Order Code RL33644
Title X (Public Health Service Act)
Family Planning Program
Updated February 9December 3, 2007
Angela Napili
Information Research Specialist
Knowledge Services Group
Title X (Public Health Service Act) Family Planning
Program
Summary
The federal government provides grants for voluntary family planning services
through the Family Planning Program, Title X of the Public Health Service Act,
codified at 42 U.S.C. §300 to §300a-6. The program, enacted in 1970, is the only
domestic federal program devoted solely to family planning and related preventive
health services. The law prohibits the use of Title X funds in programs where
abortion is a method of family planningTitle X is administered through the Office of Population Affairs
(OPA) under the Office of Public Health and Science in the Department of Health
and Human Services (DHHS). It receives its funding, however, through
appropriations for the Health Resources and Services Administration (HRSA) in
DHHS.
Although the authorization for Title X ended with FY1985, funding for the
program has continued to be provided through appropriations bills for the
Departments of Labor, Health and Human Services, and Education (Labor-HHSEducationEducation, and Related Agencies
(Labor-HHS-Education). The Title X program received appropriations of $282.9 million for
FY2006. The 110th Congress is still working on Labor-HHS-Education
appropriations legislation for FY2007. Continuing resolution P.L. 109-383 extends
funding for Labor-HHS-Education programs (including Title X) at FY2006 levels
through February 15, 2007. For FY2008, the President’s Budget requests $283.1
million$282.9 million for FY2006
and $283.1 million for FY2007. The President’s Budget requested $283.1 million
for FY2008. On November 13, 2007, the President vetoed H.R. 3043, the
Departments of Labor, Health and Human Services, and Education, and Related
Agencies Appropriations Act, 2008, which would have provided $310.9 million for
Title X in FY2008. On November 15, 2007, an attempt to override the veto failed in
the House. A continuing resolution, P.L. 110-92, as amended by P.L. 110-116,
provides temporary FY2008 funding through December 14, 2007.
The law (42 U.S.C. § 300a-6) prohibits the use of Title X funds in programs
where abortion is a method of family planning. According to OPA, family planning
projects that receive Title X funds are closely monitored to ensure that federal funds
are used appropriately and that funds are not used for prohibited activities such as
abortion. The prohibition on abortion does not apply to all the activities of a Title X
grantee, but only to activities that are part of the Title X project. A grantee’s abortion
activities must be “separate and distinct” from the Title X project activities.
Several bills addressing Title X have been introduced in the 110th Congress.
The Prevention First Act (S. 21/H.R. 819) and the Reducing the Need for Abortion
and Supporting Parents Act (H.R. 1074) would authorize Title X appropriations of
$700 million for FY2008 and “such sums as may be necessary for each subsequent
fiscal year.” Other introduced bills include H.R. 104, “[t]owhich would require
assurances that
certain family planning service projects and programs will provide pamphlets
containing the contact information of adoption centers,” and S. 351, “[a] bill to
amend Title X of the Public Health Service Act to prohibit family planning grants
from being awarded to any entity that performs abortions.”
family planning projects will provide pamphlets with adoption
centers’ contact information; S. 351 and H.R. 4133, which would prohibit Title X
grants to abortion-performing entities; H.R. 1095, which would prohibit federal
spending for any family planning activities; H.R. 2134, which would require parental
notification before providing certain family planning services to minors; and
H.Con.Res. 232, which would express the sense of Congress that confidentiality
mandates for minors should be removed from Title X and Medicaid family planning
programs. This report was originally written by Sharon Coleman. It has been revised by
by Angela Napili.
Contents
Title X Program Administration and Covered Services . . . . . . . . . . . . . . . . . . . . 1
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Abortion and Title X . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Teenage Pregnancy and Title X . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Planned Parenthood and Title X . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Legislation in the 110th Congress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Summary of Title X of the Public Health Service Act . . . . . . . . . . . . . . . . . . . . . . 910
List of Tables
Table 1. Title X Family Planning Program Appropriations . . . . . . . . . . . . . . . . . 5
Title X Family (Public Health Service Act) Family
Planning Program
Title X Program Administration
and Covered Services
Title X is administered through the Office of Population Affairs (OPA) under
the Office of Public Health and Science in the Department of Health and Human
Services (DHHS). It receives its funding through the appropriation for the Health
Resources and Services Administration. OPA administers three types of project
grants under Title X:
family planning services;1 family planning personnel training;2
and family planning
service delivery improvement research grants.3
Grants for family planning services fund contraceptive services and supplies,
and related services, such as patient education and counseling,; infertility services,;
pregnancy diagnosis,; special services to adolescents,; adolescent and extramarital
abstinence counseling and education,; breast and cervical cancer screening and
prevention,; physical examinations,; and sexually transmitted disease (STD) and HIV
prevention education, screening, and referral.4 Priority for the provision of these
services is to be given to lower-income families; grantees may use a sliding fee
schedule for determining client contributions for care, but grantees may not charge
low-income persons for care. The services must be provided “without coercion and
with respect for the privacy, dignity, social, and religious beliefs of the individuals
being served.”5
Grants for family planning personnel training are to be used to train staff and “to
improve utilization and career development of paraprofessional and paramedical
manpower in family planning services, particularly in rural areas.”6 Staff are trained
through ten10 regional general training programs, one national clinical training
program, and one national training program focused on improving Title X services
for males.7 The family planning service delivery improvement research grants are to program,
1
Catalog of Federal Domestic Assistance (CFDA) 93.217, [http://www.cfda.gov].
