Title X Origins
The United States introduced its first official domestic family planning program for low-income Americans in 1970: the Family Planning Services and Population Research Act, Title X of the Public Health Service Act (known by the shorthand Title X, which is pronounced “ten”). Republican President Richard Nixon oversaw the program’s development and implementation, demonstrating just how bipartisan U.S. support for family planning once was.
How Title X Works
Clinics in the United States that provide family planning can apply for Title X grants, which allow them to offer services to patients on a sliding, income-based scale. In 2017, 3.6 million people were financially assisted by Title X subsidies. A total of 4 million Americans obtained services at clinics receiving Title X grants (this number is higher than the number who received subsidies because people with Medicaid and other forms of public and private insurance also visit Title X clinics).
Title X grants cover a broad array of services that fall under the umbrella of family planning: contraceptive services, supplies, and information; breast and cervical cancer screenings; and STI prevention, testing, and treatment. In keeping with federal law (the Hyde Amendment), Title X funds are not permitted to be used for abortion services.
Title X Budget
Total appropriations for 2019 are $286.5 million, down from a high of $317.5 million in 2010 (when there were 1.5 million fewer women of reproductive age in the United States, and when the value of a dollar was higher).
The $286.5 million appropriated for 2017 (the enacted amount has been identical every year since 2014, and Trump has requested the same amount in his Fiscal Year 2020 budget) was distributed as 89 grants to 47 state and local health departments and 42 NGOs, covering all 50 states, the District of Columbia, and 8 U.S. territories. A total of 3,858 service sites received funds.
New Funding Rule
The Department of Health and Human Services (HHS) proposed a draft rule on June 1, 2018, which garnered hundreds of thousands of comments during the 60-day public comment period. HHS introduced the final rule into the Federal Register on March 4, 2019. After months of legal challenges, the rule went into effect on August 19, 2019. Some aspects of the rule don’t require compliance until March 4, 2020, but most stipulations require immediate compliance.
The politically motivated funding changes to Title X amount to a domestic gag rule. In addition to twice referring to a fetus as an “unborn child,” which is not a medical term, the new rule prioritizes natural family planning and abstinence, especially for adolescents, and imposes new barriers to abortion access. With the new rule:
Clinics that only offer natural family planning—and not a single FDA-approved method of contraception—are now eligible for grants. Previously, Title X clinics had to offer all FDA-approved methods of contraception.
Clinics are now prohibited from referring patients to abortion providers unless patients state a desire to terminate their pregnancies, unprompted by clinic staff. Clinic staff also, however, are now able to refuse to refer patients to abortion providers if they personally object to the procedure on “moral” grounds. Previously, all options had to be discussed with patients during pregnancy counseling, including the option to terminate.
Clinics now have to draw a “bright line” between abortion services and all other services: separate accounting, physical spaces, staff, contact info, patient health records, etc. Previously, clinics that received Title X grants for family planning services were able to offer abortion services with separate, non-federal funding, in the same facility, by the same staff.
Clinic staff are now required to document that they attempted to involve family members in the family planning decisions of minors. This is a disastrous move for minors who are being sexually abused by family members, or who would rather not seek family planning services than have their parents or guardians know they are engaging in sexual activity. Previously, minors’ privacy was protected when seeking family planning services from Title X providers.
Targeted Attack on Planned Parenthood
This new funding rule is an obvious attack on Planned Parenthood, which withdrew from the Title X program the day the Domestic Gag Rule went into effect. Until that point, Planned Parenthood clinics covered the family planning needs of 41 percent of women who rely on Title X. Planned Parenthood provides comprehensive reproductive health care, including birth control, STI screenings and treatment, breast and cervical cancer screenings, sex education, and, yes, abortion.
Because it has been illegal to use federal funds for abortion since before Title X was introduced, Title X grants have never been used to pay for abortion. Requiring Title X clinics to have a separate physical space, separate accounting, separate staff, etc. places an insurmountable—or undue—burden on family planning clinics that also provide abortion. Of course, the intention of the Trump administration is for the new rule to be an insurmountable burden: Opponents of Planned Parenthood want to see all federal funding to the organization cease.
According to the Guttmacher Institute, excluding Planned Parenthood from Title X will require other Title X clinics to increase their client caseloads by 70 percent, on average.
This Domestic Gag Rule is already having innumerable consequences for the patients who rely on Planned Parenthood and other abortion-providing family planning clinics for their subsidized health care services.
Without Title X–Supported Planned Parenthood Sites:
• Health centers will have to increase their capacity to provide contraceptive services by 116%.
• Health departments will need to expand their capacity to deliver these services by 31%.
• Hospitals will need to increase their capacity to provide these services by 77%.
• Independent agencies will have to increase their capacity to provide these services by 101%.
Source: Guttmacher Institute