In June 2018, the Trump administration proposed formal rule changes to the Title X family planning program that, once implemented, had a serious impact on the accessibility of reproductive healthcare for low-income people across the country. In this blog, I give an overview of Title X, Title X and abortion, the 2019 rule change and its immediate impacts, and what has happened with the Title X program since.
What is Title X?
Title X (pronounced “Title Ten”) is the only federally-funded program specifically dedicated to family planning in the United States. Title X is administered by the Office of Population Affairs (OPA) in the Department of Health and Human Services (HHS). The 2025 HHS budget provides the program with $286 million to provide family planning and related health services to low-income and uninsured populations.
The express intent of Title X was to address inequalities in access to contraception; the program must give priority to individuals from low-income families by law. Approximately 60% of the population the program serves have family incomes at or below the federal poverty level. By design, Title X patients are disproportionately low-income; as a result, they are also disproportionately young, people of color, and non-native English speakers. In 2023, more than half of Title X patients were under 30, almost half identified as a person of color, and nearly one in five had limited English proficiency.
Title X funds are administered in the form of Title X service grants. These grants are currently funding 86 grantees, who in turn support hundreds of subrecipients who staff thousands of service sites that serve millions of patients each year. Title X grantees can be federally qualified health centers, local or state health departments, hospitals, or independent agencies. At Title X service sites, care providers provide reproductive health services (such as STI testing and treatment and breast and cervical cancer screenings) and a broad range of family planning services related to preventing pregnancy, achieving pregnancy, and assisting families and individuals with achieving their desired number and spacing of children. In 2023, more than one-third of all Title X services were provided at Planned Parenthood clinics.
While Title X covers similar services as other federal programs like Medicaid, the programs operate very differently. While Title X distributes funds as Title X service grants, Medicaid reimburses health care providers for the services they provide to patients covered by the program. Eligibility for Medicaid is determined by income, and the program is intended to serve low-income individuals and families through a joint federal-state program. States have been required to cover family planning as part of their Medicaid programs since 1972; more than half of the states have expanded eligibility for family planning services to people who otherwise do not qualify for Medicaid. Over time, reproductive health care providers and administrators developed strategies for using Medicaid and Title X in tandem. While the majority of federal family planning dollars spent in the U.S. comes from Medicaid, the program leaves gaps that Title X fills. For example, Title X funds are often used to expand contraception counseling and outreach, support provider infrastructure, and pay for services for individuals not covered by Medicaid, such as many immigrants.
Title X and Abortion
Title X funds have never been used for abortions, as this has been explicitly prohibited since the program’s creation. Section 1008 of the original Title X statute states, “None of the funds appropriated under this title shall be used in programs where abortion is a method of family planning.” Further, even if Title X’s program guidance allowed grantees to fund abortion care, the Hyde Amendment, which prohibits the use of any federal dollars for abortion, would prohibit such spending. Differing interpretations of Section 1008, specifically the phrase ‘programs where abortion is a method of family planning,’ have led to multiple revisions of the rules governing Title X before the 2019 rule change in the more than 50 years since Title X was established. Starting in 1972, HHS interpreted Section 1008 as requiring that funds from Title X grants be kept “separate and distinct” from abortion activities undertaken by a grantee. This was the only guidance on Section 1008’s prohibition on the provision of abortion until HHS issued guidelines in 1981 requiring grantees to provide “nondirective counseling” when requested by pregnant clients including information on “(1) prenatal care and delivery; (2) infant care, foster care, or adoption; and (3) pregnancy termination” and referrals to these services upon request. In writing these guidelines, HHS’s position was that so long as the counseling offered was non-directive and referrals were only given upon request, the grantees were not ‘promoting abortion’ in a way that would violate Section 1008.
The 2019 Rule Change
The Trump administration published its proposed rule change to Title X on June 1, 2018. Despite over 500,000 public comments from healthcare providers, legal and ethical experts, public health associations, reproductive justice advocates, policymakers, and every major medical association in the United States, the rule change proceeded with no substantial changes. HHS published the final rule on March 4, 2019 and it took effect in May 2019. Initial litigation from 23 states, many medical and provider organizations, grantee organizations, and individual grantees resulted in four injunctions stopping the implementation of the rule change; all were lifted in a matter of months.
According to the Trump HHS, the rule change would bring the Title X program back into compliance with Section 1008, which it interpreted much in the same way President Reagan’s HHS did 30 years earlier. Because it believed that abortion referral would qualify as the ‘promotion’ of abortion as a method of family planning in violation of Section 1008, the rule enacted by the Trump administration only allowed for referrals for abortion in cases where it was clearly not being used as a method of family planning, such as medical emergencies or cases of rape or incest.