2
CFDA 93.260
3
CFDA 93.974
4
DHHS, HRSA, Fiscal Year 2008: Health Resources and Services Administration: Justification of
Estimates for Appropriations Committees, p. 252
Committees, p. 252, at [ftp://ftp.hrsa.gov/about/budgetjustification08.pdf], visited November
23, 2007. DHHS, OPA, 2006 Family Planning
Program Priorities, Legislative Mandates,
Key Issues, at [http://opa.osophs.dhhs.gov/titlex/
2006_ofp_priorities-mandates-keyissues.pdf], visited Feb. 9, 2007.
5
CFDA 93.217
6
CFDA 93.260
7
DHHS, Fiscal Year 2008: Health Resources and Services Administration: Justification of
(continued...)
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be used to mandateskeyissues.pdf], visitedDecember 3, 2007.
5
CFDA 93.217
6
CFDA 93.260
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and one national training program focused on improving Title X services for males.7
The family planning service delivery improvement research grants are to be used to
develop studies to improve the delivery of family planning services.
These research
grants target projects that enhance effectiveness and efficiency of the
service delivery
system.
Title X clinics provide confidential screening, counseling, and referral for
treatment. In this regard, OPA has indicated that the program is committed to
maintaining the integration of HIV-prevention services in all family planning clinics,
particularly in areas with high rates of HIV and where racial and ethnic minorities are
disproportionately affected. OPA has also affirmed that Title X’s HIV/AIDS
education activities should incorporate the “ABC” message. That is, adolescents and
unmarried persons should receive a message incorporating abstinence (A); married
persons and those in “committed relationships” should receive the message to “be
faithful” (B); and those who engage in HIV risk behaviors should receive a message
about “correct and consistent condom use” (C).8
All Title X service grantees were required by FY2002 to have at least one
project that provides family planning/reproductive health services to males.9 In 2005,
Title X grantees reported that 5% of their clients were male.10 Common services that
family planning agencies offer to males include condom provision, STD counseling,
contraceptive counseling, and STD treatment and testing.11
Ninety percent of Title X funds are used for clinical services.12 During FY2006,
At the start of
FY2008, there were 8788 Title X family planning services grantees. Such grantees
included 4243 state or local
health departments, 76 territorial health departments, 11 10
Planned Parenthood affiliates,
and 2729 other nonprofit organizations, such as hospitals, community health centers,
family planning councils, Native American health facilities, and universities. Title
7
(...continued)
7
DHHS, HRSA, Fiscal Year 2008 Justification of Estimates for Appropriations
Committees, p. 251.
8
DHHS, OPA, Examining HIV Prevention Activities in the Title X Family Planning
Program: Executive Summary, n.d.not dated, at [http://opa.osophs.dhhs.gov/pubs/eval/03may/HIV_
FP
HIV_FP%20Executive%20Summary.pdf], visited Feb. 9December 3, 2007. DHHS, OPA, 2006 Family
Family Planning Program Priorities, Legislative Mandates, Key Issues, at
[http://opa.osophs.dhhs.gov/titlex/2006_ofp_priorities-mandates-keyissues.pdf], visited Feb.
9, 2007.
9
DHHS, OPA/Office of Family Planning, Male Involvement Projects: Prevention Services
(July 2000), at [http://opa.osophs.dhhs.gov/titlex/opa_male_projects_review_july2000.pdf],
visited Feb. 9December 3, 2007.
10
Family Planning Annual Report: 2005 National Summary, November 2006, p. 11, at
[http://opa.osophs.dhhs.gov/titlex/FPAR_2005_National_Report_webPDF.pdf], visited Feb.
9
December 3, 2007.
11
“Services for Men at Publicly Funded Family Planning Agencies, 1998-1999,”
Perspectives on Sexual and Reproductive Health, vol. 35, no. 5, Sept./Oct. 2003. DHHS,
September/October 2003.
DHHS, OPA/Office of Family Planning, FY 2003 Office of Family Planning Male Grantees
Program Summaries, at [http://opa.osophs.dhhs.gov/titlex/ofp-male-grantees.html], visited
Feb. 9December 3, 2007.
12
DHHS, HRSA, Fiscal Year 2008 Justification Fiscal Year 2008: Health Resources and Services Administration: Justification
of Estimates for Appropriations
Committees, p. 251.
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hospitals, community health centers, family planning councils and universities.13
Title X grantees can provide family planning services directly or they can delegate Title
Title X monies to other agencies to provide services. Although there are no matching
requirements for grants, regulations specify that no clinics may be fully supported by
Title X funds.1314 In 2005, the latest year for which data isare available, Title X provided
services through more than 4,400 Title X clinics nationwide.1415
In 2005, Title X served more than 5 million clients, primarily low-income
women and adolescents. Ninety percent of clients had incomes at or below 200% of
the federal poverty level; sixty percent of Title X clients had no health insurance.
For For
many clients, Title X clinics are their only continuing source of health care.1516
More information on the Title X program, including regional contacts, can be
found on the Internet at [http://opa.osophs.dhhs.gov/].
Funding
Although the program is administered by OPA, funding for Title X activities is
provided through the Health Resources and Services Administration (HRSA) in
DHHS. Authorization of appropriations expired at the end of FY1985, but the
program has continued to be funded through appropriations bills for the Departments
of Labor-, Health and Human Services, Education, and Related Agencies (LaborHHSand Education (Labor-HHS-Education).
