The federal government, and up to 18 state governments, are inching their way toward Medicaid defunding of affiliates of the Planned Parenthood Federation of America, for many decades the nation’s premier funder and supplier of abortion.

The battle has shifted back and forth over that time thanks to changes in the party holding the White House and statehouses. But it has been drawn out for another key reason, and that is the early and wily decision by Planned Parenthood’s leadership and allied groups to promote passage of multiple public funding streams that aid their programs. When not actually in power and accessing the veritable Mississippi of taxpayer cash available to its domestic and international projects, Planned Parenthood allies have nested within bureaus like the federal Office of Population Affairs and merely waited for the next election.

For an illustration of the process, one of the oldest is Title X of the Public Health Services Act, enacted in 1970, before Roe v. Wade. The bill creating Title X had bipartisan sponsorship and was certainly historic; it was the first national grant program designed to put the government squarely in the family planning business (rather than merely allowing coverage of contraception in government insurance programs like Medicaid). Its location in an office devoted to “population affairs” was no accident, as panic about global population growth among the poor was much in vogue and an inspiration for federal involvement on both sides of the aisle in the 1960s. Then-Congressman George H.W. Bush’s endorsement of the law in 1970 was pivotal, but the issue trailed him for the next decade as conservatives moved in a pro-life direction and favored the candidacy of Ronald Reagan.

Efforts were immediate by pro-life advocates to hem in Title X and ensure that it did not have the effect of promoting abortion, not an easy thing to do with Planned Parenthood as the prime beneficiary. Section 1008 of the law set forth the condition that “[n]one of the funds appropriated under this subchapter shall be used in programs where abortion is a method of family planning.” The natural task for Planned Parenthood and other grantees was to ensure their continued eligibility for Title X funds even though the focus of Planned Parenthood facilities throughout its modern history has been a targeted increase in the number of abortions it carries out in low-income and minority communities. Abortion advocacy is so central to its identity that Planned Parenthood twice shelved its pro-choice national president for being insufficiently committed to the cause.

In the late 1980s, the Reagan administration moved a set of regulations under Title X meant to give teeth to Section 1008. Thus began the pattern of pro-life administrations establishing conditions that carried out the intent of Section 1008, which led to groups like Planned Parenthood litigating the issue or rejecting the funds rather than complying.

The Reagan rules held that Title X-funded projects “may not provide counseling concerning the use of abortion as a method of family planning or provide referral for abortion as a method of family planning.” Because the Title X program was to be solely focused on providing preventive care and not services for pregnant women, these patients were to be referred only to providers not engaged in the practice or promotion of abortion. This would allow referring only to “appropriate prenatal and/or social services by furnishing a list of available providers that promote the welfare of the mother and the unborn child.” The Title X grantee would be required to reject a referral to an abortion center even if requested by the woman.

Keep in mind that abortion was fully legal at this time, a point family planning groups stressed — it was among the women’s constitutional options. Planned Parenthood derided the Reagan regulation as a “gag rule” and filed suit, leading in 1991 to a 5-4 Supreme Court decision in Rust v. Sullivan that upheld the rules.

The back and forth resumed in 1993 with the election of Bill Clinton. By executive order, as one of his first actions in office, Clinton suspended the rule on the anniversary of Roe v. Wade. This allowed Title X grantees to provide counseling to women on abortion and alleviated pressure on them to maintain anything beyond financial separation between the contraception and abortion aspects of their projects. It was not until August 2000, however, that pro-abortion groups succeeded in getting Clinton to make the executive order (then as now a method of policy-making subject to swift reversal) permanent in the form of a regulatory change with public notice and comment.

After Clinton, George W. Bush reinstated the domestic Title X limits on abortion and reinstituted an international version of the policy similar to the Reagan Mexico City Policy of 1984. The merry-go-round continued with the two terms of Barack Obama. During these and subsequent periods, Congress has remained largely on the sidelines except to the extent it has continued to appropriate large sums, now approaching $300 million annually, for Title X. During the Obama years, pro-life groups continued to be dismayed with the mushrooming funds for Planned Parenthood, though — except for the Reagan years — it seemed to occur no matter which party controlled the White House.

In the late summer of 2016, as Donald Trump secured the Republican nomination against Hillary Clinton, a pro-life coalition secured a letter from him that included his commitment to defund “Planned Parenthood as long as they continue to perform abortions, and reallocating their funding to community health centers that provide comprehensive health care for women.”

