Please read our July 2018 comments on the proposed changes to Title X that we co-submitted with Advocates for Youth to the Department of Health and Human Services by Tina Hester, Executive Director at Jane’s Due Process.
On behalf of Advocates for Youth and Jane’s Due Process, we appreciate the opportunity to submit comments on the Office of Population Affairs’ proposed policy. Advocates champions efforts that help young people make informed and responsible decisions about their reproductive and sexual health. Advocates believes it can best serve the field by boldly advocating for a more positive and realistic approach to adolescent sexual health. Jane’s Due Process ensures legal representation for pregnant teens in Texas. The agency also provides information of the reproductive rights of teens and where to access confidential, non- judgmental family planning services.
We write with great concern over the proposed changes to the Title X program. Nearly 4,000 facilities nationwide currently receive Title X funding, serving over 4 million patients across the country. For patients who could not otherwise afford health care, Title X is vital to accessing preventative care and family planning tools. In 2016, 88% (3.5 million) of users had incomes that qualified them for either subsidized or no–charge services. Sixty -four percent (2.6 million) of users had family incomes at or below poverty1. Since 1970, Title X has been successful in providing high-quality care and access to testing for sexually transmitted diseases, including HIV; cervical and breast cancer screenings; wellness care; and education on contraception. In 2015, publicly funded family planning services helped prevent 1.9 million unintended pregnancies, including 440,000 teen pregnancies.
The current Title X program gives young people the power to make their own reproductive health decisions, giving them agency over their own lives. Title X, as it is currently, has some of the strongest protections for youth confidentiality. By allowing minors to pay for services based on their own income and not that of their parents, Title X prevents adolescent services from being discovered by their parents via medical bills. Treating minors in this way allows them to take charge of their treatment and keeps sensitive medical visits confidential. This is vital, especially for young people who come from abusive or neglectful homes or who face sexual coercion or partner violence.
The proposed rule encourages the provider to attempt to weaken these strong confidentiality protections, by treating the minor patient as a victim. The rules require that any minor seeking treatment be subjected to a barrage of questions meant to suss out whether the patient has been abused or is a victim of trafficking, as well as any reasons for why they have not involved their family in their health care. These questions negate the agency that an adolescent may have in taking care of their own health and turn their appointment from a consultation to an interrogation.
Young people, especially those who have experienced trauma, must make a quick decision on whether each adult who comes into their life is a safe, trustworthy individual. Patients seeking family planning services are also treated for other critical health care services such as sexually transmitted infections. By undermining a young woman’s confidentiality and eroding the trust with the clinic staff, the NPRM will cause young women to avoid or postpone STI treatment. The guidelines in the proposed Title X rules will require doctors and clinic staff to perform behavior that will be – correctly – interpreted as untrustworthy. In this environment, young people will feel even less safe disclosing the kinds of abuse that the rule changes seek to uncover.
The proposed changes to Title X encourage providers to hide information from their patients. Not only is a provider prohibited from bringing up abortion without the patient broaching the topic first, they are also prohibited from giving the patient clear information on how to proceed with an abortion should they want one. Section 59.14 gives examples of acceptable ways to honor a patient’s request for information on procuring an abortion. The provider is able to provide a list but not tell the patient which of the referred clinics perform abortions. The provider is also able to provide the patient with a list of providers who do not provide abortions. The proposed rules also prohibit offering a list of providers who solely offer abortion.
Trust between a patient and provider is of the utmost important to effectively treat an individual. A patient must believe that a provider has their best interest at heart in order to feel comfortable sharing the sensitive information that may influence their course of care. If a patient feels that their provider is steering them away from safe and effective reproductive care, or that they are scrutinizing their decisions to exclude family from their personal decisions, they may omit important information that could affect their care.
Because unintended pregnancies lead to negative health and economic consequences it is important that patients receive all the pertinent information to making decisions that will protect their health and honor their wishes. Young people deserve to be treated as in control of their own bodies, and must be provided with access to all the information needed to make the decisions that will allow them to lead healthy lives.
