Maine reproductive health providers caution worsening funding challenges under Trump

Planned Parenthood’s office on Congress Street in Portland, Maine. (Maine Morning Star)

Providers of reproductive and gender-affirming healthcare in Maine are bracing for a slew of possible changes under another Donald Trump presidency that would override protections offered by Maine state law.

Another immediate concern: funding.

Many health centers in Maine rely on federal funding and are fairly certain that those resources will be at risk, again. 

During Trump’s last presidency, his administration implemented a rule that essentially barred providers that rely on federal funding from so much as mentioning abortion care to patients. 

This rule was a change to Title X, the country’s only national federally funded program that supports what are considered family planning services. Providers in the Title X network can use these funds for services like contraception, testing and treatment for sexually transmitted infections, basic fertility services, breast and cervical cancer screenings, among others. However, Title X funds cannot be used for abortion services. 

“We are immediately planning for the loss of Title X shortly after Trump comes into office,” said Lisa Margulies, vice president of public affairs for Planned Parenthood Maine Action Fund.

Before the gag rule was removed under President Joe Biden, more than 1,000 health centers across the country left the Title X network, essentially halving the network’s capacity to serve patients. 

Local Planned Parenthood offices warn of multi-million dollar deficit, call for state funding

One of those providers was Maine Family Planning, Maine’s statewide grantee for Title X funding, which left the network while the domestic gag rule was in place after deciding that operating under the restrictions would violate medical ethics and decimate abortion access across the state. 

This meant that its 61 clinical sites — including four Planned Parenthood affiliates — were without that source of revenue, forcing a shift to greater reliance on private funding, which leadership said provided a temporary fix but was not sustainable. 

Even before Trump was re-elected, Maine Family Planning and Planned Parenthood were concerned about resources, as their centers are challenged to keep up with demand in light of stagnant state funding.  

“We know that opponents to our work have had our funding sources in their crosshairs for years,” said Olivia Pennington, director of advocacy and community engagement at Maine Family Planning. “Even under different administrations, our state funding has remained flat for a decade. So right now what we need more than anything is for the Maine Legislature to take a stand.” 

After a bill to increase annual allocations for Maine Family Planning failed last session, Pennington and Margulies said another iteration is forthcoming as the 132nd Maine Legislature prepares to begin work. 

“Our rights mean nothing without access,” Margulies said.

How would another domestic gag rule impact Mainers? 

“To the extent we lose Title X funding, it puts pressure on everything else,” Margulies from Planned Parenthood said. 

Title X was first created with bipartisan support during President Richard Nixon’s administration, designed to prioritize the needs of low-income and uninsured people, who otherwise could not access health care services, and combat escalating adverse maternal and child health outcomes.

While centers that provide abortion and gender-affirming care can receive Title X funding, those federal funds cannot be used by those centers to provide either type of healthcare. For abortion, that’s because of the Hyde Amendment, a federal law that generally prohibits using federal funds to pay for abortions. 

During Trump’s last presidency, he implemented changes to Title X that essentially amounted to a domestic version of the global gag rule, which prohibits foreign nongovernmental organizations that receive U.S. global health assistance from providing legal abortion services or referrals. Trump also reinstated the global gag rule, which has been rescinded and reinstated, administration to administration. Biden rescinded the rule in February of 2021. 

Trump’s domestic gag rule required physical and financial separation of Title X services from abortion care, removed the requirement for providers in the Title X network to discuss all pregnancy options with patients in a nondirective way, and prohibited these providers from referring for abortion care unless a patient explicitly asked, among other changes. 

The Biden administration decided to revoke the rule “in its totality” after sexual and reproductive health care supporters submitted 140,000 comments about the harms of the rule. As a result, many providers that had left the network returned, including Maine Family Planning and Planned Parenthood. 

Though they were able to keep their centers open during the gag rule, Margulies and Pennington said the loss of federal funds compounded by stagnant state funding made doing so a challenge. If the rule is implemented again, Margulies said “our most vulnerable neighbors could face catastrophic health outcomes.”

“Planned Parenthood is often the first and only provider a patient sees in the entire year,” Margulies said, noting that 58% of the organization’s patients in the 2023 fiscal year had low incomes. 

While the first thing people think of when it comes to Planned Parenthood is often abortion, its centers provide a variety of healthcare services, including STI testing, gynecological exams, cancer screenings and behavioral health services. 

The same is true of other Maine Family Planning affiliates. Pennington cited STI and human immunodeficiency virus, known as HIV, testing as particularly essential services now, given the spike in HIV in Bangor and the overall rise in STI rates across the state.  

“Because we are low-barrier, because we have a commitment to serving folks regardless of their ability to pay, because we are stigma free, we are a very trusted healthcare provider and we are uniquely prepared to respond to this moment,” Pennington said. 

Not all reproductive and gender-affirming care providers in Maine take Title X funds. The Mabel Wadsworth Center in Bangor was founded on the premise that it would never accept federal nor state funding to avoid situations like what occurred under Trump. 

The independent center was founded in 1984, around the time then-President Ronald Reagan first enacted the global gag rule. 

“Being beholden to state and federal funds can mean not being able to provide the best quality care and having to provide care based on, essentially, political opinion,” said Aspen Ruhlin, client advocate at Mabels.

Instead, Mabels is funded by clinic revenue, donations and grants. Ruhlin said the restrictions on reproductive care under Trump’s last presidency underscored the importance of independent, diversified sources of revenue. 

