The Alabama Department of Public Health (ADPH) has been silent on whether it is following current federal rules requiring health care providers to provide counseling and referrals on all pregnancy options, including abortion.
But it may soon be a moot point.
A potential Trump presidency could reverse those rules and affect reproductive health policy in Alabama, which according to the U.S. Centers for Disease Control and Prevention is 7th in highest teen birth rate nationwide, at 20.9 teen births per 1,000 females aged 15–19.
ADPH also reports that rates of sexually transmitted diseases (STIs) have been rising, with a significant increase among people aged 15-24, and Black individuals being almost three times more likely to be diagnosed with HIV than white individuals.
“Just as during the first Trump administration, President-elect Trump could again harm the Title X program through the regulatory process, without legislative action,” said Anna Bernstein, principal federal policy advisor for the Guttmacher Institute.
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Title X, a federal family planning program, funds low-cost reproductive services, including birth control and STI testing, for low-income individuals. Alabama received $5.5 million from the program in fiscal year 2024, which are administered by ADPH. As Alabama’s only Title X grantee, ADPH could risk losing federal funding if it is found out of compliance with current regulations, which mandate comprehensive pregnancy counseling.
Bernstein said that Trump could reinstate the so-called “domestic gag rule,” which imposed additional requirements on Title X grantees, mandating a physical and financial separation of services for clinics that provide abortion care outside of Title X funds.
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Such a rule would likely eliminate the current requirement for Title X grantees to provide comprehensive and non-directive pregnancy counseling.
The current rules pose a potential issue for the state in a lawsuit seeking to stop Alabama officials from prosecuting people who provide assistance to Alabamians seeking out-of-state abortions.
Attorney General Steve Marshall has argued that those helping Alabamians obtain abortion care are violating the state’s near-total abortion ban. If ADPH is complying with the federal Title X requirements and discussing options for people, including abortion, that could complicate Marshall’s position.
ADPH has not indicated whether it complies with Title X counseling rules enacted under the Biden administration, and messages seeking comment were left with ADPH.
The American Civil Liberties Union in 2023 filed a lawsuit on behalf of Alabama health care providers, arguing that Marshall’s threats to prosecute those assisting Alabamians with abortion access outside the state violate the Due Process Clause, the First Amendment, and the fundamental constitutional right to travel.
In a 2022 radio interview, shortly after the U.S. Supreme Court struck down federal abortion protections and the state enacted an effective abortion ban, Marshall said that health care providers could face felony charges for assisting Alabamians in traveling to other states to obtain legal abortion care.
It’s unclear when U.S. District Judge Myron H. Thompson could rule on the lawsuit.
Marshall has not responded to questions on whether his office would prosecute ADPH if the department provides abortion counseling.
If Trump returns to the White House, he could again push changes to Title X that critics say would impose additional restrictions on reproductive health providers.
In his previous term, Trump’s administration enacted the 2019 “Protect Life Rule,” which prohibited Title X-funded clinics from referring patients for abortions and required a “clear physical and financial separation” between Title X-funded services and abortion care. This rule prompted many clinics, including some in Tennessee, to leave the Title X program, reducing health care access for low-income patients.
“After those regulations, about a quarter of the Title X provider network withdrew from the program, either voluntarily or were disqualified. So, we are expecting to see that reemerge,” said Alina Salganicoff, senior vice president at KFF and director for women’s health policy, on a call with journalists Friday.
Although a small program, totaling under $300 million nationwide, Salganicoff said that it is a critical program for people who don’t have insurance.
Sean Tipton, chief advocacy and policy officer, said it’s important not to get caught up in speculation as Trump has not mentioned what he may specifically do with Title X. When Trump was first in office and imposed those restrictions, there were national abortion care protections via Roe v. Wade, which is no longer the case.
“Title X contraception clinics in states where abortion is illegal aren’t going to be talking about abortion anyway, so I don’t really know what they will do,” Tipton said.
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