In a busy downtown coffee shop, a drawing of a ski lift with intrauterine devices for chairs draws the eyes of sleepy customers getting their morning underway with a caffeine jolt.
The flyer touts the services of Bridgercare, a nonprofit reproductive health clinic a few miles up the road. The clinic offers wellness exams, birth control, and LGBTQ+ services — and, starting in April, it oversees the state's multimillion-dollar share of federal family planning program funding.
In March, Bridgercare beat out the state health department to become administrator of Montana's $2.3 million Title X program, which helps pay for family planning and preventive health services. The organization applied for the grant because its leaders were concerned about a new state law that sought to restrict which local providers are funded.
What is happening in Montana is the latest example of an ongoing power struggle between nonprofits and conservative-leaning states over who receives federal family planning money. That has intensified in recent years as the Title X program has increasingly become entangled with the politics of abortion.
This year, the federal government set aside $257 million for family planning and preventive care. The providers that get that funding often serve families with low incomes, and Title X is one of the few federal programs in which people without legal permission to be in the U.S. can participate.
"The program permeates into communities that otherwise would be unreached by public health efforts," said Rebecca Kreitzer, an associate professor of public policy at the University of North Carolina.
The Montana Department of Public Health and Human Services controlled the distribution of the state's Title X funds for decades. Bridgercare sought the administrator role to circumvent a Republican-sponsored law passed last year that required the state to prioritize the money for local health departments and federally qualified health centers. That would have put the nonprofit — which doesn't provide abortion procedures — and similar organizations at the bottom of the list. The law also banned clinics that perform abortions from receiving Title X funds from the state health department.
Bridgercare Executive Director Stephanie McDowell said the group applied for the grant to try to protect the program from decisions coming out of the state Capitol. "Because of the politicization of Title X, we’re seeing how it’s run, swinging back and forth based on partisan leadership," McDowell said.
A U.S. Department of Health and Human Services spokesperson, Tara Broido, didn't answer a question about whether the agency intentionally awarded grants to nonprofits to avoid state politics. Instead, she said in a statement that applicants were evaluated in a competitive process by a panel of independent reviewers based on criteria to deliver high-quality, client-centered services.
Federal law prohibits the money from being used to perform abortions. But it can cover other services provided by groups that offer abortions — the largest and best-known by far is Planned Parenthood. In recent years, conservative politicians have tried to keep such providers from receiving Title X funding.
In some cases, contraception has entered the debate around which family planning services government should help fund. Some abortion opponents have raised concerns that long-lasting forms of birth control, such as IUDs, lead to abortions. Those claims are disputed by reproductive health experts.
In 2019, the Trump administration introduced several new rules for Title X, including disqualifying from receiving the funding family planning clinics that also offered abortion services or referrals. Many clinics across the nation left the program instead of conforming to the rules. Simultaneously, the spread of covid-19 interrupted routine care. The number of patients served by Title X plummeted.
The Biden administration reversed most of those rules, including allowing providers with abortion services back into the Title X program. States also try to influence the funding's reach, either through legislation or budget rules.
The current Title X funding cycle is five years, and the amount of money available each year could shift based on the state's network of providers or federal budget changes. Jon Ebelt, a spokesperson for the Montana Department of Public Health and Human Services, didn't answer when asked whether the state planned to reapply to administer the funding in 2027. He said the department was disappointed with the Biden administration’s "refusal" to renew the state's funding.
"We recognize, however, that recent pro-abortion federal rule changes have distorted Title X and conflict with Montana law," he said.
Conservative states have been tangling with nonprofits and the federal government over Title X funding for more than a decade. In 2011, during the Obama administration, Texas whittled down the state's family planning spending and prioritized sending the federal money to general primary care providers over reproductive health clinics. As a result, 25% of family planning clinics in Texas closed. In 2013, a nonprofit now called Every Body Texas joined the competition to distribute the state's Title X dollars and won.
"Filling and rebuilding those holes have taken this last decade, essentially," said Berna Mason, director of service delivery improvement for Every Body Texas.
In 2019, the governor of Nebraska proposed a budget that would have prohibited the money from going to any organization that provided abortions or referred patients for abortions outside of an emergency. It also would have required that funding recipients be legally and financially separate from such clinics, a restriction that would have gone further than the Trump administration's rules. Afterward, a family planning council won the right to administer Title X money.
In 2017, the nonprofit Arizona Family Health Partnership lost its status as that state's only Title X administrator when the state health department was given 25% of the funding to deliver to providers. That came after Arizona lawmakers ordered the department to apply for the funds and distribute them first to state- or county-owned clinics, with the remaining money going to primary care facilities. The change was backed by anti-abortion groups, and reproductive health care providers saw it as an attempt to weaken clinics that offer abortion services.
However, the state left nearly all the money it received untouched, and although it's still required by law to apply for Title X funding, it hasn't received a portion of the grant since.
Bré Thomas, CEO of Arizona Family Health Partnership, said that even though the nonprofit is the sole administrator of the Title X funding again, the threat remains that some or all could be taken away because of politics. "We're at the will of who’s in charge," Thomas said.
Nonprofits say they have an advantage over state agencies in expanding services because they have more flexibility in fundraising and fewer administrative hurdles.
In April, Mississippi nonprofit Converge took over administration of Title X funds, a role the state had held for decades. The organization's founders said they weren't worried that conservative politicians would restrict access to services but simply believed they could do a better job. "Service quality was very low, and it was very hard to get appointments," said co-founder Danielle Lampton.
A Mississippi State Department of Health spokesperson, Liz Sharlot, said the agency looks forward to working with Converge.
In Montana, Bridgercare plans to restore funding to Planned Parenthood clinics that have been cut off from the program since 2019, recruit more health centers to participate, and expand the program's reach in rural, frontier, and tribal communities using telehealth services, McDowell said.
The organization's goal is to increase the number of patients benefiting from the federal program by at least 10% in each year of the five-year grant cycle. The clinic also plans to apply to keep its Title X role beyond this grant.
"In five years, our grant application should be a clear front-runner for funding," she said. "It’s less about 'How do we beat someone in five years?' And more about 'How do we grow this program to serve patients?'"
This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.