Under a new Trump administration rule, US family planning clinics will no longer be eligible for federal funding under Title X if they provide abortion services or referrals to other abortion providers.

Established in 1970, Title X is a federal program that helps low-income and uninsured Americans access family planning and reproductive care by administering grants to healthcare providers.

While the new regulation, commonly referred to as a domestic "gag rule" was intended to target Planned Parenthood, it's also jeopardized the futures of smaller, regional family planning and reproductive clinics as well.

Maine Family Planning, which runs 18 reproductive health clinics sites throughout the state of Maine, also withdrew from Title X. In doing so, they gave up $2 million in funding, which makes up about 30% of their annual budget.

"We didn't see a world in which we could continue to be the program, because we knew the care we deliver to our patients would suffer," Maine Family Planning communications director Deidre Fulton-McDonough told Insider.

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In May of 2018, President Donald Trump announced that his administration would institute a new rule disqualifying US family planning clinics from receiving federal funding under Title X if they provide abortion services or referrals to other abortion providers — even though no federal funding directly subsidizes abortion care itself.

The new regulation, commonly referred to as a domestic "gag rule," was mainly intended as a blow to Planned Parenthood, but it's also jeopardized the futures of smaller, regionally-based family planning clinics who lack Planned Parenthood's finances and will have a harder time making up for the loss in funding.

These smaller clinics now face a double-bind: keep their Title X funding but no longer offer abortions and referrals to patients who need them, or give up the funding and risk being able to serve fewer patients altogether.

One clinic forced to make that choice this week is Maine Family Planning, which runs 18 clinics sites throughout the state of Maine that all provide STI testing, contraception, and abortion services to tens of thousands of patients. Maine Family Planning also serves as the main Title X grantee for the state, administering Title X funding to a large network of 30 other health centers and clinics throughout Maine.

Deidre Fulton-McDonough, the communications director of Maine Family Planning, told Insider in a Thursday phone interview that like Planned Parenthood, they decided to withdraw from Title X after 48 years of participating in the program and give up $2 million in federal funding, comprising about 30% of their annual budget.

"It was a big decision," Fulton-McDonough said. "The gag rule really presented us with an impossible choice — to either accept these ideologically-tainted dollars and be forced to provide care in a way that didn't align with our medical ethics and our commitment to providing abortion care especially for rural Mainers, or reject the funding and risk undermining and wreaking havoc across our family planning network."

Title X, established in 1970, is a federal program that helps low-income and uninsured Americans access family planning and reproductive care. Unlike Medicaid, which directly covers individual people, Title X gives grant money to healthcare clinics which provide family planning services.

Read more: Planned Parenthood just forfeited $60 million in federal funding so they don't have to comply with a rule that bans abortions

Approximately $286 million in Title X grants are administered to health centers and family planning clinics, such as Planned Parenthood, through the Office of Population Affairs (OPA) within the Department of Health and Human Services (HHS) each year, with about $60 million in funding going to Planned Parenthood.

After a lengthy court battle, the rule finally went into effect in mid-July. And on Tuesday, Planned Parenthood announced they would no longer accept funding through Title X, forfeiting $60 million in federal grants.

An April 2018 report from the Congressional Research Service found that 4 million people received services funded by Title X in 2016. There are 4,000 Title X-funded health centers throughout the country, with Planned Parenthood serving approximately 41% of Title X patients.

The main healthcare services Title X subsidizes, according to a 2016 OPA report, are cervical and breast cancer screenings, STI tests, and contraception.

Under the Hyde Amendment of 1976, no federal funding from programs like Medicaid and Title X can directly subsidize abortion themselves, except in rare circumstances.

But conservative and anti-abortion groups still pushed for a domestic "gag rule" to reduce the amount of federal money going to Planned Parenthood, which many view as an inherently immoral institution for providing abortions in the first place.

In Maine, Title X helps low-income and rural patients access healthcare

This new change in Title X rules is expected to disproportionately affect low-income women with limited options for high-quality reproductive healthcare.

The same 2016 OPA report found that 89% of patients who received care through Title X funding identified as female, 64% reported family incomes at or below the poverty line, and 43% lacked public or private health insurance coverage.

Fulton-McDonough told Insider that Title X funding allowed Maine Family Planning to serve 23,000 total patients, 80% of whom are low-income and qualify for free or reduced-fee health services.

Read more: Planned Parenthood just lost $60 million in funding, and it could make it harder to access birth control

"Our mission statement as an organization is to provide comprehensive reproductive healthcare, including abortion, and to ensure reproductive freedom for all Mainers," she explained. "We didn't see a world in which we could continue to be the program, because we knew the care we deliver to our patients would suffer."

The Trump administration is pivoting towards administering Title X grants to faith-based family planning clinics. Mark Wilson/Getty Images

Maine Family Planning is now relying on private donations to make up the $2 million gap in their budget, and is working with the state of Maine to secure alternative public funding, Fulton-McDonough said, acknowledging that the network could be forced to close clinics in a worst-case scenario.

"Many of our sites are located in remote parts of the state, and they're tiny clinics. The nurse practitioners who work there and the other clinicians who work there are integral parts of their communities. These are people our patients trust," she said.

Fulton-McDonough, like many other reproductive rights advocates, contends that the gag rule is ultimately more about chipping away at healthcare options for low-income women rather than meaningfully lowering abortion rates — largely because Title X enables clinics to provide the contraceptive care that prevents unintended pregnancies in the first place.

Read more: The Trump administration awarded a family planning grant to an anti-abortion organization, signaling a major funding shift at the agency

"We consider family planning services to be really an integral part of the public health infrastructure in our state. Maine has a very low teen pregnancy rate and that's in large part thanks to the work that our clinics and our allied health centers do," she said.

A 2017 report from the Guttmacher Institute found that Maine has the highest rate of contraceptive use among women of reproductive age in the US, which Fulton-McDonough identified as "a public health victory that can be attributed in part thanks to the family planning network."

Fulton-McDonough argued that specifically targeting a program that provides care for low-income women, the gag rule is about much more than just abortion.

"This is about an attack on contraception. This is yet another salvo, we believe, by the Trump-Pence administration against poor people" she said. "It's another step toward a two-tiered healthcare system where people with means can access the high-quality care that they need, and people who aren't as well off are stuck with less effective options."