February 17, 2020 Liz Borkowski, MPH 0Comment

A new estimate from the Guttmacher Institute calculates the impact of the Title X gag rule: a 47% drop in the program’s capacity to serve female patients, most of whom have low incomes and few other options for receiving high-quality family planning services.

Prior to the Trump administration, the Title X program was a success story. Created five decades ago and sustained with bipartisan support, it funded a network of centers that provided high-quality, evidence-based family planning care to clients with low incomes — and, by one estimate, saved the government $7 for every dollar of public spending. But then, as Guttmacher’s Kinsey Hasstedt put it, the Trump administration decided to “transform Title X from an agent of reproductive autonomy to a tool of government-sponsored reproductive coercion.”

Under a new rule that took effect in July 2019, Title X providers are barred from providing comprehensive, patient-centered care for pregnant people. It prohibits providers from making abortion referrals for patients who desire them, and requires them to make referrals for prenatal care regardless of whether patients want to continue their pregnancies. The rule also imposes strict requirements for both physical and financial separation of Title X-funded activities and abortion-related services. Title X funds have never been used to pay for abortions, and requirements for separate accounting have long created a degree of financial separation. Under the new rule, though, it’s essentially impossible for a provider that offers abortion services to also receive Title X funds.

Since the rule’s provisions on referrals took effect, Title X grantees and providers have faced a wrenching choice. Continuing to accept federal funding allows them to continue providing much-needed care to communities that often have few other options — but to do so, they must provide incomplete, biased care that threatens their ethical standards.

As a recent Kaiser Family Foundation analysis and this new one from the Guttmacher Institute show, many recipients have determined that they cannot continue to accept Title X funding under this unethical rule. Guttmacher researchers compared directories from the Office of Population Affairs, which administers the Title X program, from June and October 2019; they then used media reports and direct communications to identify 1,000 sites that had left the network because of the gag rule. They calculated the number of female contraceptive patients served by each of the sites for which they had data (930) and arrived at a conservative estimate of 1.6 million, which represents a 47% reduction in female clients served by the Title X program.

The harm is not evenly spread. The Guttmacher analysis found that six states (Hawaii, Maine, Oregon, Utah, Vermont, Washington) have lost all federal funding for their Title X network, five (Connecticut, Illinois, Maryland, New York, Wisconsin) have seen a capacity reduction of 90-99%, and seven have seen capacity fall by 50-89%. Fifteen states and the District of Columbia have seen no reduction — but that could change next month, when the rules requiring physical and financial separation take effect.

What happens to these 1.6 million clients?

As is so often the case, the Trump administration seems more concerned with doing the bidding of its political allies than with the fates of people affected by its policy decisions. Its apparent goal, evident in the rule’s deletion of previous Title X grant criteria for adequacy of providers’ facilities and staff, is to shift funds away from providers that offer comprehensive family planning services and to those that limit the range of methods available — providers like the Obria Group, which does not not provide hormonal contraception and focuses on “natural family planning.”

Guttmacher Institute’s Ruth Dawson addresses the work former Title X providers and states are doing to try and prevent clients from losing access to high-quality, comprehensive care:

Despite losing these crucial Title X funds, many providers have employed valiant and creative strategies to continue serving their patients. According to media reports and discussions with providers, clinics have tried a range of options, such as allowing payment on a sliding scale, prioritizing free or low-cost services for young people, and helping patients connect to private or public insurance. But these efforts cannot make up for the havoc wrought by the gag rule, and often carry unexpected bills and confidentiality pitfalls for patients. Some providers have dipped into emergency funds, and some states—including Maryland, Nevada and New Jersey—have passed emergency funding measures. Actions like these to mitigate the negative effects on patients from loss of federal funding are admirable, but ultimately unsustainable.

Finally, some remaining Title X grantees are trying to bring new providers into the network to increase capacity, but we know that other providers—even in areas where they are available—simply do not have the capacity or expertise to absorb this patient load. Contextualizing the attack on Title X in the larger conservative agenda to cut reproductive health care and health care writ large, such as past attempts to chip away at Medicaid via block grants and systemically defund abortion providers, paints an even more dire picture of patients’ dwindling options.

I haven’t yet seen analyses of outcomes for clients of former Title X sites, but we know from a recent Texas experience that they’re unlikely to be good. Here’s what my organization, the Jacobs Institute of Women’s Health, wrote in a comment to HHS opposing this proposed Title X gag rule:

We have evidence of how abrupt elimination of established providers from a publicly funded family-planning program harms women’s access to contraception. Beginning in 2013, Texas excluded clinics affiliated with abortion providers from its publicly funded family-planning program. An analysis of claims data compared the two-year periods before and after the change took effect and found relative reductions of 36% in claims for long-acting reversible contraceptives and 31% in claims for injectable contraceptives. Among women using injectable contraceptives, the authors also found that counties with Planned Parenthood affiliates (i.e., counties affected by the policy change) experienced a 27% relative increase from baseline in Medicaid-covered births. The program saw a 24% decline in enrollment and a 41% drop in the number of women accessing contraceptives. Texas directed approximately one-tenth of program funds to a provider network without a record of providing high-quality family-planning care, but that grantee had to return most of the money after being unable to deliver the required services to tens of thousands of women.

As the Texas experience demonstrates, replacing providers that had extensive family-planning expertise and capacity is neither quick nor simple. A 2017 analysis calculated that in order to serve all female contraceptive clients currently served by Planned Parenthood centers, other types of safety-net centers would need to increase their client caseload by 47% on average. Because community health centers are located in low-income and medically underserved communities, they would be especially likely to experience a major increase in demand; however, a recent survey of health centers found that only approximately half reported that they could increase their patient capacity – and they could only do so by 10-24%.

So what happens to the 1.6 million contraceptive clients no longer served by the Title X program? Some will still get high-quality, comprehensive family planning care, either through the same provider scraping by with other funding, from another site (e.g., a community health center) that serves low-income clients, or from a provider they’re able to see because they have insurance and/or can pay the required out-of-pocket cost. Some will get care that’s less comprehensive than what they would have gotten under the old version of the Title X program and end up with a method that’s not the one they would have chosen if they’d visited a Title X site a year ago. For someone who would prefer a method that doesn’t require taking an action every single day or every single time they have intercourse, losing access to methods like IUDs and contraceptive injections is a worse outcome. In many cases that will mean dealing with more hassles or side effects in order to avoid an unwanted pregnancy, and in some cases it will lead to an unwanted to pregnancy. And given that mounting restrictions have made it harder to access abortions, some people who lose access to Title X-funded family planning services will end up giving birth to children they didn’t want to have.

As is the case with other Trump administration policies that harm public health, the impacts fall most severely on communities that already face the most challenges. Clients in underserved areas who lose a current Title X provider will have to travel farther, which will be hardest on those with the lowest incomes, least job flexibility, fewest transportation options, and most challenging family situations. Because of systemic inequities, those facing income, job, and transportation barriers are more likely to be Black, Hispanic, Native American, or immigrants.

Litigation currently underway aims to reverse this damaging Title X rule. If public health proponents win in court, that will be good news — but limited comfort to the sites that have shut down and the clients who’ve lost access to high-quality family planning care in the meantime.

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