Ask KFF: Alina Salganicoff Answers 3 Questions on Final Title X Regulations for Family Planning Clinics

On Feb. 22, the Department of Health and Human Services released the final rule regarding use of Title X federal funds for family planning clinics, which serve approximately 4 million people nationwide. These final regulations, slated to be published in the Federal Register on March 4, are very similar to what HHS proposed in November 2018. Nearly 4,000 clinics across the country participated in Title X as of 2017, and an average of 19% of their revenue for family planning services came from these federal funds. For further context, we asked Alina Salganicoff, Vice President and Director of Women’s Health Policy at KFF, three questions about the impact and implications of these final rules for the women and the Title X clinics that serve them.

1. What are the major elements of this final rule?

Salganicoff: While the Title X program has always prohibited federal funds from being used for abortion, the prior regulations permitted family planning clinics that provide or refer for abortion to participate, as long as no Title X funds were used for abortion. This final rule significantly alters the Title X program. The Trump Administration’s final regulation now blocks any clinic that provides or even refers a patient for an abortion at another facility from receiving any Title X funds. These clinics can also no longer qualify for funds to provide low-income women with comprehensive family planning and other preventive services such as breast exams, pap smears, cervical cancer screening, and STI testing. This final rule disqualifies Planned Parenthood sites and clinics that provide abortion services, as well as those that refer patients elsewhere for abortion services.

The regulation also removes the requirement that Title X clinics offer pregnancy options counseling to pregnant women that includes abortion, adoption, and prenatal care referrals.  While these final regulations require grantees to offer “a broad range of acceptable and effective family planning methods and services” — including some but not all contraceptives — it promotes the participation of organizations that offer natural family planning or abstinence in the Title X program.

2. How are these regulations likely to affect the health and care of women who seek services in clinics that receive Title X funds?

Salganicoff: There is no doubt that the regulations will affect access for low-income and uninsured women that rely on Title X clinics in a number of ways.  First, the network of providers that participate in Title X will shrink, because Planned Parenthood clinics and other family planning providers that refer for or offer abortion services will be effectively disqualified from the federal program funding.  In certain communities, women may no longer have a Title X provider that can offer them the full range of contraceptive methods in a timely fashion.  Because of this loss of federal funds, some of the clinics may close, and others will have to lay off staff and reduce hours.  This all can affect women’s access to care and place them at risk for unintended pregnancies or untreated STIs. Some women may find they will have to wait many days or weeks for a time sensitive appointment, or they may find that the most effective family planning or contraceptive method of their choice is not available to them.

For pregnant women seeking abortions, Title X-funded clinics will not be permitted to offer women direct referrals for abortion and definitely not to any providers that specialize in abortion care.  If a Title X clinic decides to offer non-directive pregnancy options counseling that includes abortion (which will cease to be a requirement), then the only information their patients could potentially receive is a list of providers that offer comprehensive primary health care services and prenatal care. The list may include some providers that also offer abortion services, but it cannot specify which providers offer abortion services, nor are clinic staff permitted to identify the abortion providers.

Imagine going to the doctor and needing time-sensitive follow-up care, but then being handed a list that includes some providers who can treat your condition and others who cannot. Meanwhile, the very specialists who provide the best quality care for the service you need are completely omitted from the list.  This is not the standard used in any other medical setting when patients are referred for follow-up services.

3. What’s likely to happen to the clinics that currently receive these funds when these requirements go into effect? 

Salganicoff: This is still unclear.  The current funding cycle under the prior regulation ends March 31, and new grants are scheduled to begin April 1.  Organizations submitted their grant applications in January. But many will no longer qualify for Title X or may withdraw from the program entirely, because the regulations would require them to violate their missions or medical standards of care by withholding information from patients about where to seek the highest quality services.

Several family planning organizations and state attorneys general have already publicly stated their intent to sue to block the implementation of these regulations.  When a similar regulation was issued by the Reagan Administration, it was challenged by family planning providers and made it all the way to the Supreme Court. In Rust v. Sullivan, the Supreme Court upheld the Administration’s right to restrict the types of providers that participate in the federal program and ban abortion referrals.  The regulation was never fully implemented. President Clinton issued a new regulation soon after he was sworn in.  I wouldn’t be surprised to see these cases make their way through the Federal Courts and even end up back at the Supreme Court.