As executive director of the Missouri Family Health Council, which helps to provide low- and no-cost reproductive health care across the state, Michelle Trupiano is used to navigating a challenging political environment. “I’m from Missouri, I work in Missouri, and Missouri’s a conservative state where our providers, in general, are used to an onslaught of attacks on reproductive health,” she said.
Even so, in 2018, when the Trump administration announced that it would be issuing new rules constraining the provision of family planning care via the Title X program, Trupiano couldn’t help but be discouraged: The administration was messing with the nation’s only program dedicated to providing contraceptives to low-income and uninsured people. And it was doing so in a way that required providers to lower their standards of care and was designed to push certain providers out of the program. “It was just one more thing in a long line of assaults,” she said.
But then last week, a glimmer of hope: On January 28, the Biden administration issued a memorandum on “protecting women’s health at home and abroad,” a first step toward undoing Trump-era policies that have constricted access to reproductive health care.
“I think everyone is hopeful that in the upcoming weeks everyone will be able to breathe a sigh of relief and just concentrate on what our providers do best,” Trupiano said, “which is providing the highest quality of care for patients.”
Removing the Gag
Biden’s action immediately lifts the “global gag rule,” also known as the Mexico City Policy, which banned the U.S. Agency for International Development from funding nongovernmental organizations that provide abortion services and counseling or engage in efforts to support abortion rights in other countries. The policy, first enacted by the Reagan administration, has been an on-again-off-again affair: It was revoked in 1993 by President Bill Clinton, reinstated by President George W. Bush, and then rescinded by President Barack Obama. President Donald Trump enacted it again and expanded its reach in ways that critics say hurt all manner of global health work, including the fight against HIV and AIDS. “These excessive conditions on foreign and development assistance undermine the United States’ efforts to advance gender equality globally by restricting our ability to support women’s health and programs that prevent and respond to gender-based violence,” Biden’s January 28 directive reads.
But the work to repeal restrictions placed on Title X, commonly referred to as the domestic gag rule, won’t be as immediate. Because the Title X changes were installed via the rulemaking process, it will take rulemaking to undo them, an administration official told Politico — a process that will have to be deliberate in order to withstand potential legal challenges before a Trump-laden judiciary.
Title X is the only pot of federal money dedicated to providing family planning and reproductive health services to low-income and uninsured individuals, the majority of whom are people of color. Since 1970, the program has provided access to contraceptives, reproductive health exams and counseling, cancer screenings, and testing and treatment for sexually transmitted infections. It has served roughly 4 million people per year, and the program rules have long allowed participation by all qualified providers. No Title X money funds abortion services; in fact, no federal funds support abortion except in exceedingly rare circumstances.
The Trump administration changed the rules for Title X in ways that crippled the program nationwide.
Nonetheless, the Trump administration changed the rules for Title X in ways that crippled the program nationwide. Ostensibly, the changes were aimed at Planned Parenthood, the conservative right’s favorite boogeyman. Before it exited the Title X program in 2019, Planned Parenthood was long the program’s largest provider. Though the group accounted for just 13 percent of Title X clinics, it served 41 percent of all program clients.
As with the Mexico City Policy, initial restrictions on Title X were enacted by President Ronald Reagan. They were tied up in litigation until the end of the George H.W. Bush presidency and ultimately rescinded under Clinton, whose rules for the program prevailed until Trump came along.
Trump’s gag rule has gone much further than the restrictions imposed by Reagan. Aimed at knocking Planned Parenthood out of the program, it bans grantees from referring patients to abortion providers and hobbles providers’ ability to counsel patients about abortion at all — even when continuing a pregnancy could pose serious health risks. The rule requires all pregnant patients to be referred to prenatal care regardless of the patient’s wishes. And it requires physical and financial separation between clinics that provide Title X services and those that provide abortion care, a direct attack on Planned Parenthood: Roughly half of the group’s health clinics are co-located with abortion service clinics.
Moreover, the Trump administration toyed with the directive that Title X grantees provide every “effective and available method” of birth control and eliminated the requirement that contraceptive methods be “medically approved,” opening the door to the administration’s desire to encourage wildly ineffective natural family planning and promote abstinence — another favorite, yet failed, conservative policy. The rule has also undermined program confidentiality requirements by pressuring Title X grantees to compel their adolescent patients to share information about their sexual partners and include their parents in family planning care.
(Notably, Trump’s Title X restrictions are also the subject of ongoing litigation. The National Family Planning & Reproductive Health Association, joined by the American Medical Association and others, has asked the U.S. Supreme Court to resolve a circuit court split on whether the rules are valid.)
“When those rules came out and started to deteriorate those standards, it has an impact — not just in Missouri, but across the country — and can erode trust among patients and providers.”
“We always did hold out Title X as this thing you’re not going to jack with. This is the standard … the highest quality of care at the highest standards and access for everyone,” Trupiano said. “So when those rules came out and started to deteriorate those standards, it has an impact — not just in Missouri, but across the country — and can erode trust among patients and providers.”
Indeed, instead of singling out Planned Parenthood, the Trump rules inflicted severe damage on the entire Title X network. According to a Guttmacher Institute analysis, the rules slashed the network’s capacity in half, jeopardizing care for 1.6 million female patients nationwide. (Title X serves everyone, so the number of patients who lost care is almost certainly higher.) Thirty states saw their network capacity drop by 25 percent or more; six states lost all of their Title X providers.
In Missouri, the network lost three Planned Parenthood clinics that served 14 percent of Title X patients. The Missouri Family Health Council receives roughly $5 million per year in Title X funds, which it currently administers to a network of 15 recipients operating 63 clinics across the state. In 2019, roughly 5,000 clients lost access because of the rule changes. That year, Missouri’s Title X allotment served 37,616 clients — out of more than nearly 400,000 people in need of publicly funded family planning services. Nationwide, an estimated 21 million people are in need of Title X, yet funding for the program has remained relatively stagnant. In addition to revoking the Trump rules, Trupiano and others would like to see the Biden administration increase funding for the program.
While Trupiano is disappointed that Biden hasn’t taken more immediate action to dismantle Trump’s domestic gag rule, she is hopeful that the Department of Health and Human Services will “act swiftly” and that change will come soon. “We were disappointed in the memorandum that there wasn’t immediate relief,” she said, but “at the end of the day, we’re hopeful we’ll no longer be burdened by the Trump administration’s rules and that we can go back to providing the highest quality care for our patients.”