Some health clinics that quit the federal family planning program over Trump anti-abortion policies are cutting staff, charging for services that had been free and making other austerity moves to avert a major hollowing out of reproductive health care for poor women.
At least four state health departments, hundreds of Planned Parenthood clinics and dozens of independent providers have withdrawn from the more than $250 million Title X program. Some have literally had to box up and return unused supplies bought with a government discount. They’re leaning on emergency funds, private donations and in some instances, state assistance.
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But it’s not enough for the most hard-pressed providers. Trying to preserve as much patient access as they can, clinics are imposing new fees, trimming sex education and suspending some sexually transmitted disease testing even as the Trump White House makes eradicating HIV a national priority.
“We’re watching the safety net disintegrate right before our eyes,” said Jessica Marcella, the vice president of advocacy and communications at the National Family Planning and Reproductive Health Association, which represents staff at thousands of Title X clinics across all 50 states.
The clinics in August quit the Title X program, which dates back to the Richard Nixon presidency, when the Trump administration added restrictions that include forbidding clinics from referring patients for abortions. Another provision, requiring additional layers of physical and financial separation between abortion and other reproductive health services, takes effect in 2020.
And the challenges to providing comprehensive reproductive and preventive care to poor women may become more severe. There could be a new wave of cuts when clinics burn through cash on hand. And while fundraising could forestall service rollbacks — and the administration insists new providers will step in to fill the void — the reality could be a permanent reduction in free or low-cost family planning services across the country.
Clinics remaining in Title X and planning to comply also are gearing up to retrain staff and counsel employees on what can and can’t be said in conversations with patients seeking to terminate a pregnancy, according to officials and two state plans reviewed by POLITICO. That’s because the new rules allow discussions about abortion but forbid actually referring a patient to a provider — a restriction critics contend is a “gag rule” that tramples on patients’ rights.
The extent of the service cuts is difficult to measure, because clinics only began exiting the program over the past two weeks. But disruptions are less likely in conservative-led states that have not been relying heavily on the more than 400 Planned Parenthood clinics that receive Title X funding. Meanwhile, the withdrawals by private and public grantees have left states including Maine, Oregon, Utah, Vermont and Washington with no Title X providers.
Trump administration officials and anti-abortion groups portray the new rules as a de facto defunding of Planned Parenthood because the organization received up to $60 million per year from the Title X program. The organization was already barred from using that federal funding to provide abortions, but the new rule would require financial and physical separation of their abortion providers and other health care services funded by Title X. Critics of the women’s health group say the policy change prevents federal funding from being used to subsidize abortion services.
Planned Parenthood, the American Medical Association and nearly two dozen states are fighting the new rules in a case that will go to the 9th Circuit U.S. Court of Appeals in late September. But in the meantime, some clinics choosing to forego the Title X funding are figuring out how to make ends meet.
The Mahube-Otwa Community Action Partnership, which serves patients in rural Minnesota, is cutting half of its family planning staff of six and plans to curtail walk-in visits and initiatives like talking to college students about safe sex.
The Lovering Health Center in Greenland, N.H., is suspending its walk-in STI testing service, imposing a hiring freeze and stopping most community outreach and education work.
The Planned Parenthood affiliate in Cleveland has stopped using a mobile health care unit that brought STI testing and sex education services to underserved areas.
And the Utah Navajo Health System is charging for once-free doctor visits, pregnancy and STI testing and other services that roughly $40,000 in Title X funds used to subsidize.
“We’re already seeing patients forego services,” Byron Clarke, the chief operating officer of the UNHS, told POLITICO. “It hits hardest on people who are already considering whether they can afford the gas money to drive to see us.”
State health departments that left the program are pledging to make up for lost federal dollars with public funds. Planned Parenthood and other providers elsewhere are turning to fundraising, with varying degrees of success.
Planned Parenthood of Illinois is relying on $3.5 million it raised since President Donald Trump was sworn in that it estimates will sustain services until June 30, 2020. The affiliate’s president and CEO, Jennifer Welch, acknowledged that afterward “there may be a time when we have to increase our cost to our patients or decrease our services to our patients.”
Smaller clinics like Mahube-Otwa and Lovering Health Center also are adapting to another reality: losing their ability to buy contraceptives and other medications they bought at a discount while part of the Title X program.
“We don’t have a lot of ability to fundraise,” said Liz Kuoppala, Mahube-Otwa’s executive director. “We don’t have large foundations or a lot of wealth to tap into in the private sector.”
The Lovering Health Center’s executive director, Lisa Leach, said she’ll emphasize the severity of the situation at her annual fundraising event in October.
“This year it’s really a call to action,” she said. “We’re asking for donors, for example, to fund five IUDs.”
Providers aiming to stay in the program submitted plans to HHS in August detailing how they plan to comply with the new rules. They have to show they’re following through with those plans by Sept. 18., and must have separate physical facilities for abortion services in place by next March.
But some grantees say they’re not entirely clear what HHS will consider as full compliance.
“I would not be shocked if they responded and said, ‘Perfect!’ and I wouldn’t be surprised if they said, ‘This is no good,” said Marj Plumb, the acting executive director of the Family Planning Council of Nebraska, the state’s sole manager of Title X funds.
Other clinics and groups managing family planning dollars, such as Wisconsin’s Department of Health Services and Unity Health Care in Washington, D.C., submitted plans to the department but are still assessing whether they can comply with the new policy.
San Francisco’s Women’s Community Clinic is also seeking more details and has said it’s ready to give up $150,000 in annual Title X funding if it feels its principles are being compromised.
“If it’s a gag rule, we’ll pull out,” CEO Vitka Eisen of the clinic’s parent group HealthRIGHT 360 said.
HHS officials have said they could find new providers to replace Planned Parenthood and other exiting groups “where possible.” But the department has declined to comment or respond to multiple questions about its search and how long that process might take.
Jonathan Imbody, vice president for government relations at the Christian Medical Association, which represents Christian health professionals, told POLITICO that he’s confident there won’t be gaps in care, even though Planned Parenthood and the other exiting providers served more than 1.5 million women in Title X.
“They won’t be missed,” he said. “Able and ready to serve Title X patients are thousands of federally qualified health centers and other nonprofit clinics across the country that provide much more comprehensive, compassionate care than does abortion-focused Planned Parenthood.”
But in some parts of the country, replacements may be hard to find. Vermont, for example, relied exclusively on Planned Parenthood for Title X services, and state officials there said they’re unaware of any potential replacement. Planned Parenthood was the only respondent each time Vermont’s health department applied for Title X funding and put out a request for proposals, according to a department spokesperson.
The Guttmacher Institute, a research organization that supports abortion rights, projects that remaining Title X clinics would have to see an average of 70 percent more patients seeking birth control to make up for Planned Parenthood’s exit — a burden Guttmacher notes poses “massive challenges” for many providers.
Organizations like the National Family Planning and Reproductive Health Association contend there’s a finite pool of providers willing to be part of Title X and its sometimes burdensome bureaucratic requirements, and that most were already part of the program. Just a handful of new grantees were added earlier this year, including the faith-based California clinic network Obria, which opposes both abortion and most forms of contraception.
“The notion there is this secondary network waiting in the wings to jump in doesn’t bear out in reality,” said Marcella of the family planning and reproductive health association.
Victoria Colliver and Renuka Rayasam contributed to this report.