A Domestic Gag Rule and More: The Administration’s Proposed Changes to Title X
Originally published on Health Affairs Blog.
On June 1, the Trump administration published a series of proposed changes to the regulations governing the Title X family planning program. For nearly 50 years, Title X has been the sole federal grant program dedicated to advancing people’s access to comprehensive contraceptive and related family planning services in the United States. The program ensures patient-centered, voluntary, confidential, and affordable care for the approximately four million people who rely on Title X-supported providers for care annually. Consistent with the program’s emphasis on meeting the needs of those who often experience barriers to care, Title X patients are disproportionately low-income and young; about one-third identify as people of color, and about one in 10 have limited English proficiency.
The proposed rule, touted by President Trump at a major antiabortion organization’s gala, revives a series of changes first advanced (but never fully implemented) under President Ronald Reagan, collectively known as the "domestic gag rule." These changes prohibit abortion referral; undermine patients’ right to unbiased, comprehensive counseling about pregnancy options; and exclude agencies that provide abortion using non-federal dollars from receiving any Title X funds. Additionally, the proposed rule seeks to fundamentally reshape both the scope of services and the network of entities supported by Title X funds. Taken together, these shifts constitute an all-out assault against Title X patients’ ability to obtain high-quality family planning care that respects their sexual and reproductive health and rights.
Prohibiting abortion referral
The proposed rule would bar clinicians from referring pregnant patients to appropriate providers for abortion services. Professional medical associations, including the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics, state that providers must offer appropriate referrals for needed follow-up care to all pregnant patients, even if a patient requests information on services to which an individual provider personally objects, such as abortion . Indeed, denying or delaying Title X patients’ ability to obtain abortions jeopardizes the health and well-being of those who have decided to terminate their pregnancies.
The proposed rule also would mandate that all pregnant patients at Title X sites be referred for prenatal and social services (such as infant or foster care, or adoption) -- regardless of their wishes. The rule employs subjective rather than medical language to justify this mandate, saying that these services are needed "to optimize the health of the mother and the unborn child."
If a patient explicitly asks to be referred to an abortion provider, the proposed rule gives sites the option to refuse. If a site chooses to comply with the patient’s request, staff would be sharply limited in what information they could offer, and how: A physician could provide the patient with a list of providers, all of which must offer "comprehensive" prenatal care, but only some of which also provide abortion. Moreover, staff would be barred from distinguishing sites that offer abortion from those that do not, leaving patients to figure that out on their own.
Undermining unbiased, comprehensive counseling
The Trump administration’s proposal would take away the guarantee that all pregnant patients obtaining care from a Title X-supported health center receive neutral, factual, and nondirective information on all their pregnancy options. Instead, providers would be given the authority to deny patients information on abortion -- even when a patient directly requests it.
This blatantly contradicts medical ethics and the tenet of informed consent in health care. It also flies in the face of the guidelines of many leading professional medical organizations that call for comprehensive, unbiased counseling on all pregnancy options. Those standards are reiterated in national, evidence-informed clinical recommendations for the provision of family planning services published in 2014 by the Office of Population Affairs (the federal agency that administers Title X) and the Centers for Disease Control and Prevention.
The proposed rule does not mention those guidelines. Instead, it empowers staff at Title X-funded entities to refuse to provide unbiased, factual counseling on all pregnancy options, based on an individual’s or entity’s objection to abortion. This shift is all the more concerning given signals that the administration intends to embrace entities unwilling to offer either comprehensive contraceptive services or counseling on abortion. The end result is clear: many patients will not get the unbiased and comprehensive information on all pregnancy options that they need and deserve. This serves to advance another of the Trump administration’s ongoing campaigns: expanding the ability of individuals and institutions to object to—and thereby deny others—sexual and reproductive health services, while defending such steps as necessary to protect "religious liberty."
Barring agencies that provide abortion
By imposing extensive physical and financial separation requirements, the proposed rule effectively excludes from Title X any safety-net health center that provides abortion using non-federal funds. Specifically, Title X-funded entities would have to maintain separate accounting records, physical spaces (such as waiting and exam rooms, entrances, and exits), workstations, phone numbers, email addresses, staff, patient health records, educational programs, and signs. The administration seems willing to go even further, asking for public comment on whether these requirements are enough or if additional considerations should be added.
This provision in particular appears to be aimed at Planned Parenthood. Excluding Planned Parenthood from the Title X program would have considerable ramifications, as Planned Parenthood health centers serve 41% of women who rely on Title X sites for contraceptive care. In order to serve all the women who currently obtain contraceptive care at Title X-supported Planned Parenthood health centers nationwide, other Title X sites would have to increase their client caseloads by 70%, on average. This impact would vary by state; without Title X-supported Planned Parenthood sites, other providers in 13 states would have to at least double their contraceptive client caseloads to maintain the program’s current reach in their states. In many states, the burden on other providers would increase to an even greater degree. Moreover, research shows that Planned Parenthood sites are better able to deliver high-quality contraceptive care to greater numbers of women than other types of safety-net providers.
