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Among the flurry of policies President Donald Trump put in force in his first week was to reimpose a ban on taxpayer dollars going to overseas groups that have anything to do with abortion. The so-called Mexico City policy was born under President Ronald Reagan and since then, with partisan regularity, Republican presidents invoke it and Democratic ones reject it.
On the Senate floor, Sen. Jeanne Shaheen, D-N.H., warned that Trump’s version was even more extreme than those of his GOP predecessors.
"Previously, under President Reagan and the Bush administrations, this policy applied only to family planning funding," Shaheen said. "But under President Trump's order, it applies to every program that falls under global health assistance. This means that it puts at risk 15 times more funding and millions more women and families."
We compared the policies of all four Republican presidents and found that on paper, Shaheen’s number is largely correct, but there’s uncertainty surrounding Trump’s policy.
The first Mexico City policy
Reagan administration officials announced a new U.S. family planning policy at the 1984 International Conference on Population in Mexico City. It required all nongovernmental organizations, foreign and domestic, receiving aid from the United States to agree that they would not perform or actively promote abortion as a method of family planning in other countries.
This applied to U.S. family planning programs run by the U.S. Agency for International Development.
President George H. W. Bush left the Reagan policy in place. President Bill Clinton rescinded it, and President George W. Bush brought it back with the focus still on family planning through the U.S. Agency for International Development.
But in 2003, Bush expanded the reach of the policy, instructing the secretary of state to apply it to "all assistance for voluntary population planning." Even as he did that, Bush excluded a number of groups and programs.
"Such organizations do not include multilateral organizations that are associations of governments," Bush wrote. "This policy shall not apply to foreign assistance furnished pursuant to the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003."
With those words, Bush exempted some of the largest and highest profile global health programs. Those programs, experts told us, dwarfed any other programs at the State Department that Bush’s order might have affected.
Trump’s presidential memorandum to reinstate the Mexico City policy is broader. In addition to the head of USAID, it is addressed to the departments of State and Health and Human Services.
"I direct the Secretary of State, in coordination with the Secretary of Health and Human Services, to the extent allowable by law, to implement a plan to extend the requirements of the reinstated Memorandum to global health assistance furnished by all departments or agencies."
The operative phrase is "global health assistance furnished by all departments or agencies." Trump’s order provides no exceptions.
It’s unclear exactly how the Trump administration will interpret those words. We asked the White House press office for details and did not hear back. The experts we reached told us they too were in the dark.
Comparing family planning and global health programs
The pipeline of family planning and global health programs is more complicated than you might expect. Governments agencies often contract with nonprofits which in turn subcontract out to smaller organizations in countries around the world. Jennifer Kates, director of global health policy at the Kaiser Family Foundation, said this makes it difficult to know the real impact of the order.
"Not all of the organizations that directly or indirectly receive U.S. government global health support carry out the activities prohibited by the policy, but figuring that out will take some time," Kates told us.
However, Kates said that in theory, Trump’s policy puts a lot more funding on the line.
"Whereas family planning assistance represents about $600 million per year, global health funding overall is close to $10 billion," Kates said.
Data gathered by the Institute for Health Metrics and Evaluation allows us to tease out exactly which programs Bush exempted from the Mexico City policy, but that Trump has included (see this IHME data graphic). Remember, Bush kept money for HIV/AIDS, malaria and tuberculosis off the table, as well as U.S. support for programs involving multiple nations, the big ones being the Global Fund and United Nations programs.
Add all of those up and you get $9.7 billion. That’s about 15 times as much money as the United States spends on family planning, which was the core program affected across all three previous Republican administrations.
Shaheen said millions of women and families might be affected. In spending, the single largest global health program is the President’s Emergency Plan for AIDS Relief, or PEPFAR. According to the latest report to Congress, PEPFAR treated 9.5 million people in 2015, at a cost of about $6.8 billion.
Trump, along with his Secretary of State nominee Rex Tillerson and U.N. Ambassador Nikki Haley, has voiced support for PEPFAR. But in theory, since many HIV/AIDS programs include a family planning component, the programs that touch those people might be affected by Trump’s Mexico City policy.
