A bitterly divided federal appeals court upheld the Trump administration’s rules Monday that prohibit recipients of U.S. family planning funds from referring any of their 4 million low-income patients for abortions and require separate physical facilities for abortion services. Those mandates have already driven Planned Parenthood out of the program.

The regulations, in effect since June, are a reasonable interpretation of laws that ban most federal funding for abortions, and do not interfere with women’s access to health care or with physicians’ duty to give accurate medical information, the Ninth U.S. Circuit Court of Appeals in San Francisco said in a 7-4 ruling.

The Supreme Court has ruled that “a state’s decision not to subsidize abortion on the same basis as other procedures does not impose a burden on women,” even those who — through no fault of the government — could not afford abortions on their own, Judge Sandra Ikuta said in the majority opinion. She said the new rules were simply intended to “ensure government funds are not spent for an unauthorized purpose.”

In dissent, Judge Richard Paez described the regulations as a “gag rule” that muzzles doctors, harms patients, and violates a 1996 law requiring federally funded pregnancy counseling to be “nondirective.” “Women and their families will suffer for it,” he said.

The majority consisted entirely of appointees of Republican presidents — including Eric Miller and Kenneth Lee, both appointed by President Trump — and all of the dissenters were Democratic appointees. Although the Ninth Circuit, long one of the nation’s most liberal appeals courts, still has a 16-13 Democratic majority, Trump’s 10 appointees have shifted the balance and increased the likelihood that random selection would produce a panel like the one that ruled Monday.

The ruling also makes it likely that Trump’s restrictions on the Title X family-planning program will remain in force, at least until he leaves office. Judges in California, Oregon and Washington state had all blocked the rules, in suits by California, other states and abortion-rights advocates, but all three injunctions were lifted by the appeals court last year.

“This is a devastating decision for the millions of low-income patients who rely on the Title X program to receive comprehensive, quality sexual and reproductive health care,” said Julie Rabinovitz, president of Essential Access Health, which distributes Title X funds in California. She said the regulations have already caused a 40% drop in the 1 million Californians formerly served by the program.

Katie McHugh, spokesperson for the Department of Health and Human Services, said the regulations are not a “gag rule,” but were designed “so that more women and men are provided services that help them consider and achieve both their short-term and long-term family-planning needs.”

Title X has prohibited nearly all federal funding for abortion since it was enacted in 1970. California and 15 other states provide their own funding for poor women’s abortions.

The federal program provided $286 million this year for birth control and reproductive care to low-income patients, mostly women, including screenings for breast and cervical cancer and sexually transmitted diseases.

Under the new regulations, doctors can discuss all options with pregnant patients at their clinics but must refer them only to prenatal care, not to abortion providers. They can give patients a list of providers in the area, including up to half who offer abortions, but cannot identify the abortion providers. And federally funded family-planning providers must place their abortion clinics in separate facilities from Title X offices.

Planned Parenthood, the largest provider of services under Title X and the only provider available in many rural areas, withdrew from the program after the rules took effect.

Ikuta, in the majority opinion, noted that the regulations were similar to rules adopted in 1988 under President Ronald Reagan and upheld by the Supreme Court before being repealed by President Bill Clinton’s administration in 2000. Although Congress in 1996 required Title X counseling to be “nondirective,” Ikuta said the law does not mandate “presentation of all possible medical options,” including abortion, but simply a “neutral” discussion of various options.

The regulations require referral to prenatal care because such care “is medically necessary for a pregnant client,” even one who wants an abortion, Ikuta said. She also said the restrictions do not violate a provision of the 2010 federal health care law that prohibits government interference with access to medical care, because the rules do not prevent women from obtaining abortions on their own.

The requirement to physically separate Title X facilities and abortion clinics was a reasonable step to “minimize the appearance that the government is funding abortion,” Ikuta said.

Paez, in dissent, said the rules interfere with health care and with clinics’ ability to offer abortions and require a doctor to refer an unwilling patient to prenatal care, “while gagging her doctor from referring her for abortion” or even from telling her which local clinics provide abortions.

Referring to the Clinton administration’s 2000 regulations that Trump repealed, Paez said the court majority “disregards 20 years of progress, insistent on hauling the paternalism of the past into the present.”

Bob Egelko is a San Francisco Chronicle staff writer. Email: begelko@sfchronicle.com Twitter: @BobEgelko