Most immediately, this proposed change would directly impact the approximately one in 10 Title X sites that offer abortion using non-federal funds, including health centers operated not only by Planned Parenthood affiliates, but also by entities such as hospitals and independent agencies. All of these sites—and potentially sites that do not offer abortion but are affiliated with those that do so—could be barred from Title X. Losing these qualified providers from the program would put unrealistic expectations on other Title X sites, which are already stretching to meet their communities’ needs and unable to readily fill such a gap. This would undoubtedly jeopardize people’s ability to obtain high-quality, affordable family planning care in many parts of the country.
Subverting the fundamental intent of Title X
It appears that the Trump administration aims to transform the very intent of the Title X program by reshaping the scope of services and the network of entities supported by Title X funds. This aim was first laid bare in the funding opportunity announcement for Title X family planning services grants released earlier this year. The proposed rule would sharpen and entrench into regulations the funding criteria for and requirements of Title X grants outlined in the funding announcement, making these drastic shifts more difficult to undo.
First, the proposed rule seeks to impose a definition of "family planning" that moves away from contraceptive care and from ensuring patients’ choice of whatever contraceptive methods they feel will work best for them. It eliminates the requirement that Title X providers offer "medically approved" family planning methods. Instead, providers would be required to offer "acceptable and effective choices," such as abstinence and adoption. The proposal emphasizes fertility awareness-based methods, and specifically natural family planning—a subset that are calendar-based and rely on abstinence during fertile windows, and are often motivated by religious convictions. The proposal also seems to set the bar low regarding the breadth of contraceptive method options a grantee must make available, in part by noting that "staffing limitations, technological capacity, economics (including costs and demand), and conscience concerns may be taken into account" in determining the scope of services offered.
Second, the proposed rule could drastically alter the network of agencies that receive Title X funding. For instance, it disadvantages specialized reproductive health providers by favoring sites that "offer either comprehensive primary health services onsite or have a robust referral linkage with primary health providers who are in close physical proximity to the Title X site." Notably, the proposal leaves the key term "close physical proximity" undefined.
The proposal makes clear that the administration intends to welcome into the Title X program entities "that refuse to provide abortion counseling and referrals," those that serve "patients who seek providers who share their religious or moral convictions," and "specialized, single-method [natural family planning] service sites." This heralds a shift away from health care providers and toward religiously motivated entities, such as antiabortion counseling centers (or "crisis pregnancy centers"), which often do not have medical staff. Taken together with the proposed shift in the type and range of "family planning" services, this raises concerns that the administration is paying lip-service to the mandate that a Title X grant ensure patients have a truly "broad range" of contraceptive method options.
Third, the proposed rule raises several concerns related to adolescent clients’ confidentiality. For example, for any patient who is a minor, clinicians would have to document their efforts to encourage the patient to involve parents or guardians in their decision-making, or document why such participation was not encouraged. It also doubles down on a provision first put forward in the funding opportunity announcement that calls on providers to screen any teen who has an STI or is pregnant to "to rule out victimization." Title X has long required providers to adhere to federal and state notification and reporting requirements, but this new layer stigmatizes adolescents who are sexually active and could discourage them from seeking care they need.
Finally, the proposed rule creates a potentially costly new requirement: The rule would redefine eligibility for free family planning services to include individuals whose employer-based insurance does not cover contraception without cost-sharing because of the employer’s religious or moral opposition. This would siphon limited Title X funding to cover the cost of care for individuals whose private insurance does not cover contraception, because of exemptions from the Affordable Care Act’s contraceptive coverage guarantee created by the administration.
The proposed rule’s publication triggered a 60-day public comment period, which will surely garner many thousands of responses. The administration must then consider and respond to those comments, after which time the regulation can be finalized. This will all happen under the leadership of the newly appointed head of the Office of Population Affairs, Diane Foley, who was named to the post just days before the proposed rule’s formal publication. Notably, Foley used to head Life Network, an agency that operates antiabortion counseling centers and abstinence-only-until-marriage programs. Foley’s author profile on a Focus on the Family-affiliated website notes that her "passion is to communicate God’s truth in the secular arena … particularly as it relates to sexual integrity and the sanctity of life."
Between the threats in the funding opportunity announcement, proposed regulatory overhaul, and newly appointed political leadership, it is clear that the Trump administration has shifted its assault against the Title X program into high gear.