‘More Than a Gag Rule’

Late last month, the Trump administration proposed a new rule that could prohibit doctors who receive a type of federal funding called Title X from explicitly referring their patients to abortion providers. Under the new rule, only a pregnant woman who has already decided she wants an abortion—rather than one who is simply weighing her options—could be given a list of medical providers, and not all of the providers can be abortion providers. The rule might still be changed before it goes into effect.

The move is the latest in a series of conservative regulatory changes the Trump administration has made to women’s health. Last year, President Trump restored the global gag rule on abortion and allowed states to withhold family-planning funds to abortion providers. More recently, changes have been made to other programs to emphasize sexual abstinence.

Eight doctors’ groups have criticized the Title X change as “dangerously intrud[ing]” on the patient-provider relationship. What’s more, it might disproportionately affect poor and uninsured women, who visit Title X clinics because they can’t afford or don’t have regular doctors. Nearly two-thirds of Title X patients have income below the federal poverty line.

To find out what impact this change would have on the ground, I recently spoke with Kami Geoffray, the CEO of the Women’s Health and Family Planning Association of Texas. It’s the nonprofit organization that disburses Title X funds to a network of about 100 clinics throughout the state. The program serves about 200,000 patients each year, and its primary purpose is to provide subsidized birth control and sexual-health services.

We discussed what the Trump administration’s proposed changes mean—and don’t mean—for women in the state with the highest repeat teen-birth rate in the nation. A lightly edited and condensed transcript follows.

Khazan: How would you describe Title X to someone who’s never heard of it before? What is the grant for?

Geoffray: Title X is the only federal grant that is solely dedicated to the provision of family-planning funding, with a focus on serving low-income populations.

The goal of Title X is essentially to prevent unintended pregnancies and to save money from other government programs. So in a state like Texas where we see over half of the births attributed to Texas Medicaid, when we can prevent unplanned pregnancies, we can avert a Medicaid birth that is still being paid for through our tax dollars.

Khazan: I think a lot of people might not know why this is necessary. How is this different from Medicaid? Is it for people who don’t have Medicaid? Is it for people who don’t have a Planned Parenthood clinic near them?

Geoffray: [In Texas,] we fund freestanding family-planning clinics, including a couple of Planned Parenthood affiliates. But we also fund a number of federally qualified health centers, some hospital and health districts, some public-health departments, both urban and rural, and one university system.

The clients look different everywhere you go. So in states like Texas, where we didn’t expand Medicaid, yes, we see about 90 percent of our clients are low-income and many of them have no other route to insurance. Uninsured people, which in Texas many times means undocumented individuals, receive services in our clinics. Minors can receive confidential services if they need them. We of course encourage family participation in conversations about sexual and reproductive health with minors, but there are certainly situations where those conversations are not safe. And so in a state like Texas that requires parental consent for contraception, Title X clinics are really the only place where a teen can go and receive confidential services if they need them.

Khazan: How big is the Texas grant compared to other states?

Geoffray: The Texas grant is the second-largest grant in the nation, mostly because we’re a sole grantee. California’s number one, and then New York and Pennsylvania follow close behind, but they have multiple grantees in their state, and then Texas. But when you think about it, our grant is about $14 million and we have 1.8 million women in need of publicly funded family-planning services in this state. So it really is a drop in the bucket, and we’re doing our best to stretch those dollars and to target them to communities most in need. But we continue to have a significant unmet need in this state.

Khazan: How is the money spent?

Geoffray: We leave it up to providers to figure out how they best want to use these funds. For many of them, it’s to pay for staffing, like their doctors, their nurses, or many of them set it up essentially as a bucket of funds to pay for uninsured individuals. But either way, direct services are delivered as a result of these Title X grants.

Khazan: Has Title X ever paid for abortions? Before this rule change, what did Title X have to do with abortions?

Geoffray: Title X has longstanding rules that abortion is not a method of family planning. So no, the answer is no. Government funding is not being used to pay for abortion services.

Khazan: So what did this rule actually change? If you already weren’t paying for abortions, what is different now?

Geoffray: This really is much more than a gag rule. There’s a lot of changes in this proposed rulemaking.

The way things work now, when a woman comes into one of our clinics and takes a pregnancy test, if she receives a positive pregnancy test, staff are able to provide counseling to her around her pregnancy options. There are three options—parenting, adoption, or termination—and we do treat these fairly equally, because we want to present information in an unbiased way.

Our philosophy is that all counseling should be led by the client. So if a client is very clear that they want to terminate a pregnancy, that is the information that they will get. If a client is very clear that they want to continue the pregnancy and parent, they will get referred into prenatal care and that is the way it will go.

So we have resource lists available that are specific to each of those options, and we provide information [depending on what the] client is really saying that they desire. What this rule seeks to do is essentially take the abortion conversation off the table. The resources that providers are able to give must include information about parenting and adoption, even when someone is very clear that they want to terminate their pregnancy.

Khazan: Does this rule mean that you cannot give clients the abortion referrals, or that you have to give them, in addition to the abortion referral, parenting and adoption resources?

Geoffray: What you cannot do is give someone only abortion referrals. You can provide them with a list of providers, and some of those providers may offer abortion. But you can’t give a list knowing that everyone on that list is an abortion provider or everyone on that list would refer to an abortion provider. The examples that are included in the rule text make it very clear that you must offer prenatal care at a minimum. You can have a list of providers, and maybe they’ll be some abortion providers on there, but if a woman asks you, “I want an abortion. How do I get that taken care of? How do I get my pregnancy terminated?” The provider has to say, "Well, abortion is not a method of family planning in the Title X project. We do not refer for abortion. I can give you a list of resources to healthcare providers. Some of these people may provide abortion.”

That’s what the rule text seems to say in these examples. Now, rule text is just that. Additional program guidance would come after rules are implemented. That will be much more granular. But the concerns that we have from what we’ve already seen in the rule text is that women will get information that’s heavily weighted toward parenting and adoption and minimizes or omits information about termination.

Khazan: And then what about minor patients? What new information do you have to collect about patients under 18?

Geoffray: We have to encourage family participation, which of course has been a longstanding provision, and Title X clinics will be required to document in the minor patient’s medical records specific actions taken with respect to each minor to encourage family participation. There’s additional information a little later on that talks about the age of people’s partners.

The biggest concern for me is that it’s pretty hard to get minor patients to engage in care. When a minor who really does need services confidentially makes it into a clinic where they can do that, and then they’re met by a provider asking questions and documenting lots of things ... it can be a very intimidating experience.

So we’re concerned that any new reporting requirements that go beyond what we already do in medical charts with minors, would just present additional barriers and prohibit them from accessing care. And in states like Texas, where we have really high teen pregnancy rates, and we have even higher repeat teen pregnancy rates, we don’t want do anything to discourage their ability to access contraception safely and confidentially.

Khazan: I think proponents of this rule would say, “So, we try to minimize the abortion option when a woman gets counseled at a Title X clinic. So she gets a general list of providers and she has to figure out for herself who’s the abortion provider and who’s not, if that’s her preferred option.” Why do you see that as a problem?

Geoffray: The communities that we serve are often low-income with few resources, childcare barriers, no paid leave. Many of them don’t have access to internet in their homes. They may be living in poverty. They may not have access to safe and stable housing. They may not have access to transportation. And so when we expect these clients to have to take that burden on themselves, to be given information that is not complete or direct or could potentially be misleading, we do a disservice to our client.