When Republican U.S. Rep. Henry Hyde (IL) initially stripped Medicaid recipients of the right to insurance coverage for abortion services more than 40 years ago, he admitted impoverished people made easier targets for his anti-choice crusade than those of means.

Dr. Deborah Oyer, medical director of Cedar River Clinics, Title X-funded providers in Washington state, sees parallels between the discriminatory Hyde Amendment and the Trump administration’s new domestic “gag rule” on Title X grantees. Some 4 million people receive care from 4,000 Title X-funded providers across the United States, and the majority live at or below the poverty line.

Cedar River Clinics, attorneys general in at least four states, and an advocacy group have announced court challenges to the rule in the past week. They argue the planned changes to the Title X family planning grant program impose unequal standards of care on millions of people with low incomes. 

Washington Attorney General Bob Ferguson said Tuesday the state would file a preliminary motion to block the rule, arguing it violates the Affordable Care Act and an annual provision in the Consolidated Appropriations Act that requires pregnancy counseling be non-directive. Attorneys general in Connecticut, Oregon, and New York, and California’s governor, have said their states will take action. Meanwhile, ten newly elected Democratic governors, including Michigan Gov. Gretchen Whitmer and Maine Gov. Janet Mills, signed a letter condemning the administration’s “politically motivated restrictions” on family planning funding. 

The governors said in the letter they would “do what is necessary to protect the health of our constituents and explore all possible avenues, including legal options, to block it from being implemented.”

The Trump rule bans abortion referrals at Title X-funded clinics, forces abortion providers to physically and financially separate abortion services from Title X family planning services, and skews the counseling patients are given. The rule mandates Title X clinics make referrals to providers offering prenatal services, whether or not the patient wants that care.

“The new rule mandates discrimination,” Oyer told Rewire.News. “People’s income should not dictate what they know” about their health-care options.

Launched during the Nixon administration with bipartisan support, the Title X grant program was designed to equalize access to modern contraceptive care as part of the federal war on poverty. The Reagan administration in 1988 instituted the first “gag rule,” which met legal challenges and was repealed in the early 1990s by the U.S. Congress, though lawmakers lacked the votes to override the veto of President George H.W. Bush. In 1993, President Bill Clinton used an executive order to suspend the so-called gag rule. The anti-choice rules, never fully implemented, were formally repealed in 2000. 

Although years of Republican-led attacks have since tried to starve Title X of funding, $286 million grant program remains a “successful, proven, public health necessity,” Clare Coleman, president and CEO of the National Family Planning & Reproductive Health Association, said in a Tuesday press conference.

Contraceptives supplied at Title X clinics have led to a sharp decline in the rate of unintended pregnancies, a 2017 Guttmacher Institute analysis found. Unintended pregnancy among U.S. teens would have been 44 percent higher without Title X, while unplanned pregnancies and abortions would have risen by nearly one-third without the grant program.

“One of the extraordinary successes of Title X is that throughout the country you can find a Title X provider, whether it’s the county health department or private not-for-profit in nearly every community,” Coleman noted.

Unless blocked in court, the new Title X rule is expected to be published March 4, and will take effect 60 days later.

The rule makes good on a campaign pledge by President Trump to “defund Planned Parenthood.” Planned Parenthood serves 41 percent of Title X patients, potentially leaving nearly 2 million low-income patients who rely on the provider without access to contraception and other care if the administration’s “gag rule” takes effect.

A 2015 analysis by the Guttmacher Institute found 103 counties where Planned Parenthood is the only provider of publicly funded contraceptives. Despite claims by anti-choice activists that local health centers could pick up the slack if Planned Parenthood was shut out of the Title X program, local health centers would need to increase their caseloads by an average of 70 percent to accommodate Planned Parenthood’s current patients, Guttmacher found.

It’s a similar story in Maine, where Title X grantee Maine Family Planning runs 18 clinics. More than 20,000 Mainers annually count on the centers for a full range of contraceptives, STI testing and treatment, cancer screenings, and at one clinic, primary care services.

“For many Mainers we see, we are their only source of health care,” said Leah Coplon, a program director who oversees the organization’s abortion services department.

To Coplon, a nurse in women’s health for over two decades, the rule represents the height of government interference in health-care decisions.

“It’s saying somebody in Washington, D.C. with an agenda knows what’s best for a 15-year-old rural Mainer with an unplanned pregnancy,” she told Rewire.News. “Having the government come in and dictate what I can and cannot say about a safe, legal procedure is outrageous.”