If the policy extends to malaria programs, the numbers climb dramatically. In 2015, American dollars protected over 16 million people with indoor spraying and many more through the distribution of nearly 30 million bed nets.
Shaheen said Trump’s Mexico City policy has a much broader reach compared to past Republican presidents, putting 15 times as much money "at risk," as well as millions of women and families.
On paper, the numbers support that comparison. Previous Republican administrations applied the abortion funding policy to family planning programs, which amount today to about $600 million. Trump included all global health spending, which is nearly $10 billion. There is no question Trump’s approach is broader and that millions more people could be affected.
The White House has not clarified how it will interpret the policy. Its reach could be much narrower than the full scope of global programs, but Shaheen included the caveat that certain dollars were "at risk," not that they definitely would be affected. It’s also true that organizations facing funding cuts could drop activities related to abortion and the funds would continue to flow.
Given what we know so far, we rate this claim Mostly True.
U.S. Senate, Sen. Jeanne Shaheen floor speech, Jan.24, 2017
White House, Presidential Memorandum Regarding the Mexico City Policy, Jan. 23, 2017
White House, Restoration of the Mexico City Policy, Jan. 22, 2001
White House, Assistance for Voluntary Population Planning, Aug. 29, 2003
Congressional Research Service, International Family Planning: The "Mexico City" Policy, April 2, 2001
U.S. Agency for International Development, Voluntary Population Activities – Restoration of the Mexico City Policy, Feb. 15, 2001
Congressional Research Service, Abortion and Family Planning-Related Provisions in U.S. Foreign Assistance Law and Policy, Jan. 24, 2017
Congressional Research Service, International Family Planning Programs: Issues for Congress, Feb. 21, 2013
Institute for Health Metrics and Evaluation, United States global health funding flows - 2015, accessed Jan. 31, 2017
Institute for Health Metrics and Evaluation, Financing Global Health 2015: Development assistance steady on the path to new Global Goals, 2016
Kaiser Family Foundation, The U.S. Global Health Budget: Analysis of Appropriations for Fiscal Year 2016, Jan. 20, 2016
U.S. President’s Emergency Plan for AIDS Relief, Twelfth Annual Report to Congress on PEPFAR, 2016
U.S. President’s Emergency Plan for AIDS Relief, Budget Information, accessed Feb. 1, 2017
Guttmacher Institute, Linkages Between HIV and Family Planning Services Under PEPFAR: Room for Improvement, Nov. 8, 2011
U.S. Agency for International Development, Annual Progress Report to Congress: Global Health Programs FY 2013, 2014
President’s Malaria Initiative, Annual reports, accessed Jan. 31, 2017
PAI, Trump’s Global Gag Rule Dramatically Expands Harmful Health Impacts, Jan. 26, 2017
Center for Health and Gender Equality, Impact of global gag rule on women's health, January 2017
New York Times, Mr. Trump’s ‘Gag Rule’ Will Harm Global Health, Jan. 26, 2017
U.S. Senate Committee on Foreign Relations, Mexico City Policy: Effects of restrictions on international family planning funding, June 19, 2001
U.S. House Committee on Foreign Affairs, The Mexico City Policy/Global Gag Rule: Its impact on family planning and reproductive health, Oct. 31, 2007
Stanford, Abortions in Africa increase despite Republican policy to curb payment for procedures, Sept. 28, 2011
Email interview, Jennifer Kates, director of global health policy, Kaiser Family Foundation, Jan. 25, 2017
Email interview, Eran Bendavid, MD, MS, Assistant Professor of Medicine, Stanford University, Jan. 30, 2017
Email interview, Kayla Albrecht, media relations officer, Institute for Health Metrics and Evaluation, Jan. 30, 2017
Email interview, Ryan Nickel, spokesman, Office of Sen. Jeanne Shaheen, Jan. 30, 2017
Email interview, Paul Hebden, senior adviser, AIDS Alliance, Feb. 1, 2017
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