The final rule contained three major changes:
First, the final rule had significant effects on provider contraception recommendations. It no longer required that providers only recommend “medically approved” methods of contraception, which allowed providers to recommend abstinence or natural family planning methods that required knowledge of and abstinence during fertile windows. Further, the final rule allowed service sites to receive Title X funding even if they only offered one method of contraception, meaning that providers could offer natural family planning or even abstinence as their only recommended method of contraception, so long as another subgrantee on their grant offered hormonal contraception methods. These changes were effective after 60 days, by May 2019.
Second, the final rule no longer required non-directive pregnancy counseling that provided pregnant patients with all of their options, a longstanding cornerstone of Title X; this counseling became ‘permitted but not required.’ Under the 2019 final rule, the only mandated pregnancy counseling was a mandatory referral to prenatal care regardless of the patient’s wishes, which providers argued was inherently directive. Further, providers could not provide patients, even those who specifically asked for an abortion referral, with information on abortion providers. Providers could only give the patient a list of clinics that provide comprehensive primary care, some of which may or may not provide abortion care, and could not do anything to distinguish which providers on the list did provide abortion care. The final rule also limited this counseling to doctors and practitioners with advanced degrees, prohibiting counseling by licensed clinical social workers, registered nurses, and other practitioners who had provided this type of counseling for decades. These changes were effective after 60 and 120 days, by May and July 2019.
Third, the final rule required full financial and physical separation of Title X-funded facilities and any related programs or clinics that provided abortion care with non-Title X funds. While financial separation of Title X-funded facilities and related facilities that provided abortion was already required for sites to receive Title X funding, the rule change required enhanced financial separation that would be monitored by HHS. This enhanced financial separation came with additional reporting requirements and restrictions on use of funds, including a specific requirement that no Title X funds be used to produce or distribute literature for or against any legislative proposals or political candidates. Enhanced financial separation was required within 120 days, by July 2019.
In addition to this enhanced financial separation, the rule change mandated onerous physical separation rules that led to all Planned Parenthood-affiliated sites leaving the Title X network. These physical separation rules required that Title X-funded projects (encompassing all grantees, subrecipients, and service sites) be entirely separate from any entity that provides abortion services with non-Title X funds. While the final determination regarding the adequacy of individual site separation was up to the Secretary of HHS, the separation included (but was not limited to): separate waiting, examination, consultation, and treatment rooms; separate contact information including websites, email addresses, and phone numbers; separate staff at separate workstations; separate health care records and electronic health records systems; and separate signage, entrances, and exits. Complete physical separation of facilities was required within one year, by March 2020.
Immediate Impacts of the 2019 Rule Change
Title X grantees were required to certify their “good faith” intent to comply with the above changes by August 19, 2019. When that day came, many grantees announced their decisions to exit the program altogether. This included Planned Parenthood and its more than 600 service sites, which at the time served approximately 40% of Title X patients. Grantees left the program for a variety of reasons, from the infeasible cost of physical separation of their facilities to an unwillingness to compromise the quality of care their patients received. Whether deciding to stay in the program or leave, providers and administrators grappled with a difficult decision.
Altogether, approximately 981 (25%) service sites that were receiving Title X funding as of June 2019 left the program in August. However, as the rule change specifically targeted service sites that specialized in reproductive healthcare such as Planned Parenthood, its impact on reproductive care services was disproportionate. Though only 25% of all service sites receiving Title X funding left the program, these service sites provided at least 46% of all Title X-funded contraceptive care, providing contraception to over 1.6 million patients across the country annually.
Thus, the rule change cut the capacity of the Title X network to provide contraception nearly in half. Further, the high-volume reproductive care sites that left the network were in many cases located in healthcare deserts, meaning there were few, if any, clinics to replace them in the network. In seven states, the Title X network’s capacity to provide contraception was cut in half; in four states, the network’s capacity was reduced by at least 90%; in six states, all Title X clinics were forced to leave the network. The majority of clinics that left the network were concentrated in the Northeast, Midwest, and West Coast U.S.
The immediate impact on patients was clear. The non-partisan Congressional Research Service reported that Title X served fewer than half as many clients in 2020 as it did in 2019 and 2018 (1.5 million, 3.1 million, and 3.8 million, respectively), 63% of which was attributed to the rule’s implementation and 37% of which was attributed to the COVID-19 pandemic and the resulting stay-at-home orders and social distancing. As a result of this reduction in services, HHS estimated that the 2019 final rule led to up to 181,477 unintended pregnancies.
By the end of the Trump presidency, a long-standing decline in the abortion rate had reversed. From 2017 to 2020, the total number of abortions increased 8%, the abortion rate increased 7%, the abortion ratio (which measures the number of abortions per 100 pregnancies) increased 12%, and the birth rate declined 6%. This is in spite of the additional difficulties faced by abortion providers during the COVID-19 pandemic, including state-level stay-at-home orders that excluded abortion care from ‘essential healthcare services’ and effectively prohibited abortion in some states for weeks at a time.
