Title X Changes Egregiously Harm Women’s Access to Comprehensive Medical Care

Changes to Title X threaten to reverse 40 years of advancement in women's health care. If we allow the Title X changes to limit what we as physicians can tell our patients, where does it end?

On Feb. 22, 2019, the Trump administration announced sweeping changes to Title X,¹ the federal program that provides funding for reproductive health services, including STI treatment, cancer screening, and contraception to millions of women. These alterations ultimately serve as a gag rule for physicians, as under the Trump administration’s changes, any physician or organization that provides or refers patients to abortion services are no longer eligible for Title X funding.² Put plainly, any referral or performance of abortion services would limit funding that is used for preventative cancer screenings, contraception, and treatment of STIs. The main beneficiaries of Title X funding are predominantly low-income and minority patients; therefore, the cessation of these services threatens to further widen health inequalities. These political decisions will affect not only women’s ability to access health care, but also physicians’ ability to offer comprehensive services.

What is Title X?
Title X was enacted in 1970 with unanimous support in the Senate and an overwhelming majority in the House. Title X was considered powerful bipartisan legislation meant to support culturally sensitive, high-quality family planning services for low-income uninsured or underinsured populations.³ Throughout the 1980s, the Title X program survived attempts to dismantle it, though the total funding for the program was reduced.^4,5 Since its inception, Title X has served as a critical facet of the American health care system. In 2017, Title X clinicians served more than 4 million patients and provided 2.8 million patients with contraceptive services. The majority of these beneficiaries reported family incomes at or below the federal poverty level. Half of these patients were uninsured, and two-thirds were men or women of color.

To be clear, Title X has never been used to finance abortions. The statute governing Title X outlines that funds may only be used where abortion is not a method of family planning. However, until this point, health care entities have maintained the ability to utilize Title X funding for contraception as well as STI screening and treatment, as well as other preventative services within clinics that also provide abortions, so long as abortions were financed separately from Title X funds. Therefore, the money that funds Title X has been used exclusively for other sexual and reproductive health care needs. However, the new regulations prohibit any Title X funds to support any health care site that also provides abortions, regardless of the fact that Title X funding would not – and has never – been used to finance abortions. Furthermore, the new regulations would threaten to remove Title X funding from any organization or provider that promotes or refers patients to abortion services.

How will Title X changes affect patients and providers?
Regardless of your political or social views on reproductive health care options, any policy that threatens our ability as doctors to provide and counsel our patients with comprehensive health care options should be opposed by all physicians. As physicians, we are bound by our profession to care for our patients and to provide the most comprehensive health care options available. The limitation of discussing or referring patients for abortion services acts as a slippery slope. Taken further, it is not difficult to imagine these limitations as the precedent for additional governmental gag rules, which could later be expanded to other issues or medical services.

The Title X changes hold numerous possible downstream consequences. As discussed by the Kaiser Family Foundation,² potential side effects include limiting the number of family planning providers, limiting low-income women’s access to contraception, compromising the quality of family planning care available, placing individual providers at increased medical liability, adding administrative burdens to clinics receiving Title X funding, and inadvertently promoting organizations that offer only “natural” family planning and abstinence. As Title X funding most directly benefits low-income women, the new rules would only serve to further health disparities that exist based on race, income, and geography.

The effects of these changes are not limited to the outpatient setting. If hospitals and health care systems receive Title X funding, these changes could severely alter the funding that individual hospitals receive. The reduction of Title X funding to outpatient clinics will undoubtedly decrease the number of available family planning practitioners. This, compounded by the limitation of referring patients to abortion providers, will severely hinder our referral practices in the emergency department, creating barriers to access for our most vulnerable patients. Additionally, the administrative burdens for tracking the complexities of Title X funding under new restraints may cause organizations to make blanket changes to their policies to prevent potential violations, even for allowable services and referrals.

There are also immediate effects that may affect both patients and providers in the emergency department. The potential decrease in family planning clinics will reduce the number of STI screening and prevention, potentially increasing the prevalence of STIs within communities and emergency department visits for STI-related complaints. This could lead to potential outbreaks in STIs, as was seen in Indiana when access to comprehensive family planning centers was obstructed and the state underwent one of the largest HIV outbreaks in the 21^st century.⁶ Perhaps if comprehensive health centers remained unencumbered, they may have performed HIV testing that could have detected the outbreak sooner and reduced its severity.

