State abortion bans in Tennessee and beyond, which constrain women鈥檚 health care, have put family planning clinics at risk of losing their federal funding.
The conflict involves the Title X family planning program, which provides services to low-income people, including minors. As of 2021, more than 3,200 clinics used federal grants to supply free or low-cost contraception, testing for sexually transmitted infections, screening for breast and cervical cancer, and pregnancy-related counseling.
Federal regulations for the program, which was established more than 50 years ago to reduce unintended pregnancies, say participating clinics must offer pregnant women information about terminating pregnancies and abortion referrals on request. But following those rules puts medical providers at odds with state laws banning abortion, some of which threaten jail time, fines, or the loss of medical licenses if they help someone end a pregnancy.
President Joe Biden鈥檚 administration at the end of March cut off Tennessee鈥檚 Title X funds after determining the state health department 鈥 which oversees its clinics and was last year 鈥 violated federal rules by not counseling patients about abortion. 鈥淐ontinued funding is not in the best interest of the government,鈥 two Department of Health and Human Services officials on March 20. The state had more than 100 Title X clinics as of March, according to an HHS directory.
In 2022, the federal government awarded Title X grants , a mix of state and local governments and private organizations. Those grantees distribute funds to public or private clinics.
Federal law prohibits clinics from using Title X money to pay for abortions. However, HHS requires clinics to offer pregnant women information about prenatal care and delivery, infant care, foster care, adoption, and pregnancy termination.
In states where abortion is generally illegal, that could mean directing patients to providers in other states. But Tennessee told family planning clinics they could discuss only services that were legal in the state 鈥 effectively cutting off any talk about abortion.
Tennessee allows abortions only under limited circumstances, including to save a pregnant person鈥檚 life. State health department policies for family planning 鈥渁re consistent with state law,鈥 said Jade Byers, a spokesperson for Republican Gov. Bill Lee. Tennessee allocated state funds to replace the federal money.
, director of Emory University鈥檚 Center for Reproductive Health Research in the Southeast, said failing to provide timely information and referrals for abortion 鈥渃ould contribute to further delays in people鈥檚 ability to access that care,鈥 especially because women may need to travel long distances for it.
The clash over the federally funded clinics is part of the widening fallout from the Supreme Court鈥檚 June 2022 decision in Dobbs v. Jackson Women鈥檚 Health Organization ending the constitutional right to an abortion.
In Idaho, which has a near-total abortion ban, two Planned Parenthood clinics with Title X funding recently stopped giving patients abortion information and halted out-of-state referrals, Planned Parenthood and the American Civil Liberties Union filed in April against Idaho鈥檚 attorney general.
State law prohibits providers from assisting in performing or attempting to perform an abortion, and violators risk having their medical license suspended.
The clinics鈥 decision came after Idaho Attorney General Ra煤l Labrador, , said Idaho law prohibits providers from 鈥渞eferring a woman across state lines to access abortion services.鈥
That interpretation is 鈥減reventing medical professionals from providing full information to their patients,鈥 said Mack Smith, spokesperson for Planned Parenthood Great Northwest, Hawaii, Alaska, Indiana, Kentucky.
Though Labrador later withdrew the letter, Planned Parenthood clinics there still are not referring patients out of state for abortions, Smith said.
Before Labrador鈥檚 letter, the lawsuit states, Planned Parenthood staff would furnish general information about pregnancy options, a list of abortion providers in other states and organizations that help defray patients鈥 abortion and related costs, and a flyer about Idaho鈥檚 abortion law. Staff would also occasionally help patients schedule care outside of Idaho. Now, 鈥淧lanned Parenthood providers no longer do so.鈥
鈥淲hen my patients require abortions, I am now forced to tell them that I am unable to help them and that I cannot say anything about their abortion options in other states,鈥 Caitlin Gustafson, a physician who had practiced at an Idaho Planned Parenthood clinic, said in a .
Kimberley Harris, a visiting assistant professor at Texas Tech University School of Law, said clinicians in states with strict bans worry about referring patients to other states because a prosecutor could interpret that as 鈥渁iding and abetting an abortion.鈥
Facilitating medication abortion in particular could 鈥減ose potential risk to health care providers,鈥 Harris said, because a patient they refer to obtain pills out of state might then take them in a state where abortion is illegal. Medication abortion accounts for most abortions in the U.S. and involves taking a series of pills during the first 10 weeks of pregnancy.
鈥淭he federal regulation might require me to provide counseling and provide information,鈥 Harris said of clinicians. 鈥淏ut if you鈥檙e telling providers that they may lose their license, or they might go to jail, or they might face a huge fine? Rightfully, they鈥檙e going to be concerned.鈥
As senior HHS officials travel the country, they are getting an earful about the issue.
HHS spokesperson Tara Broido said that, increasingly, 鈥減roviders and patients have raised concerns about the impact that the Dobbs decision has had on access鈥 to pregnancy counseling and referrals.
麻豆女优 Health News asked Broido which grantees have not been following the counseling and referral requirements. She declined to say.
People who use Title X鈥檚 services are disproportionately women. A report from HHS鈥 Office of Population Affairs said in 2021 had family incomes at or below the poverty line. Thirty-six percent were uninsured, more than two times the national uninsured rate for adults.
The Office of Population Affairs and the Centers for Disease Control and Prevention jointly that clinics are expected to follow. They include pregnancy testing and counseling.
The Title X program has been whipsawed before.
In 2019, the Trump administration from making abortion referrals. And the administration said abortion providers couldn鈥檛 share physical space with Title X clinics. The number of participating clinics subsequently dropped sharply 鈥 from 3,825 sites in 2019 to 3,031 the following year. With fewer clinics, the number of people receiving free or low-cost family planning services through the program plummeted from 3.1 million in 2019 to 1.5 million in 2020.
The Biden administration in 2021 overturned many of the Trump policies. The Biden rules remain in effect, but several states sued to block them. That litigation is ongoing.
Sarah Parshall Perry, a senior legal fellow at the conservative Heritage Foundation think tank, anticipates additional challenges to Title X rules because 鈥渟tates have an interest in defending their own laws and their ability to enforce their own laws.鈥
In Texas, which prohibits abortion with few exceptions, the nonprofit Every Body Texas oversees 154 Title X family planning clinics.
Its providers are still counseling pregnant women about options, but 鈥渢hat鈥檚 not to say it hasn鈥檛 been made very, very difficult,鈥 said Stephanie LeBleu, the group鈥檚 acting Title X director.
LeBleu said the approach to counseling 鈥渃an look different鈥 from clinic to clinic. For example, clinics in rural Texas 鈥渉ave to be a lot more cautious about how they share information with their clients,鈥 LeBleu said. Sometimes that means making a 鈥渞eferral to the referral鈥 鈥 such as directing patients to organizations like All-Options, which operates a national pregnancy options hotline.
Other Title X grantees also say they are fully complying with federal regulations. In Alabama, if patients ask for information on pregnancy options, 鈥渙ur clinics refer clients to other resources,鈥 Karen M. Landers, chief medical officer for the Alabama Department of Public Health, said in a statement. The department declined to say what those resources are and whether clinicians worry about being prosecuted under Alabama law for providing abortion counseling or referrals.
鈥淐lients are additionally informed of the legality of pregnancy termination in the state,鈥 Landers wrote.