Current Status of the Title X Network and the Path Forward

The Impact of the Trump Administration Regulations

Prior to the Trump Administration regulations, the Title X program, administered by the U.S. Department of Health & Human Services (HHS) Office of Population Affairs (OPA), served around 4 million low-income, uninsured, and underserved clients each year in approximately 4,000 clinics nationwide over the past decade.  

However, in March 2019, HHS issued  new regulations  revising the interpretation of Section 1008 of the Title X statute that states, “none of the funds appropriated under this title shall be used in programs where abortion is a method of family planning." Historically, this has largely been interpreted to mean that no funds are used to pay for abortions and clinics have maintained a full financial separation of Title X from other funding that supports abortions.

The Trump Administration had a broader interpretation of this section and issued new regulations that  prohibit  Title X clinics from providing abortion referrals, require physical separation of abortion services, and mandate prenatal care referrals for all pregnant women.

As a result of the new regulations, the number of clinics and the number of patients served by the program dropped precipitously. 

Over 1,000 (~25%) Title X sub-recipients and sites have left the Title X network.

Six states entirely withdrawing from the Title X network: Hawaii, Maine, Oregon, Utah, Vermont, and Washington.

The majority of Title X clinics in Alaska, Connecticut, Illinois, Maryland, Minnesota, New York, and New Hampshire left the program.

 Planned Parenthood  as an organization formally withdrew from the program on August 19, 2019, a decision that affected eight Planned Parenthood grantees and 410 Planned Parenthood clinics that had historically been supported by Title X funds. An additional 757 sub-recipients and clinics composed of city or state health departments, federally qualified health centers, and nonprofit organizations also withdrew from the Title X program.  

Net Change in Clinics

Despite OPA’s attempt to expand coverage to offset the grantee and site withdrawals through  supplemental grant awards , only 7 states (CO, DE, KY, ND, NM, NV, TX) had a meaningful increase in the number of Title X clinics in their state. 

The impact of the Trump Regulation differed across the US.

6 states completely withdrew from the program and 8 states had a sizable loss in participating clinics.

New Clinics in 2020

Since 2019, over 1000 clinics have left the Title X network.

From June 2019 to June 2020, there were 225 new Title X sites that joined the network, but these did not fill the substantial gaps left by the grantees and sites that withdrew from the program.   

Decrease in Clients Served

With the rules only being in place for five and a half months, OPA’s  2019 Family Planning Annual Report  showed a decrease of 840,000 clients served by the Title X program in calendar year 2019 compared to calendar year 2018, a 21% reduction in clients served.

OPA data also reflects a sizable reduction in the number of women who received preventive screenings for cervical and breast cancer and STIs.

Some of the states that left the Title X network were able to obtain state funds to offset the loss of the federal support and were able to continue providing family planning services to low-income, uninsured, and underserved clients. The future availability of these funds, however, is not certain. State budgets have been deeply challenged by the economic impact of the COVID-19 pandemic and it may be difficult for states to continue allocating funds for family planning services in the face of severe budget shortfalls.  

Litigation 

In response to the Trump regulations,  eight lawsuits challenging the regulations  were filed in federal court. There is a split in decisions between the  4th Circuit Court of Appeals , which held that the regulations are arbitrary and capricious and contrary to law, and the  9th Circuit Court of Appeals  which allowed the regulations to go into effect. The regulations are currently blocked in Maryland, but in effect in the rest of the county. The plaintiffs in the 9th Circuit case have  petitioned  the Supreme Court to review the case and resolve the circuit split. HHS has also  petitioned  the Court to review the case from the 4th Circuit. However, new regulations by the Biden Administration would make these lawsuits moot.  

Many provisions in the Trump Administration’s regulation mirror those issued in 1988 by the Reagan Administration. In 1991, the Supreme Court upheld the Reagan regulations in the case,  Rust v. Sullivan After the Court’s decision, the Reagan Administration’s rule was only in effect for one month in 1992 before it was rescinded by President Clinton in January 1993 when he came into office.  

Looking forward 

In order for Biden to restore the structure and standards of the Title X program, his administration would have to issue regulations to replace the Trump Administration’s regulations and subsequently issue a new Funding Opportunity Announcement (FOA) giving states and previous grantees an opportunity to reapply to the Title X program under the new regulations. The new FOA could assure that Title X funded projects would once again be held to the standards of providing  quality family planning services  as defined by the CDC and the OPA. These changes would enable many of the grantees and sites that have left the program to again qualify for federal funding at a time when continued state funding is uncertain and allow those who have remained in the program to again offer abortion referrals to those who seek them.

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