The planned revival of a policy dating to Ronald Reagan’s presidency that was slightly retooled and quietly submitted for federal budget review Friday may finally present a way for President Trump to fulfill his campaign promise to “defund” Planned Parenthood.

Or at least to evict it from the federal family planning program, where it provides care to more than 40 percent of that program’s 4 million patients.

Congress last year failed to wipe out funding for Planned Parenthood, because the bill faced overwhelming Democratic objections and would not have received the 60 votes needed to pass in the Senate. But Trump’s move Friday could potentially accomplish what Congress could not.

According to administration officials, the proposed rules they have submitted to the Office of Management and Budget would require facilities receiving federal family planning funds to be physically separate from those that perform abortion; would eliminate the requirement that women with unintended pregnancies be counseled on their full range of reproductive options; and would ban abortion referrals.

All those changes would particularly affect Planned Parenthood.

Planned Parenthood, which provides a broad array of reproductive health services to women and men, also provides abortion services using nonfederal funds. Cutting off funding has been the top priority for anti-abortion-rights groups, which supported candidate Trump.

“A win like this would immediately disentangle taxpayers from the abortion business and energize the grassroots as we head into the critical midterm elections,” Marjorie Dannenfelser, president of the Susan B. Anthony List, a group that opposes abortion, said in a written statement.

In a conference call with reporters, Planned Parenthood officials said they would fight the new rules.

“We’ve been very clear, Planned Parenthood has an unwavering commitment to ensuring everyone has access to the full range of reproductive health care, and that includes abortion,” said Dawn Laguens, executive vice president of the Planned Parenthood Federation of America.

Here is a guide to what the proposal could do and what it could mean for Planned Parenthood and the family planning program:

What is Title X?

The federal family planning program, known as “Title X,” is named for its section in the federal Public Health Service Act. It became law in 1970, three years before the Supreme Court legalized abortion in Roe v. Wade. The original bill was sponsored by then-Rep. George H.W. Bush, R-Texas, and signed into law by President Richard Nixon.

The program provides wellness exams and comprehensive contraceptive services, as well as screenings for cancer and sexually transmitted diseases for both women and men.

In 2016, the most recent year for which statistics have been published, Title X served 4 million patients at just under 4,000 sites.

Title X patients are overwhelmingly young, female and low-income. An estimated 11 percent of Title X patients in 2016 were male; two-thirds of patients were under age 30; and nearly two-thirds had income below the federal poverty line.

What is Planned Parenthood’s relationship to Title X and Medicaid?

Planned Parenthood’s affiliates account for about 13 percent of all Title X sites but serve an estimated 40 percent of its patients. Only about half of Planned Parenthood affiliates perform abortions, although the organization in its entirety is the nation’s leading abortion provider.

Planned Parenthood also gets much more federal funding for services provided to patients on the Medicaid program (although not for abortion) than it does through Title X. Eliminating Medicaid funding for Planned Parenthood has proved more difficult for lawmakers opposed to the organization because the federal Medicaid law includes the right for patients to select their providers. Changing that also would require a 60-vote majority in the Senate. So that particular line of funding likely is not at risk.

While opponents of federal funding for Planned Parenthood have said that other safety-net clinics could make up the difference if Planned Parenthood no longer participates in Title X, several studies have suggested that in many remote areas Planned Parenthood is the only provider of family planning services and the only provider that regularly stocks all methods of birth control.

Texas, Iowa and Missouri in recent years have stopped offering family planning services through a special Medicaid program to keep from funding Planned Parenthood. Texas is seeking a waiver from the Trump administration so that its program banning abortion providers could still receive federal funding. No decision has been made yet, federal officials say.

Why is Planned Parenthood’s involvement with Title X controversial?

Even though Planned Parenthood cannot use federal funding for abortions, opponents of abortion rights claim that federal funding is “fungible” and there is no way to ensure that some of the funding provided for other services does not cross-subsidize abortion services.

Planned Parenthood has also been a longtime public target for forces that oppose abortion rights because it is such a visible provider and vocal proponent of legal abortion services. In the early 1980s, the Reagan administration tried to separate the program from its federal funding by requiring parental permission for teens to obtain birth control.

