Trump abortion rule could hit rural communities hard

Patients could face new challenges accessing birth control and other reproductive health care services, particularly in rural areas, under changes made by the Trump administration to a federal family planning program.

Planned Parenthood, government agencies in blue states and other health providers are expected to tell the Department of Health and Human Services (HHS) on Monday that they will not comply with its new rules banning recipients of Title X family planning funds from referring women for abortions.

That means they will have to leave the Title X program, giving up millions of dollars in funding that had been used to provide low-income women and men with birth control, cancer screenings, HIV and STI [sexually transmitted infections] testing and other reproductive health services. 

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That loss in federal funding could deliver a heavy blow to already cash-strapped, non-profit clinics that are often the only providers in their communities offering low cost services.

Those clinics, though, say they cannot ethically participate in a program that would require they withhold information from patients. 

“Where else do you send somebody who’s uninsured, underinsured, has an STI or an HIV infected partner? It’s scary for us,” said Lisa Leach, executive director of Lovering Health Center in Greenland, N.H., which will leave the program Monday. 

HHS set a Monday deadline for grantees to provide evidence that they are acting in “good faith” to comply with the rules. 

Any grantee that doesn't respond, or tells HHS they won’t comply with the rules, “must relinquish its grant or face termination of its grant,” a HHS spokesperson told The Hill. 

About 100 grantees oversee hundreds of Title X-funded clinics across the country. Most grantees haven’t announced yet whether they will leave the program. 

But Planned Parenthood, which serves 40 percent of Title X patients and receives about $60 million from the program annually, said this week its 400 clinics will quit the program, leaving states like Utah, Minnesota, Vermont, and parts of New Hampshire without a Title X provider. 

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Planned Parenthood has said it will dip into its reserves to ensure it continues services for patients. But every Planned Parenthood affiliate has its own budget and will have to make its own decisions about what services it can offer. 

In Minnesota and Vermont where Planned Parenthood serves all or most Title X patients, “wait times for appointments will skyrocket and people will delay or go without care,” a Planned Parenthood official said. 

In Utah, where Planned Parenthood is the sole grantee, it will lose $2 million in Title X funding. Officials say they are raising money, seeking private funds and looking for cost savings to ensure they “never have to turn anyone away.” 

And while changes haven’t been decided yet, patients might have to pay more for services. 

“This means that women are going to have to struggle with maybe trying to come up with $10 to contribute to their health care when before they only had $5,” said Karrie Galloway, chief executive officer and president of the Planned Parenthood Association of Utah. 

“It’s pretty darn frustrating when you think that, over politics, women and their families will suffer just a little bit more. If you don’t know them, maybe you don’t care, but Planned Parenthood of Utah cares.” 

The Trump administration argues Planned Parenthood’s loss of Title X funding is a “self-inflicted” wound because the organization could just agree to follow the new rules. In addition to banning abortion referrals, Planned Parenthood would also have to stop providing abortions altogether.

HHS argues the changes are necessary to ensure clinics aren’t using federal funds for abortions. Under current law, federal funding can’t go toward the procedure. It's the biggest change the Title X program has seen in its nearly 50-year existence. 

Planned Parenthood and a host of states are suing the administration, with an appeals court holding hearings next month.

“To the extent that Planned Parenthood claims that it must make burdensome changes to comply with the final rule, it is actually choosing to place a higher priority on the ability to refer for abortion instead of continuing to receive federal funds to provide a broad range of acceptable and effective family planning methods and services to clients in need of these services,” HHS says on its website. 

But it’s likely to be the smaller health clinics, unaffiliated with Planned Parenthood and its large base of donors, that will struggle the most to continue providing services to low-income patients, particularly those in rural areas.

Leach at the Lovering Health Center hasn’t made any changes yet but might have to after Monday when the clinic loses its Title X funding, which makes up 20 percent of its budget. 

It has a small emergency fund it will draw from and is applying for foundation grants and seeking other private donations. 

But Leach said she’s already considering the changes she might have to make, like ending the clinic’s walk-in nights, where patients can come in without appointments, or doing away with STI and HIV counseling, testing and treatment. 

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She’s most worried about having to end the clinic’s sliding fee scale, which allows patients to pay for services based on their income. About 25 to 50 percent of her patients rely on that. 

“It kills me to even say it because that’s a huge reason why people seek out centers like ours,” she said. 

“It happens a lot that they’re getting services for free or close to free. And so if we’re doing away with that, they’re just going to not have those services.” 

In some states, governments are the Title X grantees. Some states led by Democrats have said they won’t accept the funding under the new conditions. 

Both Title X grantees in Illinois — the Democratic-led state government and a private nonprofit — have said they’ll leave the program. 

Washington state and Hawaii has also said they won’t comply with the rules. 

All three states said they will subsidize their clinics to make up the loss in federal funding. 

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“It is a short-term strategy, there’s no doubt about that,” said Alina Salganicoff, senior vice president and director of women's health policy at the Kaiser Family Foundation. “Some states have the ability to reprogram funding to support family planning services."

"But I’ve witnessed enough downturns," she added, "and these are the programs that really get hit hard, programs for the poor.”

HHS has not said what it will do about states that are left with no Title X providers. 

Providers leaving the program will likely continue offering similar services without the Title X funding by using private donations, changing hours or laying off staff. 

But the federal government is still required by law to fund a robust network of providers to help low-income women and men with family planning.

"Where feasible, HHS will consider a new administering agency to fulfill any obligations that the non-complying grantee is not able or willing to complete," the HHS spokesperson said. 

HHS has shown interest in awarding funds to faith-based organizations that oppose contraception and abortion. It has also indicated it might rely on federally qualified health centers [FQHC] to participate in Title X.

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But the National Association of Community Health Centers, which represents FQHCs, opposes the changes, raising questions about whether they would even be willing to participate in the program under the new rules.

"Their clinicians are going to be every bit as worried as any clinicians anywhere about not being able to counsel their patients properly," said Sara Rosenbaum, a health law and policy professor and researcher at George Washington University. 

"And to the extent that health centers start to withhold information from their patients, they face the same kind of legal liability that any doctor would face."

The American Medical Association, the nation’s largest group representing doctors, also opposes the rules for this very reason. 

Multiple studies and experts have said that FQHCs would not be able to assume Planned Parenthood's large caseload of patients.

"[Planned Parenthood] cares for such a large percentage of Title X clients that it simply unclear what's going to happen to them," Rosenbaum said. 

"This is suicidal. It's the most suicidal move I've seen from a presidential administration."