For FY2008, the President’s Budget requestsrequested $283.1 million for Title X. The
Budget Justification proposesproposed that the program become more efficient in the face of
rising drug and medical costs, and that “[i]n order to provide services for the
maximum number of clients, this will require limiting the availability of high cost,
highly effective contraceptive methods and more expensive diagnostic
technologies.”16
The President’s FY2007 Budget requested $283.1 million for Title X. House
Appropriations Committee report H.Rept. 109-515 (on H.R. 5647) and Senate
Appropriations Committee report S.Rept. 109-287 (on S. 3708) would have also
provided $283.1 million for FY2007. However, the 109th Congress did not pass
FY2007 Labor-HHS-Education appropriations legislation. Three continuing
resolutions have extended funding for Labor-HHS-Education programs (including
Title X) at FY2006 levels. The third continuing resolution, P.L. 109-383 (120 Stat.
13
42 C.F.R. 59.7(c)
1417
On November 13, 2007, the President vetoed H.R. 3043, the Departments of
Labor, Health and Human Services, and Education, and Related Agencies
Appropriations Act, 2008, which would have provided $310.9 million for Title X in
13
Email correspondence between the author and Maurice Huguley, Office of the Assistant
Secretary for Legislation, U.S. Department of Health and Human Services, October 30,
2007.
14
42 C.F.R. 59.7(c)
15
Family Planning Annual Report: 2005 National Summary, November 2006, pp. 8, at
[http://opa.osophs.dhhs.gov/titlex/FPAR_2005_National_Report_webPDF.pdf], visited Feb.
9, 2007. A p. 8. A
searchable directory of Title X providers is at [http://www.opaclearinghouse.org/
search/index.asp], visited Feb. 9December 3, 2007.
1516
Family Planning Annual Report: 2005 National Summary, November 2006, pp. 1, 9, 11,
23, at [http://opa.osophs.dhhs.gov/titlex/FPAR_2005_National_Report_webPDF.pdf],
visited Feb. 9, 2007.
16.
17
DHHS, HRSA, Fiscal Year 2008 Justification Fiscal Year 2008: Health Resources and Services Administration: Justification
of Estimates for Appropriations Committees, p. 252.
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2678), signed by the President on December 9, 2006, continues funding at the
FY2006 level through February 15, 2007. The 110th Congress is currently
considering H.J.Res. 20, which would provide funding through September 30, 2007.
FY2006 funding for Title X was contained in the Departments of Labor, Health
and Human Services, and Education, and Related Agencies Appropriations Act,
2006, P.L. 109-149 (H.R. 3010, 119 Stat. 2833, 2844). Title X was funded at $282.9
million for FY2006, $3.1 million less than in FY2005.17
The FY2006 appropriations conference agreement on H.R. 3010 (H.Rept. 109337) repeated previous years’ language that Title X funds not be spent on abortions,
that all pregnancy counseling be nondirective, and that funds not be spent on “any
activity (including the publication or distribution of literature) that in any way tends
to promote public support or opposition to any legislative proposal or candidate for
public office.” The agreement also repeated language requiring grantees to certify
that they encourage “family participation” when minors decide to seek family
planning services, and to certify that they counsel minors on how to resist attempted
coercion into sexual activity. The language also repeated a clarification that family
planning providers are not exempt from state notification and reporting laws on child
abuse, child molestation, sexual abuse, rape, or incest.18
The conferees stated in H.Rept. 109-337 that family planning funds should be
distributed to regional offices “in the same manner and time frame” as in FY2005
(when regional offices received their funding distribution within 60 days of the
appropriations bill’s enactment). In addition, the conferees said they intended that
the same percentage of appropriated family planning funds be used for clinical
services as in FY2005 (when 90% was used for clinical services).19
H.Rept. 109-337 stated that departments and agencies should also be guided by
the language in the House and Senate committee reports accompanying H.R. 3010.
In H.Rept. 109-143, the House Committee on Appropriations encouraged HRSA to
work with the Centers for Disease Control and Prevention to include HIV/AIDS
17
This figure includes the 1% across-the-board rescission required for federal discretionary
programs pursuant to P.L. 109-148, Division B, Title III, Chapter 8, Section 3801 (119 Stat.
2680, 2791-2792). Additionally, on June 14, 2006, the DHHS Secretary notified the
Appropriations Committees that he would transfer funds among DHHS programs to finance
activities related to the Medicare drug benefit call center. This transfer, authorized by
Section 208 of P.L. 109-149 (119 Stat. 2833, 2858-2859), reduced Title X funding by
0.069%, or $0.2 million.
18
The DHHS Office of Inspector General recently reviewed OPA’s activities to address
state reporting requirements. It found that “OPA has informed and periodically reminds
Title X grantees of their responsibilities” regarding these requirements, and that OPA
addresses state reporting requirements in its site visits and reviews of grantees. See DHHS,
Office of the Inspector General, Federal Efforts to Address Applicable Child Abuse and
Sexual Abuse Reporting Requirements for Title X Grantees, Report no. OEI-02-03-00530,
April 2005, at [http://oig.hhs.gov/oei/reports/oei-02-03-00530.pdf], visited Feb. 9, 2007.
19
DHHS, Fiscal Year 2006: Health Resources and Services Administration: Justification
of Estimates for Appropriations Committees, p. 74.
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testing and counseling among the services provided in family planning clinics. The
committee also directed the OPA to send Title X grantees a reminder that family
planning providers are not exempt from state notification and reporting laws on child
abuse, child molestation, sexual abuse, rape, or incest. The committee also requested
that the DHHS Secretary audit a sample of Title X recipients to check compliance
with these reporting requirements. The Senate Committee on Appropriations, in
S.Rept. 109-103, noted that Title X “authorizes the provision of a broad range of
acceptable and effective family planning methods and preventive health services.
This includes FDA-approved methods of contraception. The Committee believes
that the authority for making grants under title X must remain unchanged.”
Committees, p. 252.
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FY2008. On November 15, 2007, an attempt to override the veto failed in the House.
