Trump's family planning dystopia

Imagine that you have diabetes. You go to your local health center for information about treatment. Your doctor examines you, then tells you that you can take either take a “miracle” pill or try a “special” diet.

“I was on insulin before,” you say. “It’s what I came to you for.”

“I can’t prescribe you insulin,” your doctor responds. “The law says I have to stick to these other options.”

You’re confused. Insulin is considered standard medical care, and there is no evidence for either this so-called miracle pill or special diet. “Can you refer me to someone who can prescribe insulin?”

“I can give you a list of health centers, but I can’t tell you which ones will prescribe you insulin. Even though you said no, I need to counsel you on the pill and the diet. Also, many health centers that treat diabetes have closed. Wealthy people can find places to buy insulin, but poor people just have to go without care.”

This dystopian scenario isn’t the beginning of a sci-fi movie. It could soon be the reality in the U.S.

In June, the Trump administration published a proposed change in regulations governing the federal family planning program, Title X of the Public Health Service Act. Title X funds breast and cervical cancer screenings, sexually transmitted disease (STD) testing, and evidence-based, affordable birth control. Established nearly 50 years, Title X serves 4 million people who are overwhelmingly low-income. One-third of beneficiaries are people of color.

Here in Baltimore, the city health department oversees Title X funding, which is distributed to 23 clinics. One in three women in Baltimore are in need of publicly-funded health care services to access contraception. Of those served by Title X, 86 percent had incomes at or below the federal poverty line. Title X is a major contributor to the historic lows in unintended pregnancy. In Baltimore, teen birth rates have decreased 61 percent between 2000 and 2016. In 2010, Maryland’s Title X services saved the state nearly $148 million, preventing disease and giving generations of women the opportunity to pursue their education and career goals.

Three months ago, Baltimore City filed suit against the Trump administration for cutting our evidence-based teen pregnancy prevention program. This new proposal would compound effects of the cut, roll back gains to health and opportunity, and fundamentally change the landscape of reproductive health and the clinician-patient relationship.

First, the rule change would prevent Title X funding from going to any health centers that perform abortions or are even affiliated with those that do. It is important to note that Title X does not fund abortion services. The immediate effect is that many safety net clinics would shut down. Multiple studies have demonstrated that existing community health clinics could not come close to meeting the need for the millions of women who can no longer access needed health care.

This “gag rule” will prohibit providers from referring pregnant women to legal, evidence-based reproductive health choices, or even discussing them. As explained in Health Affairs: Clinics that “continue to qualify to participate in Title X would, as a condition of participation, be forced to agree to engage in heavily censored pregnancy counseling and to forgo medically appropriate referrals. Under the censorship requirements, grantees would be expected not only to withhold health care information from their patients but also to provide them with incomplete, misleading, and unreliable information regarding health care options.”

The implications of the gag rule are staggering. Not only does it severely undermine patients’ rights, it goes against the core values of the healing professions. The American Medical Association states in its Code of Medical Ethics that “withholding information without the patient’s knowledge or consent is ethically unacceptable.” The American Nurses Association writes that “nurses must guard against any erosive policy that hinders patients from making meaningful, informed decisions about their own health, or that blocks access to care. … This proposed rule interferes with that relationship and violates basic ethics of the profession.”

The “gag rule” has a direct impact on our clinics in Baltimore. In 2017, the Maryland legislature passed a bill to mitigate the impact of funding cuts to Planned Parenthood (though the actual funding decision is at the discretion of the governor). However, other health centers — including three sites operated exclusively by the Health Department — would still be subject to the proposal’s “gag rule” unless we turn down federal funding. The choice between censoring our providers and denying care to vulnerable women is not one that anyone should have to make.

Third, the proposed regulation alters the definition of evidence-based family planning. The current definition includes the full range of contraception methods approved by the U.S. Food and Drug Administration (FDA). The new definition de-emphasizes contraceptive care including condoms and long-acting reversible contraceptives such as intrauterine devices (IUDs). Instead, it promotes non-FDA approved methods such as fertility awareness and emphasizes abstinence. This re-classification threatens to undermine the entire landscape of family planning that has been widely recognized as one of the 10 most important public health advances of the 20th century.

Imagine a world in which we deprive patients seeking help for diabetes of access to treatment, such that the only patients who can access care are those with health insurance from their employers or are wealthy enough to pay out-of-pocket. Imagine that even when patients decide on a course of action best suited for them, clinicians knowingly withhold evidence-based treatment. Reproductive health is a critical part of every woman’s health care. Standard medical care should be based on science, not ideology. The fundamental right to health cannot be a privilege reserved only for those who can afford it.

Dr. Leana S. Wen is the Baltimore City health commissioner. Twitter: @DrLeanaWen, @BMore_Healthy.

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