Abstract Background Title X of the Public Health Service Act is a critical federal program—the only one dedicated exclusively to providing affordable, confidential, evidence-based reproductive health care to low-income populations, yet its capacity to fulfill this mandate depends on political, administrative, and fiscal decisions made across multiple levels of governance—from Congress and federal regulators to state and regional grantees and their sub-grantee clinic networks.Methods This study assesses geographic access to Title X-funded clinics across all 50 states and the District of Columbia in 2024, a period with significant program and regulatory disruption. Using the Integrated Two-Step Floating Catchment Area (I2SFCA) method—which employs road-network-based drive time thresholds calibrated to urban–rural context—applied to 2024 clinic locations and census-tract-level demographic data, we identify a confluence of spatial and nonspatial barriers to Title X.Results Findings reveal widespread and substantial gaps in geographic access, a challenge faced by people across all racial groups, rural and urban residents, and individuals with low incomes.Conclusion These findings offer a precise geographic account of where Title X's reach falls shortest—documenting the ramifications of policy retrenchment and establishing a baseline against which future policy changes can be measured.