A continuing resolution, P.L. 110-92 (121 Stat. 989), as amended by P.L.
110-116, provides temporary FY2008 funding, at the FY2007 funding level, through
December 14, 2007. Under the continuing resolution, funds are made available
under the same terms and conditions provided during FY2007.
For FY2007, the Title X funding level was $283.1 million.18 Continuing
Resolution P.L.110-5 (121 Stat. 8) provided funding through the end of FY2007.
FY2007 funding was subject to the same “requirements, authorities, conditions,
limitations, and other provisions of” the FY2006 Labor-HHS-Education
appropriations law. FY2007 funds could not be spent on activities that were
“specifically prohibited” during FY2006.19 The FY2006 appropriations law repeated
previous years’ language that Title X funds not be spent on abortions, that all
pregnancy counseling be nondirective, and that funds not be spent on “any activity
(including the publication or distribution of literature) that in any way tends to
promote public support or opposition to any legislative proposal or candidate for
public office.” The law also repeated language requiring grantees to certify that they
encourage “family participation” when minors decide to seek family planning
services, and to certify that they counsel minors on how to resist attempted coercion
into sexual activity. The law also repeated a clarification that family planning
providers are not exempt from state notification and reporting laws on child abuse,
child molestation, sexual abuse, rape, or incest.20
FY2006 funding for Title X was contained in the Departments of Labor, Health
and Human Services, Education, and Related Agencies Appropriations Act, 2006,
P.L. 109-149 (119 Stat. 2833, 2844). Title X was funded at $282.9 million for
FY2006.21
18
S.Rept. 110-107, p. 311. The Revised Continuing Appropriations Resolution, 2007
(P.L.110-5) did not specify a precise dollar figure for Title X. There was some flexibility
for the Department of Health and Human Services to determine the program amount.
19
P.L. 110-5, sec. 104-105 (121 Stat. 8, 9).
20
P.L. 109-149, Title II, sec. 211, sec. 213. (119 Stat. 2833, 2844-2845, 2859). The DHHS
Office of Inspector General recently reviewed OPA’s activities to address state reporting
requirements. It found that “OPA has informed and periodically reminds Title X grantees
of their responsibilities” regarding these requirements, and that OPA addresses state
reporting requirements in its site visits and reviews of grantees. See DHHS, Office of the
Inspector General, Federal Efforts to Address Applicable Child Abuse and Sexual Abuse
Reporting Requirements for Title X Grantees, Report no. OEI-02-03-00530, April 2005, at
[http://oig.hhs.gov/oei/reports/oei-02-03-00530.pdf], visited December 3, 2007.
21
This figure includes the 1% across-the-board rescission required for federal discretionary
programs pursuant to P.L. 109-148, Division B, Title III, Chapter 8, Section 3801 (119 Stat.
2680, 2791-2792). Additionally, on June 14, 2006, the DHHS Secretary notified the
Appropriations Committees that he would transfer funds among DHHS programs to finance
activities related to the Medicare drug benefit call center. This transfer, authorized by
Section 208 of P.L. 109-149 (119 Stat. 2833, 2858-2859), reduced Title X funding by
0.069%, or $0.196 million.
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Table 1. Title X Family Planning Program Appropriations
(in millions)
FY
Appropriation
FY
Appropriation
FY
Appropriation
1971
$6.0
1984
$140.0
1997
$198.5
1972
$61.8
1985
$142.5
1998
$203.5
1973
$100.6
1986
$136.4
1999
$215.0
1974
$100.6
1987
$142.5
2000
$238.9
1975
$100.6
1988
$139.7
2001
$253.9
1976
$100.6
1989
$138.3
2002
$265.0
1977
$113.0
1990
$139.1
2003
$273.4
1978
$135.0
1991
$144.3
2004
$278.3
1979
$135.0
1992
$149.6
2005
$286.0
1980
$162.0
1993
$173.4
2006
$282.9
1981
$161.7
1994
$180.9
2007
a$283.1
1982
$124.2
1995
$193.3
2008
ba
1983
$124.1
1996
$192.6
—
—
Sources: FY1971-FY2005: Department of Health and Human Services, Office of Population Affairs,
[http://opa.osophs.dhhs.gov/titlex/ofp-funding-history.html], and FY2007 Labor-HHS-Education
appropriations reports.
a. The FY2007 Budget Request, H.Rept. 109-515 and S.Rept. 109-287, would have provided $283.1
million for FY2007. The 109th Congress did not pass FY2007 Labor-HHS-Education
appropriations legislation. Continuing resolution P.L. 109-383 (120 Stat. 2678) continues
funding at the FY2006 level through February 15, 2007.
b. The FY2008 Budget request would provide $283.1 million for FY2008.
CRS-6; FY2006: FY2007 Senate Appropriations
Committee, S.Rept. 109-287 (p. 325); FY2007: FY2008 House Appropriations Committee, H.Rept
110-231 (p. 381).
a. The FY2008 Budget request would provide $283.1 million for FY2008. The enrolled version of
H.R. 3043, the FY2008 Labor-HHS-Education Appropriations bill, would provide $310.9
million. On November 13, 2007, the President vetoed H.R. 3043. On November 15, 2007, an
attempt to override the veto failed in the House.
Abortion and Title X
The law prohibits the use of Title X funds in programs where abortion is a
method of family planning.2022 On July 3, 2000, OPA released a final rule with respect
to abortion services in family planning projects.2123 The rule updated and revised
regulations that had been in effect since 1988.2224 The major revision revoked the “gag
rule,” which restricted family planning grantees from providing abortion-related
information. The regulation at 42 C.F.R. §59.5 had required, and continues to
require, that abortion not be provided as a method of family planning. The July 3,
2000 rule amended the section to add the requirement that a project must give
22
42 U.S.C. § 300a-6. In addition, so-called “Hyde amendments” to Departments of Labor,
Health and Human Services, Education, and Related Agencies Appropriations bills have
also restricted federal abortion funding. For more background, see CRS Report RL33467,
Abortion: Legislative Response, by Jon O. Shimabukuro and Karen J. Lewis.
