Planned Parenthood is a Title X grantee in more than a dozen states — and is a sub-recipient of funds in many others. | Scott Olson/Getty Images Health Care Blue states threaten to drop family planning program over Trump abortion rule

Some Democratic states plan to withdraw from the main federal family planning program if they can’t win a court challenge to stop the Trump administration from steering the money away from health providers who offer abortions or make abortion referrals.

Oregon and Washington already have said they would opt out of the Title X program, which steers $286.5 million for birth control and reproductive health services for low-income women, if the new rules take effect in early May. Maryland could soon join them, and other states may follow. They say the new restrictions would undermine medical care for patients, and, in some cases, violate state laws.


Of the 23 states, including the District of Columbia, suing over the policy changes, only four told POLITICO they plan to stay in the program, citing concerns about giving up those federal dollars even with strings attached.

The Trump administration‘s sweeping revamp of the Title X program last month could cut off tens of millions of federal family planning dollars to Planned Parenthood and other providers that offer abortions. Some of the money would be steered toward anti-abortion, faith-based care providers. Participating physicians would also be banned from providing referrals to an abortion provider, which critics call a “gag rule.” There already are long-standing restrictions on using federal money to perform abortions.

Some key provisions in the new rule are due to take effect May 3 if courts don't freeze them. Grantees can drop out, and HHS can move to find others. HHS is “committed to providing a broad range of contraceptive services to patients who are in need of those services,” a department spokesperson wrote in an email.

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Pulling out of Title X would create a funding gap, and neither Washington state nor Oregon have said how they would make up the dollars if their suits are unsuccessful. Washington’s lawsuit says the state would not be able to make up the shortfall and would be forced to “restrict the population of patients eligible for subsidized family planning services.”

Over the weekend, Maryland's House of Delegates approved pulling out of Title X if new rules take hold, but the Senate and governor would have to approve the bill barring the state health department from accepting the money — and requiring the state to cover the funding difference. Republican Gov. Larry Hogan’s office declined to say whether he would veto the measure if it clears the Democratic-controlled state Senate. In 2017, a bill requiring Maryland to cover the costs of Planned Parenthood’s services if federal funding were blocked became law without Hogan’s signature.

The Trump administration and conservative lawmakers argue that Title X has been supporting abortion providers at the expense of other reproductive health services, including contraception and cancer screenings. HHS Secretary Alex Azar told the House Energy and Commerce Committee last week that without the changes, taxpayers will continue "inappropriately subsidizing" the "abortion enterprise."

The 21 state attorneys general — mostly from Democratic states, but a few like Maryland with a Democratic attorney general and a Republican governor — suing together over the rule say it intrudes on the doctor-patient relationship.

“We won’t stand by and let the government control what doctors can and can’t say to their patients,” said Oregon Attorney General Ellen Rosenblum, who is a lead in the multi-state lawsuit. Washington and California filed their own lawsuits on behalf of their state’s patients and doctors.

The lawsuits were filed in three separate federal courts, and there’s an expectation at least one will decide whether to block the rule’s implementation before May 3. Washington’s suit is set to be heard on April 25. The others have not yet received a hearing date.

Some of the states party to the suits, however, say they still need the money. Delaware, Rhode Island, Virginia and Nevada told POLITICO they would stay in the program, even if the courts don’t block the rule from taking effect.

“I can’t quite imagine how we would provide care for again those who are really struggling to meet basic needs and get access to health care services,” said Kara Odom Walker, the secretary of the Delaware Department of Health and Social Services. The funding covers crucial services like basic women’s cancer screenings and testing for sexually transmitted infections at 55 Delaware clinics, she said.

Many of the states on the lawsuit have health departments that serve as recipients of Title X dollars. In states like Washington, Oregon, Delaware and Rhode Island, they are the sole grantee, adding significant weight to their decision about participation.

The Trump administration is expected to announce in just over a week which states and providers will receive grants, and the funding cycle is slated to begin April 1. The grantees in each state distribute funds to a variety of clinics, such as Planned Parenthood affiliates, community health centers, school-based organizations and more.

Planned Parenthood is a Title X grantee in more than a dozen states — and is a sub-recipient of funds in many others. Its president, Leana Wen, has already said the organization won’t participate under the new rules, and the organization, along with the American Medical Association, filed a separate lawsuit challenging the rules.

A court-mandated delay of the rules’ implementation would give states, community health centers and other clinics more time to decide if they want to comply with the changes while the cases wind their way through the courts.

But the state attorneys general argue the rule should be struck down for good, contending it would result in higher health costs from unintended pregnancies, cancers detected too late and the spread of sexually transmitted infections. That’s in part because, they argue, low-income women who lose access to Title X clinics and become pregnant as a result are likely to depend on Medicaid to cover their maternity care, delivery and post-partum care.

Anti-abortion advocacy groups that lobbied the administration to enact the rule disagree, and say they’re confident that if state health departments quit, other providers will take their place.

“It is a shame that some states are so committed to promoting abortion that they would give up federal family planning dollars — holding women’s health hostage to abortion allegiance,” Susan B. Anthony List President Marjorie Dannenfelser told POLITICO. “We are hopeful that other entities devoted to authentic health care for women — not abortion — will step forward.”

HHS stated in the rule that “other, new entities will apply for funds, or seek to participate as subrecipients, as a result of the final rule,” and that “the net impact on those seeking services from current grantees will be zero.”

Azar echoed these assurances before Congress last week, saying: “I think we actually may see an influx of additional providers willing to come in and be a part of Title X” because of the new rules.

Filling the void could be challenging, especially for smaller organizations without past experience applying for Title X funds. Washington state said in its lawsuit that the state health department spent more than 300 hours on its most recent application — an investment individual faith-based or community clinics may not be able to make.

About a half dozen community health centers in Washington state receive Title X funds and are trying to decide if they’d remain in the program under the new rules, and provided an alternate funding source appears. Bob Marsalli, CEO of the Washington Association for Community Health, told POLITICO his member clinics are weighing “how to manage the disruption of the provider-patient relationship in an appropriate way.”

Under the revamped rules, clinics offering abortions would need to construct physically separate entrances, hire separate staff and maintain separate medical records for its abortion and non-abortion providers — a requirement reproductive care groups argue is so costly that some, or even perhaps many, sites would be forced to close.

Should courts decline to grant an injunction, these states currently on the fence will be forced to choose between a set of options they see as unacceptable.

“It will be very difficult for states to turn away federal money, especially states with high rates of STIs and high rates of teen pregnancies,” Alina Salganicoff, the director of women's health policy at the Kaiser Family Foundation, said.

“The ones who walk away will have fewer resources and they’re going to have to either figure out a way to get state funds to subsidize those services or make cutbacks. And the ones that accept the money will be faced with disqualifying some of their providers, particularly those that provide abortion services.”