'So easy to destroy, so hard to build': understanding impacts of federal rule changes on the Title X program, 2018-2024.

Introduction: Title X is the only federal program that directly funds family planning care. Recent Rule Changes have resulted in back-and-forth shifts to the program. Our goal was to understand how the federal Title X Rule Changes have impacted grantees and their perceptions of future program participation. Methods: In 2024, we conducted qualitative interviews with 25 grantees and national partners and held listening session focus groups with 37 grantees and subrecipients. Results: We identified 5 themes: (1) Title X is seen as both programmatically burdensome and essential; (2) the 2019 Rule Change demonstrated how grantee organizational and state contexts impact their responses and decision-making; (3) external environmental factors created additional systems stressors; (4) the 2021 Rule Change resulted in return to the network but reintegration/ readjustment were taxing; and (5) existing grantee differences still impact capacity for future participation. Conclusions: We found that while Title X is viewed by grantees as a vital component of the reproductive health safety net, Rule Changes significantly increase the burden (regardless of program participation) of service delivery. Importantly for policymakers, subsequent recovery after program restoration is nonlinear and highly dependent on grantee characteristics and the local environments in which they operate.