Title X (Public Health Service Act) Family Planning Program

Summary

The federal government provides grants for family planning services through the Family Planning Program, Title X of the Public Health Service Act (42 U.S.C. §§300 to 300a-6). Enacted in 1970, it is the only domestic federal program devoted solely to family planning and related preventive health services. In 2014, Title X-funded clinics served 4.1 million clients.

Title X is administered through the Office of Population Affairs (OPA) in the Department of Health and Human Services (HHS). Although the authorization of appropriations for Title X ended with FY1985, funding for the program has continued through appropriations bills for the Departments of Labor, Health and Human Services, and Education, and Related Agencies (Labor-HHS-Education).

The Consolidated Appropriations Act, 2016 (P.L. 114-113) provided $286 million for Title X, the same as the FY2015 level. The FY2016 act continued previous years' requirements that Title X funds not be spent on abortions, that all pregnancy counseling be nondirective, and that funds not be spent on promoting or opposing any legislative proposal or candidate for public office. Grantees continued to be required to certify that they encourage "family participation" when minors seek family planning services and to certify that they counsel minors on how to resist attempted coercion into sexual activity. The appropriations law also clarified that family planning providers are not exempt from state notification and reporting laws on child abuse, child molestation, sexual abuse, rape, or incest. The President's FY2017 budget proposes to increase Title X funding by 5% to $300 million.

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.

Title X Program Administration and Grants

The federal government provides grants for family planning services through the Family Planning Program, Title X of the Public Health Service Act (42 U.S.C. §§300 to 300a-6). Enacted in 1970, it is the only domestic federal program devoted solely to family planning and related preventive health services. Participation in family planning services by Title X clients is, by law, voluntary.¹

Although Title X is the only federal domestic program primarily focused on family planning, other programs also finance family planning, among their other services. These programs include Medicaid, the Health Centers program under Section 330 of the Public Health Service Act, Maternal and Child Health Block Grants, and Social Services Block Grants. In FY2010, Medicaid accounted for 75% of U.S. public family planning expenditures (including federal, state, and local government spending). In comparison, Title X accounted for 10%.²

Title X is administered by the Office of Population Affairs (OPA) under the Office of the Assistant Secretary for Health in the U.S. Department of Health and Human Services (HHS). Although the program is administered through OPA, funding for Title X activities is provided through the Health Resources and Services Administration (HRSA) in HHS. 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, and Education, and Related Agencies (Labor-HHS-Education).

In 2014, Title X-funded clinics served 4.129 million clients, primarily low-income women and adolescents. Of those clients, 9% were male, 69% had incomes at or below the federal poverty level, and 88% had incomes at or below 200% of the federal poverty level.¹⁴ For 61% of clients, Title X clinics are their "usual" or only regular source of health care.¹⁵ In 2014, 54% of Title X clients were uninsured.¹⁶

The number of Title X clients served in 2014 was 9% lower than in 2013 (when there were 4.558 million clients), and 21% lower than in 2010 (when there were 5.225 million clients).¹⁷ The Family Planning Annual Report and the HRSA FY2017 Budget Justification suggested several reasons for grantees' decreased capacity to serve clients,¹⁸ including

• reduced revenues for family planning projects, such as decreases in funding from state government programs, Title X, block grants, and other funding sources.¹⁹
• staffing shortages for family planning projects, for example, due to difficulties in provider recruitment and retention.
• increased unit cost of providing services and upfront costs for infrastructure improvements (such as purchasing new health information technology and entering new contracts with insurers).

