Title X funding increase under Biden could help immigrants

On Wednesday, the Department of Health and Human Services announced $256.6 million in funding for 76 grantees in the Title X network.

Among the grantees was Public Health Solutions, which has a network of sexual and reproductive health centers in New York. According to Sarah Blust, director of the sexual and reproductive health centers, Title X typically provides about one-third of funding for the two PHS clinics in Brooklyn.

The centers have been trying to rebound after a Trump-era rule preventing federal funding from going to clinics that offered abortion services or referrals. Although she would like to expand services, this new round of funding will provide dire support to “maintain operations and to survive,” she said.

Since the 1970s, Title X clinics have provided reproductive health services to under- and uninsured patients, including family planning counseling and low-cost or free contraception. Among those most affected by changes in funding are immigrant women and girls, advocates say: In many states, Title X clinics are among the few places uninsured immigrant women can access reproductive health care.

But in recent years, the program has been treated like a political football. In 2019, the Trump administration slashed funding for Title X clinics and changed HHS rules — to qualify for federal funding, clinics were no longer allowed to provide abortion counseling or services. As a result, thousands of clinics such as Blust’s decided to forgo the federal funding to continue offering counseling and services related to abortion.

In 2021, the Biden administration restored the program to its Obama-era state, but the years of decreased funding meant clinic dollars had been stretched further. Now, many Title X physicians say that simply restoring funding is not enough.

Earlier this week, the Biden administration announced budget plans for 2023 that included $400 million for Title X funding, a $113.5 million increase from the previous year’s funding for the program. Funding for 2022 has already been decided by Congress’s omnibus spending bill, which reapproved flat funding of $286.5 million, the amount put in place by the Obama administration in 2014 — the last time funding for Title X was increased.

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“These awards mark the first time since September 2019 when vital Title X services are available nationwide,” said HHS Secretary Xavier Becerra in a statement announcing the latest round of Title X grants. “As communities face unyielding assaults on reproductive health care, I am proud that our nation can help bolster access to essential health and family planning services.”

Title X grants are awarded on a three-year cycle. Although the Biden administration has taken steps to bolster funding in the interim, including providing grants to clinics in states with abortion bans, time will tell whether the changes are enough to address the gaps in coverage specifically experienced by immigrant women, advocates say.

Three times as many women who are not U.S. citizens lack insurance, compared with documented citizens. And as barriers to accessing contraceptive, reproductive and other forms of gender- and age-specific care increase in many states, Title X clinic operators say they need increased staff, medication and structural support to address the full breadth of the health-care needs of these patients.

Audrey Sandusky, senior director of policy and communications at the National Family Planning and Reproductive Health Association, said that Congress’s continuation of previous funding levels means that clinics will not get the financial support they need this year. “The Biden budget kind of signaled its commitment to family planning, [but] it does not have any, any power to actually make that come to fruition,” she said.

Title X providers offer services for free or on a sliding scale, as well as compassionate and nonjudgmental elements of care that make them trusted resources for health-care information, advocates say. Throughout history, American medical establishments have disregarded or abused low-income and immigrant patients. Immigrant patients are less likely to seek care, often because of their immigration status. Undocumented immigrants are also prevented from participating in most public and private health-care systems, which leads to high rates of uninsurance among immigrant populations.

Before the implementation of the Trump rule, HHS funded 4,000 clinics across the country. According to a May 2021 letter signed by 23 state attorneys general, 1,272 clinics had by that point exited the program after the implementation of Trump’s rule. Overall, the number of clients served at Title X clinics dropped by 60 percent, or about 2.4 million clients, according to the letter.

Most Americans disapproved of the Trump administration’s so-called gag rule, according to Kaiser Family Foundation polling, but the vast majority of elected Republican officials favor restrictions on abortions and most Republican voters dislike Planned Parenthood — though generally approve of access to birth control options.

Wendy Redford, medical director at Wesley Community and Health Center in Phoenix, said that about 65 to 70 percent of her clinic’s patients are uninsured and a high percentage of patients at her clinic are undocumented. The Trump rule forced many clinics in Arizona to close, and as a result, the move “really drove people to us because they knew that we were a trusted Title X partner in the community that had access every single day to whatever they needed: pregnancy testing or birth control or STI screening,” she said.

Sandusky said that across the board, the Trump administration rule was seen as having undermined the standard of care not just in reducing funding, but also in eliminating rules mandating that “medically approved” services be offered to patients.

“It disregarded national clinical standards that were in place that … put the patient first,” Sandusky said. “There is a really high standard of care within the Title X program … to meet the patient where they are.”

That standard of care, Sandusky said, involves providing an interpreter whenever possible so that patients receive care in their primary language, which can be especially important to make sure immigrant patients can advocate for themselves and receive appropriate care.

Even with supplemental New York state and Medicaid federal funding, April Lockley, medical director of Public Health Solutions Sexual and Reproductive Health Centers in Brooklyn, found she still had to change patient care depending on insurance status, which is often determined by documentation status. To meet financial constraints of uninsured and mixed-status patients, Lockley said she adjusts prescriptions to a cheaper brand or finds coupons for prescriptions online. In the case where a patient requires imaging, Lockley refers them to public hospitals, where she said the waiting list to receive a mammogram can be six to eight months.

“It’s a real disparity in care not to be able to access the same services that someone who does have insurance is able to,” Lockley said.

For Melida Tamayo, a social worker at the Public Health Solutions’ Fort Greene location, the Trump-era period of uncertainty about what counseling she could provide was difficult. Tamayo said that because of chronic underfunding, the clinic is unable to offer as many free medications and services they would like, particularly when it comes to reproductive and sexual health. She said that they’ve had to turn away clients seeking medication that could prevent against common and potentially life-threatening sexually transmitted illnesses, which may force them to forgo care or seek it elsewhere at a high financial cost.

About one-third of the center’s patients are born outside the United States, Tamayo added, and during the pandemic, she has seen more young patients seeking pregnancy counseling.

Immigrant women and girls “shouldn’t be worrying about where they are going to get the money to pay for a sonogram or for their oral contraceptives, when there are many other things that they have to worry about,” she said.