Don't Celebrate Prematurely: The Trump Administration Has A "Plan B" For De-Funding Planned Parenthood

by Diane Klein

The collapse of the American Health Care Act (AHCA) was the biggest headline of March 24, 2017. The New York Times called it a "major defeat," and the next day, CNN called it an "acute embarrassment."  What Paul Ryan presented to the Republicans as a Hobson's choice - take this version of "repeal and replace" or nothing at all - instead left him in the position of Buridan's ass: starved for votes, unable to move left without alienating the Freedom Caucus (née the Tea Party), or right without losing moderate Republicans.

A crucial flashpoint in the debate was Planned Parenthood, a bête noire of the far right. The abandoned AHCA included provisions that directly targeted the organization, although not by name.  As the CBO explained, the AHCA cut off federal funds to any 501(c)(3) entity both "primarily engaged in providing family planning and reproductive health services and related medical care" and "that provides abortions" (other than in cases of rape, incest, or to save the woman's life), and, crucially, "that had expenditures under the Medicaid program that exceeded $350 million in fiscal year 2014."  There is only one such entity: Planned Parenthood Federation of America (including its affiliates and clinics).

Naturally, Planned Parenthood and its supporters were exultant at having "saved" the funding, and even the story that day was headlined, "Cecile Richards Credits Planned Parenthood Supporters With Stopping AHCA." But while all of us were distracted by Devin Nunes and the unfolding Russia scandal, the Republicans kept Planned Parenthood in the crosshairs. On March 30, 2017, Vice President Mike Pence, an ardent abortion foe, cast a tie-breaking vote in the Senate to send a new defunding bill to Trump's desk. And given the alacrity with which Trump reinstated the "Mexico City policy" barring foreign aid to groups that even provide abortion counseling - it was one of the executive orders Trump signed on his first business day in office, January 23, 2017 - there is no reason to think he will hesitate to sign this bill.

To understand what the new bill does, we first need to understand how federal funds reach Planned Parenthood. It happens two ways. When a Medicaid recipient is treated at Planned Parenthood, generally the patient is not charged at all. Then the Planned Parenthood clinic submits a claim to Medicaid, as it would to any insurer. Medicaid reimburses Planned Parenthood. The state Medicaid agency then bills the federal government for all statewide Medicaid reimbursements in a set period (not just those from Planned Parenthood), and the federal government in turn reimburses the state Medicaid agency.

Then there is Title X. Title X is a dedicated federal family planning program originally sponsored by then-Representative George H.W. Bush and signed into law in 1970 by then-President Nixon. Title X funds go directly to states (rather than using a reimbursement process). While the AHCA focused on Medicaid funding, the new bill targets Title X, the source of about 25% of Planned Parenthood's $528 million in government funding.

Keep in mind that neither the AHCA nor the new bill affects federal funding of abortions.  Although Planned Parenthood does provide about 325,000 abortions per year (between 1/3 and 1/2 of all abortions performed in the U.S., depending on whose statistics one relies on for total numbers), federal funds have not paid for abortions since 1976's Hyde Amendment prohibited such use of federal money (except in cases of rape, incest, or when the woman's life is endangered).

Similarly, Title X grants do not cover abortion. Such grants are awarded competitively, based on how well a provider can offer the family planning services sought. Good data suggest that Planned Parenthood is often the best provider of these services. Although only about 10% of Title X funding recipients are Planned Parenthood affiliates, they treat about one-third of those receiving these services nationwide. In many places (103 of the 491 counties served by Planned Parenthood), Planned Parenthood clinics are the only places to go to receive not only contraception and sex education, but also Pap smears, breast exams, and STD tests and treatment. This is what Title X pays for.

In theory, whether the provider also offers abortions should be irrelevant to its Title X eligibility, although Mike Pence has spent ten years trying to prevent Title X funds from going to those who also provide abortions. Since 2011, thirteen states (including the second and third most populous states, Texas and Florida, comprising 48 million people, as well as Kansas, New Hampshire and others) have excluded Planned Parenthood from eligibility for Title X funds because it is also an abortion provider. In some cases, this has resulted in significant geographic areas, and those who live in them, being left entirely without Title X family planning services. Litigation challenging funding denials reached inconsistent results.

In response, in December of 2016, the Obama Administration issued a final rule barring states from withholding Title X funds on the basis that a potential recipient also provides abortions. After a public comment period in which over 90% of the nearly 150,000 comments supported the rule, it went into effect on January 18, 2017, two days before Trump took office.

This is the rule that the Trump Administration is poised to overturn. In February, 2017, the Republican-controlled House used the Congressional Review Act (which requires action within 60 days of a rule) to pass H.J. Res. 43 disapproving the rule, and the Senate followed on March 30, 2017, thanks to Pence's tie-breaking vote. When Trump signs the bill, states that wish to prevent Planned Parenthood from receiving federal Title X family planning funds, simply because Planned Parenthood also provides abortions, will be free to do so. States that already restrict abortion access will be able to force any clinic committed to providing abortions to forgo Title X funds - or alternatively (as abortion foes surely hope), to stop providing abortions to preserve Title X eligibility.

It is worth stepping back to try to understand this attack. In those pre-Roe v. Wade years, when the "Zero Population Growth" movement arose, even Republicans apparently publicly supported access to cheap and reliable birth control. The GOP of 1970 saw contraception and sex education as the mainstream (feminist) left does today: as the best preventatives for unwanted pregnancy and thus the best way to reduce the need for abortion.  But times, and party politics, have changed. Today's Republican Party is under the control of those - like Pence and Ryan - who see abortion and contraception as two sides of the same sexual libertine coin, practices that disconnect (especially women's) sexual activity and expression from procreation and responsibilities of marriage and family.  In 2011, in a symbolic first time vote, the House, voted to completely defund Title X.

But the Republican effort against Planned Parenthood is not about saving taxpayer money. In the context of the federal budget, the amounts in question are trivial. The AHCA measure was estimated to save only about $156 million in the first year: $178 million of reduced direct spending, offset to some degree by the additional costs of several thousand additional Medicaid-funded births and the first year of medical care for the thousands of resulting children who would themselves be eligible for Medicaid.  The entire budget for Title X, zeroed out for FY2017, was just $286.5 million in the last year of the Obama Administration.

Like Medicaid reimbursement to Planned Parenthood, Title X is a crucial part of the reproductive health safety net for many of our nation's most vulnerable people - young women, poor women, women of color - and the children they already have. 75% of the users of Planned Parenthood's services live at or below 150% of the federal poverty line, meaning, they have an income of less than $18,000 annually for one person. Their life prospects, and their economic viability, depend on reliable control over reproduction - a kind of freedom the "Freedom Caucus" appears to care little about.

The CBO's analysis of the AHCA stated:
To the extent that there would be reductions in access to care under the [AHCA], they would affect services that help women avert pregnancies. The people most likely to experience reduced access to care would probably reside in areas without other health care clinics or medical practitioners who serve low-income populations. CBO projects that about 15 percent of those people would lose access to care.
Those are the women the GOP wants to deprive of access to basic reproductive health care and choice. The AHCA loss was a setback - but the Title X bill shows Republicans are far from giving up.