Impact of Title X Rules Unclear for Nurses


In late June, a federal court ruled that new family planning rules can take effect, despite ongoing litigation to strike them down. For the first time, providers receiving Title X funds are faced with figuring out the practical aspects of the new rule, including any day-to-day impact on nurses who care for reproductive-age women. ANA is following fast-moving developments with the Title X “gag rule,” and continues to be alert to the rule’s unique implications for nursing.

To recap: Title X is the federal program dedicated to ensuring that patients with low incomes have access to a range of approved family planning methods, along with related reproductive health care and prevention. Title X is administered by the Office of Population Health (OPA) within the Department of Health and Human Services (HHS). The program serves about 4 million people each year.

In March 2019, OPA revised Title X regulations to bar grantees from referring patients to abortion providers and to restrict the content of counseling offered to pregnant patients in additional ways. ANA has vocally opposed these provisions on ethical grounds: Nurses are ethically obligated to foster patient trust, “giving patients complete and accurate information about their health care options so they may make meaningful, informed decisions about their health.”

The details of the final rule raise practical issues for RNs working at sites with Title X funding. Section 59.14 allows only advanced practice clinicians, such as nurse practitioners or certified nurse-midwives, to provide pregnancy counseling, subject to the problematic referral limitations noted above. By the terms of the regulation, RNs and other personnel can provide only information about prenatal care.

While the rule certainly seems to limit the scope of RN practice in family planning, it is unclear how a nurse should proceed in an encounter with a patient who has just learned they are pregnant. This question is especially critical at sites in underserved areas where advanced practice clinicians are not always available. OPA has so far not provided any guidance on how a Title X provider in such circumstances can comply with the rules.

What happens now? In general, OPA has not publicly clarified how and when it will enforce the rules. The National Family Planning and Reproductive Health Association (NFPRHA) has publicly urged OPA “to take the time to properly expand on and better describe how it will interpret aspects of the rule — using examples that reflect the wide range of provider settings and administrative structures present in Title X.”

Despite the practical uncertainty, in the absence of judicial or legislative action to overturn it, the Title X final rule is effectively now in place. Some states may, as Illinois’ governor just announced, drop out of Title X altogether and substitute their own funding for family planning. NFPRHA recommends grantees consult their local counsel.

Nursing advocates are engaged in legislative efforts around Title X , and are working to address the implications of the rule for patient access as well as nursing practice. As clarity about implementation emerges, ANA will be tracking stories from nurses who experience direct consequences of the rule on their practice or their patients. If you have information that you would like to share about implementation of the Title X final rule, please contact

Congressional and Judicial Actions Addressing Border Conditions


By Brooke Trainum and Janet Haebler

As we celebrate America’s birthday and the freedoms we enjoy, recent headlines remind us that others’ have not been as fortunate. The July 4th holiday comes right after a federal judge’s order to US Customs and Border Protection (CBP) addressing concerns in detention facilities holding refugees. On June 28th, a federal judge in Texas ruled that “CBP must permit health experts into detention facilities holding migrant children to ensure they’re ‘safe and sanitary’ and assess the children’s medical needs.” This order is only applicable in the El Paso and Rio Grande Valley regions, due to the subject of the lawsuit. Judge Dolly Gee gave the Trump administration a deadline of July 12th to report what they have done to correct the conditions. This ruling is on the heels of Secretary of Health and Human Services Alex Azar stating in an interview shared by Politico that “the centers run by CBP were not good conditions for kids to be in.”

The situation at the border is complex in nature and for many that can lead to a feeling of helplessness and despair. ANA has repeatedly expressed concerns with the Department of Health and Human Services (HHS), the Department of Homeland Security (DHS) and Congress, most recently via a June 2019 letter sent to DHS. Additionally, Congress recently passed emergency supplemental funding to help alleviate this situation. Given the complexities of this issue there was even disagreement within the political parties on how to address this crisis.

The reports coming from these detention facilities are unfathomable. There are two main government agencies that oversee refugee shelters, with both DHS and HHS each carrying a different mission. The Office of Refugee Resettlement (ORR) within HHS is specifically responsible for unaccompanied minor children; however, it has been the facilities overseen by DHS and CBP that has made the news most recently as having unsafe, unsanitary, and inhumane conditions.

What many do not realize is the unacceptable conditions of border detention facilities is not new. Greater media attention has highlighted the situation. Accommodations erected decades ago were intended for single males, not families. The situation has been exacerbated by a backlog in the immigration court system. Under standard procedures, detention is intended to be for a short duration, not exceeding 72 hours, while claims for asylum are received and processed. Yet, it has been reported that in mid-2019, the average length of detention exceeded one week. In May and June 2019, between 14,000 and 18,000 people were held by CBP each night. And yet another confounding factor is that several of the detention facilities housing refugees are operated by private corporations who have contracts with Immigration and Customs Enforcement (ICE).

While many agree that immigration laws need to be reviewed and modernized, this is an issue where many Americans are split on the solution. Due to this divide, ANA has focused on the immediate issue of a humanitarian crisis affecting the health and well-being of those impacted at the border. As nurses, we have a duty through the Code of Ethics for Nurses to speak out and advocate for the human rights and health care needs of all, particularly the most vulnerable.