Title X Quandaries

By on May 28, 2018

Wyoming family planning providers say vulnerable women at risk with ‘domestic gag rule’ 

JACKSON HOLE, WY – It has been a tumultuous time for family planning clinics. Since the election of President Trump, clinics have been told all their programs will be cut, they have lost employees and money due to the defunding of the Affordable Care Act Navigator Program, and most recently, they’ve been faced with a potential reinstatement of the “domestic gag rule.”

The rule, first created under Ronald Reagan, makes it illegal for clinics receiving federal funds to provide abortions, or to even talk about them. While there are no abortion providers in Wyoming that receive federal funding, the proposal would limit the quality of care clinics could provide.

For now, medical providers live with the constant threat that their doors could close at any time.

Back and Forth

In July 2017, Trump announced a plan to cut all Title X programs, which fund clinics that provide contraception, STD and HIV testing, and cervical and breast cancer screenings. Wyoming’s clinics would have to end services by March 31, 2018. Then, just a month before that deadline, they received word that they could apply for funding.

On May 18, more bad news arrived. The Trump administration proposed a new policy that would cut funding to any clinics who provide abortions, or who even talk about abortion.

Wyoming’s Title X clinics do not provide abortions. But the gag rule would prohibit providers from even mentioning abortion to their patients.

The Wyoming Health Council has been the Wyoming recipient of the Title X grant since 1990. It uses that funding to support 19 clinics across the state, including Teton County Public Health. These clinics serve uninsured and underinsured women. Patients receive not only family planning information and cancer screenings, but diabetes testing, domestic violence screenings, and drug and alcohol addiction referral.

No Title X recipient has ever or will ever use those funds for abortions. Clinics that do provide abortions, like Planned Parenthood, receive money from elsewhere to do so.

When Susie Markus, the executive director at Wyoming Health Council, learned all Title X funding would be pulled, she thought it was over. “I was starting to sell things, to close things down,” she said. “I told my office landlord we couldn’t guarantee another year.”

The board prepared to dissolve.

It had already been a challenging time for the council. Earlier in 2017, their federal funding was cut for another program: the Affordable Care Act Navigator Program. The staff of six was whittled to one: Markus.

It was difficult for Markus to imagine Wyoming without the council and the other Title X grantees. Low income women would be left with few options to receive both reproductive and primary healthcare.

In 2016, clinics across the state served 7,458 different patients. Teton County Public Health served 650 people through Title X.

(U.S. Department of Health and Human Services)

“Without us, people without insurance or money might be living with life-threatening conditions,” Markus said.

The people who visit Wyoming Health Council and Teton County Public Health may be uninsured, undocumented, afraid to talk to their family or primary care physician, or on Medicaid. In many cases, the 13 percent of Wyomingites on Medicaid cannot find family planning services other than Title X providers. About 90 percent of those served in Wyoming had incomes below 250 percent of the federal poverty line.

The preventative care provided by clinics not only improves the health of individuals, but saves taxpayers. In 2010, for example, 2,100 unintended pregnancies were prevented by Title X services in Wyoming.

“People think we provide abortions, but we prevent them,” Markus said. “We prevent unintended pregnancies that cost the state a lot of money, that are really expensive for taxpayers.”

Because of Title X, providers can provide patients with cheap contraception options—birth control pills are just a few dollars a month and IUDs are $50 or less, depending on a person’s income. For uninsured women, the cost of an IUD without a Title X clinic could be anywhere from $500 to $800.

Wyoming providers had just begun grappling with ending their services when they got word they would be eligible for more Title X funding. The grant is due this week.

This means their services will likely not change much.

According to Markus, the Trump administration’s version of the grant requires providers to focus more on abstinence education, natural family planning methods, increased family participation in young women’s decisions about contraception, and “voluntary participation,” meaning that women cannot be coerced into going to a clinic.

Wyoming’s clinics already emphasize abstinence, family involvement, and fertility planning, Markus said, and they never coerce women into treatment.

“They also wanted to make sure that none of the funds could be used for abortion,” Markus said. “But we never have and we can’t. That’s in the law.” 

Uncertain Times

But for family planning clinics that do provide abortion and receive Title X funding, the future is less certain. Trump has proposed to defund Planned Parenthood, and most of the Title X grantees in other parts of the country are Planned Parenthood clinics. Without Planned Parenthood, close to three million patients nationwide will lose their biggest healthcare provider.
“We can’t distance ourselves from Planned Parenthood,” Markus said. “That’s like saying you’re not my sister anymore.”

Providers in Wyoming would be impacted if they could no longer discuss abortion with patients or even answer questions about it. That includes local providers.

Jodie Pond, director of health at Teton County Public Health, said that if the gag rule were to go into effect, “it would limit our ability to provide options, counseling and referral. It limits our ability to give unbiased medical information.”

Many proposals never come to fruition, Pond said, so for now, “nothing is changing in our program. We just have to be patient and wait. Once final guidance comes of course we will comply to be a Title X recipient.”

The threat of funding being pulled at any moment has left medical providers in a state of anxiety.

Esther Gilman-Kehrer is a family nurse practitioner at the Laramie Reproductive Health Clinic which serves some of the poorest people in the state.

Trump’s proposal would impact the quality of care she could provide, she said. “For me personally, I think it would be really hard. I would have a hard time gagging myself, because it limits women’s options entirely and it’s not appropriate. It also treats women like children, as if they don’t know the options. They do know the options, and they come to us for help.”

The gag rule would limit Gilman-Kehrer’s ability to do her job, as would the obligation to provide abstinence-only education. Under Title X, providers already talk to teenagers about how abstinence is the only sure way to prevent STDs and pregnancy. “But we’re also realistic, and if teens want a method of birth control, we provide it,” she said.

“It’s honestly difficult to keep your doors open in a safety net organization when it’s a hot button issue,” she said. There is another clinic in Laramie that provides healthcare to uninsured people, but it doesn’t provide reproductive care.

For that reason alone, it receives more funding than the Reproductive Health Clinic.

These are uncertain times, but Gilman-Kehrer is a firm believer in the merits of her work. “This is a college town,” she said, “and being able to provide reproductive services for college women to be able to achieve the goals they’ve set for themselves, to give them control over their reproductive health, and to help them maximise their potential is what it is all about.” 

Pond echoed her sentiments. Without Teton County Public Health, people, especially women, would suffer. For a brief period of time several years ago, there was not a Title X provider. “We heard through anecdotal evidence that unintended pregnancies rose during that time,” she said. 

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