23
“Standards of Compliance for Abortion-Related Services in Family Planning Services
Projects,” 65 Federal Register 41270, July 3, 2000, and “Provision of Abortion-Related
Services in Family Planning Services Projects,” 65 Federal Register 41281, July 3, 2000.
24
42 C.F.R. Part 59, “Grants for family planning services.”
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pregnant women the opportunity to receive information and counseling on each of
the following options: prenatal care and delivery; infant care, foster care, or adoption;
and pregnancy termination. If the woman requests such information and counseling,
the project must give “neutral, factual information and nondirective counseling on
each of the options, and referral upon request, except with respect to any option(s)
about which the pregnant woman indicates she does not wish to receive such
information and counseling.”
According to OPA, family planning projects that receive Title X funds are
closely monitored to ensure that federal funds are used appropriately and that funds
are not used for prohibited activities such as abortion. The prohibition on abortion
does not apply to all the activities of a Title X grantee, but only to activities that are
part of the Title X project. The grantee’s abortion activities must be “separate and
distinct” from the Title X project activities.2325 Safeguards to maintain this separation
include (1) careful review of grant applications to ensure that the applicant
understands the requirements and has the capacity to comply with all requirements;
(2) independent financial audits to examine whether there is a system to account for
program-funded activities and non-allowable program activities; (3) yearly
comprehensive reviews of the grantees’ financial status and budget report; and (4)
periodic and comprehensive program reviews and site visits by OPA regional offices.
It is unclear exactly how many Title X clinics also provide abortions through
their non-Title X activities. In 2004, following appropriations conference report
directions, DHHS surveyed its Title X grantees on whether their clinic sites also
provided abortions with non-federal funds.24 Grantees were informed that responses
20
42 U.S.C. § 300a-6. In addition, so-called “Hyde amendments” to Departments of Labor,
Health and Human Services, and Education, and Related Agencies Appropriations bills have
also restricted federal abortion funding. For more background, see CRS Report RL33467,
Abortion: Legislative Response, by Karen Lewis and Jon Shimabukuro.
21
“Standards of Compliance for Abortion-Related Services in Family Planning Services
Projects,” 65 Federal Register 41270, July 3, 2000, and “Provision of Abortion-Related
Services in Family Planning Services Projects,” 65 Federal Register 41281, July 3, 2000.
22
42 C.F.R. Part 59, “Grants for family planning services.”
23
65 Federal Register 41281-41282, July 3, 2000.
2426 Grantees were informed that responses
were voluntary and “without consequence, or threat of consequence, to nonresponsiveness.” The survey did not request any identifying information. DHHS
mailed surveys to 86 grantees and received 46 responses. Of these, nine indicated
that at least one of their clinic sites (17 clinic sites in all) also provided abortions with
non-federal funds, and 34 indicated that none of their clinic sites provided abortions
with non-federal funds; three responses had no numerical data or said the information
was unknown.
Title X supporters argue that family planning reduces unintended pregnancies,
thereby reducing abortion.27 On the other hand, Title X critics argue that federal
funds should be withheld from any organization that performs or promotes abortions,
such as the Planned Parenthood Federation of America. These critics argue that if
25
65 Federal Register 41281-41282, July 3, 2000.
26
DHHS, Report to Congress Regarding the Number of Family Planning Sites Funded
Under Title X of the Public Health Service Act That Also Provide Abortions with Non(continued...)
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were voluntary and “without consequence, or threat of consequence, to nonresponsiveness.” The survey did not request any identifying information. DHHS
mailed surveys to 86 grantees and received 46 responses. Of these, nine indicated
that at least one of their clinic sites (17 clinic sites in all) also provided abortions with
non-federal funds, and 34 indicated that none of their clinic sites provided abortions
with non-federal funds; three responses had no numerical data or said the information
was unknown.
Title X supporters argue that family planning reduces unintended pregnancies,
thereby reducing abortion.25 On the other hand, Title X critics argue that federal
funds should be withheld from any organization that performs or promotes abortions,
such as the Planned Parenthood Federation of America. These critics argue that ifNonFederal Funds, 2004. The DHHS was directed to conduct the survey by FY2004
appropriations conference report H.Rept. 108-401, pp. 800-801.
27
An example of this argument can be found in U.S. Senate, Committee on Appropriations,
Subcommittee on Departments of Labor, Health and Human Services, Education, and
Related Agencies, Threat to Title X and Other Women’s Health Services, Hearing, 104th
Cong., 1st sess., August 10, 1995. S.Hrg. 104-416 (Washington: GPO, 1996), pp. 16-21. See
also Rachel Benson Gold, “Title X: Three Decades of Accomplishment,” The Guttmacher
Report on Public Policy, vol. 4, no. 1 (February 2000), p. 7.
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a family planning program is operated by an organization that also performs
abortions, the implicit assumption and the message to clients is that abortion is a
method of family planning.2628
Teenage Pregnancy and Title X
In 2005, 26% of Title X clients were aged 19 or younger.2729 Critics argue that
by funding Title X, the federal government is implicitly sanctioning nonmarital
sexual activity among teens. These critics argue that a reduced teenage pregnancy
rate could be achieved if family planning programs emphasized efforts to convince
teens to delay sexual activity, rather than efforts to decrease the percentage of
sexually active teens who become pregnant.2830 (See CRS Report RS20873, Reducing
Teen Pregnancy: Adolescent Family Life and Abstinence Education Programs, by
Carmen Solomon-Fears, for a broader discussion of teen pregnancy.)