With a limited number of outpatient abortion providers, women may turn to unsafe termination practices. This would undoubtedly increase the number of presentations to the ED for complications associated with these dangerous procedures. Lack of access to safe abortions, predominantly in low-income minority women, led to more than 15,000 abortion-related deaths in the 1920s. The year after abortion was legalized in New York state, the maternal mortality rate dropped by 40%.⁷ To say that limiting the ability of physicians to perform or refer patients for abortion will limit the number of abortions is unfounded. What will be reduced is the number of safe abortions, but with this the number of unsafe abortions will rise. Patients who lack access to safe and affordable care may resort to extreme means, such as at home terminations, mail-order medically induced abortions, and unsterile practices, thereby increasing the rates of morbidity and mortality.

Summary
As Dr. Leana Wen, emergency physician and former president of Planned Parenthood, said:

As a doctor, this compromises the oath that I took to serve my patients and help them with making the best decision for their own health…. My patients expect me to speak honestly with them, to answer their questions, to help them in their time of need. It's unconscionable and unethical for politicians to restrict doctors like me from speaking honestly to our patients.¹

Days after this statement, Planned Parenthood, one of the nation’s largest recipients of Title X funding, stopped accepting any Title X funding, as they refused to allow their ability to care for women and the public health to be in any way infringed upon by policy debates.

EMRA's official policy statement on Title X emphasizes the importance of protecting women’s health care, as well as patients’ right to information and access:

These changes aim to block federal funds from family planning providers that provide abortion services, counseling, or referrals - effectively decreasing the network of clinics and scope of family planning services offered to women, especially low-income and uninsured patients. EMRA believes in protecting access to women’s health care. Our patients, especially vulnerable populations who depend on Title X funding, deserve full information and referrals. EMRA opposes the proposed Title X rule on the basis that they will detrimentally decrease patient access to women’s health care including reproductive care.⁸   

The changes to Title X threaten to reverse 40 years of advancement in women’s health care. It places us in a world where patients not only lack access to STI testing, sexual education, contraception, and cancer screening, but also limits physicians from fully discussing known medical treatments with our patients. If we allow the Title X changes to limit what we as physicians can tell our patients, where does it end? At what point will we tolerate governmental restrictions in our discussions with patients? Join EMRA, the AMA, and other organizations in opposing efforts to reduce access to comprehensive family planning solutions and women's health. Don’t let politics get in the way of providing patients with evidence-based medical care.

Acknowledgments
The authors would like to thank Dr. Angela Cai and Dr. Sriram Venkatesan for their contributions in the process of creating this article.

References

1. McCammon S. Title X: Trump Administration Proposes Changes To Federal Family Planning. NPR News. Published February 22, 2019. Accessed September 24, 2019.
2. Sobel L, Salganicoff A, Frederiksen B. New Title X Regulations: Implications for Women and Family Planning Providers. Kaiser Family Foundation. Published March 8, 2019. Accessed September 26, 2019.
3. Nixon R. Statement on Signing the Family Planning Services and Population Research Act of 1970. The American Presidency Project. Published December 26, 1970. Accessed October 3, 2019.
4. Crum G. Health Care Policy and the Reagan Administration: The Case of Family Planning. J Health Hum Resour Adm. 1990;12(4):524-535.
5. Belluck P. Trump Administration Blocks Funds for Planned Parenthood and Others Over Abortion Referrals. The New York Times. Published February 22, 2019. Accessed October 5, 2019.
6. Conrad C, Bradley H, Broz D. Community Outbreak of HIV Infection Linked to Injection Drug Use of Oxymorphone — Indiana, 2015. CDC. Published May 1, 2015. Accessed October 15, 2019.
7. Pollitt K. Abortion in American History. The Atlantic. Published May 1997. Accessed October 10, 2019.
8. EMRA. The Trump Administration's changes to Title X harm women's access. Accessed October 2019.