May 29, 2018 Liz Borkowski, MPH 1Comment

The Trump administration’s latest move to deny reproductive autonomy to women with low incomes takes the form of a Notice of Proposed Rulemaking on major changes to the Title X family planning program. For more than four decades, this federal program has helped people with low incomes and insufficient insurance access high-quality, culturally sensitive reproductive healthcare. The 4,000 centers it funds provide care to approximately four million clients seeking family planning services each year, and they’re located in 90% of the counties where women in need of publicly funded family planning care live. Under the Trump administration’s proposal, this infrastructure is under threat.

Like the Global Gag Rule, which forces groups receiving US assistance for public-health work in other countries to refrain from mentioning abortion as a condition of continuing to receive funding, this domestic Gag Rule puts family planning providers in the position of choosing between federal dollars and their missions of offering comprehensive reproductive healthcare.

The proposed rule “would prohibit recipients from using Title X funds to perform, promote, refer for, or support abortion as a method of family planning.” In acknowledgment of providers’ duty to promote patient safety, it concedes, “a doctor would be permitted to provide nondirective counseling on abortion.” Providers could give patients “a list of licensed, qualified, comprehensive health service providers, some (but not all) of which provide abortion in addition to comprehensive prenatal care” — but only if “a woman who is currently pregnant clearly states that she has already decided to have an abortion.”

In addition to intruding into individual patient-provider communication, the proposal adds requirements that seem designed to reduce access to reproductive health providers for those with low incomes. For decades, the Hyde Amendment has prohibited the use of federal funds for abortion services, and Title X regulations have required that grant recipients that provide abortions engage in detailed bookkeeping to ensure no Title X funds support abortion care. Now, however, the Trump administration proposes that Title X grantees that offer abortion care maintain physical as well as financial separations between abortion services and Title X-supported activities — e.g., by establishing a completely separate facility for abortion care.

Complying with such a requirement wouldn’t just force Title X providers to direct funds away from patient care and towards additional infrastructure. It would also advance one of the key goals of those who oppose reproductive autonomy: Stigmatizing abortion rather than recognizing it as a safe, effective medical procedure that approximately one out of every four U.S. women will have by the age of 45. Rather than severing a key component of reproductive healthcare from their practices and participating in attempts to shame their patients, many providers will refuse to accept federal funding that comes with such damaging strings attached.

Impacts of a weakened Title X program

Those who promote these kinds of rules claim to want to see fewer abortions, but the result of this policy would be the opposite. The best way to reduce the number of abortions is to increase access to contraception, and Title X providers are very good at that. This policy, coupled with a disturbing turn away from evidence-based guidelines in the latest Title X funding announcement, will pull funding from centers with strong track records of providing high-quality family planning care to those with low incomes, and direct it to …. well, there doesn’t seem to be a very good plan for where the money should go instead. Lawmakers who want to stop federal dollars from going to Planned Parenthood seem fond of touting community health centers as an alternative, but these centers are not at all equipped to handle the kind of influx of family planning clients that Trump administration proposals would create. When Texas decided to stop giving state family planning dollars to providers that offer abortion services, access to some of the most effective forms of contraception declined, and one of the inexperienced organizations that received the largest chunk of funds had to return most of it after being unable to deliver the required services to tens of thousands of women.

If the centers currently in the Title X network lose federal funding, those who suffer most will be those who face the most barriers to accessing healthcare — in particular, women of color with low incomes. Here’s Marcela Howell, founder of In Our Own Voice: National Black Women’s Reproductive Justice Agenda:

Black women specifically have already been historically and systematically denied the resources, services, and information they need to make these important and personal health decisions. We account for 27.6 percent of all U.S. abortions, and because of social and economic inequality, women of color are disproportionately likely to depend on federally funded health care. Increasing restrictions on our reproductive care hurts our ability to raise healthy families and further oppresses our communities. We already face heightened barriers to family planning resources. HHS is gambling with our lives, putting Black women at even greater risk.

And here’s Ann Marie Benítez, Senior Director of Government Relations at the National Latina Institute for Reproductive Health:

The proposed rule would be disproportionately devastating for people of color, including the Latinx community — the most uninsured group in the United States. Of the 4 million people who receive Title X care, half are women of color and 32% of patients identify as Hispanic. For many individuals who are living with low-income, are uninsured or underinsured, or are undocumented, Title X clinics are a trusted source of comprehensive, evidence-based, culturally-sensitive, and linguistically-appropriate healthcare services. For many Latinxs, regardless of immigration status, Title X family planning clinics are the only healthcare providers they know where they can access contraception, STI testing, and preventive services like cervical cancer screenings. Without Title X providers in communities across the country, Latinxs will have an even harder time accessing the life-saving care and education on abortion-related services that they need.

That point about healthcare services is important. Weakening the Title X network also means patients with low incomes — who are disproportionately women of color — have less access to STI testing and screening for breast and cervical cancers.

And here’s UCSF Bixby Center obstetrician-gynecologist Sanithia Williams, reminding us what our priorities ought to be:

Our country is facing a crisis in maternal mortality right now, where black women are three to four times more likely to die in pregnancy and childbirth than their white counterparts. Instead of taking up this cause, and ensuring that all women have access to comprehensive and equitable reproductive health care and pregnancy care, this administration is taking this opportunity to galvanize their base at the cost of women’s access to medically accurate care.

Every person deserves access to quality, evidence-based, full-spectrum reproductive health care, including abortion. Ideologically motivated government interference flies in the face of medical ethics, tying the hands of healthcare providers and threatening the bodily autonomy of our patients. Women of color and women who receive a low income, who already face significant inequities in our healthcare system, will bear the burden of this callous and unjust policy.

The notice of proposed rulemaking is open for comments for 60 days (until 7/31), and the Trump-Pence administration will be hearing from a lot of us who know that public health includes access to the full range of sexual and reproductive health services as a fundamental right.

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