The abortion fight is about to move from Congress to the White House

As Democrats prepare to take over the U.S. House of Representatives, abortion foes are shifting their efforts to a friendlier branch of government: the Trump administration. Specifically, abortion opponents are targeting the Title X program, which provides federal funding for family planning services for low-income Americans.

More than 4 million people participate in the Title X program each year, receiving services like STD testing, cancer screenings, and birth control. Right now, none of the $286.5 million dedicated to Title X can be used to pay for providing abortions. (Since the 1970s, Congress has decreed that no federal dollars can be used to pay for abortions, except in limited circumstances.)

But the White House can flex its rule-making muscle to push through changes to Title X that would make it harder for clinics that provide abortions to operate, such as requiring they create physically separate spaces for abortions, and limiting doctors’ freedom to refer patients to providers that offer abortions. Advocates in the field widely expect these changes, first proposed in May, to be finalized within the next eight weeks.

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“When you have a friendly administration, that opens up doors for administrative activities,” said Kristi Hamrick, a spokesperson for Students for Life of America, the United States’ largest anti-abortion organization dedicated to mobilizing students. “So we just have to look at all the different funding streams and all the different programs.”

Students for Life President Kristan Hawkins met with White House administrators last week to discuss post-midterms strategy. She also suggested other administrative changes such as asking that the Department of Health and Human Services stop funding fetal tissue research and that Planned Parenthood no longer be eligible for federal sex ed grants.

Finalizing the Title X changes will likely be one of the administration’s first anti-abortion initiatives under the new divided Congress. The Trump administration is already exploring the possibility of halting more than $100 million worth of research projects that involve fetal tissue.

Title X is the only federal program devoted to paying for family planning services, and right now a lot of that money goes to clinics that also provide abortions, such as Planned Parenthood. Nailing down how much money Planned Parenthood receives through Title X is difficult thanks to the program’s diffuse grant structure, but about 41 percent of patients covered by the program are seen at Planned Parenthood–operated clinics.

Family planning groups are girding for a fight, but for the time being they're waiting to see how closely the Trump administration’s finalized rules hew to their initial proposed rules.

“We have not seen a final version, obviously, of that rule, so we have not sued on that issue,” said Audrey Sandusky, the director of advocacy and communications for the National Family Planning and Reproductive Health Association. “But that’s clearly on the table.”

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A lawsuit could temporarily prevent the rules from taking effect, but given the conservative makeup of the courts, that pause would be temporary. The new regulations closely mirror changes made to Title X in the 1980s by President Ronald Reagan’s administration. When Title X recipients sued, the Supreme Court found the changes to be constitutional. Reagan’s rules were ultimately in place for only a short time before President Bill Clinton took office and reversed them, said Laurie Sobel, associate director for Women’s Health Policy at the Kaiser Family Foundation.

According to Sobel, the White House’s proposed rules would likely put every family planning provider that offers abortions in financial jeopardy — including Planned Parenthood — by preventing them from participating.

“You would be required to build a separate clinic under these rules,” she said. “No one can afford to build an entirely new clinic.”

Doctors would also no longer be able to refer patients for abortions, unless a pregnant patient specifically asks for a referral. Patients would then be supplied with a list of potential health care providers who offer comprehensive prenatal care; the doctor would not be able to indicate which providers on that list offer abortion. As for abortion clinics that only offer the procedure, rather than a range of prenatal care services, Sobel believes they would not make the list.

Advocates for the changes say that the Title X program, as is, undergirds support for abortion by helping keep abortion providers’ doors open.

“There is no need to marry abortion and birth control through federal dollars,” Hamrick said. “There are many other places where women can go.”

Health care advocates agree with that assessment and say losing Title X money, or trying to negotiate around its new rules, could force some providers to shut down. “There’s network-wide trepidation that these new changes could result in staff layoffs,” Sandusky said. “It could force health center closures, and ultimately it could result in fewer people getting the quality care they need.”

Eight of the 30 family planning clinics operated through Indiana’s Title X grant would close if the Trump administration’s proposed changes go into effect, estimated Kristin Adams, who heads the Indiana Family Health Council. As Indiana’s sole Title X grantee, her organization received $5 million from Title X during the last grant cycle. Those dollars make up about 80 percent of the council's funding, Adams told VICE News.

While other providers could step in to fill in some of the gaps left behind, Adams isn’t so sure that patients won’t suffer.

“It could be unintended pregnancies. It could be people choosing not to go. It could be STDs not being treated in a timely manner because you don’t know where to go,” she said. “Just the start-up of getting a new clinic up and running doesn’t happen overnight, so there may be months of disrupted service.”

Just one in five community health centers told the Kaiser Family Foundation in a nationwide survey earlier this year that they could increase their patient caseload by 25 percent or more.

“They either don’t have the staff, or the staff doesn’t have the training,” Sobel added. “If you look at those clinics, they don’t provide the same range of contraceptive services.”

As she awaits the finalized changes, Adams said, “We just try to continue working with our partners. We address each day as it comes.”

“We have a lot of new patients, but we also have a lot of people who have used Title X services from when they were teenagers and now they’re middle-aged adults,” Adams said. “Some of these changes — I really wonder what happens to my patients.”

Cover: A motorist passes a Planned Parenthood clinic on May 18, 2018 in Chicago, Illinois. The Trump administration is expected to announce a plan for massive funding cuts to Planned Parenthood and other taxpayer-backed abortion providers by reinstating a Reagan-era rule that prohibits federal funding from going to clinics that discuss abortion with women or that share space with abortion providers. (Photo by Scott Olson/Getty Images)