When the Supreme Court issued its ruling that overturned Roe v. Wade, Justice Clarence Thomas wrote in a concurring opinion that the court "should reconsider" its past rulings related to contraception.
Thomas' words highlighted a new battle over reproductive rights in the U.S., advocacy groups say. Republican lawmakers in some states have pushed for new restrictions on contraceptive access, and the Democratic-controlled House of Representatives passed legislation last month to protect the right to contraception.
Part of that fight centers on Title X, a federal program that offers birth control and other reproductive health care to low-income patients. Title X had bipartisan support when President Richard Nixon created it in 1970, but it has become a lightning rod in the debate over abortion.
Advocates like Clare Coleman, president and CEO of the National Family Planning & Reproductive Health Association in Washington, D.C., are now calling for Democrats to use every tool at their disposal to increase financial support for Title X, which they say has long been underfunded.
"I think the Supreme Court has sent a signal to those who oppose both abortion and contraception to have at it, to come and attack these programs," Coleman said. "We're hopeful ... Democrats will fight to the wall."
A low-cost option for people in need
For many patients, like New York resident Rhea Beddoe, Title X is a lifeline that stretches beyond birth control.
Beddoe was working at a law firm and had a medical procedure to remove precancerous cells. Then she got laid off and lost her benefits. She needed a follow-up appointment that would have cost $300 without insurance.
So Beddoe called a local Planned Parenthood, filled out paperwork on her income and scheduled an appointment. She could afford it because the Title X-funded clinic charged on a sliding fee scale. And her follow-up tests showed no signs of cancer.
"It was such a relief that I was able to get the care that I needed when I was uninsured and unemployed," Beddoe said.
Title X-funded clinics are often a first stop for reproductive health care.
Adela Griswold, a nurse-midwife at a Title X-funded clinic in Virginia, says a patient might come in looking for birth control and leave having had their first pap smear, gotten a COVID-19 booster and been tested for STIs.
Griswold also provides referrals for other services, including mental health.
"We are often the sole entry point to care for folks," she said. "They wouldn't be getting care elsewhere otherwise."
The 'gag rule' and a funding crunch
Those Title X services aren't available everywhere. Not only has the program been underfunded, Coleman says, some longtime providers even faced surprise funding cuts this year as their grants either weren't renewed or were scaled back.
California's Title X allocation dipped by about $8 million in the latest round of funding. In Nevada, a local health department is shelving plans to hire new staff because of budget cuts. And in Virginia, a health department serving parts of the Shenandoah Valley announced last month it would no longer offer family planning services.
The cutbacks are connected to changes the Trump administration made to Title X in 2019. It banned participants from providing or referring patients for abortion services, except in the case of incest, rape or medical emergency.
The regulation was popular with former President Donald Trump's base but sparked a backlash — critics called it the "gag rule." In response, about 25% of Title X clinics withdrew from the program or stopped receiving funding.
The Biden administration reversed those rules in October 2021, prompting a flood of new applications from healthcare providers — but Congress didn't approve new funding. So more health care providers are now competing for a share of that money, and some lose out.
A fight at the federal and state levels
Olivia Gans Turner is head of the Virginia Society for Human Life, as well as American Victims of Abortion. Both groups are part of the National Right to Life Committee, which says it doesn't take a position on Title X funding but supported the Trump administration's ban on providers making abortion referrals.
"We had no problems with funding going to legitimate contraceptive programs because we don't take a position on contraception," Turner said. "What we wanted to prevent was the funding of organizations or programs that were also promoting or practicing abortion."
Title X doesn't actually fund abortions. But Turner said abortion providers shouldn't be eligible for any federal funds — even if it's earmarked for other services such as birth control.
"You could say, 'Well, the one doesn't go to the other,' " Turner said. "Except, if I give you the money to pay the rent, you've got a lot more money to go to the movies this week, don't you?"
It's not an argument likely to sway Democrats, who still control Congress. But as with many issues, they face an obstacle in the U.S. Senate's filibuster rules. Sen. Tim Kaine, D-Va., who is among the Democrats pushing to increase Title X funding, said that "finding Republican support for Title X has not been easy."
Kaine believes the Supreme Court decision overturning a Constitutional right to abortion might galvanize support for access to contraception. "I think people are realizing, well, we can't take this for granted, that may open up an opportunity for us to be successful," he said.
Meanwhile, legislative battles are playing out at the state level. Earlier this year, some Republican lawmakers in Missouri unsuccessfully tried to ban taxpayer funding for emergency contraception, which some lawmakers consider a form of abortion. And Republicans in several states, including Missouri and Texas, have passed laws barring Planned Parenthood from seeing Medicaid patients for family planning services.
Coleman said she expects more legislation during upcoming statehouse sessions this winter. And she thinks the Supreme Court's decision underscores the urgency that access to contraception not be taken for granted.
"We need to stop questioning whether or not this is possible," Coleman said. "This is clearly possible. The legitimacy and legality of contraception is threatened."