The program’s supporters, on the other hand, argue that the Title X program
should be expanded to serve more people in order to reduce the rate of unintended
pregnancies. According to DHHS, in FY2005, Title X family planning services
24
(...continued)
Federal Funds, 2004. The DHHS was directed to conduct the survey by FY2004
appropriations conference report H.Rept. 108-401, pp.800-801.
25
An example of this argument can be found in U.S. Senate, Committee on Appropriations,
Subcommittee on Departments of Labor, Health and Human Services, and Education, and
Related Agencies, Threat to Title X and Other Women’s Health Services, Hearing, 104th
Cong., 1st sess., Aug. 10, 1995. S.Hrg. 104-416 (Washington: GPO, 1996), pp. 16-21. See
also Rachel Benson Gold, “Title X: Three Decades of Accomplishment,” The Guttmacher
Report on Public Policy, vol. 4, no. 1 (Feb. 2000), p. 7.
26
helped avert 980,000 unintended pregnancies, including more than 250,000
unintended teen pregnancies.31 Supporters of expanding family planning services
argue that the United States has a higher teen pregnancy rate than some countries
(such as Sweden) where a similar percentage of teens are sexually active, in part
because U.S. teens use contraception less consistently.32
Planned Parenthood and Title X
In May 2003, the General Accounting Office (GAO; now named the
Government Accountability Office) updated a report on federal funds provided to
several nonprofit organizations and their affiliates involved in health-related
28
An example of these arguments can be found in Threat to Title X and Other Women’s
Health Services, pp. 22-35.
2729
Family Planning Annual Report: 2005 National Summary, November 2006, p. 11, at
[http://opa.osophs.dhhs.gov/titlex/FPAR_2005_National_Report_webPDF.pdf], visited Feb.
9, 2007.
28.
30
An example of these arguments can be found in Threat to Title X and Other Women’s
Health Services, pp. 22-35.
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helped avert 980,000 unintended pregnancies, including more than 250,000
unintended teen pregnancies.29 Supporters of expanding family planning services
argue that the United States has a higher teen pregnancy rate than some countries
(such as Sweden) where a higher percentage of teens are sexually active, in part
because U.S. teens use contraception less consistently.30
Planned Parenthood and Title X
In May 2003, the General Accounting Office (GAO; now named the
Government Accountability Office) updated a report on federal funds provided to
several nonprofit organizations and their affiliates involved in health-related
activities during FY2001.31
31
DHHS, HRSA, Fiscal Year 2008 Justification of Estimates for Appropriations
Committees, p. 429. See also the discussion of publicly funded family planning services
in “Programs to Reduce Unintended Pregnancy,” in The Institute of Medicine, The Best
Intentions: Unintended Pregnancy and the Well-Being of Children and Families
(Washington: National Academy Press, 1995), p. 220, at
[http://www.nap.edu/catalog.php?record_id=4903], visited December 3, 2007.
32
An example of these arguments can be found in Threat to Title X and Other Women’s
Health Services, pp. 16-21. See also Jacqueline E. Darroch, et al., “Differences in Teenage
Pregnancy Rates Among Five Developed Countries: The Roles of Sexual Activity and
Contraceptive Use,” Family Planning Perspectives, vol. 33, no. 6 (November/December
2001), pp. 244-251.
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activities during FY2001.33 The report provides information on the Planned
Parenthood Federation of America, the Population Council, the International
Planned Planned
Parenthood Federation, the Alan Guttmacher Institute, Advocates for Youth,
and the
Sexuality Information and Education Council of the United States (SIECUS).
Information was collected from each organization with respect to their expenditure
of federal funds. Only Planned Parenthood and the Alan Guttmacher Institute
reported spending Title X funds.
Planned Parenthood operates through a national office and 117110 affiliates; these
affiliates receive funds directly and indirectly from other Title X grantees, such as
their state or local health departments. Planned Parenthood also operates more than
860 local health centers.3234 The Alan Guttmacher Institute is an affiliate of the
Planned Parenthood Federation and provides policy analysis and conducts research.
According to the GAO report, in FY2001 Planned Parenthood spent $58.7 million
of Title X funds, and the Alan Guttmacher Institute spent $315,320 of such funds;
together this amounts to approximately 23% of Title X appropriations for that year.
29
DHHS, Fiscal Year 2008: Health Resources and Services Administration: Justification
of Estimates for Appropriations Committees, p. 429. See also the discussion of publicly
funded family planning services in “Programs to Reduce Unintended Pregnancy,” in The
Institute of Medicine, The Best Intentions: Unintended Pregnancy and the Well-Being of
Children and Families (Washington: National Academy Press, 1995), p. 220, at
[http://books.nap.edu/catalog/4903.html#toc], visited Feb. 9, 2007.
30
An example of these arguments can be found in Threat to Title X and Other Women’s
Health Services, pp. 16-21. See also Jacqueline E. Darroch et al., “Differences in Teenage
Pregnancy Rates Among Five Developed Countries: The Roles of Sexual Activity and
Contraceptive Use,” Family Planning Perspectives, vol. 33, no. 6 (Nov./Dec. 2001), pp.
244-251.
31Legislation in the 110th Congress
Several bills on the Title X program have been introduced in the 110th Congress.
