by Michael Hiltzik
The “gag rule” is over.
The centerpiece of the Trump administration’s attack on women’s reproductive health was its 2019 rule banning abortion referrals, requiring coercive anti-abortion counseling for pregnant patients and imposing stringent financial standards for clinics offering federally funded reproductive care.
This policy, known by critics as the gag rule, achieved the goal its drafters plainly intended: The capacity for delivering health care to low-income women under the half-century-old Title X federal program was slashed nearly in half, reducing contraception options for as many as 1.6 million patients.
The rule struck especially hard at Planned Parenthood, which served more than 40% of such patients nationwide and had become the target of right-wing anti-abortion activists. In the face of a federal mandate to deliver substandard health care, Planned Parenthood withdrew entirely from Title X.
The rule “decimated patients’ access to affordable birth control” and services such as screening for cancer and sexually transmitted diseases, especially for “people of color and people with low incomes,” says Planned Parenthood Chief Executive Alexis McGill Johnson.
Now the Biden administration is consigning the gag rule to the trash heap. Last week, the administration started the process of rolling back the Title X rules to where they were before Trump.
The Biden administration’s rule proposal is blunt about the impact of the gag rule on women’s and family health: In a nutshell, it’s been devastating.
According to the Department of Health and Human Services, the lights effectively went out of family planning and women’s health clinics coast to coast. More than 1,000 service sites, or about 25% of the total, left the Title X program.
Nationwide, the caseload declined by 844,083 patients, or more than 20%. Low-income, minority and uninsured patients suffered the most, exacerbating health care inequities that were already punishing for those groups.
HHS calculates that in 2019, the year of the Trump rule, 225,688 fewer clients received oral contraceptives than in 2018, 49,800 fewer received hormonal implants and 86,000 fewer got IUDs. Some 300,000 fewer Pap tests and breast exams were performed and 276,000 fewer HIV tests. Some 151,000 fewer teens received family planning services.
The Trump rule may have led to as many as 181,477 unintended pregnancies.
What’s most important about this toll is that it had nothing to do with any judgment about public health needs. It was 100% about ideology, specifically anti-abortion ideology.
Trump’s minions tried to dress up the gag rule as a response to the possibility that reproductive health clinics were quietly diverting Title X funds to abortion services or referrals, but that was a lie.
Neither the Government Accountability Office nor any of the oversight agencies that regularly audited providers ever found any diversions of federal funds that would justify the stricter provisions of the Trump rule. Also, as the HHS proposal states, federal courts have consistently held that “governments cannot restrict access to funds for one activity simply because it may ‘free up’ funds for another.”
In 1988, Republican Ronald Reagan issued the first gag rule of Title X, prohibiting any discussion of or referrals for abortions.
As HHS reports, the 1988 rule required providers to “maintain strict physical and financial separation between Title X projects and abortion related activities.” Reagan also barred “lobbying, education, dues-paying or any other activities which could be interpreted to encourage or promote abortion.”
A torrent of lawsuits challenged the rule, but it was upheld by the Supreme Court in 1991. Following that decision, however, the Reagan rule was in effect for only one month in 1992 before it was rescinded by the new president, Bill Clinton, immediately upon his inauguration in 1993.
Trump’s HHS not only reinstated the 1988 gag rule, but added a few more roadblocks. It added new reporting and record-keeping requirements, cynically loading down providers of reproductive health services with more burdens.
Most important, the rule eliminated the requirement that Title X providers offer patients information about the full range of pregnancy options, prohibited them from referring patients to abortion providers and required them to refer all pregnant patients for prenatal care, whether or not the patients wanted it.
Women’s health providers were faced with two unpalatable choices, as the Guttmacher Institute, which is devoted to women’s health care, observed: They could either agree to provide care that “does not adhere to medical or ethical standards,” or “exit the program because they are unwilling to comply with the New Rule’s requirements for substandard care.”
Many would choose the second option, the institute predicted, leaving the Title X program without enough providers to serve needy patients. That’s exactly what happened.
It’s not enough to say that Biden’s new rule will produce a sea change in the delivery of birth control and other health care services to low-income women; it will restore their level of health care to where it was before it was vandalized.
Michael Hiltzik is a columnist for the Los Angeles Times.
