With abortion in spotlight, can Biden reverse 'devastating' drop in family planning program?

WASHINGTON – After the Trump administration prohibited federally funded clinics from providing abortion information to patients, Planned Parenthood of Utah turned to private donors and used patient-paid fees to continue offering family planning services.

Now that the Biden administration has lifted the Trump-era restrictions, health care providers across the country are working to rebuild the Title X network that was substantially diminished over the past two years. Title X provides federal funds to health care providers for family planning services, as well as preventative care

“I’d like my $2 million back,” Karrie Galloway, president and CEO of Planned Parenthood Association of Utah, said of the federal funding her organization used to receive. “It takes a lot of effort  – and effort takes people and money – to put things back into place.”

The 2019 changes effectively blocked clinics that offer abortion services from receiving Title X funding. In addition, grant recipients could not make referrals to abortion services and had to refer pregnant patients to prenatal care – a restriction opponents called a "gag rule." 

In this file photo taken on May 31, 2019, Pro-choice supporters and staff of Planned Parenthood hold a rally outside the Planned Parenthood Reproductive Health Services Center in St. Louis, Missouri, May 31, 2019.

The number of patients served by the federal government’s only grant program for family planning care fell from 3.9 million to 1.5 million people, mostly because of the Trump administration changes that prompted more than one quarter of care sites to leave the program, according to the Office of Population Affairs, which administers the program at the Department of Health and Human Services.

Efforts to restore the program – including a potentially historic boost in funding – come as the Supreme Court is considering whether to allow states to put new restrictions on abortions or ban them outright. 

"The future of reproductive health looks somewhat bleak," said Audrey Sandusky, spokeswoman for the National Family Planning and Reproductive Health Association. "I think what we’re seeing is some major strides in one area with an unfortunate situation in another."

The Title X program had historically served around 4 million low-income, uninsured, and underserved people a year.

The Department of Health and Human Services, which estimates the Trump-era restrictions caused about 63% of the decrease in family planning users and the coronavirus pandemic the rest, anticipates it will take at least two years to rebuild the network of Title X clinics. 

"The decline in clients served and services provided is devastating," the department wrote when it published the new rules last month. 

Historic increase in funding

Democrats hope to expand – and not just restore – the program’s reach. The 2022 spending bills still pending in Congress include up to a 75% funding increase.

That historic level of increase – one of the most significant proposed boosts for any federal program – would be "game changing," Sandusky said.

Extra funding is crucial, she said, because getting patients back in the door “is definitely not an on-off switch.”

Arizona, however, shows how the network could come back larger than before.

Health and Human Services Secretary Alex Azar, President Trump and Vice President Pence.

After Planned Parenthood withdrew from the program in 2019, the Arizona Family Health Partnership – which receives and administers Title X funding in the state – sought other providers. New health centers were added to the program, but the process took long enough that not all are receiving patients yet.

In the meantime, however, Arizona Family Health Partnership is working with Planned Parenthood to rejoin the network – as long as the federal government approves the state’s request for additional funding.

“If all goes well, and there is additional funding in the network,” said Arizona Family Health Partnership CEO Bre Thomas, “absolutely we'll have more sub-recipients, we'll have more clinics, and we'll have more clients.”

Still, Thomas knows that funding that’s bumped up by the current White House can quickly disappear in a future administration or through a legal challenge.

“Now I’ve seen how quickly it can turn,” she said.

In fact, after the new Biden administration rules went into effect last month, Ohio and 11 other states sued to block implementation. A federal judge could announce any day whether the changes can continue as they’re being litigated.

“Everything in reproductive health is always bumpy,” said Lisa David, president and CEO of Public Health Solutions, the largest public health non-profit serving New York City. “It’s bumpy because of the politics and it’s bumpy because everything goes to court and gets delayed.”

David’s group was among those that challenged the Trump administration rules. The Supreme Court dismissed the challenges in May because the new administration was in the process of changing the disputed restrictions.

David called the Trump rules “extraordinarily disruptive, both to our operations and to the patients.” She had been in the process of closing health centers in Brooklyn when the state stepped in to replace the federal funding. It took about four months to get staffing and patient load back to normal, she said.

Trust Women's founder and CEO Julie Burkhart stands in the doorway of an operating room at the Trust Women South Wind Women's Center in Oklahoma City.

States without Title X funding

State funds have been filling the gap in Vermont, but that’s not sustainable, said Lucy Leriche, Vice President of Vermont Public Policy at Planned Parenthood Northern New England.

“Ultimately, this is not something that states, individually, should be funding,” she said.

Still, George Hill, president and CEO, Maine Family Planning, was envious of states with full-time legislatures to turn to when the rules changed in 2019.

“It was a nail biter for me,” he said of efforts to find other funding sources after he withdrew from the program. Hill said he relied on a “truckload of fundraising,” both in Maine and across the country to keep serving about 27,000 patients.

He’s hoping to hear by the end of the month whether Maine will receive special “dire need” funding from the federal government before the regular grant requests are awarded next year.

Maine and Vermont are among the five states without any Title X funded clinics. The others are Hawaii, Washington and Oregon.

Another seven states, including New York, have Title X clinic networks operating at less than 25% of their original capacity, according to the Kaiser Family Foundation, a nonpartisan health research organization.

It’s difficult to tell if patients in those states are no longer receiving care or just getting it without the support of federal funding said, Brittni Frederiksen, a senior policy analyst with the foundation.

“Most states were able to continue their networks in some way, shape or form,” she said. “But it's just hard to know how long that would actually be feasible.”

In addition, Frederiksen said, if the Supreme Court eliminates or restricts the right to an abortion through a case expected to be decided next year, that will increase the need to rebuild the Title X network.

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Emily Halvorson, center, of Washington, with Planned Parenthood, joined groups of pro-choice and anti-abortion activists outside the Supreme Court, Monday, Nov. 1, 2021.

Some clinics told the Biden administration they've had to push more of the costs onto clients. As a result, more patients didn’t get recommended tests, such as for cancer or sexually transmitted infections. Some chose cheaper, but less effective, methods of birth control.

In Utah, Planned Parenthood pinched pennies, raised private funds and charged patients a $10 copay.

“Which I'm sure stretched a lot of people,” Galloway said, “but for some they could share in what was happening.”

In California, the largest Title X recipient in the country went from funding 366 clinic sites to 238 in the state, a 35% reduction.

But as soon as the rules changed last month, Essential Access Health immediately expanded, bringing the total of funded clinics up to 392, higher than before.

“They are seeing patients and we’re so excited,” said CEO Julie Rabinovitz.

If Congress approves the 75% increase in funding included in the Senate’s version of the 2022 budget, that could help Essential Access Health move toward Rabinovitz’s dream of having a clinic in each of California’s 58 counties.

That, Rabinovitz said, “would be fabulous.”

Madison Tolchin leaves after having a health checkup at a Planned Parenthood clinic on April 14, 2017 in Wellington, Florida.

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Maureen Groppe has covered Washington for nearly three decades and is now a White House correspondent for USA TODAY. Follow her on Twitter @mgroppe.