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Governors threaten to withdraw from Title X program over “gag rule” targeting abortion providers
Protesters hold signs as they march to the White House during a march and rally to support women’s health programs and protest the White House global gag rule on March 8, 2017 in Washington, D.C. Justin Sullivan/Getty Images

Democratic governors are threatening to pull their states out of the federal Title X family planning program in protest of the Trump administration’s proposed “gag rule” that will affect millions of women around the country.

The proposed Title X changes specify that the federal family planning funds, which are used for reproductive health care services, “may not directly or indirectly facilitate, promote, or encourage abortion in any way.”

Opponents predict the changes could target Planned Parenthood and other providers’ federal funding and weaken women’s reproductive choices by limiting how medical providers can provide information about abortion to patients.

Governors Jay Inslee of Washington, Kate Brown of Oregon and David Ige of Hawaii released statements this week vowing to withdraw their states from the Title X program should the changes be finalized and withstand legal scrutiny.

“If the Trump gag rule is adopted and legal challenges are unsuccessful, it would leave me no choice but to act in the best interests of the citizens of Oregon and our state law, and withdraw our state’s participation from an unethical, ineffective Title X program that reduces access to essential preventive health services,” Brown said in a statement.

Inslee also noted his state would “explore all possible avenues, including legal options, to block this policy from harming the women of Washington,” suggesting his government could mount a potential lawsuit against the new rules.

New York Gov. Andrew Cuomo did not specifically say the state would withdraw itself from the program, but said in a letter to Department of Health and Human Services Secretary Alex Azar condemning the rules that “it will be impossible for New York to continue its comprehensive Title X program” if the rules are enacted. Cuomo also threatened taking legal action, promising the state would “explore all legal avenues available to us.”

Withdrawing from Title X could have widespread effects for the four states. In 2016, Title X funding served 13,335 people in Hawaii; 90,168 people in Washington; 306,070 people in New York and 50,423 people in Oregon, according to the National Family Planning and Reproductive Health Association.

While they did not go as far to threaten withdrawal from the program or legal recourse, Colorado Gov. John Hickenlooper and Pennsylvania Gov. Tom Wolf also spoke out about the proposed Title X changes in recent days, as the public comment period for the proposed rule came to an end.

“Let me be clear, there is no role for government to step between a woman and her doctor,” Wolf said at an event in support of women’s reproductive health rights on July 25. “President Trump’s plan to implement a Title X gag rule will cut women off from critical health care services like birth control and preventive care, including cancer screenings, and will censor doctors and strip federal funding from certain health care providers for discussing legal health care procedures with their patients.”

The governors’ comments echo those made in a letter sent by the Democratic Governors Association to Azar in May after the proposed rule was first announced, which denounced the “dangerous proposal” and predicted it would “upend decades of bipartisan cooperation, taking away women’s healthcare through trusted medical providers like Planned Parenthood and eroding their access to comprehensive, medically accurate information.”

Attorneys general from 12 states and the District of Columbia, some of which overlap with the states whose governors have spoken out, also sent a letter to Azar Monday calling for the rule to be withdrawn.

If the rule is finalized, the attorneys general predicted it would “lead to serious public health threats, increased risk of unintended pregnancies, and gaps in care” and affect over 1.6 million patients in the attorneys general’s states alone.

More than 200 members of Congress, 80 mayors and the Reproductive Freedom Leadership Council, a coalition of 274 state legislators from 43 states, have also sent letters to the HHS protesting the proposed rule.

The proposed Title X changes, which were first introduced in May, would impose a “bright line” between Title X-funded services and abortion services, which do not receive federal funding. Title X provides federal grants for family planning and reproductive services such as preventative care, counseling and screenings for sexually transmitted diseases and cancer, serving 4,100 clinics and approximately 4 million patients. Patients covered by Title X, who are primarily low-income women ineligible for Medicaid, can receive free or low-cost care through the program.

Title X also funds general operating costs, such as staff salaries and rent, and made up 19% of participating clinics’ annual revenue as of 2016, according to the Kaiser Family Foundation.

Under the proposed changes, Title X providers would be required to “maintain clear physical and financial program separation” between Title X-funded services and abortion services, which could threaten federal funding for the one in 10 Title X sites that offer abortions. It would also prohibit Title X-funded medical providers from providing referrals to abortion providers and remove a guarantee that medical providers counsel pregnant women about all their options, including abortion, leading opponents to decry the regulations as a “gag rule.”

A Kaiser Family Foundation analysis predicted that the new rules would result in Title X funds going toward faith-based and other organizations that promote abstinence and natural family planning methods, and noted that current Title X providers who do not provide abortions could withdraw from the program over “concerns about clinical standards of care, medical liability, and burdensome administrative requirements.” Axis Community Health, a San Francisco-based Title X provider that does not offer abortions, has already sent a letter to the HHS saying it will no longer participate in Title X if the changes go through.

The public comment period for the proposed rule came to an end Tuesday after receiving 197,480 comments both for and against the potential changes. Polling has suggested that Americans are largely against the policy; a Hart Research Associates survey conducted on behalf of Planned Parenthood in May found that 73% of Americans, including 44% of Republicans, disapprove of a policy that would make it illegal for federally funded health care providers to offer referrals or counseling about abortion. A Kaiser Family Foundation poll released in July found that 64% of women opposed allowing federal funding to go to providers that do not counsel pregnant women about all of their options, while 58% opposed prohibiting federal funds from organizations that also perform abortions.

Now that the public comment period has ended, the government must decide whether to finalize, modify or reject the rule. According to a timeline shared by the Kaiser Family Foundation, the final regulations are likely to be published in September, and any legal challenges could be brought after the rule is finalized. A federal court has already upheld other Trump administration changes to Title X, which amended guidelines for how grants are awarded, after Planned Parenthood filed suit against the policy.

In addition to lawmakers, the medical community has also come out against the proposed changes to Title X. The American Medical Association sent a letter to Azar Tuesday decrying the policy, joining such other health organizations opposed to the changes as the American College of Obstetricians and Gynecologists; the American Academy of Pediatrics; the American Nurses Association; the National Association of Community Health Centers and over 110 other organizations.

“Title X is the only federal program dedicated specifically to providing low-income patients with essential family planning and preventive health services and information,” AMA CEO and executive vice president Dr. James L. Madara wrote in the letter.

“The AMA believes that this proposed rule, if finalized, would limit access to critically needed care and services for millions of individuals who depend upon the Title X program for their care and would result in harm to patients and the public’s health,” he wrote.