The Trump administration recently finalized new rules that could strip federal funding from Planned Parenthood clinics and others that refer women for abortions. Two days later, Live Action, a prominent pro-life activist group, tweeted:
The timing was notable and the message clear: Anti-abortion pregnancy centers can—and should—take the place of pro-choice reproductive health-care clinics. And under the new changes to Title X federal family planning grants, President Donald Trump has created the conditions to make that possible. While Title X clinics that continue to refer patients for abortion stand to lose significant funding, the door has been swung open for anti-abortion counseling centers commonly known as crisis pregnancy centers.
The Title X family planning program was created in the 1970s to serve low-income Americans, and the last major update came under the Clinton administration in 2000. Through grants to thousands of health-care providers across the country, Title X provides a range of sexual health-care services, including contraception, pregnancy testing, pelvic exams, and STD and STI testing, serving more than four million patients in 2017. The Trump administration first floated anti-abortion changes to Title X in May of 2018. The final rule is expected to be published on March 4th, starting the clock for various deadlines to comply with the changes, beginning in as little as two months.
Deemed a "gag rule" by pro-choice groups, the controversial regulation (similar to rules under previous Republican presidents) has been cheered by pro-life groups and slammed as ideologically motivated by dozens of prominent health organizations, including the American College of Obstetrics and Gynecologists, the American Nurses Association, and the American College of Physicians, who signed a joint letter arguing it will do "indelible harm to the health of Americans and to the relationship between patients and their providers." Among the changes, Title X-funded clinics will be banned from even referring patients for abortions, and "by forcing providers to omit critical information about health care and resources available, the final regulation directly undermines patients' confidence in their care," the groups said.
The rule was specifically designed to open the door to providers who object to abortion, a position that has seized much of the attention since the rule was first floated last year. The Department of Health and Human Services (HHS) made this explicit in the final rule when it noted that "potential grantees and sub-recipients that refuse to provide abortion counseling and referrals will clearly be eligible to participate in the Title X program." (It mentions "unborn" baby or child nine times; makes no mention of "fetus"; and uses the word "conscience," in the context of abortion views, 70 times.) But the regulation makes a number of other changes that critics see as a concentrated shift away from expansive family planning options and toward faith-based groups opposed to abortion, especially crisis pregnancy centers.
Critics point to a few key sections. Under the new regulation, all women who test positive for pregnancy "shall" be referred to prenatal care and "may" be referred to "social services or adoption agencies"—a directive that could elevate the services of crisis pregnancy centers simply by increasing potential referrals. It also removes the phrase "medically approved" from the language around accepted forms of contraception offered at Title X sites, a change seen by critics as a weakening of the standards of care that would also make room for more ideologically motivated groups to apply for funding. Natural family planning methods that track women's ovulation, of the kind often espoused by pro-life groups such as crisis pregnancy centers who oppose other contraceptive methods, are "less effective than other forms of contraception such as the oral contraceptive pill, IUD, implant, and condoms," according to the Kaiser Family Foundation.
The regulation also changes the language regarding whether and how sites that provide only a single method of contraception might receive funding, and this is where many say the impact could be felt most acutely. Currently, organizations that offer a single method "may participate" as long as they're part of a broader network (called a "project") that offers a broad range of options. That standard remains, but the new rule includes the added emphasis that "such projects are not required to provide every acceptable and effective family planning method or service."
Kinsey Hasstedt, a senior policy manager who specializes in Title X at the reproductive health research non-profit the Guttmacher Institute, says the reason for that addition becomes clear in the department's preamble, which focuses heavily on widening the groups eligible to apply. "Increasing client choices among family planning clinics and methods in a project is likely to decrease unintended pregnancies, not increase them, because clients are more likely to visit clinics that respect their views and beliefs and to use methods that they desire and that fit their individual circumstances," it reads. HHS also states that a "positive outcome" from the change would be that "new providers who previously were unable to participate in Title X projects due to conscience concerns with the 2000 regulations will be free to apply for a Title X grant or to participate in a Title X project." The result isn't just an open door for crisis pregnancy centers to apply for funding, Hasstedt says, but "a pretty clear call to those sites to do so."
"The administration has outlined quite clearly [its] intention to increase competition even though the [full range] of highly qualified providers are already participating in Title X, and so it's really to allow these other entities to have an opportunity to redeem federal funding," says Jessica Marcella, vice president of advocacy and communications for the National Family Planning and Reproductive Health Association.
That "could allow for a real shift in the network for providers supported by Title X," Hasstedt says.
Title X is built on the core commitment to non-coercive, voluntary services—a commitment Hasstedt says is threatened. "When we start talking about a world in which Title X funding might shift from trusted providers of high-quality care to new grantees and new sites that might provide a very limited set of services, or might seek to coerce [patients], particularly pregnant patients, away from abortion and toward childbirth, it's really shifting the fundamental purpose and impact of the program in a really troubling way," she says.
The rule is widely viewed as a creative effort to defund Planned Parenthood—long a rallying cry among Republicans—but in focusing on the role of crisis pregnancy centers, the Trump administration is following a well-established playbook in many Republican-controlled states that already seek to directly fund their work.
A 2018 Rewire analysis found that anti-choice pregnancy clinics expected to receive "an unprecedented $40.5 million in taxpayer dollars from 14 states" that year. In Texas, which accounted for nearly half of that spending, it found that a single crisis pregnancy network took in $3.95 million. Real Alternatives, another network that says it operates in Pennsylvania, Michigan, and Indiana, says it received more than $7 million from Pennsylvania during the 2016–17 fiscal year.
When Live Action tweeted that crisis pregnancy centers "outnumber abortion facilities four to one," it relied on estimates from the pro-life Charlotte Lozier Institute, which counted 2,752 crisis pregnancy centers nationwide in 2017. According to the Guttmacher Institute, there were 272 abortion clinics in 2014. Health care provided by faith-based groups varies widely (Hasstedt noted faith-based or religiously motivated groups "that are dedicated to a full package of care and high-quality family planning services" already participate in Title X funding), even among crisis pregnancy centers, but they've been singled out and criticized for a trend in providing inaccurate information or coercive care. One 2016 study in Georgia found crisis pregnancy centers in that state provided false information about abortion, limited contraception information and sexually transmitted disease testing, and advertised abortion reversal (an unproven and dubious medical concept). A recent essay published in the AMA Journal of Ethics argued that, while the clinics are legal, they're also unethical.*
And in states that are already politically hostile to abortion, the new rule might only formalize what already often takes place. In the Southeast, a non-profit organization called Provide exists solely to help train health-care providers on how to refer patients for abortions. In its comments to HHS over the proposed rule, Provide noted that, in the states where it works, abortion providers are already "difficult to identify and locate, even for healthcare providers," and that "healthcare providers routinely and understandably overestimate and misidentify abortion care providers already." The inference being that women are already not being given accurate referrals for abortion services in those states.
In a press release summarizing the regulation, HHS said the change "places a high priority on preserving the patient/healthcare provider relationship" and argued it will expand choice, improve services, and increase innovation.
Marcella's organization, the National Family Planning and Reproductive Health Association, has announced plans to sue the Trump administration over the new rule, as has Washington state's attorney general, and other states have similarly threatened to fight the change.
"The reality is that it's even hard at this point to understand how far out these ramifications will extend," Marcella says, but the new rule "is fraying community trust" among Title X patients. She worries that, "if we put women in the position where they don't believe they can have their needs met, they will forgo that care."
For those who need publicly funded family planning care, she adds, "the future looks pretty bleak."
*Update—March 6th, 2019: This post has been updated to accurately reflect the Guttmacher Institute's data on abortion clinics.