Family planning clinics across the country are now grappling with a once-unthinkable choice. Under new rules by the Trump administration, clinics funded by the only federal program dedicated to family planning are banned from referring patients for abortions.
Now, each provider must decide whether to remain in the Title X program. Do they follow the administration’s so-called “gag rule” but keep the money they may need to keep clinic doors open? Or do they leave, risking serving fewer patients with fewer services?
On Monday, Planned Parenthood declared it would rather leave than obey what it believes to be an unethical ban on referrals for a legal procedure. Its departure leaves the Title X program unrecognizable, since its clinics served 40% of the 4 million low-income people who rely on the program for STI tests, cancer screenings, and birth control.
But not everybody will be following in Planned Parenthood’s footsteps. The only Title X grantees in Virginia, Indiana, Missouri, and Arizona all confirmed to VICE News that they intend to stay in the program. Pennsylvania’s AccessMatters, one of the state’s five grantees, also confirmed that it's given the Trump administration an outline of how it will comply with the new changes. Last year, the five organizations collectively served more than 230,000 people at Title X-funded clinics.
But that doesn’t mean they feel great about staying.
“No one is making what feels like a good decision, whether or not they choose to stay or go. They have been pinned between a rock and a hard place,” explained Jessica Marcella, vice president for advocacy and communications for the National Family Planning and Reproductive Health Association, which represents dozens of providers who receive money through Title X.
“Everyone is sort of focused on their commitment to patients and they are weighing impossible decisions and impossible factors to figure out how they can best serve the patients that they have. And it breaks one way or the other, and never neatly.”
On Monday, grantees — which receive money directly from the Department of Health and Human Services, and can both run their own clinics and parcel the funds out to other organizations — were required to submit a plan outlining how they will start complying with the changed rules, like the requirement that providers financially separate any abortion-related services from their other offerings.
Oklahoma’s Community Health Connection, which receives about $300,000 as one of the state’s three Title X grantees, handed one in. Like many Title X-funded clinics, the organization doesn’t perform abortions, but instead offers a full range of birth control options, family planning help, and primary care. Uninsured patients can pay for services using a sliding fee scale.
Practically, it’s not too difficult to obey the new rules, CEO Jim McCarthy told VICE News. (It is also already illegal to use federal money to pay for abortions, except in very limited circumstances.)
Now, if a patient at a Title X-funded clinic asks for a referral for an abortion, a doctor can hand them a list of providers. A minority of the providers on that list can offer abortion; the doctor is unable to indicate, in any way, which providers may double as abortion clinics.
When asked if that’s enough information to give patients, McCarthy laughed.
“It’s not a full disclosure,” he said. “If we were to refer someone out for a mammogram, we would probably give them more information than that.”
Even with the help of Title X dollars, Community Health Connection is already strapped for resources: Last year, its providers had to turn away 6,000 requests for appointments — in a state that already has the second-highest rate of teen pregnancy in the country.
“In Oklahoma, the demand for low-cost medical services far outstrips the capacity to deliver them,” McCarthy said. “I do not believe that we would turn down the money as some sort of protest… That doesn’t help anything in the long run.”
Still, McCarthy called the changed rules “unfortunate.”
“Quite candidly, in 21st century America, everyone should have access to healthcare, and I think it’s an important point that a woman’s health is her choice. I’m old enough to remember life before this current situation,” McCarthy said, referring to the days before Roe v. Wade, the 1973 Supreme Court decision that legalized abortion nationwide. “Unfortunately, there were individuals who out of desperation did things that were detrimental to their health in order to terminate pregnancies.”
In an email, Michelle Trupiano, executive director of the Missouri Family Health Council Executive Director, also alluded to the United States’ intensifying war over abortion and reproductive health.
“Unfortunately, for those of us who work in reproductive health throughout Missouri, these types of restrictions are commonplace — whether they are from the federal government or our state legislature,” Trupiano wrote. Missouri has just one abortion clinic left, and it’s now facing losing its license to perform abortions due to a dispute with the state over, in part, the clinic’s inability to compel physicians to sit for interviews with regulators. The Missouri legislature also recently passed a law to ban abortion as early as eight weeks into a pregnancy. That law is set to take effect next week.
Planned Parenthood’s decision to leave still touches grantees that have decided to stay. For example, the grantee Arizona Family Health Partnership will remain in the program, but four of the Planned Parenthood-run clinics that it used to fund will no longer take its Title X money. The organization is now trying to find replacements, but that’s a long, arduous process.
“No one is making what feels like a good decision, whether or not they choose to stay or go.”
Several states and reproductive health groups have sued over the changes to Title X. That litigation over the rule changes is still unfurling, which also complicates providers’ decisions about whether to stay. The U.S. Court of Appeals for the 9th Circuit will hear oral arguments in the case in late September — five days after the deadline for Title X beneficiaries to come into compliance with most of the changed rules. (Another requirement that clinics physically separate their abortion-related services from others will not go into effect until March of next year.)
“The ground is moving under our feet,” the leader of one state’s grantee organization told VICE News. While that grantee has also submitted a compliance plan, the leader asked not to be identified because they were still waiting to see how the Trump administration would respond to the plan.
Realistically, though, they admitted that it was unlikely that they would leave Title X regardless of any further demands from the administration.
“In other states, [with] smaller dollar amounts, with state governments that are supportive of shoring up these dollars — they may be able to say, ‘I don’t want to comply with Title X at all,’” the grantee organization head said. But in their state, “I can only ask of philanthropy so much.”
Correction: A previous version of the article misstated the court that will be hearing oral arguments on the changes to Title X. The U.S. Court of Appeals for the 9th Circuit will be hearing the case.
Cover: Pro-choice activists, politicians and others associated with Planned Parenthood gather for a news conference and demonstration at City Hall against the Trump administrations title X rule change on February 25, 2019 in New York City. (Photo by Spencer Platt/Getty Images)