptive counseling and service provision, confidentiality practices, and finances. We found the sites were adversely affected by the 2019 rule in several ways. There was financial disruption for sites that left the program, and they had to eliminate sliding fee scale as a result, so patients had to pay for their care — a serious access barrier.”
VandeVusse and colleagues also found that Title X confidentiality protections were affected because patients had to use private insurance to cover the costs that were previously paid by Title X. If patients were minors and did not want their guardians to know about their reproductive care visit, the loss of the sliding fee scale meant they either had to come up with money to pay for the doctor’s visit or use their parent’s insurance — which could breach their privacy.
“Then, there were the sites that were receiving Title X funds and were no longer able to counsel pregnant patients who were seeking abortions on how to access care,” VandeVusse says. “This led to distress for providers because they were not able to provide the full range of options in counseling, and they were concerned about running afoul of new regulations and were unsure of what they could say.”
Overall, the gag rule created barriers to care and increased sexual and reproductive health inequities. “We collected data in 2020, so it was giving us a snapshot when restrictive policies were put in place,” VandeVusse explains. “This research speaks to what happens or could happen if policies are put in place that restrict access to contraception.”
The rule severely undercut the purpose of Title X, particularly with minors. “Title X is dedicated to providing confidential care and provides care to people under the age of 18,” VandeVusse notes.
VandeVusse and colleagues found that the gag rule’s changes and their effect on sliding fee scales forced clinics to spend more time counseling patients on the financial side of care. “Now, suddenly, you may not qualify or may qualify for another state program,” VandeVusse says. “Other sites talked about how providers had assistance funds they could use for patients, but had to use their discretion on when to use this and which cases to use them on.”
As a result of funding disruption, Title X sites reported seeing fewer people choose long-acting reversible contraceptives (LARC) because out-of-pocket costs were increasing. “Those were big impacts,” VandeVusse says. “Not being able to offer abortion as an option — even if patients were asking about it — was difficult for them, and some said, ‘I feel like I’m swearing when I say ‘abortion’ now — it’s a curse word.’”
For example, Title X sites had to erase abortion options — and the word itself — from patient resource sheets. Or, they may include a site that provides contraception and abortions on the resource sheet, but they could not tell patients that this particular one also offered abortion care. “That was added stress for providers as well as barriers for the patients,” VandeVusse says.
The nation’s reproductive health services are changing with the spread of state abortion bans after the June 2022 overturn of Roe v. Wade. Some hospitals and states prohibit providers from discussing and referring patients for abortion care, making the experience of the 2019 gag rule relevant today.
Although the Biden administration ended the gag rule in October 2021, some states are implementing similar speech bans.2,3
“It highlights how these kinds of restrictions can increase barriers to care and make it more difficult for providers to center their patients’ needs when there are barriers to what they can say and there are restrictions on what they are able to do,” VandeVusse explains. “It makes it more difficult for them to focus on their patients’ needs.”
- VandeVusse A, Mueller J, Kirstein M, et al. The impact of policy changes from the perspective of providers of family planning care in the US: Results from a qualitative study. Sex Reprod Health Matters 2022;30:2089322.
- Planned Parenthood. In huge victory for sexual and reproductive health care, Biden-Harris administration announces end to Title X gag rule. Oct. 4, 2021.
- Donegan M. In Idaho, we’re seeing how freedom of speech is being curtailed around abortion. The Guardian. Oct. 3, 2022.
Providers at more than 50 family planning facilities in three states reported disruptions and challenges after the 2019 Trump-era rule that changed the federal Title X program.
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