Update 4/1/19: The Trump administration awarded $1.7 million in Title X funds to the Obria Group for fiscal year 2019; Obria said in a release that it will receive that amount for the next three years.
Faith-based crisis pregnancy centers (CPCs)—which espouse anti-choice, anti-birth-control, and pro-abstinence values—have historically existed outside the medical system. They often locate themselves near abortion providers to attract those seeking abortion care but, until recently, few offered any medical services beyond pregnancy tests. They were almost never licensed medical facilities.
Now, a growing number of CPCs, also called “pregnancy resource centers,” are offering more medical services like ultrasounds and testing for sexually transmitted infections (STIs). Some are also pursuing licensure and installing electronic health record systems. As licensed medical clinics, CPCs can bill insurers including Medicaid and qualify for government health grants instead of relying entirely on donations. Under the Trump administration’s proposed changes to the Title X family planning program, CPCs may even gain access to federal grants originally designed to provide birth control and other comprehensive reproductive health services at low or no cost to low-income people. Kaiser Health News says the final regulation is expected any day.
Title X is the only federal grant program solely dedicated to providing comprehensive family planning and reproductive health services. The grant money, administered by the Department of Health and Human Services (HHS), is intended to help low-income people access a full range of contraceptive and pregnancy options, STI testing and treatment, and screenings for conditions like breast and cervical cancer. In 2017, 67 percent of Title X patients had incomes at or below the federal poverty level. Patients are also disproportionately young (65 percent were under 30 in 2017) and people of color. The program awards about $260 million in grants every year.
In order to be eligible for Title X grant money under current regulations, providers must offer a broad range of family planning services, including access to FDA-approved methods of contraception. They must also provide counseling and referrals for all pregnancy options, including prenatal care, adoption, and abortion (though no Title X funds can actually be used to pay for abortions). Since CPCs don’t meet these criteria, they don’t qualify for Title X funds under current rules.
However, the Trump administration has proposed sweeping changes to the program that could make CPCs eligible for Title X grants for the first time. The proposal not only removes the requirement that Title X providers offer information and referrals for abortion, but bans Title X providers from talking about abortion at all, even when patients ask. (Hence, this proposal is known as the Domestic Gag Rule.) Other proposed changes would explicitly bar abortion providers from receiving grants, and eliminate the requirement that providers offer “medically approved” contraceptive methods, while placing an emphasis on abstinence and “natural family planning.”
The Trump administration official who has final say over which applicants will receive Title X grants is the former CEO of an anti-choice organization that operates two CPCs in Colorado.
Planned Parenthood currently serves 41 percent of Title X’s four million patients, according to the Guttmacher Institute. If the proposed changes go through, Planned Parenthood affiliates and other clinics that offer abortion services—and even those that merely provide abortion referrals—would be ineligible to apply.
Instead, clinics that don’t provide FDA-approved contraceptive methods could become eligible for family planning money. Obria Medical Clinics, a five-state network of “pro-life” pregnancy centers that was originally founded under the name Birth Choice Health Clinics, is explicit about its mission to expand, medicalize, and seek outside funding. “Our vision is to unite 200 of the top pregnancy centers/clinics across the country under the Obria trademarked brand making the Obria brand the competitive model to compete with the national abortion providers,” reads the Obria Group website. “The goal is to provide an alternative healthcare model to break the relationship our patients currently have with the large abortion clinics.”
In a Politico story last month, Obria Group CEO Kathleen Bravo acknowledged that relying on donations alone isn’t sustainable; she wants to tap into federal grants. Some Obria clinics are offering expanded services like STI testing and pursuing licensure, with more to follow. Politico reported that Obria applied for 2018 Title X funding but was rejected, because its refusal to provide condoms, FDA-approved birth control, and abortion referrals are disqualifying under current regulations. However, if the Trump administration does adopt its proposed changes to the program, Obria centers may qualify. Bravo declined via a representative to comment for this article.
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“The free pregnancy test is something these centers have long provided, along with what they call pregnancy options counseling, which we know is biased, and limited, and omits information. Now there’s a trend whereby a lot more centers have been offering medical services, mostly 'limited ultrasound services,'” says Andrea Swartzendruber, an assistant professor of epidemiology and biostatistics at University of Georgia’s College of Public Health. Swartzendruber was the lead author on a recent study that analyzed the health information provided on Georgia-based pregnancy center websites. “We’ve seen a lot of misinformation and false advertising, with centers claiming that you might not even need an abortion, claiming they can predict from an ultrasound whether you’re going to have a miscarriage.”
“Crisis pregnancy centers are not health centers. Health centers provide accurate information. Crisis pregnancy centers, on the other hand, lie to women about medical facts,” says Leana Wen, a physician and the new president of the Planned Parenthood Federation of America and Planned Parenthood Action Fund. “Imagine if this were any other aspect of healthcare. Would we allow for so-called health centers to exist that provide misleading, scientifically inaccurate information about cancer, or heart disease, or diabetes? We would not.”
Numerous CPCs already receive government funding, usually via abstinence-only education programs. At least seven states have diverted a total of more than $30 million in federal TANF (or welfare) funding to CPCs. This year, the Trump administration gave more than $3 million to CPCs through its new Competitive Abstinence Education program and an abstinence education program that is part of the Affordable Care Act.