Grantees also suggested several potential reasons for a decrease in demand,²⁰ including

• Patient Protection and Affordable Care Act (ACA) insurance coverage expansions, because newly insured clients can choose to seek care from private practitioners and other non-Title X providers.
• increased use of long-acting reversible contraception (LARC), which could reduce the frequency of client visits in the long run, compared with some other types of contraception (such as oral contraceptives that require refills).²¹
• recent clinical guideline changes. For example, pap tests are now recommended every three years instead of annually.²²

In 2014, there were 94 Title X family planning services grantees. Such grantees included 50 state, local, and territorial health departments and 44 nonprofit organizations, such as hospitals, community health agencies, family planning councils, and Planned Parenthood affiliates.²³

Title X grantees can provide family planning services directly or they can delegate Title X monies to other agencies to provide services. Although there is no fixed matching amount required for grants, regulations specify that no Title X projects may be fully supported by Title X funds.²⁴ In 2014, Title X provided services through 4,127 clinics located in the 50 states, the District of Columbia, and the U.S. territories and Freely Associated States.²⁵

Grants for family planning personnel training are used to train staff and to improve the utilization and career development of paraprofessionals.²⁶ Staff are trained through five national training programs for Coordination and Strategic Initiatives; Management and Systems Improvement; Family Planning Service Delivery; Quality Assurance, Quality Improvement and Evaluation; and a National Clinical Training Center.²⁷ Family planning service delivery improvement research grants are used for studies to enhance effectiveness and efficiency of the service delivery system.²⁸

Requirements on the Use of Title X Funds in

P.L. 114-113, Consolidated Appropriations Act, 2016

P.L. 114-113 continues previous years' requirements regarding the use of Title X funds:

• Title X funds shall not be spent on abortions.
• All pregnancy counseling shall be nondirective.
• Funds shall not be spent on promoting or opposing any legislative proposal or candidate for public office.
• Grantees must certify that they encourage "family participation" when minors decide to seek family planning services and that they counsel minors on how to resist attempted coercion into sexual activity.
• Family planning providers are not exempt from state notification and reporting laws on child abuse, child molestation, sexual abuse, rape, or incest.

According to the HRSA Justification, the proposed FY2017 funding level would support family planning services for 4.26 million clients. The program's FY2017 goals include preventing 1,278 cases of infertility through Chlamydia screening and preventing 977,400 unintended pregnancies.³⁰ The FY2017 target for cost per client served is $328.41, with the goal of maintaining the cost per client below the medical care inflation rate.³¹

OPA also plans to use FY2017 funds to train and support providers in adopting the standards in "Providing Quality Family Planning Services, Recommendations of CDC and the U.S. Office of Populations Affairs."³² OPA would also use FY2017 funds to develop a Family Planning Delivery System Improvement Center "that will use evidence based principles to support the delivery of quality family planning services within a sustainable system of care." OPA also plans to create a centralized data center for Family Planning Annual Report (FPAR) data, supporting a shift from grantee-level aggregate reporting to de-identified encounter-level reporting.³³

As more clients have gained health insurance through the ACA, the Title X program has encouraged clinics to increase their number of contracts with insurance plans and to recover more costs through reimbursements and billing third-party payers. OPA expects that clinics' additional investment in third-party billing, along with improved electronic health records adoption, will increase revenue and allow the Title X program to serve more clients.³⁴

As mentioned previously, P.L. 114-113 provided $286.479 million for Title X in FY2016, the same as the FY2015 enacted level.³⁵ The FY2016 act continued previous years' requirements that Title X funds not be spent on abortions, among other requirements (see text box "Requirements on the Use of Title X Funds in P.L. 114-113, Consolidated Appropriations Act, 2016").

