In a sweeping social policy shift, the Trump administration is seeking to remake health rules at home and abroad for women, gay and transgender people, restricting access to abortion, curtailing support for contraception and narrowing the scope of civil rights in healthcare.
The turnaround has its foundations in the quiet, behind-the-scenes influence of Vice President Mike Pence, who has been driven throughout his political career by his evangelical Christian beliefs to restrict abortion and prioritize the rights of religious conservatives.
Pence has been in the spotlight for leading the administration's failed effort to repeal and replace Obamacare. But other changes, affecting health policy domestically and abroad, are moving ahead with far less attention.
Under the direction of two secretaries recommended by Pence, the Department of Health and Human Services has moved to slash funds from teen pregnancy-prevention programs, curb abortion both in the United States and abroad and strip civil protections for transgender patients.
The administration has emphasized abstinence programs, led by appointees who believe contraception harms women, and pushed to cut government funds for Planned Parenthood—a longtime cause for Pence while he was in Congress. Planned Parenthood, a national network of healthcare providers, offers infertility services, contraception and abortions.
Public health civil rights offices, marshaled to strengthen LGBT rights under Obama, have been retooled into a new Office of Conscience and Religious Freedom. This month, the office unveiled a final "conscience rule" to strengthen protections for healthcare workers who object to performing abortions and sterilizations or treating gay and transgender patients.
And the HHS, along with the State Department—headed by Pence ally Mike Pompeo, also an evangelical Christian—has expanded the campaign beyond U.S. borders. Trump-appointed officials are seeking to delete language in international documents at the United Nations they contend promotes access to abortion and expands healthcare rights to transgender individuals.
"There has never been anything like it," Marjorie Dannenfelser, president of the Susan B. Anthony List, an anti-abortion group, said of her working relationship with Pence. "The policy I believe can't get done without Vice President Pence and his team."
A cadre of religious conservatives appointed in the early days of the administration is driving the changes, largely from within HHS, which administers most government health programs, along with the State Department and White House. Many appointees come from religious and conservative groups, some of whom regularly protested outside abortion clinics during the Obama years.
In the Trump-Pence West Wing, "everywhere I turn are colleagues, mentors and friends who have fought in the pro-life trenches for decades," Katy Talento, who handled health policy in the White House, told an anti-abortion group in Texas. She last week announced plans to leave the administration. "I still can't believe they let us all in the complex every day."
Emboldened by the movement and by the new conservative majority on the Supreme Court, states including Alabama and Missouri have passed laws in recent weeks that nearly outlaw abortion, spurring nationwide protests.
The shift has generated legal challenges, and chunks of the agenda are bottlenecked in the courts. Recently, a federal judge in Washington State blocked new rules meant to cut funding from facilities offering abortion.
The campaign has been more successful abroad. Pompeo in March held a rare news conference to say the administration was strengthening an effort to combat abortion globally. "We're determined to make sure that we don't allow taxpayers' dollars to get to those places," he said, citing groups performing or referring abortions, and announcing a cut in funds to Latin America.
Pompeo's declaration marked an expansion of the Mexico City Policy, which requires foreign non-governmental groups that receive U.S. health aid not provide, refer or counsel on abortions. Implemented by every Republican administration since 1984, the policy in the past applied to U.S. family planning funds, or about $600 million. In one of his first acts as president, Trump signed an order expanding the rule to cover nearly all U.S. global health aid, or more than $8 billion.
Nationally, this public health battle has often been pushed to the background by the nonstop churn of Trump's tweets and controversies.
"One of the benefits of Trump's Twitter approach is it creates headlines, and that's what it's intended to do, and underneath those headlines, everyone else in the administration can go about peacefully doing their job," said David McIntosh, president of the conservative Club for Growth and a longtime Pence friend. HHS has "released several very important, significant regulations that changed the nature of Obamacare, of healthcare, with very little coverage in the press."
The effort has startled some public health veterans. "It's very, very extreme," said Megan Huchko, director of the Center for Global Reproductive Health at Duke University. "It seems we're moving backward in pretty profound ways."
The vice president declined interview requests for this article. Administration officials say his voice matters. Kellyanne Conway, senior counselor to the president, praised Pence's advocacy on cutting federal support for Planned Parenthood.
"It means a great deal to the president to hear that from somebody who had been a legislator on Capitol Hill for 12 years, a governor for four, and somebody who like the president is trusted by the small c conservative movement as a full-spectrum conservative," Conway said.
One senior HHS official told Reuters the agency is correcting the course set by the Obama administration on the government's role in enforcing LGBT rights and whether providers have to perform abortions. "Our rights to religious freedom have too long been treated as a second-class right compared to others and it's time for that to change," said Roger Severino, director of the agency's Civil Rights Division.
