In a victory for the Trump administration, a U.S. appeals court on Monday upheld rules that bar taxpayer-funded family-planning clinics from referring women for abortions.
The 7-4 ruling by the 9th U.S. Circuit Court of Appeals overturned decisions issued by judges in Washington, Oregon and California. The court had already allowed the administration's changes to start taking effect while the government appealed those rulings.
The changes ban taxpayer-funded clinics in the Title X program for low-income women from making abortion referrals, a restriction opponents characterize as a "gag rule."
Beginning March 4, the rules will also prohibit clinics that receive federal money from sharing office space with abortion providers, which critics said would force many Title X providers to find new locations, undergo expensive remodels or shut down — further reducing access to the program.
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Title X patients receive affordable birth control, reproductive care and other care through the program, including breast and cervical cancer screenings and HIV testing.
Abortion is a legal medical procedure, but federal laws prohibit the use of Title X or other taxpayer funds to pay for abortions except in cases of rape, incest, or to save the life of the woman. Under Title X, a 1970 law designed to improve access to family planning services, federal money may not be used in programs "where abortion is a method of family planning."
Abortion rights supporters and opponents have argued for decades whether counseling a patient about abortion or referring a patient to a different provider for an abortion violates that language. Abortion opponents and religious conservatives say Title X has long been used to indirectly subsidize abortion providers.
"Congress has long prohibited the use of Title X funds in programs where abortion is a method of family planning and (the Department of Health and Human Service’s) recent rule makes that longstanding prohibition a reality," U.S. Justice Department spokeswoman Mollie Timmons said in a written statement celebrating the 9th Circuit's ruling. "We look forward to continuing to defend this vital rule against all challenges."
More than 20 states and several civil rights and health organizations challenged the rules in cases filed in Oregon, Washington and California. Judges in all three states blocked them from taking effect, with Oregon and Washington courts issuing nationwide injunctions. One judge called the new policy "madness" and said it was motivated by "an arrogant assumption that the government is better suited to direct women’s health care than their providers."
Planned Parenthood, which served 1.6 million of the 4 million patients who received care through Title X, has already left the program in protest, giving up about $60 million a year in federal funding.
Overall, nearly 1,000 clinics have left Title X, according to the National Family Planning and Reproductive Health Association. Washington and Oregon have abandoned the program entirely. In Vermont, all of the Title X clinics were Planned Parenthood, leaving none there.
In California, the number of patients served by the program has fallen 40 percent under Trump's rules — and it will fall further once the physical separation requirement takes effect March 4, said Essential Access Health, which administers Title X in California.
The administration’s new rules are a return to the spirit of rules that were adopted in 1988 and subsequently upheld by the Supreme Court in the 1991 case Rust v. Sullivan. Under the Clinton administration, those rules were abandoned in favor of a requirement that the clinics provide neutral abortion counseling and referrals upon request.
The 9th Circuit's majority opinion, by Judge Sandra Ikuta, stressed the Rust decision.
"In light of Supreme Court approval of the 1988 regulations and our broad deference to agencies’ interpretations of the statutes they are charged with implementing, plaintiffs’ legal challenges to the 2019 rule fail," she wrote.
Further, she said, the so-called gag rule is no such thing: While providers may not make a referral for an abortion, they may discuss abortion with their patients.
The dissent, by Judge Richard Paez, argued that since the Rust decision, Congress had barred the Department of Health and Human Services from imposing rules "that frustrate patients’ ability to access health care." He called the ruling a throwback to the "paternalism of the past."
"The majority would return us to an older world, one in which a government bureaucrat could restrict a medical professional from informing a patient of the full range of health care options available to her," Paez wrote.
He also said the rule violates the requirement that pregnancy counseling be neutral: "It requires a doctor to refer a pregnant patient for prenatal care, even if she does not want to continue the pregnancy, while gagging her doctor from referring her for abortion, even if she has requested specifically such a referral," he wrote.
The American Medical Association criticized the ruling as "government overreach and interference" that prohibits frank conversations between physicians and their patients.
Marjorie Dannenfelser, president of the anti-abortion group Susan B. Anthony List, insisted in a written statement that "abortion is not 'family planning.'"
"President Trump’s Protect Life Rule honors ... the plain language of the Title X statute by stopping the funneling of Title X taxpayer dollars to the abortion industry, without reducing family planning funding by a dime," Dannenfelser said.