Suppressing Preferred Contraceptive Methods
We are particularly concerned with the changes that allow Title X grantees to offer limited contraception options. The proposed rule states that “projects are not required to provide every acceptable and effective family planning method or service.”3 This weakens the Title X programs standing as comprehensive and keeps patients from making the best decisions about their health due to lack of information or treatment option.
Providing a broad range of contraceptive options has been a key part of the Title X program since its inception. In 1969, President Richard M. Nixon called on Congress to “establish as a national goal the provision of adequate family planning services within the next five years to all those who want them but cannot afford them”.The Title X program was created in response to this request. Since then, the Title X program has provided millions of patients with comprehensive, non-directive care and full information on all forms of contraception and family planning methods. The proposed rules seek to change this characteristic of the program by no longer requiring that a Title X project provide all medically approved family planning methods. It also requires that all pregnant patients be encouraged to seek prenatal care even if they have decided that abortion is the right choice for their circumstance. These changes open the door for clinics and facilities who would push their ideology on patients despite what a patient may actually want. By receiving Title X funding, organizations that focus only on abstinence as a form of family planning, would be confused for other projects that also receive Title X funding but provide a wide range of family planning options. This is misleading to patients, and does the patient a disservice, while failing to meet the original goal of the Title X program.
An Unfair Burden on Providers While the proposed rules do a disservice to all who seek care from Title X projects, it also forces the projects themselves and the providers into an untenable position. As previously mentioned, the proposed rules require Title X projects to obscure requested information and to present incomplete information to patients (§59.14 NPRM). These rules force a doctor to act unethically. By limiting what medical information a provider can and cannot share with their patients, the new proposed Title X rules is forcing doctors to violate the AMA’s code of ethics. The American medical association’s Code of Medical Ethics Opinion states that “Except in emergency situations in which a patient is incapable of making an informed decision, withholding information without the patient’s knowledge or consent is ethically unacceptable.”
In states like Texas, laws have already mandated the separation of abortion from other health care entities. We have already seen abortion providers forced out of hospitals and into independent abortion-only clinics. In these states, it will be impossible to create lists that include providers who “provide abortion, in addition to comprehensive prenatal care” as the new rule demands, because of the deliberate isolation that has already occurred. This will lead to Title X projects deciding either to ignore the patient’s request for information on abortion, or to violate the new regulations by providing the patient with accurate information. Even those clinics that do not provide abortion services may find themselves dealing with the terrible choice of either following ideological and harmful rules that could negatively impact the communities they serve or risk shutting their doors altogether by no longer accepting Title X funds. Each year, Jane’s Due Process collects data from pregnant clients in Texas as to why they were not using birth control. One of the reasons given for not accessing family planning services is the cost. By closing off access to well-established family planning providers, the federal government will close off options for young women for free or health subsided services. This action can only lead to additional unintended pregnancies and will be detrimental to the health and educational goals of young women in high school and college.
Currently, Title X clinics provide safe, confidential, and comprehensive care to young people who want to prevent a pregnancy or who think they might be pregnant. When young people are referred to a Title X clinic, we expect that they will receive comprehensive, nonjudgmental care. Young people expect to be cared for and to receive complete information and appropriate referrals. They expect non-directive counseling on contraceptive options and access to medically approved contraceptive methods. Title X has funded comprehensive family planning for low- income patients for nearly 5 decades, and during that time, Title X projects have provided quality care.
The proposed rules diminish the quality of care by eliminating non-directive counseling, weakening confidentiality protections, and putting an unfair burden on patients and providers. Young patients will no longer be able to rely on Title X clinics for unbiased care in a moment of crisis and they may find themselves with incomplete information. For all of these reasons and those described above, we oppose the proposed changes to the Title X program.
Advocates for Youth and Jane’s Due Process appreciate the opportunity to submit comments on Department of Health and Human Services’ proposed changes to the Title X program, and we urge the Department to take our concerns into consideration. Thank you again for the opportunity to provide comments on this matter.