THE PENCE EFFECT
When Trump secured the GOP nomination in 2016, he had yet to win over skeptical evangelical voters who questioned his varying stances on critical issues, most notably abortion. Trump previously had said he supported a woman's right to choose whether to terminate a pregnancy.
His selection of Pence as his running mate helped him win over those voters. The Trump-Pence ticket ultimately secured 80 percent of white born-again and evangelical Christians.
In a White House marked by turnover, the amiable Pence has been a quiet presence prodding the administration to align with his faith-based agenda. Aides describe him as a man whose effectiveness is rooted in a willingness to shun the limelight and put like-minded proteges in crucial jobs.
"Pence's influence has come from ... getting people who have the same worldview as Pence in key positions at things you care about and then trusting them to make decisions," said Paul Winfree, who served as deputy director of the White House Domestic Policy Council under Trump and is now at the conservative Heritage Foundation think tank.
The vice president's allies and former aides are salted throughout the administration, carrying out significant shifts in federal health insurance programs. One change cheered by the religious right made it easier for employers to not cover contraception.
A key Pence ally is Seema Verma, a healthcare consultant who worked with him in Indiana, now administrator of the Centers for Medicare and Medicaid Services. Under Verma, the agency has worked to roll back Obamacare's expansion of Medicaid, the insurance program for the poor and disabled that covers more than 70 million Americans.
Both HHS secretaries under Trump were pushed by Pence: Tom Price, an ally in Congress who was fired in 2017 for using expensive charter flights for public business, and Alex Azar, who worked as a senior pharmaceutical company executive and lobbyist in Indianapolis while Pence was governor. At a January event, Azar called Pence "my friend and mentor."
The agency took on a new religious tone. Price hosted a Bible study on Wednesday mornings for members of Congress and political appointees, a former senior HHS official said.
SOLDIER IN ABORTION WARS
After being elected to Congress on his third try, in 2000, Pence formed connections to the Washington anti-abortion movement, including Dannenfelser, the Susan B. Anthony List president. Dannenfelser had previously served as staff director of the Congressional Pro-Life Caucus. She and Conway encouraged Pence to run for president in 2012, though he declined.
Three times, he introduced bills to bar HHS from funding Planned Parenthood. His efforts failed, but won him fierce loyalty among anti-abortion activists.
Elected Indiana governor in 2012, Pence signed a bill that banned the use of fetal tissue in research, a law now being challenged in court. Another bill he signed banned abortions for reasons of the sex, race or disability of the fetus, and required that fetal remains be cremated or buried. This week, the Supreme Court upheld the burial requirement but left in place a lower-court ruling that blocked the abortion ban.
In the Trump White House, Pence serves as a chief advocate for religious conservatives, making sure they have a voice in policy-making. While he does not always have a hand in specific policies, Pence's ardent support has empowered the administration's religious conservatives to action.
Other times, he gets directly involved. During the Republican campaign to repeal Obamacare, Dannenfelser said she attended a meeting in Pence's office, helping the vice president and staff craft language to add anti-abortion provisions to the failed bill.
Another focus has been the Mexico City Policy involving U.S. aid to non-government groups. "It's unfortunate enough that we continue to fund Planned Parenthood here in the U.S.; we don't need to export a pro-abortion ideology overseas," Pence said at a House hearing in 2007.
Now, under the expanded Mexico City rule Pence advocated, some groups have refused U.S. funding because abortion is part of their mission. One result: shuttered clinics.
In Kenya, services are already being reduced, said Jedidah Maina, director of the Trust for Indigenous Culture and Health, which offers programs on sexual and reproductive health and operates a health services hotline. One partner organization no longer provides free healthcare for the impoverished, and another was forced to reduce HIV services, she said.
In Peru, the reproductive-rights advocacy group PromSex said it was unable to apply for a grant to combat human trafficking from the U.S. Agency for International Development because it fights for access to abortion. In a November 2017 email obtained by Reuters, a USAID contracting officer said if the group "were carrying out activities or planning to carry out any activity related to family planning methods, it could not commit itself with the Government of the United States."
Despite the changes, a USAID spokesperson said, the U.S. remains "the largest donor" of family planning aid in the world.
At the United Nations and World Health Organization, U.S. representatives appointed under Trump-Pence have worked to pull references to "gender" and "sexual and reproductive health" from international rights documents.
In April, the United States threatened to veto a U.N. resolution aimed at combating rape as a weapon of war because it would have included language providing victims with sexual and reproductive healthcare. The phrase "sexual and reproductive health" was cut from the final resolution. A spokesman for the United Nations Population Fund said the cut was "regrettable," adding that "denying survivors access to such services is a human rights violation that can have dire consequences."
One document obtained by Reuters outlined talking points for U.S. officials before a WHO summit. In it, political appointees wanted to make clear the United States "does not support abortion in our reproductive health assistance, nor do we recognize abortion as a method of family planning."
