Doctors and nurses at nearly 70 community health clinics across Colorado that receive federal family-planning dollars have learned a stock phrase this year in case a patient asks how to get an abortion.

“Our clinic does not refer for abortion,” they say. Or if they want to get more specific: “Our clinic receives federal Title X funds and cannot refer for abortion.”

Colorado received $4.3 million in federal money this year to administer a family-planning program that gives out free and low-cost birth control across the state. The program, which provides intrauterine devices and other contraception, is credited by public health officials with lowering the rate of unwanted pregnancies and abortions in Colorado.

Until last summer, the clinics could give patients a list of abortion providers and freely discuss that option with women who wanted to terminate their pregnancies, though some stopped short of making a referral. That changed when a new Trump administration rule took effect.

The gag rule bans health clinics receiving the Title X family-planning dollars from referring clients for abortion. Clinics can, however, provide a list of referrals for adoption agencies or prenatal care physicians.

In response, some Colorado clinics, including TriCounty Health Department’s six sexual-health clinics in Arapahoe, Adams and Douglas counties, have abandoned the practice of giving out separate referral lists for adoption, prenatal care or abortion services, as they did before the rule. Instead, they give out one list that includes physicians who do all three — doctors who perform abortions are on the list but only because they also do prenatal care or counsel on adoption.

It’s up to patients to call the phone numbers and find out which one will provide an abortion.

The federal rule is caught up in several court battles, and the attorneys general of multiple states, including Colorado, have sued the Trump administration in an effort to block it.

In March, a second phase of the federal rule goes online — physical and financial separation for abortion services at any clinic that receives Title X dollars.

This means that clinics must set up a separate entrance and walls for patients seeking abortions. (This part of the rule isn’t likely to affect clinics here because none still receiving the federal dollars are providing abortion services). Clinics also must have separate work space, phone numbers and email addresses for employees, and an accounting system that keeps abortion services separate from birth-control or other services.

Clinics and the state health department say the guidance on how to comply with that part of the rule in particular is not clear.

Two health providers in Colorado walked away from the federal dollars after the new rule was passed. Those are Boulder Valley Women’s Health Center, which provides abortions and has two locations, and the Colorado Coalition for the Homeless, which has five health clinics and does not provide abortions.

The rest — 69 county public health departments, Denver Health clinics and community clinics — decided to follow the new rule.

The majority disagreed with the ban on referring patients to abortion providers, but, since they are safety-net clinics, felt compelled to continue providing low-cost contraception, said Jody Camp, section manager of the family planning unit at the Colorado Department of Public Health and Environment.

“To walk away from those federal dollars would have crippled their work,” she said. “The ones that stayed, they had to really grapple with the decision. It’s not easy to walk away from a huge pot of money.”

Camp said only a few clinics have asked for guidance on how to answer when a patient asks how to get an abortion, and she provides the stock answer.

The state health department’s legal team and the state Attorney General’s Office have spent months reviewing the federal rule, she said. The state health department also has held meetings to educate the clinics on the rule. “Nationwide, folks have been very confused on how to unpack it,” Camp said.

At first, the rule seemed more restrictive than it is now being interpreted by state health officials.

TriCounty Health initially created a video to show patients — instead of letting a nurse talk to them about abortion — to remove any concern about comments not permitted under the gag rule, said Susie Pfeiffer, nurse manager of the sexual health program. The video went over the three options for an unexpected pregnancy — keeping the baby, adoption and abortion.

The health department stopped using the videos a few weeks ago after receiving an update from the state on the interpretation of the federal rule, realizing a nurse could still mention abortion — just not refer to a clinic that provides it.

Ginny Ehrlich, chief executive of the abortion-rights and reproductive health organization Power to Decide, said she is concerned that, under the gag rule, clinics are now more likely to refer women to religious-based pregnancy centers than to full-service medical clinics.

“All people deserve access to quality, accurate and comprehensive health care. Period. End. Stop,” she said.

The federal rule is similar to a Colorado law put in place two decades ago. In 1999, under former Gov. Bill Owens’ administration, spending state money on abortion was banned. In order for clinics to receive state funding for health programs, the abortion side of their work had to move to a separate building or at least have a separate entrance.

Planned Parenthood hasn’t received federal dollars in Colorado since soon after the state’s rule took effect, relying instead on philanthropy. (The organization does receive some state grant money for HIV prevention and through Medicaid.) A Planned Parenthood clinic in Fort Collins was set up with a separate entrance for patients seeking abortions in an initial attempt by the organization to comply with the state gag rule, before that attempt was abandoned.

Planned Parenthood of the Rocky Mountains is fighting the new federal rule in solidarity with other women’s health clinics nationally, including by taking out an ad against Colorado Republican U.S. Sen. Cory Gardner, spokeswoman Whitney Phillips said.

The rule is an “assault on patients” seeking comprehensive health care and stigmatizes those seeking abortion by making them enter through a separate door, she said.

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