S. 21/H.R. 819, the Prevention First Act, was introduced in the Senate January
4, 2007, and in the House February 5, 2007. These companion bills would authorize
Title X appropriations of $700 million for FY2008 and “such sums as may be
necessary for each subsequent fiscal year.” S. 21 was referred to the Senate
Committee on Health, Education, Labor, and Pensions. H.R. 819 was referred to the
House Committees on Energy and Commerce, Ways and Means, and Education and
Labor.
H.R. 1074, the Reducing the Need for Abortion and Supporting Parents Act,
was introduced in the House February 15, 2007. One of its provisions would
authorize Title X appropriations of $700 million for FY2008 and “such sums as may
be necessary for each subsequent fiscal year.” H.R. 1074 was referred to the House
Committees on Energy and Commerce, Ways and Means, and Education and Labor.
S. 351, the Title X Family Planning Act, was introduced January 22, 2007. It
would prohibit Title X funds from going to entities that perform abortions or whose
subgrantees perform abortions, except in certain physician-certified cases where the
woman is “in danger of death unless an abortion is performed.” This prohibition
would not apply to hospitals, unless the hospital subgrants to a non-hospital entity
that performs abortions. S. 351 would require Title X grant applicants to certify that
33
U.S. General Accounting Office, Federal Funds: Fiscal Year 2001 Expenditures by
Selected Organizations Involved in Health-Related Activities, GAO-03-527R, May 16, 2003,
at [http://www.gao.gov/cgi-bin/getrpt?GAO-03-527R], visited Feb. 9December 3, 2007. This
report has
not been updated subsequently.
3234
Planned Parenthood by the Numbers, at [http://www.plannedparenthood.org/about-us/
who-we-are/pp-numbers-5551.htm], visited Feb. 9, 2007.
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Legislation in the 110th Congress
Several bills on the Title X program have been introduced in the 110th Congress.
The Prevention First Act (S. 21/H.R. 819) was introduced in the Senate January 4,
2007, and in the House February 5, 2007. The Prevention First Act would authorize
Title X appropriations of $700 million for FY2008 and “such sums as may be
necessary for each subsequent fiscal year.” The bill also has provisions on several
topics other than the Title X program, including Medicaid family planning services,
emergency contraception, insurance coverage of contraceptives, and teen pregnancy
prevention. S. 21 was referred to the Senate Committee on Health, Education, Labor,
and Pensions. H.R. 819 was referred to the House Committees on Energy and
Commerce, Ways and Means, and Education and Labor.
S. 351, the Title X Family Planning Act, was introduced January 22, 2007. It
would prohibit Title X funds from going to entities that perform abortions or whose
subgrantees perform abortions, except in certain physician-certified cases where the
woman is “in danger of death unless an abortion is performed.” This prohibition
would not apply to hospitals, unless the hospital subgrants to a non-hospital entity
that performs abortions. S. 351 would require Title X grant applicants to certify that
they and their subgrantees adhere to the abortion prohibition. It would also require
the DHHS to provide Congress with an annual list of Title X grantees that perform
abortions; if an entity appears on the list, it would be ineligible for subsequent fiscal
year Title X funds unless it certifies that it no longer performs abortions. S. 351 was
referred to the Senate Committee on Health, Education, Labor, and PensionsDecember 3, 2007.
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they and their subgrantees adhere to the abortion prohibition. It would also require
the DHHS to provide Congress with an annual list of Title X grantees that perform
abortions; if an entity appears on the list, it would be ineligible for subsequent fiscal
year Title X funds unless it certifies that it no longer performs abortions. S. 351 was
referred to the Senate Committee on Health, Education, Labor, and Pensions.
H.R. 4133, the Title X Abortion Provider Prohibition Act, was introduced
November 9, 2007. The bill would prohibit Title X assistance to any entity unless
it certifies that it will not perform, nor provide funds to any other entity that
performs, an abortion during the period of assistance. The prohibition would not
apply to hospitals, unless the hospital provides funds to a non-hospital entity that
performs an abortion. The bill has exceptions for abortions performed in cases of
rape, incest against a minor, or certain physician-certified cases where the woman is
“in danger of death unless an abortion is performed.” H.R. 4133 would also require
the DHHS Secretary to provide Congress an annual report listing, for each entity
receiving a Title X grant: information on any abortions it performed, the date that
it last certified that it would not perform abortions, and any other entities to which
it makes available funds received through Title X grants. H.R. 4133 was referred to
the House Committee on Energy and Commerce.
H.R. 1095, the Taxpayers’ Freedom of Conscience Act, was introduced
February 15, 2007. It would prohibit federal officials from expending federal
funding for “any population control or population planning program or any family
planning activity (including any abortion procedure), irrespective of whether such
program or activity is foreign or domestic.” H.R. 1095 was referred to the House
Committees on Foreign Affairs and Energy and Commerce.
H.R. 104, the Adoption Information Act, was introduced January 4, 2007. It
would require the DHHS Secretary to annually prepare, update, and distribute to each
Title X service grantee pamphlets listing contact information for all adoption centers
in the state where services are provided. Title X service projects would be required
to provide “assurances satisfactory to the Secretary” that they will (1) give the
pamphlet to each family planning client at the time the person inquires about
services, (2) orally inform the client that the pamphlet is from DHHS and has a
comprehensive list of adoption centers in the state, and (3) give the client “an
opportunity to read the pamphlet.” H.R. 104 was referred to the House Committee
on Energy and Commerce.