FY2016 appropriations were subject to a clause, known as the Weldon Amendment, stating that "None of the funds made available in this Act may be made available to a Federal agency or program, or to a State or local government, if such agency, program, or government subjects any institutional or individual health care entity to discrimination on the basis that the health care entity does not provide, pay for, provide coverage of, or refer for abortions."³⁶ Some have argued that the Weldon Amendment conflicts with regulations that require Title X family planning services projects to give pregnant women the opportunity to receive information, counseling, and referral upon request for several options, including "pregnancy termination."³⁷ In the February 23, 2011, Federal Register, HHS stated of potential conflicts, "The approach of a case by case investigation and, if necessary, enforcement will best enable the Department to deal with any perceived conflicts within concrete situations."³⁸

(in millions, current dollars, not adjusted for inflation)

FY

Appropriation

FY

Appropriation

FY

Appropriation

1987

2003

$273.4

1988

2004

$278.3

1989

2005

$286.0

1990

2006

$282.9

1991

2007

$283.1

1992

2008

$300.0

1993

2009

$307.5

1994

2010

$317.5

1995

2011

$299.4

1996

2012

$293.9

1997

2013

$278.3

1998

2014

$286.5

1999

2015

$286.5

2000

2016

$286.5

2001

2002

At the request of OPA's Office of Family Planning, the Institute of Medicine (IOM) of the National Academy of Sciences independently evaluated the Title X program and made recommendations in A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results (2009).³⁹

IOM found that family planning—"helping people have children when they want to and avoid conception when they do not—is a critical social and public health goal," and that the "federal government has a responsibility to support the attainment of this goal." IOM noted, for example, that family planning can prevent unintended and high-risk pregnancies, thereby reducing fetal, infant, and maternal mortality and morbidity. IOM also stated that the appropriate use of contraception can reduce abortion rates and cited "ample evidence that family planning services are cost-effective."⁴⁰ IOM made specific recommendations to increase program funding and to improve program management, administration, and evaluation.

Among IOM's recommendations was that OPA's Office of Family Planning "review and update the Program Guidelines to ensure that they are evidence-based." IOM noted, for example, that the guidelines required female Title X clients, including adolescents, to have pelvic and breast examinations within six months of their initial visit, though "relevant abnormalities are rarely found in adolescents." At the time of the IOM report, Title X Program Guidelines had not been updated since 2001.⁴¹

In response to the IOM recommendations, OPA released new program guidelines in April 2014.⁴² The new guidelines draw on systematic literature reviews and existing recommendations from organizations, such as the CDC, the U.S. Preventive Services Task Force, the American Congress of Obstetricians and Gynecologists, the American Academy of Pediatrics, the American Society for Reproductive Medicine, and the American Urological Association. For example, the new guidelines state that pelvic exams and clinical breast exams are "not needed routinely to provide contraception safely to a healthy client" (though they may be recommended for some cases, such as inserting an intrauterine device, fitting a diaphragm, cancer screening for non-adolescents, assessing gestational age after a positive pregnancy test, if the client has certain STD symptoms, as part of infertility care, or to address other non-contraceptive health needs). OPA states that the new guidelines have "a foundation of empirical evidence and information supporting clinical practice."⁴³ Also in response to the IOM report, HHS contracted with IOM to convene a Standing Committee to advise the Title X program on issues raised by the 2009 report, as well as other emerging family planning issues.⁴⁴

The Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended) has numerous provisions that may impact Title X clinics. Notably, ACA increases access to health insurance.⁴⁵ (In 2014, 54% of Title X clients were uninsured, down from 63% in 2013.)⁴⁶ Federal ACA regulations and guidance also require most health plans and health insurers to cover contraceptive services without cost-sharing.

ACA has several provisions that may increase health insurance coverage in the populations served by Title X. These provisions could help free up funds that Title X clinics have historically spent on serving the uninsured. For example,

