In a move we applaud, the Biden administration is working to undo a harmful action that prevented low-income individuals from obtaining comprehensive scientific information from their doctors on family planning options. The Department of Health and Human Services (HHS) recently issued a notice of proposed rulemaking stating it would revise a disastrous rule issued under the prior administration that significantly altered the Title X program, a federal grant program that supports family planning services for low-income individuals. The 2019 rule caused over 1,000 health centers to lose vital funding from the Title X program, thereby preventing low-income communities and communities of color from obtaining needed medical services.
We at the Union of Concerned Scientists are strongly opposed to the 2019 rule and previously classified it as an attack on science by the prior administration. Patients expect their doctors to be honest with them and provide comprehensive medical information based on the best available science. Policies that touch on science-based issues, including family planning policy, should be driven by scientific evidence, not by political ideology. We therefore decided to issue a public comment in support of the Biden administration’s action to bring the Title X program back to its science-based roots of providing comprehensive medical care to those most in need.
Trump-era rule was designed to restrict public health options for low-income individuals
In March 2019, HHS issued a final rule that undermined the doctor-patient relationship at clinics funded by the Title X program. The rule eliminated the requirement that Title X clinics provide pregnancy counseling that included the discussion of abortion as an option, if requested by the patient. Under the 2019 rule, patient access to counseling on abortion was highly restricted and was allowed in only a very specific circumstance. A pregnant person had to explicitly ask the Title X clinic for a referral to a health care provider that offered abortion services. A doctor (but no other clinical staff) would be permitted (though not required) to provide a list of providers that offered comprehensive prenatal care. However, the doctor was not allowed to specify which health care provider on the list offered abortion services.
What medical provider could possibly follow this convoluted set of instructions? The new set of instructions removed science from the conversation. It essentially censored medical experts from providing their patients with scientific information that could help the patients decide on the best course of action for their reproductive health and their family planning needs.
The 2019 rule was vehemently opposed by the medical community. The American Medical Association (AMA) issued a statement saying that the rule “would undermine patients’ access to high-quality medical care and information, dangerously interfere with the patient-physician relationship, and conflict with physicians’ ethical obligations.” A joint letter co-signed by 19 prominent health organizations stated that “by forcing providers to omit critical information about health care and resources available, the final regulation directly undermines patients’ confidence in their care.”
Several medical groups argue that this rule violates the principle of informed consent, since doctors and other medical personnel cannot provide patients with comprehensive information on all available medical procedures.
The 2019 rule’s impacts on health were devastating
Rather than comply with the 2019 rule, health centers began to withdraw in large numbers from the Title X program, resulting in at least 1.5 million people losing access to Title X funded services. As a result, the data shows that damages caused by the 2019 rule has had enormous health consequences, consequences that were disproportionately borne by low-income individuals and people of color. Compared to 2018, in 2019 Title X health providers offered:
- 280,000 fewer cancer screenings
- 3 million fewer sexually transmitted disease screenings
- 278,000 fewer confidential HIV tests
- 573,000 fewer low-income clients
- 129,000 fewer Black clients
- 270,000 fewer Latinx clients
In essence, the Trump-era rule worked to gut the Title X program, despite the prior administration’s promise that the rule would cause new applicants to apply for Title X funding and result in “more clients being served.”
Science requirements were written out of the 2019 rule
One of the 2019 rule’s most insidious features was that it explicitly struck out language that ensured that the Title X program was rooted in science. The rule eliminated the term “medically approved” from the longstanding regulatory requirement that Title X clinics provide “a broad range of acceptable and effective medically approved family planning methods.” This was not a small change. It shifted the program away from HHS’ previous science-based requirements that Title X grantees adhere to FDA-approved contraceptives and to the CDC’s and HHS’ recommendations for providing Quality Family Planning Services.
The rule also explicitly added “abstinence counseling” as an acceptable form of Title X family planning services. The science is clear on abstinence-only education – it is not an effective family planning tool. Abstinence education has been shown in the scientific literature to be one of the least effective methods to prevent unwanted pregnancies.
We need to stop gagging doctors and disenfranchising marginalized people
For the last 50 years, the Title X federal grant program has played a critical role in ensuring access to a broad range of family planning and related preventive health services for millions of low-income or uninsured individuals and others. However, the 2019 rule served to undermine the Title X mission and instead codified political rhetoric. This prevented millions of people, especially low-income individuals and people of color, from accessing quality health care services.
There is abundant evidence showing that restricting abortion access and other reproductive rights are based on wholly unscientific concepts; are rooted in a long history of racist and misogynistic policies; and create additional risks for low-income women, women of color, trans men, and genderqueer people. The Biden administration is right to return the Title X program back to its science-based origins so that it can continue to provide important and life-saving services to marginalized people across the US.