With Planned Parenthood Out of Title X, Clinics Face “A Terrible Choice”

August 27, 2019
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A motorist passes a Planned Parenthood clinic on May 18, 2018 in Chicago, Illinois. (Scott Olson/Getty Images)

Since Planned Parenthood’s decision to remove itself from Title X, the federal program that provides reproductive care for nearly 4 million low-income Americans, thousands of health care workers and administrators have been scrambling. In private meetings across the country, many are asking the same question: what next?

“Total, total shock,” said lawyer and health policy researcher Sara Rosenbaum in a recent interview. “This is way beyond Planned Parenthood.” Days after the organization announced it would pull out of Title X, Rosenbaum, who has consulted on health care issues under six presidential administrations, was still reeling.

“What kind of an administration would blow up an entire network for a valuable public health program, without even having remotely thought through what the access implications are?” she said. “It’s breathtaking disregard for health and life.”

Planned Parenthood — which has long been a target of the Trump administration — serves 1.6 million recipients of Title X. Earlier this summer, the Department of Health and Human Services (HHS) finalized a series of changes to the program amid protests from doctors and medical associations.

The changes include what critics call a “gag rule,” which forbids doctors from referring patients directly to an abortion provider. Rather than complying, Planned Parenthood pulled out of the $260 million program.

If the most recent Title X rule changes are not successfully challenged in the courts, experts including Rosenbaum said the U.S. system risks losing hundreds of clinics — not just Planned Parenthood’s.

To comply with the guidelines, clinics must now prove physical separation between their general health service areas and facilities in which abortions are performed. By HHS’s estimation, approximately 20 percent of Title X providers would have to renovate their clinics at a cost of between $20,000 and $40,000. (Title X funds have never paid for abortions, and clinics that provide them have long been obligated to keep separate financial records for general health and abortion services.)

That has left the future of many clinics — and patients — uncertain. Gretchen Ely, a professor of social work at the University of Buffalo, said any clinic closures will hurt vulnerable men and women first. “You’ll see them slipping out of this system into a free-for-all, depending on what state they’re in,” she said.

According to HHS spokeswoman Mia Heck, all grantees, including Planned Parenthood, knew what the new Title X regulations were when they accepted last year’s round of funding. She said they are now trying to blame the government for their own actions.

“They are abandoning their obligations to serve their patients under the program,” Heck said in a statement. “HHS is grateful for the many grantees who continue to serve their patients under the Title X program, and we will work to ensure all patients continue to be served.”

What Comes Next?

Some states, including Washington, California and Maine, are challenging the rule in court and have pledged to make up the difference in funding as long as they can.

“We are going to do everything we can to mitigate the harmful effects of this rule,” said Lacey Fehrenbach, assistant secretary of prevention and community health in Washington.

For now, Washington’s Title X-supported clinics are being funded from state coffers. Based on predictions by the state’s health department, Washington projects it can maintain its current level of service until March 2020. After that, they’re going to start considering reducing eligibility or narrowing the list of Title X-eligible services, which currently includes mammograms and testing for sexually transmitted infections.

“All the clinics that receive this Title X money are going to be faced with whether or not they’re going to let the gag rule stand and take the grant money, which I’m sure is contrary to their mission, or are they going to drop the Title X and no longer be able to serve patients,” Ely said. “It’s a terrible choice for a health care provider.”

In early July, Rosenbaum and nearly 200 other members of the American Public Health Association submitted a “friends of the court” statement supporting an injunction against the controversial changes to the Court of Appeals for the Ninth Circuit. The court determined that while cases went ahead in California, Oregon and Washington the new Title X rules would stand.

On July 20, the HHS issued an ultimatum: all clinics, agencies and providers of reproductive health care across the country had to provide evidence they were acting in “good faith” with the new rule by Aug. 19 or lose funding. Planned Parenthood asked the court to intervene, but the request was quickly denied.

Jodi Tomlonovic, executive director of the non-profit Family Planning Council of Iowa, has worked in public health for three decades. When contacted by FRONTLINE, she said she was stunned by the court’s refusal to hear additional arguments. Her state is one of 13 where more than 40 percent of women receive services from Planned Parenthood.

“This is a loss for access to family planning in Iowa,” she said. “Particularly for the low-income and very vulnerable populations that need the Title X safety net.”

Tomlonovic has witnessed the effects of clinic closures firsthand. In 2017, Iowa’s state lawmakers abruptly defunded all clinics that either performed abortions or referred patients to abortion providers when asked. Soon after, four of the state’s Planned Parenthood locations — including one in Keokuk, Iowa, which had never provided abortions — abruptly closed. While Title X clinics eventually reopened in the other communities, Keokuk, a city of 10,000 people, was still without a clinic. If the current guidelines remain in place, similar tableaus are likely to play out across the country.

And despite HHS’s claims otherwise, Rosenbaum predicted that the country’s other federally qualified health centers won’t be able to handle the tsunami of provider-less Title X patients that will be jettisoned into the system.

Nationwide, health centers serve an average of 320 patients seeking contraceptives every year. By comparison, Planned Parenthood clinics serve an average of 3,000. Its clinics only make up 13 percent of Title X providers but serve around 40 percent of Title X patients. A recent study by the Kaiser Family Foundation found that only 6 percent of American health centers would be able to increase their capacity by 50 percent or more.

Even if a federally qualified health center can handle taking on former Planned Parenthood Title X patients, many don’t want to, according to Rosenbaum. “Let’s say you were a health center and you have 50,000 patients,” she said. “You are a $50 million-a-year operation, and suddenly there’s $100,000 out there for you, except that money is toxic . . . and potentially you are creating a lot of legal liability for yourself, because of course [the government] made the pregnancy testing and counseling toxic. They’ve said that you have to withhold information from these patients. And you have to do a compulsive maternity care referral even for patients who don’t want it.”

There is no legal defense based on “the funder made me do it,” Rosenbaum added. “If the funder is telling you to practice substandard medicine and you injure a patient, it’s too bad for you. Maybe you shouldn’t have taken that money.”

In the meantime, oral arguments in the California, Oregon and Washington cases will be heard in a San Francisco court on Sept. 23. If the rule changes are allowed to stand — and even if the legal challenges take more than a few more months — Ely anticipates that there will be a steep increase in unintended pregnancies across the country, similar to the one seen in Texas after it defunded its Title X programs. Those pregnancies, she said, are often the result of rape or unwanted sexual contact.

Ely, who considers herself “Catholic-by-proxy,” said she doesn’t understand the logic of the current administration’s fight, which she said targets people who are already marginalized. “I don’t see how you could make the argument that these cuts align with a Christian philosophy,” she said. “The people who are being impacted are already alive.”

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