• States can expand Medicaid eligibility to include most nonelderly, nonpregnant individuals with income at or below 133% of FPL, effectively 138% FPL with the 5% income disregard.⁴⁷ (In 2014, 69% of Title X clients had incomes under 101% of FPL; another 14% had incomes between 101% and 150% of FPL.)⁴⁸
• ACA gives states the option, through a Medicaid state plan amendment, of providing targeted Medicaid family planning services and supplies to certain individuals who would otherwise be ineligible for Medicaid.⁴⁹
• ACA requires most private health plans that offer dependent coverage for children to continue to make such coverage available for young adult children under the age of 26.⁵⁰ (In 2014, 46% of Title X clients were younger than 25 years old; another 22% were aged 25 to 29.)⁵¹
• ACA provides certain individuals and small businesses with access to private health plans through new health insurance exchanges and subsidizes the premium costs for certain individuals. To ensure access for low-income individuals, exchange plans are required to have a sufficient number and geographic distribution of "essential community providers," which include Title X projects.⁵²
• Beginning in 2014, ACA's individual mandate provision requires most individuals to have health insurance or pay a penalty.⁵³

OPA has established FY2016 Program Priorities to guide the project plans of family planning services grantees. In response to ACA, one of these priorities is demonstrating Title X clinics' ability to bill Medicaid and private health insurance. Project plans should have "evidence of contracts with insurance and systems for third party billing as well as the ability to facilitate the enrollment of clients into insurance and Medicaid optimally onsite; and to report on numbers assisted and enrolled."⁵⁴

According to the FY2017 HRSA Justification, the Administration expects that Title X clinics will increase revenue, in part by raising the proportion of clients who have health insurance and by billing third parties.⁵⁵ Title X clinics also provide enrollment assistance to clients eligible for Medicaid or exchange plans under ACA.⁵⁶ OPA awarded one-year grants in FY2014 and FY2015 to help Title X clinics enroll uninsured clients in health coverage.⁵⁷

Title X supporters state that, although clinics funded by Title X could see increased revenues from Medicaid and private insurance, the Title X program is still necessary:

In addition to medical care, Title X supports activities that are not reimbursable under Medicaid and commercial insurance plans… Title X has made a major contribution to the training of clinicians; that need remains today… Title X helps to support staff salaries, not just for clinicians but for front-desk staff, educators and finance and administrative staff. Title X provides for individual patient education as well as community-level outreach and public education about family planning and women's health issues. Title X also helps to support the infrastructure necessary to keep the doors open—subsidizing rent, utilities and infrastructure needs like health information technology.⁵⁸

Some Title X supporters argue that Medicaid and private health insurance reimbursements do not cover the full cost of providing care.⁵⁹ Some advocates also note that even with ACA's health coverage expansions, family planning services will still be sought by uninsured persons and dependents who, for confidentiality reasons, might not wish to bill reproductive health services to their parent's or spouse's health insurance.⁶⁰ Advocates maintain that even with the ACA, there will still be strong demand for safety net providers, such as many Title X clinics, that provide health care to underserved populations.⁶¹

ACA requires most private health plans to cover certain preventive services for women without cost-sharing.⁶² HHS commissioned the Institute of Medicine to recommend preventive services to be included in this requirement.⁶³ Adopting the IOM recommendations, federal rules and guidelines require that most health plans cover, without cost-sharing, "All Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity," as prescribed.⁶⁴ Some have noted that this requirement, by removing up-front cost barriers, could result in more women switching to longer-acting contraceptive methods, such as hormonal implants and intrauterine devices.⁶⁵ OPA has identified "Patient access to a broad range of contraceptive options, including long acting reversible contraceptives (LARC)" as one of the key Title X issues in FY2016.⁶⁶ HHS has also added Title X clients' rate of LARC use to the list of outcome measures for assessing program performance.⁶⁷

The Family Planning Annual Report: 2014 National Summary contains Title X program data from 2014, the first year that ACA's major coverage provisions were in effect. Clients' insurance coverage rates have risen: 43% of Title X clients had health insurance in 2014, compared with 35% in 2013 and 31% in 2010.⁶⁸ Title X projects also reported increased revenues from private third-party payers such as private health insurance plans: $95.1 million in 2014, compared with $69.2 million in 2013 and $50.4 million in 2010.⁶⁹ However, Title X projects' Medicaid revenues and total revenues have both decreased since 2010.⁷⁰

