Read more about the Trump administration’s new family planning rule here.

Reproductive health advocates are bracing themselves for the finalization of the Trump administration’s Title X “domestic gag rule.” The anti-choice policy would ban providers receiving Title X funds from referring patients for abortion services and force abortion providers under the program to physically separate abortion services from other family planning services.

But what is the Title X family planning program, and why do the administration’s policies threaten access to reproductive health care?

In order to provide public funding and support to family planning services nationwide, the federal grant program commonly referred to as “Title X” was created as part of the Public Health Service Act, signed into law by Republican President Nixon in 1970. With Title X, Nixon made good on his campaign promise that “no American woman should be denied access to family planning assistance because of her economic condition.”

Around the 1960s, when courts were ruling to allow the use of contraception in the United States, new research found that access to family planning and contraceptive services could help prevent unplanned pregnancies, according to the Guttmacher Institute. More studies revealed the long-term socioeconomic benefits of preventing unplanned pregnancies and the health benefits of spacing pregnancies. The problem was that access to care was largely determined by income. The first federal grants to address this issue and support family planning services for low-income women came in 1965 as part of President Lyndon Johnson’s War on Poverty efforts. Nixon’s Title X followed.

“The Title X program is the nation’s only dedicated source of funding for subsidized family planning and reproductive health care,” Audrey Sandusky, communications director for the National Family Planning and Reproductive Health Association (NFPRHA), said in an interview with Rewire.News. “It supports a network of providers nationwide and it’s a diverse network of providers. So Title X funding goes to any entity that has demonstrated a strong capacity to meet the rigorous criteria that the program requires. It’s a competitive grant program.”

Today, the U.S. Department of Health and Human Services’ (HHS) Office of the Assistant Secretary for Health by the Office of Population Affairs oversees Title X funding. Organizations can use Title X funds to provide direct health-care services, train health-care professionals providing family planning care, research family planning methods and service delivery, and develop and distribute informational materials.

According to reproductive health advocates, the program has expanded over time to include a broader range of reproductive and sexual health needs. New administrations can attempt to adjust what the program funds, “usually in response to emerging public health threats,” said Emily Stewart, vice president of public policy at Planned Parenthood, a major recipient of Title X funds, in an interview with Rewire.News.

Stewart cited the Obama administration’s expansion of the program to include screening for HIV and AIDS and other sexually transmitted diseases. Breast and cervical cancer screenings are also now included in family planning care under Title X.

Costs for services at Title X clinics are based on income. For people living at or below the federal poverty level, services are provided free of charge. And teens who seek care at these clinics are evaluated based on their income, not that of their parents or guardians. Title X clinics also serve the health-care needs of a large population of people who don’t qualify for Medicaid but also can’t afford private health insurance. Annual report data from HHS revealed that Title X centers served 4 million family planning patients in 2017. About two-thirds of these people live in poverty.

Title X clinics are the main source of medical care for six in ten women who receive services there. The number of men being served by the program has also increased dramatically in the last decade. By 2017, 12 percent of Title X patients were men. The same year, 54 percent of Title X patients were white, 22 percent Black, and 33 percent Latinx, meaning that a disproportionate number of Black and Latinx people are receiving services through Title X.

As written into the original 1970 law, “[n]one of the funds appropriated under this title shall be used in programs where abortion is a method of family planning.” This component of the law has been a key point of debate for many years, especially during President Ronald Reagan’s administration. Based on current policy interpretations, clinics that also offer abortion care can receive Title X funding, but they must keep all of their non-abortion services financially separate in order to confirm that such funding is not being used for abortions. Sandusky noted, however, that “Title X also ensures non-directive options counseling, which means providers can counsel on healthy pregnancy, adoption, and abortion in the case of a positive pregnancy test.”

The new threats to federal family planning funds

According to advocates, the Trump administration presents a threat to the family planning grant program that hasn’t been seen before. “In modern history, we have not seen any administration issue as damaging policy in the collective around reproductive health access as this administration,” Stewart said. “They have done more in just over two years as any administration in modern history has done in eight.”

Among the devastating policies Stewart listed was a rollback of a Title X requirement that providers offer patients a broad range of contraceptive care and birth control options. “The first funding opportunity announcement [FOA] didn’t even have the word contraception in it.”

The administration’s use of FOAs to accomplish political objectives has rattled advocates and put the program at serious risk. “This administration, instead of using the FOA to build on the foundation of the program and to answer the call of the public health community, has gone in the complete opposite direction and has used these FOAs to exact a political agenda designed to actually crack the foundation of the program,” Stewart said.

Sandusky said the administration over the last two years has shortened every Title X grant, seemingly in order to bring each provider into compliance with new, politically motivated grant requirements as quickly as possible.

In 2017, Trump proposed deep cuts to the Title X program in his budget proposal.

According to Sandusky, doing so would decimate the program. “Under that current funding level, the program could really only meet one-fifth of existing need for publicly funded family planning,” she said. “We’ve seen challenges at both a regulatory and funding perspective and then, of course, we are anticipating some of the most troubling changes and the most far-reaching changes in this proposed [domestic gag] rule.”

Trump’s domestic gag rule designed to “fundamentally dismantle” Title X

The gag rule would ban Title X family planning providers from making referrals for abortion services and require providers to physically separate their Title X practices from their abortion services. Physical separation could mean everything from building new entrances and exits, to opening completely new facilities and hiring more staff.

“This rule is really clearly designed to fundamentally dismantle this program and its originating purpose of expanding access to affordable birth control and reproductive health care,” Stewart said.

Many Title X clinics that offer preventive health-care services and a range of family planning services also provide abortions and abortion referrals. That includes some Planned Parenthood affiliates, who in 2015 made up 13 percent of clinics funded through Title X and provided care to 41 percent of patients seeking contraceptives. However, Stewart told Rewire.News that should the finalized version of the gag rule go into effect, Planned Parenthood would withdraw from the program.

That, according to advocates, is the point of the Trump rule. “The cruelty of this rule cannot be overstated,” Sandusky said. “This is an attempt to impose a new ideological value system on the program and it will jeopardize the health and well-being of millions of poor and low-income people across the country. What the administration is trying to do is really to suppress the ability of Title X providers and undermine providers expertise to deliver the highest quality, affordable, confidential family planning and sexual health care to those who need it the most.”

In the face of attacks, political opposition to the gag rule has begun to mobilize. Stewart points to the wave of pro-choice candidates elected to the U.S. House of Representatives and state offices throughout the country in 2018 as evidence that Trump’s anti-choice policies are unpopular among voters. Polling data taken just before last year’s election showed that abortion and reproductive health-care access was a galvanizing issue for Democratic voters.

“We feel really inspired by that grassroots energy and we at Planned Parenthood are going to be doing everything we can to channel, to continue the fight against this rule and the other attacks on reproductive health that we’ll continue to see from this administration,” Stewart said. “We’ll definitely be looking for champions in Congress to be a part of highlighting the harm of this rule and to be holding this administration accountable for their actions to hamper access to reproductive health care.”

However, the new Democratic and pro-choice majority in the House may not be enough to stop millions of people from losing access to a full range of reproductive health-care options for many years. Stewart said that rolling back Trump administration rules could take just as long as implementation took in the first place.

“People would be losing access to health care for many, many years even if a new administration came back committed to growing the program back to where it was,” she said.