That was followed by efforts to eliminate abortion counseling. Starting in 2011, in an effort to get the organization defunded, undercover groups accused the organization of ignoring sex traffickers and selling fetal body parts. Planned Parenthood denied the allegations, which were proved false in court.

What happened the last time an administration tried to move Planned Parenthood out of Title X?

In 1987, the Reagan administration proposed what came to be known as the “gag rule.” Though the Trump administration’s new proposal is not yet public, because the details are still under review by the federal Office of Management and Budget, the White House released a summary, saying the new rule will be similar although not identical to the Reagan-era proposal.

The original gag rule would have forbidden Title X providers to offer abortion counseling or refer patients for abortions. It would have required physical separation of Title X facilities from those that provide abortions and would have forbidden recipients to use nonfederal funds for lobbying, distributing information or in any way advocating or encouraging abortion. (The Planned Parenthood Federation of America, the umbrella group for local affiliates, has a separate political and advocacy arm, the Planned Parenthood Action Fund.)

Those rules were the subject of heated congressional debate through most of the George H.W. Bush administration and were upheld in a 5-4 Supreme Court ruling in 1991, Rust v. Sullivan. Even then, the gag rule did not go into effect because subsequent efforts to relax the rules somewhat to allow doctors (but not other health professionals) to counsel people about the availability of abortion created another round of legal fights.

Eventually the rule was in effect for only about a month before it was again blocked by a U.S. appeals court. President Bill Clinton canceled the rules by executive order on his second day in office, and no other president has tried to revive them until now.

How is the Trump administration’s proposal different from earlier rules?

According to the summary of the new proposal, released Friday, it will require physical separation of family planning facilities from those that provide abortions, will repeal current counseling requirements, and will ban abortion referrals.

One of the biggest differences, however, is that the new rules will not explicitly forbid abortion counseling by Title X providers.

But Planned Parenthood officials say that allowing counseling while banning referrals is a distinction without a difference.

“Blocking doctors from telling a patient where they can get safe and legal care in this country is the definition of a gag rule,” said Kashif Syed, a senior policy analyst for Planned Parenthood.

What happens next?

All proposed rules are reviewed by the OMB. Sometimes they emerge and are published in a few days; sometimes they are rewritten, and it takes months.

Meanwhile, Planned Parenthood officials say they will not know whether they will take legal action until they see the final language of the rule. But they say they do plan to use the regulatory process to fight the proposed changes that have been made public so far.

Kaiser Health News is a nonprofit news service and an editorially independent program of the Kaiser Family Foundation. It is not affiliated with Kaiser Permanente. KHN’s coverage of women’s health care issues is supported in part by The David and Lucile Packard Foundation.

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The White House is expected to announce as early as Friday that it is reviving a rule first proposed during the Reagan administration that bars groups who provide abortions, discuss the procedure or refer patients for abortions from receiving federal family planning funds, a Trump administration has confirmed.

The proposed regulation would apply to Title X, the federal program that provides $260 million annually for contraception, screenings for sexually transmitted diseases, and other reproductive health services to millions of low-income people, according to the White House official, who asked not to be named.

The rule change would put Planned Parenthood back in the cross-hairs after repeated attempts by congressional Republicans to de-fund the family planning group, which also provides abortions, but says the federal money it receives does not go toward paying for the procedures.

Under current law, federal funding for abortions is prohibited in most cases. However, anti-abortion rights advocates have long made cutting funds to any group providing abortions or referring patients for abortions a high priority.

The new rule, expected to be announced by the Department of Health and Human Services, would also bar federal funds for any group that discusses abortion with patients or shares space with an abortion provider.

Abortion-rights supporters have described the proposal as a “gag rule” and say it would undermine reproductive health care for low-income patients.

However, anti-abortion rights groups praised the proposed change. Students for Life of America, which says it has members on more than 1,200 U.S. university and high school campuses, said in a statement:

“These changes are long overdue as abortion is not healthcare or birth control and many women want natural healthcare choices rather than hormone-induced changes,” the group’s president, Kristan Hawkins, said. “The Trump Administration has every right to require that Title X programs focus on healthcare, not abortion, and to keep such programs aimed at helping women make a plan for a family outside of the facilities designed to making sure women don’t have a family at all.”