The number of Title X clients served in 2014 (4.1 million) was 9% lower than in 2013 (when there were 4.6 million clients) and 21% lower than in 2010 (when there were 5.2 million clients).⁷¹ As noted above in "Client Characteristics," a decrease in demand might be explained in part by ACA coverage expansions, because newly insured clients can now seek care from private practitioners and other providers. Increased LARC use could also affect demand by reducing the frequency of client visits in the long run, compared with some other contraceptive methods (such as oral contraceptives that require refills). The number of female Title X clients using hormonal implants or intrauterine devices in 2014 was 4% higher than in in 2013 and 35% higher than in 2010.⁷²

ACA may also impact Title X clinics in other ways. For example, because ACA increased the rebate percentage drug makers pay on drugs purchased for Medicaid beneficiaries, Title X clinics likely will receive larger discounts on drugs obtained through the 340B drug discount program.⁷³ ACA also increased funding for teen pregnancy prevention efforts, expanded health care workforce programs, and increased funding for community health centers (many of which are Title X providers).⁷⁴ HHS contracted with IOM to convene a Standing Committee to advise the Title X program. Among other topics, the IOM Standing Committee was tasked with examining the roles of family planning, reproductive health, and Title X in health reform.⁷⁵ OPA also awarded FY2014 research funding to "conduct data analysis and related research and evaluation on the impact of the Affordable Care Act on Title X funded family planning centers."⁷⁶ For Title X grantees and clinics, the Title X Family Planning National Training Centers have compiled resources and provided training on how ACA may affect Title X.⁷⁷

The law prohibits the use of Title X funds in programs where abortion is a method of family planning.⁷⁸ On July 3, 2000, OPA released a final rule with respect to abortion services in family planning projects.⁷⁹ The rule updated and revised regulations that had been in effect since 1988.⁸⁰ 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 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."⁸¹

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.⁸² 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.⁸³

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, HHS surveyed its Title X grantees on whether their clinic sites also provided abortions with non-federal funds.⁸⁴ Grantees were informed that responses were voluntary and "without consequence, or threat of consequence, to non-responsiveness." The survey did not request any identifying information. HHS mailed surveys to 86 grantees and received 46 responses. Of these, 9 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; 3 responses had no numerical data or said the information was unknown.

Title X supporters argue that family planning reduces unintended pregnancies, thereby reducing abortion.⁸⁵ HHS estimates that Title X family planning services helped avert 941,000 unintended pregnancies in 2014.⁸⁶ The Guttmacher Institute estimates that clinics receiving Title X funds helped avert 345,000 abortions in 2013.⁸⁷

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 federal funding for non-abortion activities frees up Planned Parenthood's other resources for its abortion activities.⁸⁸ Some critics also argue that if 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.⁸⁹

In 2014, 18% of Title X clients were aged 19 or younger.⁹⁰ 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.⁹¹ (See CRS Report RS20301, Teenage Pregnancy Prevention: Statistics and Programs, by [author name scrubbed].)

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 HHS, in 2014, Title X family planning services helped avert an estimated 171,800 unintended teen pregnancies.⁹² 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. Some also argue that recent trends in U.S. teen birth rates can be explained in part by changes in teen contraceptive use.⁹³

By law, Title X providers are required to "encourage" family participation when minors seek family planning services.⁹⁴ However, confidentiality is required for personal information about Title X services provided to individuals, including adolescents.⁹⁵ OPA instructs grantees on confidentiality for minors:

It continues to be the case that Title X projects may not require written consent of parents or guardians for the provision of services to minors. Nor can any Title X project staff notify a parent or guardian before or after a minor has requested and/or received Title X family planning services.⁹⁶

The April 2014 Title X guidelines state,

Providers of family planning services should offer confidential services to adolescents and observe all relevant state laws and any legal obligations, such as notification or reporting of child abuse, child molestation, sexual abuse, rape, or incest, as well as human trafficking. Confidentiality is critical for adolescents and can greatly influence their willingness to access and use services. As a result, multiple professional medical associations have emphasized the importance of providing confidential services to adolescents.