Summary of Title X of the Public Health Service Act
Below is a summary of Title X of the Public Health Service Act, codified at 42
U.S.C. §300 to §300a-6, Population Research and Voluntary Family Planning
Programs:
H.R. 2134, the Parent’s Right to Know Act of 2007, was introduced May 3,
2007. It would prohibit Title X service providers from providing contraceptive drugs
or prescription devices to a minor unless one of the following criteria is met: (a) the
provider has notified a parent or guardian in writing at least five business days
earlier, (b) the minor has a parent or guardian’s written consent, (c) the minor is
emancipated, or (d) a court has directed that the minor may receive the contraceptive
drugs or prescription devices. Each Title X provider would be required to annually
certify compliance with these requirements. H.R. 2134 was referred to the House
Committee on Energy and Commerce.
H.Con.Res. 232, “It is the Sense of the Congress that the confidentiality
mandates for minors should be removed from family planning services programs
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operating under Title X of the Public Health Services Act and Medicaid,” was
introduced October 10, 2007. It notes that Title X services “were extended to minors
under the age of 16 as a result of the United States Supreme Court decision in Carey
v. Population Services International;35 consequently, Title X clinics can provide
minors with free contraceptives without a parent’s knowledge or consent.”
H.Con.Res. 232 was referred to the House Committee on Energy and Commerce.
During Senate consideration of the FY2008 Labor-HHS-Education
Appropriations bill (H.R. 3043) in October 2007, several floor amendments
pertaining to Title X were submitted but no further action was taken.
! S.Amdt. 3329 would have prohibited the bill’s funds from going to
Planned Parenthood “for any purpose” under Title X.
! S.Amdt. 3392 would have amended Title X to require funding
recipients to annually report on and certify their compliance with
state reporting requirements on child abuse, child molestation,
sexual abuse, rape, and incest. Recipients found not complying with
state reporting requirements would have lost Title X eligibility for
three subsequent years.
! S.Amdt. 3413, S.Amdt. 3421, S.Amdt. 3422, S.Amdt. 3423,
S.Amdt. 3424, and S.Amdt. 3425 would have prohibited the bill’s
funds (including Title X funds) from going to local education
agencies that allow birth control distribution to certain minors
without a parent’s or guardian’s separate, prior, written consent.
During House consideration of the FY2008 Labor-HHS-Education
Appropriations bill (H.R. 3043), two floor amendments pertaining to Title X were
offered.
! H.Amdt. 594 would have prohibited the bill’s funds from going to
Planned Parenthood “for any purpose” under Title X. H.Amdt. 594
was offered and subsequently defeated by roll call vote on July 19,
2007.
! H.Amdt. 554 would have prohibited Title X funds to providers that
in the previous 36 months had violated state notification and
reporting laws related to child abuse, child molestation, sexual
abuse, rape, or incest. H.Amdt. 554 was offered and subsequently
withdrawn by unanimous consent on July 18, 2007.
Summary of Title X of the Public Health Service Act
Below is a summary of Title X of the Public Health Service Act, codified at 42
U.S.C. §300 to §300a-6, Population Research and Voluntary Family Planning
Programs:
35
431 U.S. 678 (1977). The case is discussed briefly in Kenneth R. Thomas, ed., “Privacy
after Roe: Informational Privacy, Privacy of the Home or Personal Autonomy?,” United
States Constitution, Analysis and Interpretation, 2005, at [http://www.crs.gov/products/
conan/Amendment14/topic_S1_4_17_3.html], visited December 3, 2007.
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Section 1001. Project Grants and Contracts for Family Planning Services
The Secretary may make grants to and enter into contracts with public or
nonprofit private entities to assist in the establishment and operation of voluntary
family planning projects to offer a broad range of acceptable and effective family
planning methods and services (including natural family planning methods, infertility
CRS-10
services, and services for adolescents). Entities which receive grants or contracts
must encourage family participation in their projects.
Section 1002. Formula Grants to States for Family Planning Services
The Secretary may make grants to state health authorities to assist in planning,
establishing, maintaining, coordinating, and evaluating family planning services. The
state health authority must have an approved state plan for a coordinated and
comprehensive program of family planning services.
Section 1003. Training Grants and Contracts
The Secretary may make grants to public or nonprofit private entities and enter
into contracts with public or private entities and individuals to provide the training
for personnel to carry out family planning service programs.
Section 1004. Research
The Secretary may conduct and make grants to public or nonprofit private
entities and enter into contracts with public or private entities and individuals for
projects for research in the biomedical, contraceptive development, behavioral, and
program implementation fields related to family planning and population.
Section 1005. Informational and Educational Materials
The Secretary may make grants to public or nonprofit private entities and enter
into contracts with public or private entities and individuals to assist in developing
and making available family planning and population growth information (including
educational materials) to all persons desiring such information.
Section 1006. Regulations and Payments
The Secretary may promulgate regulations and must determine the conditions
for making payments to grantees to assure that such grants will be effectively utilized
for the purposes they were made.
Grantees must assure that (1) priority will be given to the furnishing of services
to persons from low-income families; and (2) no charge will be made in such project
or program for services provided to any person from a low-income family except to
the extent that payment will be made by a third party (including a government
agency) which is authorized or is under legal obligation to pay the charge.
The Secretary must be satisfied that informational or educational materials
developed or made available under the grant or contract will be suitable for the
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purposes of this title and for the population or community to which they are to be
made available.
In the case of any grant or contract under Section 1001, such assurances shall
provide for the review and approval of the suitability of such materials, prior to their
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distribution, by an advisory committee established by the grantee or contractor in
accordance with regulations.
Section 1007. Voluntary Participation
The acceptance by any individual of family planning services or family planning
or population growth information (including educational materials) shall be voluntary
and shall not be a prerequisite to eligibility for or receipt of any other service or
assistance from, or to participation in, any other program of the entity or individual
that provided such service or information.
Section 1008. Prohibition of Abortion
None of the funds appropriated under this title shall be used in programs where
abortion is a method of family planning.
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