In a statement, HHS said the phrase "sexual and reproductive health" has "unfortunately evolved" to include abortion. "The United States under President Trump's leadership unequivocally supports the empowerment of women and girls, including health promotion for women and girls across the lifespan," it said.
Emails and memos from U.S. officials at the U.N. obtained by Reuters show the influence of the Center for Family and Human Rights, or C-Fam, a private U.S. research institute formed to affect policy at the U.N. to align with conservative Catholic views. In a fundraising pitch, C-Fam's president, Austin Ruse, said "sexual orientation and gender identity is code for odious sexual behavior and gender lunacy."
Starting in 2017, when the center had a seat on the U.S. delegation to a U.N. conference on women's rights, administration officials have worked to accommodate its positions, the documents show.
"Thank you for having sent proposed changes" to a draft document of the Commission on the Status of Women, an aide to then-U.N. Ambassador Nikki Haley wrote C-Fam in 2018. "We reviewed them all carefully and included many, many of them in our initial comments."
In 2017, during negotiations over a document on violence against women, another C-Fam official wrote an email flagging language he thought would help establish a right to abortion for migrants. "This is just tragic and speaks volumes about the culture we are projecting to the rest of the world," wrote Stefano Gennarini, the group's vice president for legal affairs.
"Oh dear," replied a State Department official. "I do hope we can find a way to rectify this language." The phrase, alluding to "reproductive rights," did not make it into the final version.
Gennarini said the administration, while not granting all his group's requests, has been true to its promises in promoting anti-abortion policies.
"Simply put, for U.N. language related to abortion and used to promote abortion, this administration has certainly taken the strongest position that any Republican administration has ever taken," he said.
TITLE X BATTLE
Last year, Pence made a forceful argument directly to Trump to rewrite the rules regarding Title X, the U.S. federal program dedicated to affordable birth control and other reproductive healthcare, to cut out abortion providers such as Planned Parenthood, administration sources said.
The new version of Title X released in February would begin to accomplish Pence's goal, making it clear the program barred the use of funds to "perform, promote, refer for, or support abortion as a method of family planning." Such language would limit Planned Parenthood operations and prevent doctors from discussing abortion with patients. A federal court blocked the rule.
Planned Parenthood still received Title X money this year, though cut from about $28 million to $16 million. And HHS took a new step, awarding up to $5.1 million to Obria, a network of medical clinics in southern California funded in large part by Catholic groups that describes itself as "led by God" and does not offer abortions. Obria in May sued HHS on religious freedom grounds, saying it shouldn't have to participate in abortions to spend the grant money.
"Many women want the opportunity to visit a professional, comprehensive health care facility—not an abortion clinic—for their health care needs," Kathleen Eaton Bravo, founder and CEO, is quoted saying on the group's website. "Today HHS gave women that choice."
Pro- and anti-abortion groups say the grant marks a noteworthy shift.
"It's very clear from how quickly we were able to hit the ground running that the vice president certainly had an influential role," said Kristan Hawkins, president of Students for Life of America, who regularly meets with Pence. "One example is opening the door to life-affirming pregnancy centers and businesses through federal grant programs like Title X."
HHS Secretary Azar gave political appointees more power over grants. Appointees changed the points system for evaluating applicants, giving less emphasis to "adequacy of the applicant's facilities and staff," while boosting those who promoted "natural family planning" and abstinence.
Christine Dehlendorf, director of the Person-Centered Reproductive Health Program at the University of California, San Francisco, said the Office of Population Affairs canceled two grants for ongoing research into contraception. One was restored through litigation.
Dehlendorf said she lost about $800,000 in funding for a study of how well medical providers meet women's contraception preferences, which included natural family planning methods favored by some conservatives. There was "no reason to eliminate it other than a lack of a general desire to meet women's reproductive health needs," Dehlendorf said.
A day after creating the new Conscience and Religious Freedom division last year, HHS proposed a new rule that would allow health workers to deny care based on religious or moral objections. The final rule was put in place this month, and applies to foreign groups that receive U.S. funding. HHS also proposed a rule, not yet final, to strip "gender identity" from the non-discrimination protections in the Affordable Care Act; the agency said it cannot enforce those protections because of court decisions.
At the Office of Personnel Management, the government's HR office, the website was changed last year to remove references to transgender people in a section advising managers to avoid discrimination. "They clearly say that they don't think transgender people have any protections in law," said Gillian Branstetter, of the National Center for Transgender Equality.
In a May commencement speech at Liberty University, a Virginia evangelical institution, Pence depicted Christians as under siege from the "secular left."
"Some of the loudest voices for tolerance today have little tolerance for traditional Christian beliefs," he told the graduates. "You're going to be asked to bow down to the idols of popular culture."
"Decide here and now that you're going to stand firm."
© 2019 Thomson Reuters. All rights reserved.
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