SEATTLE (AP) — A U.S. appeals court on Monday upheld Trump administration changes that include additional hurdles for those seeking abortions through a federal program that helps low-income women.

The 7-4 ruling by the 9th U.S. Circuit Court of Appeals overturned decisions issued by judges in Washington, Oregon and California. The court had already allowed the administration’s changes to begin taking effect while the government appealed those rulings.

The rules ban taxpayer-funded clinics in the Title X program from making abortion referrals and prohibit clinics that receive federal money from sharing office space with abortion providers — a rule critics said would force many to find new locations, undergo expensive remodels or shut down.

More than 20 states and several civil rights and health organizations challenged the rules in cases filed in Oregon, Washington and California. Judges in all three states blocked the rules from taking effect, with Oregon and Washington courts issuing nationwide injunctions. One called the new policy “madness” and said it was motivated by “an arrogant assumption that the government is better suited to direct women’s health care than their providers.”

Planned Parenthood has already left the Title X program over the new rules, giving up about $60 million a year in federal funding.

The 9th Circuit’s majority opinion, by Judge Sandra Ikuta, found that the U.S. Supreme Court had already approved nearly identical regulations in a 1991 decision.

The dissent, by Judge Richard Paez, found that since the high court’s decision, Congress had barred the Department of Health and Human Services from imposing rules “that frustrate patients’ ability to access health care.”

The American Medical Association criticized the ruling.

“This government overreach and interference demands that physicians violate their ethical obligations – prohibiting open, frank conversations with patients about all their health care options – if they want to continue treating patients under the Title X program,” it said in a written statement. “It is unconscionable that the government is telling physicians that they can treat this underserved population only if they promise not to discuss or make referrals for all treatment options.”

Abortion is a legal medical procedure, but federal laws prohibit the use of Title X or other taxpayer funds to pay for abortions except in cases of rape, incest, or to save the life of the woman. Abortion opponents and religious conservatives say Title X has long been used to indirectly subsidize abortion providers.