They’re calling it a funding cliff for sexual health in America. Pap smears and HIV tests will be cancelled. IUD appointments will have to be rebooked; condoms and birth control pills that used to be free will now come with a price tag. Maternal health outcomes will worsen, and STDs will spread. Some nurses, doctors, and other health clinic staff will be laid off, and clinic hours will be slashed. The long-term impacts for public health could be horrific.

On 31 March, millions of Americans may lose access to birth control and STD screening services provided by the Title X program, a $286m annual public health investment that provides sexual and reproductive care for Americans, mostly women, who are low-income or lack health insurance. More than 2 3 million people used the program in 2023; now, they are likely to be denied care – being forced to pay out-of-pocket for services that used to be free, or to make the decision to go without.

It’s not that there’s no more money for the program; Congress has appropriated the funds. It’s not that clinics are not competent to provide the care; Title X has been in place for almost 60 years. Instead, the funding may run out at the end of March – endangering the health and safety of millions – because the Trump Department of Health and Human Services is refusing to conduct the basic administrative tasks needed for it to function.

Every year, the hundreds of non-profit clinics and local health departments that receive Title X funding provide a budget and some basic data about how they have used the funds in the past year and how they intend to use them going forward. This allows HHS to oversee the program more effectively. This information is usually delivered with a funding renewal application that providers submit in the fall. But last year, the Trump HHS department, under the leadership of vaccine skeptic Robert F Kennedy Jr, announced that clinics would need to change their priorities in order to keep receiving Title X program money in 2026.

They said that new guidance would be issued by the end of the year, and that clinics would be able to apply once it was out. But the guidance was never issued; the 31 December deadline came and went without a peep from HHS. A new application was not made available for month, either. And so the healthcare of millions of Americans is set to disappear – poof – in defiance of Congress, without an explanation when the money officially runs out on 31 March. Untold numbers may get sick as a result. No one seems to be able to explain why.

Clinics are scrambling. It’s not clear how they’re supposed to guarantee care for their patients in need; its not clear what, exactly, HHS wants from them. A group of Democratic senators sent a letter to Kennedy last week asking for all existing Title X grants top be extended by one year, so as to prevent a public health catastrophe from unfolding as a result of his department’s mismanagement. A second letter, signed by 128 Democratic members of Congress, followed early this week.

By way of response, the department finally uploaded an application that clinics can use to seek a continuation of their funding. That document went online on Friday evening. The clinics, who usually have three to four months to collect and submit all the requested data, will have until just this Friday, 20 March, to apply.

An HHS source told NPR that the department has just 10 staffers assigned to sift though what are likely to be dozens upon dozens of applications. If they can’t get through that task in the span of a week – as it seems inevitable that they won’t be able to – then there will be funding delays, and the needed public health money will not go out on 1 April as planned.

What’s the cause of this laughable delay? It’s a truism that one should never attribute to malice that which is sufficiently explained by incompetence. But when you’re talking about the Trump administration, you can’t rule out the possibility that it’s both.

The Title X program was long uncontroversial: the funds do not cover abortion, and birth control and STD screening and treatment subsidies have been shown to have strong positive effects for public health, educational and employment attainment, and women’s equality.

Perhaps that last bit is the problem: in a moment where the conservative political world is becoming more and more extremist in its gender politics, the notion that the federal government would subsidize birth control – the medical interventions that allow a woman to finish school, to work, to disentangle themselves from abusive or unsatisfying relationships with another person, and to live as dignified and independent adults – is increasingly anathema to a Republican party that is committed to male supremacy and women’s subordination.

Maybe this is why Donald Trump, in his original 2026 budget proposal, wanted to eliminate funding for Title X. Maybe this is why the rightwing thinktank the Heritage Foundation, in their Project 2025 initiative that outlined priorities for the new Trump administration (in which the now head of the Office of Management and Budget head Russell Vought was a key contributor) proposed changing the Title X program from one that provided birth control to women so that they could have children when and if they wanted, to one that encouraged them to give birth early and often, and to propagandize about “the importance of marriage and family to personal well-being”.

The promise of Title X is to create a world where women can control their own lives, including by declining motherhood if they so desire. Little wonder, then, that the program would be neglected, mismanaged or sabotaged by the Trump administration: that’s a world that they can’t tolerate.