July 29, 2019 Liz Borkowski, MPH 0Comment

The Title X family planning program has long provided voluntary, high-quality, evidence-based care to clients with low incomes, but its ability to uphold standards of care and its own programmatic requirements is under threat. The Trump administration issued a domestic gag rule that enacts coercive counseling standards for pregnant patients and prohibits providers from giving referrals to abortion providers to patients who desire them. It also imposes needlessly stringent requirements for physical and financial separation of Title X-funded activities from those related to abortions.

“The Trump administration is seeking to transform Title X from an agent of reproductive autonomy to a tool of government-sponsored reproductive coercion,” explains Kinsey Hasstedt in Guttmacher Policy Review. Title X’s programmatic standards require informed consent and evidence-based standards of care, which includes informing patients of all relevant options – for pregnant patients, parenting, adoption, and abortion – and providing services or referrals based on the choices they make. Under the new rule, providers may not give referrals for abortions and must refer pregnant patients for prenatal care, regardless of patients’ preferences. And the rule’s language on options counseling is unclear but nonetheless chilling, Hasstedt writes for Health Affairs Blog:

As in the proposed version, the final rule eliminates Title X’s long-standing requirement that all pregnant patients be offered nondirective pregnancy options counseling, including information about parenting, adoption and abortion. … The administration declines to meaningfully define what kind of “nondirective” counseling would be deemed acceptable, instead saying it will clarify in future guidance. In the meantime, the rule promotes confusion: The preamble emphasizes that providers cannot “promote, encourage or advocate” for abortion, and the final regulatory text prohibits “any counseling…as an indirect means of encouraging or promoting abortion as a method of family planning.” Taken together with the rule’s stated intent to expand the administration’s auditing and enforcement authority, these restrictions could have a damaging “chilling effect” on providers.

The effects on the Title X provider network will be severe and far-reaching. Many grantees and individual providers will not feel that they can ethically provide incomplete, biased care to patients who rely on them. They face a choice between continuing to accept federal funding that allows them to serve communities that need them and upholding their ethical standards.

Lawsuits against the rule are pending. After a panel of Ninth Circuit appeals court judges ruled that the Title X gag rule can go into effect while legal challenges proceed, the Trump administration announced that enforcement would begin right away. The Office of Population Affairs, which administers the program, did not provide immediate guidance on implementation. Effects on the Title X network are already evident.


Major Title X providers withdraw


Maine Family Planning had served as the state’s Title X grantee for nearly five decades; it received federal funds that it used both to operate its own network of 18 clinics and to fund Title X work at other health centers. The organization withdrew from the program, saying in an announcement on Twitter, “We won’t compromise on care or medical ethics.” NPR’s Sarah McCammon reported:

[Maine Family Planning] President and CEO George Hill said in an interview with NPR that at least 25% of the organization’s funding comes from Title X, and a total of 50 sites across Maine could be affected by the rule.

“Our doors are gonna remain open … It’s gonna be an enormous challenge to replace these dollars, but we simply can’t accept them,” Hill said.

Hill said Maine Family Planning provides abortions using private funds. For other services normally funded by Title X, Hill said the group will tap into reserves and explore other potential funding sources.

“This rule is so onerous and arrogant that we simply cannot accept the federal funds with these limitations on them and provide what we believe is the full range of reproductive healthcare services that our patients deserve,” Hill said.

Illinois also withdrew from the Title X program and announced it would use state funds to replace an estimated $2.4 million that 28 grantees would have received. “While I’m committed to bringing as many federal dollars to the state as possible, I refuse to sacrifice our values and allow vital care to lapse,” said Governor JB Pritzker. “In this state, we trust women to make their own health care decisions and will guarantee access to reproductive health care for all of our residents.”

POLITICO’s Alice Miranda Ollstein and Rachel Roubien report on likely outcomes in other states:

Oregon, which is leading a 21-state lawsuit against the rule, is consulting with state attorneys, a spokesperson for the state’s health department said. Washington state, which is also challenging the rules in court, said Tuesday that it is reviewing options.

“It’s safe to say that Washington state won’t come into compliance with the rules,” Casey Katims, spokesperson for Gov. Jay Inslee, a Democratic presidential candidate.

Maryland and Massachusetts, which are both challenging the rules in court, passed laws this year creating state reserve funds for clinics set to lose money under the new Trump administration rules. Both are traditionally blue states with moderate Republican governors.

But some states challenging the rules in court plan to remain in Title X. Delaware, Michigan, Rhode Island and Virginia will stay, state officials confirmed to POLITICO this week. Two other states, Nevada and North Carolina, last month said they expected to remain in the program after the 9th Circuit lifted the injunction on the Trump rules. However, individual providers they contract with could still leave the program’s provider network over disagreement with the rules.

Planned Parenthood, which serves approximately 40% of all recipients of Title X services, promptly announced that its clinics had stopped using Title X dollars and was instead using emergency funds to continue providing care. “It is unethical and dangerous to require health care providers to withhold important information from patients,” said Jacqueline Ayers, the organization’s vice president for government relations and public policy.


Uncertainty and upheaval


After stating on a Monday (July 15) that they would require immediate compliance with the rule, OPA sent a notice five days later (on a Saturday night) telling Title X recipients that the government “does not intend to bring enforcement actions” against clinics that are making “good-faith efforts to comply,” the Associated Press reported. The National Family Planning and Reproductive Health Association, which represents many Title X-funded organizations, slammed the lack of guidance that OPA provided to grantees and warned, “OPA’s failure to provide detailed implementation guidance may be the start of a game of ‘gotcha’ as it assesses compliance with the rule.”

Operators of clinics that received discounted drugs and devices because through the 340B program because of their Title X status may have to dispose of those items when they leave the program, Roubien and Ollstein pointed out. “Clinic operators say they may have to return or destroy IUDs, hormonal patches, NuvaRings and birth control pills if they leave the federal family planning program,” they write.


Impacts on patient care


As frustrating and wasteful as it is for state officials and Title X grantees to spend time and energy responding to the gag rule’s abrupt implementation — and in some cases, to move substantial funds from other public health priorities in order to ensure state residents can still access high-quality family planning care — the primary reason to care about this situation is its impact on patient care. Bustle’s Jo Yurcaba spoke to eight people working in reproductive healthcare in different regions of the country to describe these effects. Here’s their example from West Virginia:

Sharon Lewis, executive director of Women’s Health Center of West Virginia, tells Bustle it would be “ludicrous” for the center — the only abortion provider in the state — to continue taking Title X funds but abandon a core part of its services. The center typically serves about 2,000 patients under the Title X grant program, and she says they’re working on strategies to make up the funds they will lose by refusing to comply.

“I think that Title X is a critical program for access to reproductive health services for low-income women and men,” she tells Bustle. “Taking the access to care, and primarily the access to information, away from patients is unconscionable, in my opinion.”

New York Times columnist Nicholas Kristof also addresses the situation in West Virginia, noting that the state gave Trump the highest margin in the 2016 election. He spoke to 17-year-old Meredith, who couldn’t receive her regular hormonal birth control injection from the Women’s Health Center as they avoid using their 340B-purchased stock. She left instead with a prescription for birth control pills to fill at a pharmacy, telling Kristof, “I’m a 17-year-old with a job that doesn’t pay well, and I can’t worry about bringing a child into this world.”

It’s still possible that the courts will strike down the gag rule and Title X providers will no longer be faced with a choice between federal funds and comprehensive, ethical care. In the meantime, though, many patients with low incomes will face reduced access to the kind of high-quality family planning care that until now has been a hallmark of the Title X program.

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