Reproductive health advocates expect President-elect Trump to reinstate a rule that weakened the country’s sole federally funded family planning program during his first term once he returns to office next year.
The Title X Family Planning Program, which makes it easier for millions of low-income Americans to access reproductive services like birth control, emergency contraception and abortions, is still grappling with the impact of restrictions imposed by the first Trump administration five years ago.
In 2019, the administration issued a rule that barred providers receiving Title X funds from mentioning abortion or providing abortions and stipulated that program recipients had to be physically separated from any abortion activity.
Before the rule, Title X funds helped support roughly 4,000 clinics across the country that offered family planning services to 3.9 million low-income or uninsured Americans, according to health policy research nonprofit KFF.
The rule forced 1,000 clinics to withdraw from the program, leaving six states — Hawaii, Maine, Oregon, Utah, Vermont and Washington — without any Title X-funded services in 2020, according to a report from the Department of Health and Human Service’s Office of Population Affairs.
These closures, along with the restriction on movement that came during the COVID-19 pandemic, reduced the number of people served by the program to 1.5 million by 2020.
Most of those who went without care as a result were likely uninsured, according to Power to Decide, a nonprofit organization that works to end unplanned pregnancy.
President Biden’s administration quickly reversed those regulations after he was elected in 2020, but the program and the number of people it serves have yet to bounce back.
Reproductive health advocates told The Hill they anticipate Trump will try to reinstate the rule earlier in his second term than he first issued it during his first time in office, most likely within less than 12 weeks after he resumes power on Inauguration Day.
Uninsured Americans would be hit especially hard by the rule’s potential return, advocates stress, noting that services provided through clinics with Title X funding are particularly essential for such patients, who might receive their only medical care for the whole year during those visits.
“Taking away those family planning services and critical public health services from people who can’t afford it otherwise means that they are going to go without and that is unconscionable,” said Brigitte Amiri, deputy director of the American Civil Liberties Union Reproductive Freedom Project.
Maine Family Planning, a nonprofit that offers reproductive health care, was one of the clinic networks forced to leave the Title X program in 2019. George Hill, the organization’s president and CEO, told The Hill it did not need to shut down clinics, but leadership had to scramble to find new funding sources to replace the 25 percent revenue it lost from leaving the program.
Hill is concerned that a reinstatement of the rule — and the cost of the legal battle that would come with it — could place the network’s rural clinics in a vulnerable position or make it harder to provide new mobile medical services to home-bound Mainers.
Advocates point to Project 2025 — a conservative policy blueprint spearhead by the Heritage Foundation — as evidence that the future of Title X is in jeopardy.
The project calls for the reinstatement of the 2019 rule in addition to asking Congress to complement it by passing legislation that would ban family planning grants from going to entities that perform abortions or provide funding to other abortion providers.
One such bill is the Title X Abortion Provider Prohibition Act, which was introduced in 2021 by Sen. Marsha Blackburn (R-Tenn.) but has since sat in a Senate committee.
Project 2025 also calls on the federal government to eliminate “religious discrimination” in the grant selection process in the Title X program and to guarantee the “right of conscience and religious freedom of health care workers and participants” in the program.
Trump sought to distance himself from Project 2025 during the campaign, saying he had “nothing to do” with the proposal. A number of its authors served in his first administration, however, and since his reelection he has tapped multiple people tied to it to staff his forthcoming one.
Clare Coleman, president and CEO of the National Family Planning & Reproductive Health Association, believes that any new rule issued by the Trump administration to reinstate the 2019 regulations will seek to further restrict access to sexual and reproductive health care.
She told The Hill, for instance, that she is worried a new rule would also require Title X program recipients to receive parental notice or consent before offering services to minors.
This is the case in Texas, where the state’s 156 Title X recipients were mandated to get parental consent before serving teens in a March ruling. Texas is one of a handful of states that requires parental consent before a teenager can receive birth control, but the Title X program offered an exception to that rule.
Before the March ruling, Title X clinics in Texas could provide contraception to minors without their parents’ knowledge and regardless of income or immigration status.
The decision came after a years-long legal battle that involved a federal lawsuit from the Biden administration arguing that Title X regulations overruled Texas law. Earlier this year, Texas Attorney General Ken Paxton (R) sued the Biden administration arguing that Title X could not preempt the state’s parental consent laws.
Coleman also worries that a new rule could bar counseling on abortion, impose even stricter physical separation requirements on facilities that provide abortion care with non-Title X funds or bar any entity that funds an abortion provider from being part of the program.
“A lot of state governments fund abortion providers in their Title X programs,” she said. “So, this would affect nonprofits and state agencies.”
Another possibility, she fears, is that a new rule would designate some emergency contraception like IUDs as capable of causing an abortion and seek to disqualify them from program coverage.
There is also a concern that a new rule would work to further stigmatize people who are transgender or gender-nonbinary, for example, by requiring that Title X program recipients can only treat people with regard to their biological sex, Coleman added.
Some clinics that use Title X funds, like Maine Family Planning, provide LGBTQ patients with gender-affirming care.
Ultimately, though, reinstating a version of the 2019 rule is a means to make it difficult for “disfavored providers” like Planned Parenthood to withdraw from the program and make it easier for favored providers to join, advocates say.
Some of those favored providers are religiously affiliated health systems, like Catholic-run hospitals and health systems, or other health systems that are ideologically opposed to abortion, like Obria and crisis pregnancy centers.