Healio Special Report: Health Care and Politics
Healio Special Report: Health Care and Politics
February 25, 2019
5 min read

Doctors concerned, lawsuits threatened, after HHS issues final Title X rule

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On Friday, HHS issued its final rule regarding the Title X family planning program, with the agency saying its changes “make notable improvements designed to increase the number of patients served and improve the quality of their care.”

Within hours, clinicians, medical societies and state leaders voiced opposition to the decision.

HHS decision

According to an HHS statement, the final rule “ensures a holistic and health-centered approach” to family planning needs, regardless of a person’s age or sex. Its components include:

  • Necessitating clear financial and physical separation between Title X-funded projects and programs or facilities where abortion is available as a family planning method.
  • Forbidding abortion referrals as a method of family planning and removing the requirement that Title X providers offer abortion counseling and referral.
  • Enhancing program transparency by requiring more complete reporting by grantees about subrecipients and more clearness regarding informal partnerships with referral.
  • Safeguarding women and children who have experienced incest, intimate partner violence, molestation, child or sexual abuse, rape, and trafficking by requiring that Title X clinics provide staff with yearly training in these areas and have site-specific plans in place to protect victims/survivors of sexual assault.
  • Mandating Title X clinics be in compliance with state and local laws on notification and reporting of the aforementioned crimes.
  • Requiring counseling for minors on how to resist attempts to force them into sexual activities.
  • Necessitating clinics encourage meaningful communication between parents and children.
  • Preserving the confidential relationship between patients and medical professionals within statutory requirements.
  • Explaining that individuals may be considered for Title X services if they cannot acquire employer-sponsored insurance coverage for certain contraceptive services as a result of their employer’s religious beliefs or moral convictions and the limitations of their own financial resources.
  • Supplying high quality comprehensive family planning services to those currently unserved or underserved, while maintaining Title X’s integrity and keeping it consistent with statutory requirements.

HHS added it received more than 500,000 comments to steer the first “substantial update” to Title X in almost 20 years.

Societies, clinicians, states respond

Barbara McAneny
Barbara L. McAneny

AMA was one of the many in the medical community that expressed dismay at HHS’ announcement, saying the decision interferes with some of medical care’s basic tenets.

“The patient-physician relationship relies on trust, open conversation and informed decision-making and the government should not be telling physicians what they can and cannot say to their patients. With this action, the administration wants to block physicians from counseling patients about all of their health care options and from providing appropriate referrals for care,” Barbara L. McAneny, MD, president of the AMA, said in a statement.

Ana María López, MD, MPH and president of ACP, said the final rule violates the ACP's methodology.

Ana Maria Lopez 2018
Ana Maria López

"The final rule contradicts ACP’s longstanding health and ethics policy, which supports access to quality, accessible, and affordable health care for all Americans. As a physician, I know many patients who already have trouble accessing health care and may forgo preventive care services and treatment altogether in the face of uncertainty and lack of resources. ACP believes that limiting access to services and advice will put patients’ health at risk," she said in a statement.

"If the administration is seeking to enact policies that truly make America healthier, ignoring the health care needs of women, the importance of patient-centered care, and the centrality of the patient-physician relationship does not support health. ACP strongly urges the administration to withdraw its changes to restrict federal funding for the Title X Family Planning program and instead, protect Americans by embracing policies that uphold the key tenets of our country’s health care system: access to affordable, quality care for all patients," López continued.

The American Academy of Family Physicians said in a statement it was "disheartened" by the decision to remove funding from some women's health services, and, like the ACP, urged HHS to reconsider its decision.

"The [AAFP] is deeply disappointed that the administration has finalized a Title X rule that both interferes in the physician-patient relationship and impedes access to evidence-based care for patients. We call on the administration to reconsider its decision and immediately rescind this rule to protect the health and wellbeing of the millions of women who rely on the resources Title X supports," John Cullen, MD, president of the AAFP said.

“By dictating what medical information family physicians can and cannot provide to patients, this rule amounts to an unconscionable level of intrusion with the practice of medicine. It forces family physicians to omit important and accurate medical information necessary for our patients to make timely, fully-informed decisions, and it encroaches on our physicians’ codes of ethics and responsibility to our patients. When our government restricts the information that can be given to women, women will receive substandard medical care and their health will suffer," Cullen continued.

In tweets earlier this month, Lisa Hollier, MD, president of the American College of Obstetricians and Gynecologists, said ACP and AAP had met with the Trump administration to discuss the proposed rule while it was still being finalized.

Lisa Hollier
Lisa Hollier

In a tweet on Feb. 22, Hollier said the final rule makes a serious, detrimental overhaul to Title X.

“We join leaders in medicine strongly opposing new regulations, which deny essential access to care for millions of women. The final rule undermines the scope and purpose of the historic #TitleX program,” Hollier said.

Image of Maria Muzik
Maria Muzik

Maria Muzik, MD, MSc, an associate professor in the departments of psychiatry, obstetrics and gynecology at the University of Michigan School of Medicine, told Healio Primary Care Today  that the ramifications of the decision extend beyond reproductive health.

“Some Planned Parenthood services include counseling regarding reproductive health and providing birth control. [Studies have shown] access to birth control reduces rates of unintended pregnancies; in turn, unintended pregnancies increase risk for perinatal depression, which in turn, increases risk for intergenerational adverse sequelae,” she said.

“Not offering reproductive health treatments increases the risk for such mental health problems,” said Muzik.

The Endocrine Society said the decision has effects that are beyond a patient’s physical well-being.

“By limiting women’s access to preventative care, the changes to the Title X funding program finalized by the administration will increase medical costs and cause many women with various disorders to forgo treatment. We urge the administration to eliminate these new eligibility criteria to ensure that all centers qualified to provide these services have equal opportunity to receive Title X grant funding,” the society said in a statement.

Planned Parenthood, another entity affected by the HHS decision, drew a comparison to a another medical condition as it voiced its displeasure.

“Imagine if the Trump administration prevented doctors from talking to our patients with diabetes about insulin. It would never happen,” Leana Wen, MD, president of Planned Parenthood Federation of America, said in a statement. “Reproductive health care should be no different. Reproductive health care is health care, and health care is a basic human right.”


The concerns surrounding the final rule extend beyond the medical community. Attorneys general from at least three states — all governed by Democrats — vowed to do what they could to reverse the potential effect of the final rule.

“The Trump administration just enacted baseless regulations pushing an anti-choice political agenda on families across the country. ... These new rules are dangerous and unnecessary, and will prevent millions of Americans from obtaining the care they need and deserve. ... We will take legal action,” Letitia James, attorney general of New York, said in statement, with similar sentiments echoed by the governors of California and Oregon.

Planned Parenthood also said it intends to “fight this rule through every possible avenue.”

Doctor consulting with patient 
On Friday, HHS issued its final rule regarding the Title X family planning program. Within hours, medical societies, doctors and state leaders had voiced opposition to the decision.

Healio’s Health Care and Politics Resource Center includes the latest news on health care laws, proposals, regulations and policies in the United States and how they are likely to affect clinicians and patient care. In addition, this page features expert opinions on the impact of health care reform on clinical practice across a wide range of specialties. Be sure to bookmark the page for future reference. – by Janel Miller

Disclosure: Healio Primary Care Today could not confirm relevant financial disclosures at the time of publication.

Editor's Note: This story has been updated from a previous version to reflect new comments from ACP and AAFP.