After years of policy whiplash, Planned Parenthood and other reproductive health-care providers that offer or refer for abortions will once again be welcome into the federal Title X family planning program.

In early October, President Joe Biden reversed the domestic “gag rule” put in place by the Trump administration in 2019, which kicked a quarter of providers out of Title X—a $287 million program designed to provide family planning services for those with low incomes.

Just as health insurance gains were stalling for the first time in years, the dovetailed effect of the COVID-19 pandemic and Trump’s gag rule decimated Title X access. Rewire News Group first reported last month that in 2020, the number of patients using Title X dropped by more than half nationally.

All this might have spelled disaster for Mississippi, a state with one of the highest rates of uninsured folks, some of the worst maternal health outcomes, and the highest rate of infant mortality, teen pregnancies, and sexually transmitted infections.

Further, Title X family planning users have been on a downward trend since 2005. In Mississippi, users were down from about 70,000 in 2005 to 35,000 in 2020—with a decrease every year except for an unexplained bump in 2019.

Yet when the pandemic first hit Mississippi, nothing seemed to change. The number of patients stayed pretty steady in 2020, only declining by about 5,000 or 12 percent from the year prior—one of the smallest declines across the United States last year.

But in July 2020, Dr. Thomas Dobbs, head of the Mississippi State Health Department, told this reporter that the health department—which is the sole Title X grantee in the state—was planning to cut back family planning services because the department needed to shift resources to fighting COVID-19.

“We are definitely going to have to do less reproductive health work,” he said, during a July interview about contact tracing.

What he meant by “less” is now clear, thanks to emails obtained by Rewire News Group that show state staffers reaching out to the U.S. Health and Human Services in December 2020 about “suspending all family planning services in MSDH county health departments,” once vaccination campaigns began. Our nurse practitioners are “working COVID response and in some areas we have not been able to have a [family planning] clinic on a consistent basis,” one February 2021 email between a county administrator and the state family planning director said. “Right now it is hard to spare the nurses and NP from the vaccine sites because we are so short staffed.”

No providers, partner orgs or patients who talked to Rewire News Group for this story were alerted that family planning in the state would be severely interrupted, but MSDH did add a line to its website in April 2020 advising family planning patients to call ahead.

Jamil Dawson, executive director of Five Horizons community clinic in Starkville, Mississippi, which serves East Mississippi and West Alabama, said part of earning community trust involves clear and plain communication. His clinic does not yet offer family planning services, but they hope to partner with the state soon.

“I do feel like as a health-care system, we all can do a better job explaining things to our communities and allowing our communities to ask questions of us,” Dawson said. “They might not make us comfortable, we might not enjoy it, but we owe it to them because we need their buy-in and we need their action.”

Deep cuts in Mississippi

By March 2021, at least 13 of the largest, most centrally located Mississippi clinics were offering limited or no care at all. Patients received letters telling them, effective immediately, they should look elsewhere for care. Some clinics suggested calling other health department clinics that were also closed, while others advised patients to find a private doctor. Those that stayed open often had long waits.

Overall, in the first four months of 2021, Mississippi’s Title X visits were down 55 percent compared to the first four months of 2020, according to state health department data obtained through a public records request.

At least three other states—North Dakota, Ohio, and Oklahoma—also used a rare HHS public health emergency loophole to divert Title X funds into COVID response. But none reported cuts to their network as deep as Mississippi.

Other than health department clinics, federally qualified health centers (known as FQHCs or community clinics) are the only other primary and preventive care providers specifically geared toward low-income families, but there aren’t enough of them to go around. The entire federal community clinic program launched in Mississippi in the 1960s, and a nationwide effort to bring care to rural communities followed, but there are only 20 organizations serving Mississippi and the need goes well beyond that.

Only five of the state’s 20 FQHCs work with the health department to offer Title X care.

Not until late April (after this reporting began) did the health department make an effort to contact partner organizations and FQHCs to alert them that they might be receiving unexpected patient referrals.