The rule, first proposed during the Reagan era, was hit by legal challenges by Planned Parenthood and other groups and was never fully implemented. It was later rescinded altogether by President Bill Clinton. Abortion-rights groups are likely to take to the courts again in efforts to stop the proposal.

“This ‘gag rule’ is not only unconscionable, but it undermines medical ethics by forcing health care professionals to withhold accurate and timely medical information from patients,” Dr. Jenn Conti, a fellow with Physicians for Reproductive Health, said in a statement Thursday.

“As a provider of comprehensive reproductive health care, it is my number one priority to keep my patients safe and honor the trust they give me. If I can’t mention the word ‘abortion,’ then I am not providing my pregnant patients who want to know all of their options with complete, accurate, unbiased medical information,” she said.

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The tall, gangly man twists a cone of paper in his hands as stories from nearly 30 years of addiction pour out: the robbery that landed him in prison at 17; never getting his GED; going through the horrors of detox, maybe 40 times, including this latest, which he finished two weeks ago. He’s now in a residential unit for at least 30 days.

“I’m a serious addict,” says Julio Cesar Santiago, 44. “I still have dreams where I’m about to use drugs, and I have to wake up and get on my knees and pray, ‘let God take this away from me,’ because I don’t want to go back. I know that if I go back out there, I’m done.”

Santiago has some reason to worry. Data on opioid addiction in his home state of Massachusetts shows the overdose death rate for Latinos there has doubled in three years, growing at twice the rate of whites and blacks.

Opioid overdose deaths among Latinos are surging nationwide as well. While the overall death toll is still higher for whites, it’s increasing faster for Latinos and blacks, according to data from the Centers for Disease Control and Prevention. Latino fatalities increased 52.5 percent between 2014 and 2016 as compared to 45.8 percent for whites. (Statisticians say counts for Hispanics are typically underestimated by 3 to 5 percent.) The most substantial hike was among blacks — 83.9 percent.

The data portrays a changing face of the opioid epidemic.

“What we thought initially, that this was a problem among non-Hispanic whites, is not quite accurate,” says Robert Anderson, mortality statistics branch chief at the CDC’s National Center for Health Statistics. “If you go back into the data, you can see the increases over time in all of these groups, but we tended to focus on the non-Hispanic whites because the rates were so much higher.”

There’s little understanding about why overdose deaths are rising faster among blacks and Latinos than whites. Some physicians and outreach workers suspect the infiltration of fentanyl into cocaine is driving up fatalities among blacks.

The picture of what’s happening among Latinos has been murky, but interviews with nearly two dozen current and former drug users and their family members, addiction treatment providers and physicians reveal language and cultural barriers and even fear of deportation could be limiting the access of Latinos to life-saving treatment.

Few bilingual treatment options

Irma Bermudez, 43, describes herself as a “grateful recovering addict.” She’s living in the women’s residential unit at Casa Esperanza, a collection of day treatment, residential programs and transitional housing in Boston’s Roxbury neighborhood.

Bermudez says the language barrier keeps anyone who can’t read English out of treatment from the start, as they try to decipher websites or brochures that advertise options. If they call a number on the screen or walk into an office, “there’s no translation — we’re not going to get nothing out of it,” Bermudez says.

Some of the Latinos interviewed for this story describe sitting through group counseling sessions, part of virtually every treatment program, and not being able to follow much, if any, of the conversation. They recall waiting for a translator to arrive for their individual appointment with a doctor or counselor and missing the session when the translator is late or doesn’t show up at all.

SAMHSA, the federal Substance Abuse and Mental Health Services Administration, maintains a Find Treatment website which includes listings of treatment offered in Spanish. But several Massachusetts providers listed there could not say how many translators they have or when they are available. The SAMHSA site is only available in English, with Spanish-language translators only available by phone.

At Casa Esperanza, 100 men are waiting for a spot in the male residential program, so recovery coach Richard Lopez spends a lot time on the phone trying to get clients into a program he thinks has at least one translator.

After battling with voicemail, says Lopez, he’ll eventually get a call back; the agent typically offers to put Lopez’s client on another waiting list. It frustrates him.

“You’re telling me that this person has to wait two to three months? I’m trying to save this person today,” he says. “What am I going to do, bring these individuals to my house and handcuff them so they don’t do nothing?”

