Changes to Title X: the "Domestic Gag Rule"

Public health and community networks are important locations for service delivery and civic engagement. During this time when many local and state governments are stretched thin, and a series of policy decisions have undermined public health infrastructure, we have a critical opportunity to examine and raise awareness of how reductions in federal funding for sexual and reproductive health services (SRH) compound other socio-economic and political trends that impact health equity and health outcomes in already marginalized communities.

Title X is a federal grant program administered by the US Department of Health and Human Services (HHS). Since 1970 it has supported the provision of comprehensive family planning and preventive health services for low-income individuals who are uninsured or underinsured. Title X funding benefits some of the most marginalized communities: women, low-income individuals, young people, LGBTQIA+. The program supports almost 4,000 sites nationally and serves 4,000,000 people on average, annually. 

In August 2019, the Trump Administration implemented new regulations to the Title X program that reduced access to critical sexual and reproductive health services. Under the new regulations, Title X providers must certify that they do not refer patients for abortion care or provide abortion care and family planning services at the same location, effectively doubling running costs for major SRH service providers such as Planned Parenthood. These changes also interacted with other factors affecting the right to sexual and reproductive health, such as rural hospital closures and hospital consolidation, housing shortages, TRAP laws, funding for crisis pregnancy centers, the availability of comprehensive sex education, the opioid epidemic, the COVID-19 pandemic, and the erosion of social safety net programs. New Title X regulations from the Biden Administration, set to go into effect November 8, 2021, would end some of these provisions, but it will take time before their impact is felt.

With funding support from the Collaborative for Gender and Reproductive Equity, in May of 2020 GHJG began working in partnership with clinical and community-based groups in Maine, North Carolina, and Wisconsin to document the how Title X and other policy changes have impacted the provision of health services, and which populations are experiencing those changes the most. We aim to provide research and analysis that reduces harm, supports a more equitable rebuilding of safety net programs, and informs the proactive policy agendas of our partners in each state.

A Partner-informed Research Agenda

We are implementing this work in three states that represent a spectrum of restrictive abortion laws, Medicaid coverage and eligibility requirements, and political prioritization of public health.

In each state, we are conducting key informant interviews with clinical, community-based, and advocacy organizations that are affected by a mix of regressive policies at municipal and state levels. Interviewees include sexual and reproductive health service providers that do and do not receive Title X funding in each state, as well as local non-governmental organizations that promote health equity and reproductive justice by providing referral and direct service at the community level and advocating for structural change. 

Interviews are surfacing concerns about the reach of SRH care to underserved populations, inequity drivers of health outcomes, and the political polarization of public health. The data reveal key questions for future exploration by researchers and advocates such as:

• How does Medicaid expansion change the reach and equity of SRH service provision?
• How has COVID-19 influenced SRH decision making? 
• How does the option for no-touch abortion care impact client decision making?
• Does telehealth disproportionately impact certain populations? 
• Are crisis pregnancy centers meeting the healthcare needs of their clients?

Interwoven with the qualitative research process is the development of state-specific indicator dashboards for use by our state partners. Our goals are to reflect partner and interviewee priorities, state legislative and policy happenings, and a broader conceptualization of relevant outcomes. The dashboards link laws and policies with indicators and outcomes including health coverage, sexual and reproductive health, environmental health, housing, community safety, substance use, etc., related data sources, information about data granularity, and available stratification variables.

By centering the needs and priorities of communities across the three states we hope to make it easier for our partners and their networks to find and use the evidence they need for their own policy advocacy to advance sexual and reproductive justice, and to identify emerging interactions and trends that may require new policies and approaches.