The letter sent from the health department to partner organizations reads:

Despite the disruption the pandemic has caused, the need for family planning remains critical to quality healthcare. We must all continue to work together to ensure family planning remains an essential element of service delivery across the state of Mississippi. MSDH is closely monitoring service delivery disruptions and will keep you updated.

June Gipson is president and CEO of Jackson’s My Brother’s Keeper, a leader in HIV care across the South, and founder of Open Arms Healthcare Center, which focuses on LGBTQ care and has one of the health department’s few subgrants to provide family planning care. Despite working with the health department for years, she didn’t receive the letter.

Gipson said the state health department didn’t tell her they were reducing Title X care or that she should expect more referrals. But her clinic saw an uptick in family planning patients this year, and the health department asked her to contract for more mobile family planning. Both now make sense, though she’s shocked no word was given to her, or—more importantly, she said—to patients. Sudden disruptions in care will ripple through Black communities, she said, and risk permanently severing hard-won trust.

“If you find a place that you can go and you’re getting your care there, if they bail and dip out on you—that’s absolutely devastating, in particular when it’s already a struggle when you are Black going to the doctor,” Gipson said, referring to culturally competent care and barriers like transportation and cost. She added that it’s unethical, at best, for any clinic to close up shop without alerting all patients, and dangerous, at worst, to interrupt potentially life-saving care, like HIV meds and annual exams.

Data backs up and contextualizes Gipson’s point about trust, buy-in, and access. Sixty percent of folks using Title X-funded family planning clinics have no other encounters with the medical system, according to research from the academic journal Perspectives on Sexual and Reproductive Health. It’s even higher for uninsured people—65 percent of whom said family planning clinic visits were their only source of health care in the past year.

“If their clinic is no longer offering Pap smears and no longer offering colposcopies, what are women doing about that?” said Jamie Bardwell, co-founder of Jackson-based reproductive health access group Converge. “Cervical cancer does not suddenly stop because there’s a pandemic.”

Health departments that were already on limited scheduling before the pandemic stopped offering appointments altogether in some areas of the state, including metro Jackson and high-need communities in the Mississippi Delta. This came at a time when the pandemic had already blocked access to reproductive health care for many. A third of U.S. women disproportionately queer and of color, reported pandemic-related disruptions in care.

Moreover, fertility preferences shifted during the pandemic. In May 2020, a third of women reported wanting to delay pregnancy or have fewer children because of the pandemic. Black, Latinx, low-income, and queer folks were more likely to want to delay, but they also struggled the most to access preventive services.

Health-care experts and advocates say the disruptions in preventive and reproductive health care will be felt for years, not only in accessing contraceptives, but also screening for disease that’s vital to catch early, like breast and cervical cancer—both of which have sky-high death rates in Mississippi, likely due to the very issue of lacking access to screenings.

“We know that because of the pandemic, women have not been able to access preventive care,” Danielle Lampton, Converge’s other co-founder, said. “That’s not a matter of choice. That is not a delay of preventive services because of a decision a woman makes. It is a delay of preventive services because we do not have Medicaid expansion, and the Title X network is not reliably providing the cancer screenings they once did.”

Mississippi’s Title X program is a patchwork, Bardwell said. “The [agency] has health departments in almost every county or sometimes multiple health departments in the county. As a Title X grantee that is appealing to the federal government because they have statewide coverage, they have buildings across the state.”

But buildings do not ensure quality care as mandated by HHS, or even provision of services during the pandemic, she said. “The impact of reducing services this dramatically will be felt for years to come, not only for the individual woman, but also for her family.”

Bardwell points to neighboring Louisiana, whose health agency also holds a Title X grant. Not only did they not disrupt care during the pandemic, but they went virtual and mobile, offering drive-up contraceptives, take-home STI swab kits, and telehealth exams. Other state health department Title X grantees pivoted too, by extending use of long-acting reversible contraceptives (LARCs), providing self-administered contraceptive shots, and prescribing oral contraceptive supplies for a full year.