Casa Esperanza Executive Director Emily Stewart says Massachusetts needs a public information campaign via Spanish-language media that explains treatment options. She’d like that to include medication-assisted treatment, which she says is not well understood.

Some research shows Latino drug users are less likely than others to have access to or use the addiction treatment medicines, methadone and buprenorphine. One study shows that may be shifting. But, Latinos with experience in the field say, access to buprenorphine (which is also known by the brand name Suboxone) is limited because there are few Spanish-speaking doctors who prescribe it.

Cultural barriers — ‘It’s not cool to call 911’

Lopez has close ties these days with health care providers, the police and EMTs. But that has changed dramatically from when he was using heroin. On the streets, he says,”It’s not cool to be calling 911,” when a person sees someone overdose. “I could get shot, and I won’t call 911.”

It’s a machismo thing, says Lopez.

“To the men in the house, the word ‘help,’ sounds like degrading, you know?” he says. Calling 911 “is like you’re getting exiled from your community.”

Santiago says not everyone feels that way. A few men called EMTs to help revive him. “I wouldn’t be here today if it wasn’t for them,” he says.

But Santiago and others say there’s growing fear among Latinos they know of asking anyone perceived as a government agent for help — especially if the person who needs the help is not a U.S. citizen.

“They fear if they get involved they’re going to get deported,” says Felito Diaz, 41.

Bermudez says Latino women have their own reasons to worry about calling 911 if a boyfriend or husband has stopped breathing.

“If they are in a relationship and trying to protect someone, they might hesitate as well,” says Bermudez, if the man would face arrest and possible jail time.

Ties in the community

Another reason some Latino drug users say they’ve been hit especially hard by this epidemic: A 2017 DEA report on drug trafficking noted that Mexican cartels control much of the illegal drug distribution in the United States, selling the drugs through a network of local gangs and small-scale dealers.

In the Northeast, Dominican drug dealers tend to predominate.

“The Latinos are the ones bringing in the drugs here,” says Rafael, a man who uses heroin and lives on the street in Boston, close to Casa Esperanza. “The Latinos are getting their hands in it, and they’re liking it.”

NPR agreed not to use Rafael’s last name because he uses illegal drugs.

Some Spanish-speaking drug users in the Boston area say they get discounts on the first, most potent cut. Social connection matters, they say.

“Of course, I would feel more comfortable selling to a Latino if I was a drug dealer than a Caucasian or any other, because I know how to relate and get that money off them,” says Lopez.

The social networks of drug use create another layer of challenges for some Latinos, says Dr. Chinazo Cunningham, who treats many patients from Puerto Rico. She primarily works at a clinic affiliated with the Montefiore Medical Center in the Bronx, in New York City.

“The family is such an important unit — it’s difficult if there is substance use within the family for people to stop using opioids,” Cunningham says.

The burden of poverty

Though Latinos are hardly a uniform community, many face an additional risk factor for addiction: poverty. About 20 percent of the community lives in poverty, compared to 9 percent of whites according to the Kaiser Family Foundation. In Massachusetts, four times as many Latinos live below the poverty line as do whites. The majority of Casa Esperanza clients were recently homeless. The wait time for one of the agency’s 37 individual or family housing units ranges from a year to a decade.

“If you’ve done all the work of getting somebody stabilized and then they leave and don’t have a stable place to go, you’re right back where you started,” says Casa Esperanza’s Stewart.

Cunningham says the Latino community has been dealing with opioid addiction for decades and it is one reason for the group’s relatively high incarceration rate. In Massachusetts, Latinos are sentenced to prison at five times the rate of whites.

“It’s great that we’re now talking about it because the opioid epidemic is affecting other populations,” Cunningham says. “It’s a little bit bittersweet that this hasn’t been addressed years before. But it’s good that we’re talking about treatment rather than incarceration, and that this is a medical illness rather than a moral shortcoming.”

Nationally, says the CDC’s Anderson, there’s no sign that the surge of overdose deaths is abating in any population.

“We’ve already had two years of declining life expectancy in the U.S. and I think that when we see the 2017 data we’ll see a third year,” says Anderson. “That hasn’t happened since the great influenza pandemic in the early 1900s.”

The death numbers for 2017 are expected out by the end of this year.

This story is part of a reporting partnership with NPR, WBUR and Kaiser Health News.

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