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Reproductive Health and Equity Maternal and Child Health

Balancing Program Integrity and Access to Reproductive Health Services: The Battle Over Title X In Tennessee and Oklahoma

April 24, 2024


Title X is a federal grant program that funds family planning and reproductive health care services in the U.S. Two states with abortion bans recently loss Title X grant funding because of the grant’s requirement that pregnant patients receive counseling options that include abortion. While the federal government had the right to terminate funding, clients (who are mostly young and have low incomes) lost access to important care as a result of their states’ decision to ban abortion.

Title X is a federal grant program that funds family planning and reproductive health care services in all 50 states and all U.S. territories. Title X is one of the federal government’s smaller safety net programs, with an annual budget of less than $300 million (for comparison, the WIC budget was $5.7 billion in 2022). However, it is vitally important to the individuals it serves. The majority of Title X clients are young and have low incomes; through the program, they receive low cost, or no cost, family planning and reproductive health care services.

Due to the services provided using federal funds, Title X has been the subject of litigation and politically motivated regulations over much of the past decade. During the Trump administration, Title X regulations were promulgated that prohibited providers from making referrals “for abortion as a method of family planning.” Under President Biden, the 2019 rules were rescinded and replaced by a rule requiring that providers give pregnant patients full nondirective options counseling, with all options including abortion. However, once the Dobbs decision permitted states to ban abortion, state Title X grantees began to struggle with how to comply with the Title X rules regarding options counseling and the legal status of abortion in their states.

Both Oklahoma and Tennessee, states in which abortion is banned, lost their Title X grants because they refused to provide nondirective options counseling that included abortion. Both states sued the federal government seeking a return of funding, and as of this writing, both states have lost with courts finding that they did not meet the conditions of participation for the grant.  

Title X grant funds previously held by Tennessee and Oklahoma’s state health departments were transferred to community organizations in those states. In Tennessee, that amounted to almost $8 million in lost funding to the state health department. Oklahoma lost over $4 million in Title X grants. It does not appear that the county health departments in those states stopped providing family planning services, but the states lost millions of dollars that previously funded safety net health care services. The money was transferred to organizations with much smaller provider networks. Converge, Inc. which is now the Title X grantee for Tennessee does not appear to have any open clinics in Tennessee. In January 2023, Tennessee listed over 100 county health department sites as Title X service sites. The two organizations that received Oklahoma’s Title X funding have a combined total of four sites in Oklahoma. Contrast this with the more than 75 county health departments that previously served as service sites.

While the Tennessee decision was a win for the Department of Health and Human Services (HHS) and its 2021 Final Rule, it is difficult to imagine that removing millions of dollars in funding from established Title X programs with longstanding, community-based provider networks and reallocating those funds mid-program year would have a positive impact on patient access. Title X clients categorically have low incomes; to eliminate funding for convenient, local, health care sites for those patients and allocate funding to organizations that have minimal, if any, locations will inevitably create access issues. We have seen time and time again that local health departments are trying to do their best for their communities in politically uncertain times. Losing millions in federal grant funding will only exacerbate the reproductive health care deserts that already exist.

HHS had the right to terminate grant funding to agencies that no longer complied with program requirements, and the courts confirmed that HHS properly and legally made those termination decisions. However, a strong provider network is not in place to support the clients who rely on that funding, and it is those patients who will suffer, not the politicians who passed the abortion bans.

This article was written by Joanna S. Suder, J.D., Senior Attorney, Reproductive Health, and reviewed by Kathleen Hoke, J.D., Director, Eastern Region, Network for Public Health Law.  

The Network for Public Health Law provides information and technical assistance on issues related to public health. The legal information and assistance provided in this document do not constitute legal advice or legal representation. For legal advice, please consult specific legal counsel.