Providers should encourage and promote communication between the adolescent and his or her parent(s) or guardian(s) about sexual and reproductive health. Adolescents who come to the service site alone should be encouraged to talk to their parents or guardians. Educational materials and programs can be provided to parents or guardians that help them talk about sex and share their values with their child. When both parent or guardian and child have agreed, joint discussions can address family values and expectations about dating, relationships, and sexual behavior.⁹⁷

Although minors are to receive confidential services, Title X providers are not exempt from state notification and reporting laws on child abuse, child molestation, sexual abuse, rape, or incest.⁹⁸

Some minors who use Title X clinics have dependent health coverage through a parent's private health insurance policy. However, for confidentiality reasons, they may not wish to bill family planning or STD services to their parent's health insurance. According to OPA, Title X clinics "commonly forgo billing" health insurers in order to maintain confidentiality.⁹⁹

As for payment of services provided to minors, Title X regulations indicate that "unemancipated minors who wish to receive services on a confidential basis must be considered on the basis of their own resources."¹⁰⁰ Program requirements instruct that "Eligibility for discounts for unemancipated minors who receive confidential services must be based on the income of the minor."¹⁰¹

Supporters of confidentiality argue that parental notification or parental consent requirements would lead some sexually active adolescents to delay or forgo family planning services, thereby increasing their risk of pregnancy or sexually transmitted diseases.¹⁰²

Critics argue that confidentiality requirements can interfere with parents' right to know of and to guide their children's health care. Some critics also disagree with discounts for minors without regard to parents' income, because the Title X program was intended to serve "low-income families."¹⁰³

The Planned Parenthood Federation of America (PPFA) operates through a national office and 59 affiliates, which operate more than 650 local health centers.¹⁰⁴ Affiliates participating in Title X can receive funds directly from HHS or indirectly from other Title X grantees, such as their state or local health departments.¹⁰⁵ The Guttmacher Institute found that in 2010, Planned Parenthood clinics made up 13% of Title X clinics, but served 37% of Title X clients.¹⁰⁶

In March 2015, the Government Accountability Office (GAO) released a report with data on the obligations, disbursements, and expenditures of federal funds for several nonprofit organizations, including PPFA and its affiliates.¹⁰⁷

According to the GAO report, in FY2012, HHS reported obligating $18.67 million, and disbursing $19.08 million, to PPFA affiliates through the Title X program.¹⁰⁸ These figures reflected funds that HHS provided directly to these organizations. They did not include Title X funds that reached Planned Parenthood or its affiliates indirectly through subgrants or that passed through from state agencies or other organizations.

The GAO report also showed PPFA affiliates' expenditures of Title X funds. Most of these expenditures were identified through audit reports that PPFA affiliates submitted to comply with Office of Management and Budget (OMB) audit requirements.¹⁰⁹ Expenditures included federal funds provided directly or indirectly to these organizations. The most recent expenditure data were from FY2012, when Planned Parenthood and its affiliates reported spending $64.35 million from the Title X Family Planning Services program.¹¹⁰

On September 22, 2015, the Congressional Budget Office estimated that PPFA and its affiliates receive approximately $60 million annually through the Title X program.¹¹¹

Author Contact Information

Footnotes

42 U.S.C. §300a-5 states: "The acceptance by any individual of family planning services or family planning or population growth information (including educational materials) provided through financial assistance under this title (whether by grant or contract) 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."

Adam Sonfield and Rachel Benson Gold, Public Funding for Family Planning, Sterilization and Abortion Services, FY1980-2010, Guttmacher Institute, March 2012, http://www.guttmacher.org/pubs/Public-Funding-FP-2010.pdf. More background is in Institute of Medicine (IOM), "Non-Title X Family Planning Funding Sources," in A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results, ed. Adrienne Stith Butler and Ellen Wright Clayton (Washington: The National Academies Press, 2009), pp. 117-121, http://www.nap.edu/catalog/12585/a-review-of-the-hhs-family-planning-program-mission-management.

