“This is the Trump administration’s true agenda laid bare: restrict and control how women access basic health care for the sake of an extreme political agenda.”

The Trump administration could soon prioritize millions of taxpayer dollars for anti-choice goals rather than providing evidence-based family planning, including contraception and cancer screenings, to a diverse, low-income population.

Advocates expect the U.S. Department of Health and Human Services (HHS) this week or next to open up the grant application process for Title X, the federal family planning program for people with low incomes. Title X is perhaps best known for covering “a broad range of effective and acceptable contraceptive methods” and offers much more in the form of contraceptive education and counseling; breast and cervical cancer screenings; sexually transmitted infection and HIV testing, referral, and prevention education; and pregnancy diagnosis and counseling, according to the program’s 2016 annual report.

HHS solicits Title X providers through a “funding opportunity announcement” that outlines the terms to obtain grant money. The agency hasn’t yet posted the announcement, but it’s coming, according to a grants notice acting as a placeholder on a federal website, grants.gov. The notice lists an estimated $260 million on tap, with grants ranging from $150,000 to $22 million. Applications will be due in early January and awards distributed on April 1.

By all appearances, HHS is following routine procedures for soliciting Title X grants. But matters of reproductive health are anything but routine in the Trump-era HHS, stacked from top to bottom with anti-choice extremists. Among them is Teresa Manning, the deputy assistant secretary of the Office of Population Affairs charged with administering the Title X program despite her beliefs that “contraception doesn’t work” and that “family planning is something that occurs between a husband and a wife and God.”

Under Manning’s leadership, the Office of Population Affairs in July shortened the grant cycles for Title X recipients, forcing them to reapply en masse upon the release of the funding opportunity announcement. Title X providers will now have to meet whatever new terms an avowedly anti-choice administration outlines in the funding opportunity announcement—or risk their future in the family planning arena.

“These are folks who understand women’s health, who’ve been doing it, who get it,” according to Mara Gandal-Powers, senior counsel for reproductive rights and health at the National Women’s Law Center (NWLC).

In an interview, Gandal-Powers underscored advocates’ “huge concern” that the announcement could unlock federal money for grantees that previously wouldn’t have been eligible to apply or otherwise lack women’s health experience.

Like crisis pregnancy centers—anti-choice fake clinics that lie to pregnant people to persuade them against having an abortion?

“Like a crisis pregnancy center, or something that even has an innocuous name that doesn’t actually know what it’s doing on women’s health, or a state that then would try to administer it in a way that would be preferable to this administration but not helpful for women,” Gandal-Powers said.

Wide-Ranging Consequences Threaten Reproductive Justice

Attacks on Title X are an issue not only of reproductive health and rights but also of reproductive justice, a framework created by Black women around core principles: the right to have children, not have children, and parent in safe and healthy environments. Of the 4 million Title X patients, 30 percent self-identified as Black or African American, Asian, Native Hawaiian or Pacific Islander, or American Indian or Alaska Native; 32 percent self-identified as Hispanic or Latino; and 13 percent had limited English proficiency, according to HHS’ 2016 annual report on the program. Many patients live at the intersections of multiple oppressions; for example, 64 percent have incomes at or below the 2016 federal poverty level of $24,300 for a family of four in the 48 contiguous states and Washington, D.C., the report found.

Audrey Sandusky, director of advocacy and communications for the National Family Planning & Reproductive Health Association, which represents Title X providers, voiced concern for the program’s patients.

“We could see restrictions that could really pull the rug out from under the existing Title X network and disrupt health care providers’ ability to deliver high-quality, evidence-based care millions of people rely on,” Sandusky said in an email.

Advocates don’t know exactly what will be in the final call for Title X grants. But the administration’s repeated attempts to undermine the program, and reproductive rights and health writ large, don’t bode well for their best guesses. Could HHS favor “fertility awareness” providers aligned with a leaked White House memo promoting the so-called rhythm method over far more effective forms of birth control? Or will it reinstate the Reagan-era “domestic gag rule” to exclude Title X providers that offer abortion care with their own funds, in accordance with the federal Hyde Amendment, or even those that refer patients for abortion care as part of reproductive health care?

Could HHS officials ban certain patient categories eligible to receive care under Title X in an effort to steer teens and adolescents away from birth control? HHS in October led the administration’s rollback of the Affordable Care Act’s birth control benefit based in part on the claim that no-copay contraception “could, among some populations, affect risky sexual behavior in a negative way.” To the administration, “some populations” include “teenagers and young adults who are not already sexually active and at significant risk of unintended pregnancy.”

Curtailing reproductive health-care access through the funding opportunity announcement is an easier lift than doing so through the federal rulemaking process. There are, however, limits to what the agency can and can’t do in countering federal law. And the Title X statute, posted under the umbrella of the Office of Population Affairs’ Title X information, requires grants to fund “a broad range of acceptable and effective family planning methods and services” for people who otherwise couldn’t afford it.

“From a legal perspective, the idea that you would take the time to write a funding opportunity that is not in alignment with the statute is just ridiculous. It’s a ridiculous way to run an agency,” the NWLC’s Gandal-Powers said. “You’re opening yourself up to lawsuits.”

HHS ultimately may roll substantive Title X attacks into the federal agencies’ larger regulatory war against women’s health-care benefits, which advocates have similarly charged runs counter to the intent of federal law. But don’t discount administration officials using the funding opportunity announcement as yet another last-ditch effort to undermine their sworn enemy: Planned Parenthood.

Planned Parenthood in the GOP’s Crosshairs—Again

Planned Parenthood is an open target on the Title X front. The health-care organization’s affiliates serve about one-third, or 1.5 million, of the program’s 4 million patients, according to data from the end of last year. Could the Trump-era HHS wield the funding opportunity announcement against Planned Parenthood’s Title X funding—about $60 million, according to a nonpartisan Congressional Budget Officeestimate from 2015? 

The first 11 months of Trump’s presidency lean toward the affirmative. Trump in April delivered the final blow to the Obama administration’s federal safeguards intended to stop state-level interference in Title X funding for Planned Parenthood and other providers that offer abortion care with their own funds. Trump’s doomed fiscal year 2018 budget proposal, a “pro-life” wish list, excluded Planned Parenthood from participation in any HHS program, including Title X.

Republicans in the U.S. House of Representatives zeroed out Title X funding in their fiscal year 2018 spending bill, pitting their extreme approach to family planning against the U.S. Senate’s more moderate proposal maintaining the approximately $286 million from the prior fiscal year. Republicans in both chambers repeatedly targeted Planned Parenthood’s Medicaid reimbursements, a separate, and larger, pot of federal money essential to reaching the poor and rural.

Planned Parenthood has already gone on offense.

“A woman’s ability to decide whether and when she becomes pregnant should not be up for debate. We have historically low rates of pregnancy among teenagers, of unintended pregnancy, and of abortion in this country because of expanded access to birth control,” Dawn Laguens, executive vice president of Planned Parenthood Action Fund, said in a statement.

“This is the Trump administration’s true agenda laid bare: restrict and control how women access basic health care for the sake of an extreme political agenda.”

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