Mabels and other healthcare centers receive block grants from Maine’s statewide abortion fund, Safe Abortions For Everyone, or SAFE, which offers financial support for people living in or traveling to Maine to seek abortion care. 

SAFE Executive Director Abbie Strout-Bentes said the fund hasn’t made any changes at this point in preparation for another Trump administration. However, SAFE, which had previously been volunteer-run, brought Strout-Bentes on specifically to shore up the fund in light of an uncertain future around abortion access. 

“Our funding is all individual donations or private grants, not federal grants, so we don’t have any fears around [funding] changes, except that in general across the country, right now donations towards direct care for abortion are dwindling,” Strout-Bentes said. “We don’t know yet if we’ll see a jump in donations as a result of the election.”

SAFE has had to increase its block grant sizes for a number of clinics recently, which Strout-Bentes said indicates that the people who need help may need more help. The fund also offers gift cards to help offset associated costs for transportation, pain medicine, pads or income lost due to taking time off work to get an abortion. 

“We have some of the best laws in the country, and there’s still a need in our state for an abortion fund and there’s still need for support around transportation and other ways to really make sure everybody can access the care they need,” Strout-Bentes said. “I think that just helps broaden the understanding of what abortion access looks like across the country, because funds are needed, both in states where there’s lots of restrictions or bans, and in states like ours.”

Funding concerns beyond Title X

Beyond Title X, healthcare providers in Maine are considering a myriad of ways the Trump administration could attempt to cut off funding. 

Margulies is thinking about the potential for Planned Parenthood and other abortion providers being excluded from Medicaid programs. Under Maine law, MaineCare, Maine’s Medicaid program, is required to cover abortion and several medically necessary gender-affirming treatments for people with the clinical diagnosis of gender dysphoria, but federal changes would likely supersede that. 

Over the summer, local Planned Parenthood offices warned of a multi-million dollar deficit driven by systemic underfunding of reproductive care compounded by impacts from the COVID-19 pandemic, insufficient reimbursement rates and increased demand for free and discounted care. 

“Now that we see the writing on the wall with the Trump administration, we anticipate those deficits to worsen,” Margulies said, “and so I think that actually really speaks to what we need Maine leaders to do.”

After Trump won the presidential election on Nov. 5, Maine Family Planning President and CEO George Hill called for the Maine Legislature to act. 

“The time is now for lawmakers to fully fund the state family planning bill, which has remained flat for a decade, to ensure sexual and reproductive healthcare is accessible to everyone in need,” Hill wrote in a statement. “Family planning care IS fundamental medical care.”

Last session, the Legislature considered a bill from incoming Senate majority leader Teresa Pierce that would have increased annual funding to nearly $3.4 million a year. State funding has remained flat at roughly $978,000 for a decade, while Maine Family Planning representatives say expenses have gone up.

“The instability of Maine’s federal funding source was by no means limited to the 2018 gag rule, nor was it cured by the Biden administration’s disposal of the gag rule in 2021,” Hill wrote in testimony submitted to the Legislature’s Health and Human Services committee in support of the bill. 

Although the bill was passed by both chambers and funded, it ultimately failed because a final enactment vote on it wasn’t taken.

While Pennington with Maine Family Planning declined to say whether the next iteration will similarly call for the same level of funding, both she and Margulies said they are working closely with legislators to prioritize the issue. Like Title X, those funds would not go toward abortion or gender-affirming care. 

“Maine voters reelected a pro-reproductive rights majority to the state legislature,” Margulies said, referring to voters maintaining the state’s Democratic trifecta. “They said really loudly and clearly, we value our reproductive rights and healthcare. But, our rights mean nothing without access, and that’s what we’re talking about when we talk about sustaining the state family planning system.”

Concerns beyond funding 

In October, Trump said he would veto a federal abortion ban after previously declining to say whether he would. 

“We have to hold him to that,” Margulies said, “but again, we know that he doesn’t need to sign a national abortion ban to severely restrict and jeopardize access to care in Maine and around the country.”

One example is a plan in Project 2025 — a policy map from the Heritage Foundation that Trump has disavowed connection with but members of his former administration helped develop — to criminalize providers for mailing or receiving abortion supplies under an interpretation of the Comstock Act.

This anti-obscenity law from the late 19th century once banned the mailing of boxing photographs, pornography and contraception and is still on the books despite not being enforced in decades. If the Trump administration were to enforce that law, it could apply in Maine despite protections afforded in state law, Margulies said. 

Providers are also concerned about changes to the healthcare landscape that don’t hinge on laws, including perception of reproductive and gender-affirming care and the communities that seek it. 

“Anti-abortion extremists have made the progress they have by controlling the narrative and framing abortion as a shameful thing,” Ruhlin from the Mabel Wadsworth Center said. “It’s very similar when it comes to LGBTQ+ rights. This framing of queer folks as being like ‘other,’ as being ‘bad,’ that framing is what allows you know for homophobia and transphobia to flourish.”

This type of rhetoric was seen in Maine during consideration of the state’s shield law last session, which protects providers of healthcare that is already legal in Maine, including abortion and gender-affirming care, from legal challenges by states where that care is banned. Republican lawmakers decried the legislation, and in doing so often spread false information. 

While shoring up funding and continuing to provide healthcare amid possible federal changes, Ruhlin sees education and combating misinformation as an essential role for Mabels and other healthcare centers moving forward — “really centering the fact that the communities we serve and the care we provide is both essential and normal to really help challenge some of those not great cultural values that create stigma for our work.”