The pledge was broad enough to include Title X as well as the largest source of family planning funding, the federal-state Medicaid partnership. An analysis of federal expenditures for family planning in 2006 found that Title X accounted for just shy of 12% of funding while Medicaid accounted for more than 70% of the total. The ratio is likely similar today. As president, Trump proceeded to restore most of the Title X limitations on grantees that supply abortion, issuing regulations in 2019 that were strong enough that many Title X grantees, including Planned Parenthood, refused the funds, filed more suits, and made a show of asserting “grave harm” to women who allegedly relied on Title X and Planned Parenthood for their health care.

The suits failed and these new limits prevailed for the rest of President Trump’s term. A separate and much more significant pro-life effort failed, however: a drive to use the reconciliation process in Congress to stop Medicaid funding. Reconciliation is a tortuous and unique step that sets budget parameters but has established rules that limit policy-making amendments. Pro-life groups in 2017 saw their best chance in decades of ending Planned Parenthood funding for a year via reallocation of the group’s Medicaid money to federally qualified health centers. The Senate then as now was narrowly divided, but if PP was to be defunded it could only occur through the reconciliation process in which filibustering is not permitted and a simple majority vote prevails. In a surprise move, the issue was finally moved to a vote, only to see Republican Senator John McCain striding to the desk on the Senate floor and giving the reconciliation measure a fatal thumb’s down. The fight to defund PP of its Medicaid trove was lost.

Today, the issue remains high in the minds of right-to-lifers. Planned Parenthood receives about $700 million annually from the federal government. It has declining patient tallies and does less in terms of patient care almost every year, with the exception of dizzying increases in abortion and the provision of puberty blockers, including to minors. The battle for now has shifted to the states where the Supreme Court heard a lawsuit from South Carolina challenging the state’s decision to bar Planned Parenthood from its Medicaid program. Oral argument took place on April 2 — but more on that later.

Regarding the smaller Title X allocation to PP, pro-life advocates have been hoping for the kind of defunding action that GOP presidents have pursued since 1988. Their case should be bolstered by the fact that in 2025, thanks to the 2022 Dobbs decision, states are free constitutionally to protect human life in the womb from assault. That would appear to make Section 1008 all the more compelling as a measure to ensure the federal government affords no funding for entities that promote lethal actions prohibited under state laws. Properly understood, Planned Parenthood’s massive and deliberately rising abortion rate represents the failure of its family planning program.

Some encouragement for pro-life forces occurred with the Trump administration’s recent action to file a brief in the South Carolina case supporting the state’s power to cut off Planned Parenthood. There is also encouragement, albeit not as clear, in the administration’s actions suspending Title X funding for several Planned Parenthood affiliates. Reports on the suspensions suggest, however, that the grounds for action have more to do with Planned Parenthood’s potential noncompliance with the president’s DEI executive order and concerns about its passive response to human trafficking, a problem first documented by undercover journalists in 2015. News reports state that the suspensions may be reconsidered based on Planned Parenthood’s response.

In contrast, Planned Parenthood will certainly be carrying out abortions in the future. It is by far the firmer ground on which to end its funding — if the states can outlaw abortion as the taking of human life, they (and the federal government) can surely declare the ineligibility of an entity that helms the deadly trade.

The Department of Health and Human Services has reportedly given the Planned Parenthood centers 10 days to decide if they will comply with the White House directives. Planned Parenthood’s highly compensated nonprofit executives are foaming appropriately at the suspensions, but the group has a well-established record of making just enough public relations adjustments to elude authorities. In fact, the group has signed onto a legal brief in the Medicaid case heard last Thursday in which the Center for Reproductive Rights argues that Medicaid funding of abortion suppliers is needed to remedy the fall-out from America’s eugenic past. The notorious Buck v. Bell case that found compulsory sterilization of the unfit constitutional is scorned in the brief. No mention is made of Planned Parenthood’s decades of celebration of eugenics and Margaret Sanger and Alan Guttmacher’s leadership of that sector of law and society. The attorneys hope that the Supreme Court will forget and overlook the tragedy of abortion rates among minorities that continue to dwarf those of other population subgroups.

No matter what side of the national family planning program debate one embraces, providing taxpayer support to an entity that has taken the lives of millions of the unborn, and aims to take millions more, is the antithesis of building healthy families. Welcome as the suspension of nine Planned Parenthood affiliates is, the administration has more than enough grounds, as does Congress, to end all funding for the scions of Sanger once and for all. The Supreme Court should concur and soon we will learn more.