Dan Gorenstein: Welcome to Day 4 of Trump Week.

So far, we’ve heard about a lot of big ideas from the president that haven’t really amounted to much.

But today, we look at an area where the president has come closer to delivering on his promises: reproductive health. 

From the Annenberg Studio at the University of Pennsylvania, I’m Dan Gorenstein, and this is Tradeoffs.

DG: A former White House senior official told us that the Trump administration’s top goals on reproductive rights were “protecting unborn life and preserving conscience rights.” 

We’ve asked Maya Manian, a visiting law professor at American University who studies reproductive rights, what this has looked like in practice.

DG: In one word or phrase, Maya, how would you describe the Trump administration’s efforts around reproductive rights?

Maya Manian: I would say the efforts aimed to limit access to abortion care and to restrict access to contraception.

DG: So let’s take these one at a time, starting with contraception. This has to do with exemptions to the Affordable Care Act, right? Can you walk us through what the Trump administration did here?

MM: So to understand that, I have to backtrack a little bit to compare the Trump regulations to the Obama era regulations.

Congress passed what was known as the Women’s Health Amendment as part of the ACA.

News clip: New or renewing health insurance plans must now cover preventive services to women at no out-of-pocket cost, including annual ob gyn exams, birth control…

MM: So in the Obama era, there were rules issued that ensured that religious organizations could exempt themselves from birth control coverage. The government would then give those employees of that organization their own way to get their birth control.

In 2017, the Trump administration, the Department of Health and Human Services, issued new regulations.

News clip: President Trump is rolling back Obamacare’s contraceptive mandate, giving businesses and organizations more power to object to providing that coverage

MM: That would allow almost any employer to refuse to include birth control in their health insurance plan based on either a religious or a, quote, “moral objection.” And these Trump regulations do not contain any alternative mechanism to ensure women’s access to birth control coverage. 

DG: And these rules were challenged and the case went all the way up to the Supreme Court, right?

MM: Yes, that’s correct. 

News clip: We come in with this Fox News alert about two important rulings from the highest court in our land…

MM: And the Supreme Court ultimately upheld these rules.

News clip: …allowing employers to opt out of Obamacare’s birth control mandate.

MM: Without an alternative mechanism to access that care.

DG: Care that can cost up to a thousand dollars out of pocket each year.

So Maya, obviously the Supreme Court just ruled on this. So I can’t imagine we have much data or evidence about the impact of the ruling yet. But are there any estimates on how many women could lose access to birth control because of the rule?

MM: The government’s own estimates were that at a minimum, between about 70,000 and 126,000 women would lose birth control coverage under these very broad exemptions issued by the Trump administration.

DG: And do we know what kind of impact that would have on these people?

MM: We know that access to contraception reduces the rate of unintended pregnancy. We know that unintended pregnancy rates are highest among low income women, among younger women and among women of color. We also know that the most effective forms of contraception are the most expensive. So this is why having health insurance coverage for contraception is very important.

DG: Ok, so let’s move to abortion. As you noted, President Trump has been very clear. He wants to limit access. Roe v. Wade, though, of course, is still the law of the land. So the Trump administration has focused its anti-abortion efforts on something called Title X. First, can you just briefly explain what Title X is?

MM: Yeah. So for about 50 years, Title X has been the federal program that provides access to contraceptive and related family planning services to low income people in the U.S.

DG: And what changes has the administration made to this program that’s been around for 50 years?

MM: So they’ve made two key changes.

DG trx: The first said that any clinic getting Title X funds had to create a physically separate office for any abortion services.

MM: Not only separate physical spaces — separate phone numbers, email addresses, staff, health records, educational programs, etc. The second element is that clinicians in these Title X clinics cannot provide abortion referral. This is often called the domestic gag rule because it’s a provision relating to what clinicians can and cannot say.

DG: Basically, the Trump administration, by making changes to Title X, has forced clinics to spend a bunch of money, and, in the minds of many providers, undermine the patient-doctor relationship. 

MM: Yes, it appeared to people to be particularly aimed at Planned Parenthood. And in fact, Planned Parenthood did withdraw from the Title X program. And Planned Parenthood is one of the main providers under Title X.

DG: And what impact is that having?

MM: So the estimate is that because of the rule, roughly one in every four Title X service sites left the network. So according to data from the Guttmacher Institute, which is a research organization.

DG: It’s also an organization that supports abortion rights.

MM: Yes, that’s correct. So the Guttmacher Institute estimate is that care for about 1.6 million female patients nationwide has been jeopardized. 

DG: Jeopardized because these clinics no longer have access to a nearly $300 million federal program.

So, some clinics have restricted hours, others have cut staff, and a few have shut down altogether.

MM: And again, Title X patients are disproportionately low income patients.

DG: Obviously a lot of reproductive rights laws end up in front of the Supreme Court where President Trump has appointed two conservative justices. But he’s also put around 200 other judges on the federal bench. That’s a quarter of all active judges in the country. What kind of impact will that have on reproductive rights?

MM: So it will have a great impact. The U.S. Supreme Court only hears about 100-150 appeals of the more than 7,000 cases it is asked to review every year. So decisions made by the lower courts are the last word in thousands of cases.

DG: My final question: Based on what we’ve seen so far, what would you expect to see from a second Trump term?

MM: One thing that I think is very interesting and looking at what the Trump administration has done is that they have aimed at restricting access to both abortion and contraception. We know from empirical evidence that expanding access to contraception reduces the rate of unintended pregnancy, which reduces the rate of abortion. So in the longer past, you didn’t also see attacks on contraception. So what I expect to see in a second Trump administration is more attempts to limit access to both contraception and abortion.

DG: Maya, thanks so much for taking the time to talk with us on Tradeoffs. 

MM: Thank you very much for having me.

DG: Tomorrow, we’ll wrap up our discussion on President Trump’s health policy record by examining his response to the COVID-19 pandemic and looking ahead toward what a potential second Trump term might look like for health policy. 

I’m Dan Gorenstein. This is Tradeoffs.