“The work that we have done at Converge is trying to really figure out what is that experience like of a patient accessing this care,” said Bardwell, who used to run the Title X program at the Mississippi health agency. “The family planning services at the health department have been limited for a long time—I think they would tell you that their staffing is very minimal. And because of that, wait times can be very long. And we believe that is very problematic for the patient experience.”

The fate of funding

The state health department declined requests for an interview, but provided an email statement in May: “Currently all health departments are offering family planning services. However, the capacity of the 86 sites is different based on multiple factors. … All areas maintained some level of service.” But just a few weeks earlier, in March 2021, state health officer Dobbs sent out an email to his management team noting that “currently the health department reproductive health program is underserved for obvious reasons,” and that leadership should think strategically and equitably about how to “restart” programs.

“COVID has revealed this long-standing instability of the entire Title X network in Mississippi,” Bardwell said. The deep cuts health clinics had already faced meant that the state was ill equipped to respond in a crisis: a perfect storm. But it’s not just Mississippi’s mistakes that added to the downpour.

Thanks to new federal data, we now know the long-lasting effect of the Trump’s administration’s big step to limit Title X services by forcing Planned Parenthood out of the program.

Biden has since reversed his predecessor’s change, but the so-called gag rules that barred providers that offer abortions didn’t affect most of the states with pandemic-related cuts, like Mississippi, North Dakota, and Oklahoma, which already had single-state provider Title X programs.

For those states with single providers, Bardwell said the answer is not only Medicaid expansion and more state public health funding, but also rethinking how services are offered. Most state health departments have moved away from providing direct services and instead share resources with partner organizations and clinics.

She reiterates the research that shows folks without insurance are more likely to receive their care at health departments than other clinics. According to the recent federal data, 54 percent of Mississippi’s Title X patients were uninsured—one of the highest rates in the United States. That number could be even higher. Multiple sources questioned the validity of MSDH record-keeping.

In the most recent federal data, the state agency reported that 33 percent of patients’ income levels were “unknown or not reported”—the most of any state.

“If people who are uninsured are primarily relying on the health department, then if services at the health department become even more limited or non-existent than what they were previously, then you have cut an entire access point out,” Bardwell said.

“And we believe that no matter your income, where you live, that we all deserve access—and quality access—to care.”

Almost all of the nearly dozen Title X experts, providers, and advocates interviewed for this series said funding has been and will continue to be the biggest barrier to expanding quality family planning care.

The national association that represents Title X grantees lobbied Congress for a $737 million Title X budget for 2022. President Biden recently proposed $340 million for the program—an increase of more than $50 million from the current budget, but a far cry from meeting demand, experts say.

Dawson, the CEO of the East Mississippi community clinic, knows funding is at the heart of the issue in Mississippi, but wants to see this crossroads turn into better communication from all health-care stakeholders across the state.

“Part of me does understand that there’s certainly a need to allocate ‘enough resources’ for COVID. And we’ve all heard about robbing Peter to pay Paul,” Dawson said. “But I would be interested to hear what is the long-term plan to ensure that that doesn’t cause a reduction in services provided to people out in the community?”

Dawson echoes Bardwell and said stand-alone clinics can pivot more easily during an emergency, and should be considered an asset to future family planning programs.

“We can’t physically have a presence there with brick and mortar buildings, but we’ve got telemedicine and telehealth programs and we can be mobile and do satellite clinics,” he said. “There are all these other options and we can be better equipped to do these things than even the health department, in my opinion, because we’re a stand-alone entity. Programs like ours need to be the extensions of the health department in that we are the ones who can get into these communities and provide these services as well.”

“And we can’t exist out here without them. So on both ends there should be a lot of motivation to straighten these things out,” he said. “And you know, each day [we] have another day to get it right. All the past mistakes are real, and they’re certainly things to be learned from to ensure we don’t do them again going forward. COVID has given us an opportunity to have these conversations again.”

Correction: This article was updated to include Jamil Dawson’s correct job title.