Health care clinics that largely serve low-income, uninsured women and college students may have to cut services or absorb losses if Hawaii forgoes more than $2 million in annual federal funding for family planning services.

In July, Gov. David Ige and three other governors pledged to reject the Title X funds if a proposal by the Trump administration goes into effect prohibiting the grants from going to providers that perform abortions or refer patients to abortion providers. Critics of the proposed rule changes said they amount to a gag order and could undermine women’s health care.

However, there are no plans to make up for the lost federal funding, and health care experts say the rule changes could take effect as early as October.

Cindy McMillan, a spokeswoman for the governor, said Ige is looking at other funding options and that his “focus is on getting women the health care that they need.” However, she didn’t know what those options were and said the governor was traveling and unavailable for comment.

Matthew Shim, chief of the state Department of Health’s Family Health Serv­ices Division, said using state funds might be a possibility, but it would need to be worked out through the state’s normal budget process.

The state budget isn’t approved until May, and funds aren’t generally released until the start of the fiscal year beginning July 1. The governor could make an emergency request to the Legislature, but it’s not clear whether he intends to do so.

Meanwhile, clinics contacted by the Star-Advertiser say they haven’t been informed of any alternative funding and are preparing to make cuts or absorb losses.

Standing up to Trump

Federal Title X funds are awarded to the state Health Department, which distributes about $2 million in grants annually to health clinics statewide. The other recipient of Title X funds is Planned Parenthood, which receives about $600,000 for its clinics on Maui and Oahu. In total, the funding supports family health services at 32 health centers throughout the state, such as Waianae Coast Comprehensive Health Center, Kalihi Palama Health Center and Kokua Kalihi Valley Comprehensive Family Services. The funding also supports student health centers at the University of Hawaii at Hilo, Kauai Community College and University of Hawaii Maui College.

In June the Trump administration proposed significant changes to the Title X program that deliver on objectives long held by abortion opponents and satisfy Trump’s campaign pledge to strip funding from Planned Parenthood.

If patients ask for a referral for an abortion, a doctor can give them a list of health care providers that offer comprehensive prenatal care but can’t tell them which offer abortions. The new rules also stipulate that new funding be directed to faith-based organizations and organizations that promote abstinence and fertility awareness as a method of contraception.

Federal law already bans taxpayer dollars from directly funding abortions. Supporters of Trump’s proposal say the rule changes ensure funds don’t indirectly support abortions. Anti-abortion groups have also sought restrictions to Title X funding as a way of crippling Planned Parenthood’s overall budget and ability to operate.

Under the new rules, Planned Parenthood would automatically lose its funding because it performs abortions. None of the other clinics funded by Title X in Hawaii offer abortion services, but critics say curtailing health care providers’ ability to counsel patients about abortion, even if a pregnancy puts a woman’s health at risk, infringes on free speech and jeopardizes women’s health.

On July 31 Ige said that he would withdraw Hawaii from the Title X program if the rules go into effect, joining governors from New York, Oregon and Washington.

“I am proud to join my fellow governors, Hawaii residents, and millions of Americans in opposing the proposed gag rule on Title X,” Ige said in a statement announcing his decision. “This is not an issue about life or choices. This is an issue about the rights of millions of individuals who deserve the best health care available. Legally and ethically, patients have the right to learn about all their medical options and determine for themselves which option is best. The gag rule undermines that right and puts women’s health in grave danger.”

Ige’s decision has been applauded by critics of the rule changes, but it’s also left Title X recipients uncertain about how to move forward without the funding. The final regulations are expected to be published in September, according to information from the Kaiser Family Foundation, a nonpartisan health care policy organization. New federal rules generally go into effect within 30 to 60 days of publication.

Laurie Field, a spokeswoman for Planned Parenthood Votes Northwest and Hawaii, said Planned Parenthood is anticipating its funding could be cut in late October.

In 2016 Planned Parenthood said that its Hawaii clinics used Title X funds to provide health care to more than 1,400 people and education to thousands more.

Facing uncertainty

UH Hilo has been receiving $90,000 in Title X funds annually to support its Family Planning Health Clinic, which accounts for about 60 percent of the Student Medical Services’ operational budget. The majority of the funds go to support salaries of clinic staff and provide services such as contraception, pelvic exams, Pap smears, pregnancy tests, the morning-after pill and sexually transmitted disease testing.

Vice Chancellor for Student Affairs Farrah-Marie Gomes said the services were too important to cut, noting that roughly half of those served don’t have health insurance. She said the university might look to cut services in other areas or increase the students’ health care fees from $7 a semester.

“I don’t think as a college campus we can even entertain the idea that we would cut back on those services, so internally we would have to look at how to make up for the lost revenues,” said Gomes.

Hamakua-Kohala Health uses Title X funds largely to support sex education in area schools.

“As we see it, the funding for women’s health and especially for education in that area is being threatened, and we just don’t know. I think that is the biggest issue, the ambiguity,” said Milton Cortez, chief of operations at the community health center. “We know that we are going to take a hit; we don’t know how big of a hit, and we don’t know for how long. We may be able to fund it for a year, but what happens after that?”

Diana Shaw, executive director of Lanai Community Health Center, said Title X funds have helped reduce unplanned pregnancies and abortions in Hawaii by helping ensure access to contraception and sex education. She said her clinic had already decided to reject the Title X funds if the Trump administration rules go into effect.

“What they were proposing was basically going to violate the sanctity of the trust between a provider and the patient,” said Shaw. “Telling a provider that they had to read from a script, that they could not say certain things, that’s totally outrageous. That’s not the America that we know nor one that we will participate in. So we had already decided and started looking at different ways that we could provide this service to our community without Title X funding.”

The Lanai Community Health Center has been receiving $120,000 annually, which Shaw said is significant for a small clinic. She said the clinic would have to decide where to make cuts.

State Rep. Della Au Belatti, who chairs the state House’s Health and Human Services Committee, said it’s the governor’s responsibility to ensure there are contingency funds in place if the Trump administration rules do go into effect and Hawaii opts out of the program.

“Because he made the announcement that he was going to reject the funds knowing that this was funding for critical services within our community, particularly in our rural communities, I think it was important that the governor had some backup funding strategy,” said Belatti. “And I hope in his budget he does have that.”

Belatti said that she hopes the Ige administration will challenge the rules on legal grounds, arguing that they violate free speech.