Another project of Swartzendruber’s, the Crisis Pregnancy Center Map, identified 2,537 crisis pregnancy centers in the US, two-thirds of which are offering some limited medical services. (A recent report from the Charlotte Lozier Institute, the research arm of the anti-choice organization Susan B. Anthony List, claims the number of centers is slightly higher, at 2,750.)
Swartzendruber and her colleagues found that, in Georgia, 22 percent of CPCs advertised some kind of STI testing; however, only five percent offered treatment. According to the Lozier report, 678 centers nationwide provide STI testing, and 487 provide both testing and treatment—a number that has more than doubled in the past decade.
While some CPCs offer testing, it may not follow accepted guidelines. “We found that at some centers it was difficult to get test results. They were clear that they wanted you to come back, sometimes even for multiple visits if they tested for multiple STIs. That is not in line with a public-health approach, where you try to get as many people tested as efficiently as possible, with as few barriers as possible,” Swartzendruber says. “There are centers that are offering breast exams, Pap smears. I’ve seen some that are advertising prenatal care. I really question that. These centers do not generally operate in a way where they establish an individual as a patient and provide regular care.”
At some CPCs, there is “fuzziness” around the issue of prenatal care, says Katrina Kimport of the University of California San Francisco’s Advancing New Standards in Reproductive Health program. Kimport has studied pregnant women’s experiences at CPCs, including a recent study in which she and her colleagues interviewed pregnant women in Southern Louisiana who’d visited CPCs during their pregnancy. “I interviewed people who said the staff was very clear and told them they needed to go elsewhere for prenatal care. There were other people who believed they were receiving prenatal care, but they didn’t know if the people caring for them were licensed medical professionals,” she says. “Future research needs to examine the consequences of that.”
Though some chains like Obria might welcome being included in the Title X program, Kimport says some CPCs will never be interested in federal funding. “The roots of the pregnancy help center movement are in Evangelical Christianity and Catholicism, but especially in Evangelical Christianity, where these values are often paired with a suspicion of government. This prospect of more federal funding is one that may cause debate within that movement,” she says.
She also notes that some—though not all—CPCs offer emotional support and items like baby clothes, car seats, formula, and cribs, resources that low income women may lack. “It’s not quite free. It’s at no cost, but to receive those things you do need to go and meet with people, receive counseling, and sometimes watch videos. These are experiences people would not have to go through were they not poor,” Kimport says.
Decision confidence is high among women seeking abortions, says Kimport, meaning a CPC visit is unlikely to change the mind of someone who is specifically looking for an abortion. It is also difficult to say how many pregnant people really visit CPCs—Kimport and her colleagues spent two years recruiting participants for their Louisiana study and found only 14.
However, Wen is concerned that the increasing provision of medical services at CPCs may divert more patients from full-service health centers including Planned Parenthood. “Anti-abortion counseling centers have a long and well-documented history of using deceptive tactics, like misleading websites and advertisements, to make women believe that they provide information about the full range of options, when in fact they don’t,” she says.
“CPCs pose risks to individuals and public health through practices which don’t meet medical, ethical, or business standards,” Swartzendruber says. “They target young people, low-income people, and people of color, who are already at a disproportionate risk of adverse health outcomes. Title X is meant for low-income folks. It is so unfortunate that those people would carry a disproportionate burden if the proposed changes stand.”
Emily Nestler, senior staff attorney at the Center for Reproductive Rights, agrees that if the proposed changes to Title X go through, low-income women and women of color would be disproportionately harmed.
“A majority of Title X patients identify as members of racial or ethnic communities that often face significant health challenges due to systemic inequities, including black and African Americans, 21 percent, and Hispanic and Latino patients, 32 percent,” Nestler says, adding, “Title X is popular, successful, and has had bipartisan support for decades. Right now, we are at a 30-year low for unintended pregnancy, and a historic low for pregnancy among teenagers, largely because of expanded access to birth control. We should not be walking that progress back.”
When asked if Planned Parenthood would mount a legal challenge should the Trump administration adopt its proposed changes to the Title X program, Wen says, “This is about taking away lifesaving care from our patients who already bear the brunt of disparities and inequities. We will do everything in our power to continue to provide lifesaving care to our patients.”
The Trump administration’s proposed changes to the Title X program are part of a broader campaign to expand the ability of federal contractors and private businesses to claim religious exemptions under anti-discrimination law. “Health and Human Services (HHS) has also proposed a rule that would allow healthcare workers to turn patients away for any religious or moral reason. The rule applies to any entity receiving funds through HHS, including state and local governments, abortion clinics, LGBTQ health centers, and hospitals. While the rule is clearly intended to target patients seeking reproductive care and LGBTQ people, it is incredibly broad and could impact a wide range of patients seeking medical care,” Nestler says.
Under the Obama administration, the official HHS definition of “sex discrimination” included gender identity and pregnancy termination. “Sex stereotyping,” which includes discrimination on the basis of sexual orientation, was also prohibited. Insurance companies offering plans through the marketplace and institutions receiving HHS funding—which includes most hospitals and community clinics as well as Title X clinics—were officially barred from discriminating against patients for these reasons. Under the new proposed HHS rule, providers would have license to turn away patients because they are LGBTQ, seeking abortions, or for any reason they claim is moral or religious. This could change the entire landscape of healthcare in the US, and further alter the Title X program by allowing providers to turn away the patients who are most in need.
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