Service sites that left the network faced significant difficulties, having to reduce staff hours, charge their patients additional fees, or close some sites entirely. Those that stayed open struggled to retain their patients and provide them the same quality care they were receiving before. Providers and administrators at these sites tried dipping into emergency funds, prioritizing free or low-cost services to young people, shifting to a sliding-scale payment method, and even connecting patients to public or private health insurance. Some state governments, such as those in Maryland, Nevada, and New Jersey, passed emergency funding measures to keep clinics open. However, many if not all of these solutions were short-term stopgaps designed to stop the bleeding; they were not sustainable, long-term solutions.
Many of the reproductive healthcare providers and administrators at former Title X sites I interviewed left the network because they were concerned about their ability to provide complete and accurate options counseling. Many also expressed that the fallout from the rule change affected them more than their patients, as they took on additional work from sourcing external funding to shouldering the workload of staff whose funding was cut. Many described stress and trauma which they attributed to “big unknowns” after the 2016 election, calls to ‘defund Planned Parenthood,’ their loss of Title X funds, and the COVID-19 pandemic. Some felt insulated from the worst effects of the rule change by their state or regional political contexts. Most of the providers and administrators I interviewed coped with losing their Title X funds by seeking external funding, often needing to spend hours assembling a patchwork of funding mechanisms on a case-by-case basis. Most also expressed a sense of risk reincorporating Title X funds into their budget in the future and were unsure that applying for future Title X funding would be ‘worth it.’
Recovery of the Title X Network Under the Biden Administration
On January 28, 2021, President Biden called for official review of rules governing the use of federal funds for the provision of reproductive healthcare, including Title X. On April 14, 2021, The Biden administration published a proposed rule entitled “Ensuring access to equitable, affordable, client-centered, quality family planning services” which outlined negative impacts of the 2019 rule change and proposed its revocation. Once it took effect on November 8, 2021, the 2021 final rule entirely revoked the 2019 final rule. In order to help the Title X network recover from the fallout of both the 2019 rule change and the COVID-19 pandemic, the program was also given an additional one-time funding boost of $50 million as part of the American Rescue Plan Act of 2021.
Since these regulatory and funding changes, the Title X network has grown considerably. Approximately 61% of the service sites that left the network after the 2019 rule change had rejoined by 2023, including 70% of Planned Parenthood sites. In addition, 777 new sites joined the network, leading to an overall 2% increase in Title X service sites from 2020 to 2023. All six states that were left with no Title X sites after the rule change have since rejoined the network.
In contrast, some states were pushed out of the Title X network by the Biden administration. In 2023, the administration cut off Title X funding to Tennessee and Oklahoma, where state health departments argued they were unable to provide counselling on or referrals for abortion due to state-level abortion bans. The states subsequently sued the administration, lower courts sided with the federal government, and the Supreme Court rejected a request from the Oklahoma Attorney General to restore their Title X funding in September 2024.
Title X Under the Second Trump Administration
In March of this year, the Trump administration restored Title X funds for Tennessee and Oklahoma. On that same day, the Trump administration notified 16 of the current 86 Title X grantees, including all nine Planned Parenthood grantees which administer 144 service sites in 20 states, that their funding would be “temporarily paused” leaving at least seven states with no Title X funding. The National Family Planning and Reproductive Health Association (NFPRHA) believes that these funds are potentially being withheld due to the grantees’ public statements in support of diversity, equity, and inclusion (DEI). NFPRHA and the ACLU sued HHS in April and as of last week (July 2, 2025) some grantees have started receiving notices from HHS that their funding is being restored.
While the Trump administration has not moved to revoke the 2021 final rule, the recently passed One Big Beautiful Bill Act includes a provision that prohibits federal Medicaid reimbursements to family planning and reproductive health organizations that provide abortions. This provision was temporarily blocked by a U.S. District Judge after Planned Parenthood sued the administration, and a 14-day temporary restraining order was filed on July 7, 2025. Within 14 days, HHS must “take all steps necessary to ensure that Medicaid funding continues to be disbursed” to Planned Parenthood. Despite this temporary restraining order, some Planned Parenthood locations have stopped accepting Medicaid patients.
Conclusion
The Trump administration’s 2019 rule change had a devastating effect on the Title X federal family planning program, cutting the capacity of the Title X network to provide contraception nearly in half. The rule change impacted providers and patients alike, leaving providers to scramble to provide care and leading to an estimated 181,477 unintended pregnancies. The Biden administration revoked the 2019 rule in 2021 and by 2023 the network had recovered significantly. Since returning to office at the beginning of this year, President Trump and his administration have again targeted Planned Parenthood and other reproductive healthcare providers, pausing Title X funding for nearly one in five grantees and attempting to strip Planned Parenthood and other providers of federal Medicaid funding. While at least one Title X grantee has recently had their funding restored and a judge has temporarily blocked the Medicaid defunding, legal challenges that will determine the fate of federal family planning funding continue to play out. I will revisit the administration’s attempts to ‘defund Planned Parenthood’ in the coming weeks.