Catalog of Federal Domestic Assistance (CFDA), Program number 93.217, http://www.cfda.gov.

CFDA, Program number 93.260.

CFDA, Program number 93.974.

HHS, Health Resources and Services Administration, Fiscal Year 2017 Justification of Estimates for Appropriations Committees, p. 394, http://www.hrsa.gov/about/budget/budgetjustification2017.pdf.

Title X clinical guidelines are laid out in Loretta Gavin, Susan Moskosky, and Marion Carter, et al., "Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs," Morbidity and Mortality Weekly Report, vol. 63, no. RR-4 (April 25, 2014), pp. 1-29, http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6304a1.htm.

CFDA, Program number 93.217. See also 42 C.F.R. §59.5.

42 C.F.R. §59.2 defines "low-income family" as having income at or below 100% of the Federal Poverty Guidelines (FPL). The regulation states that "'Low-income family' also includes members of families whose annual family income exceeds this amount, but who, as determined by the project director, are unable, for good reasons, to pay for family planning services. For example, unemancipated minors who wish to receive services on a confidential basis must be considered on the basis of their own resources."

42 C.F.R. §59.5.

Christina Fowler, Julia Gable, Jiantong Wang, and Beth Lasater, Family Planning Annual Report: 2014 National Summary, RTI International, Research Triangle Park, NC, August 2015, pp. 8-9, 21-22, http://www.hhs.gov/opa/pdfs/title-x-fpar-2014-national.pdf.

Jennifer J. Frost, U.S. Women's Use of Sexual and Reproductive Health Services:Trends, Sources of Care and Factors Associated with Use, 1995–2010, Guttmacher Institute, New York, 2013, p. 1, http://www.guttmacher.org/pubs/sources-of-care-2013.pdf.

Fowler et al., Family Planning Annual Report: 2014 National Summary, pp. 21 and 23.

Ibid., p. A-2.

Fowler et al., Family Planning Annual Report: 2014 National Summary, pp. ES-3 and C-2. HRSA, Fiscal Year 2017 Justification of Estimates for Appropriations Committees, p. 391.

Fowler et al., Family Planning Annual Report: 2014 National Summary, pp. 57, A-22 to A-27.

Fowler et al., Family Planning Annual Report: 2014 National Summary, pp. A-16 to A-18.

Loretta Gavin, Susan Moskosky, and Marion Carter, et al., "Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs," Morbidity and Mortality Weekly Report, vol. 63, no. RR-4 (April 25, 2014), p. 20. Fowler et al., Family Planning Annual Report: 2014 National Summary, p. A-19.

Fowler et al., Family Planning Annual Report: 2014 National Summary, p. 7.

42 C.F.R. §59.7(c).

Fowler et al., Family Planning Annual Report: 2014 National Summary, p. 7. A searchable directory of Title X providers is at HHS, OPA, Title X Grantees List, http://www.hhs.gov/opa/title-x-family-planning/initiatives-and-resources/title-x-grantees-list/.

CFDA, Program number 93.260.

HHS, OPA, National Training Centers, http://www.hhs.gov/opa/title-x-family-planning/training/national-training-centers/.

A list of research grant projects is at HHS, OPA, Research, http://www.hhs.gov/opa/title-x-family-planning/research-and-data/research/.

HHS, HRSA, Fiscal Year 2017, Justification of Estimates for Appropriations Committees, p.389.

Outcome measures for the Title X program are described in "Enclosure II: Department of Health and Human Services' Evaluations of Title X Family Planning Program Outcomes," in U.S. Government Accountability Office (GAO), Health Care Funding: Federal Obligations to and Expenditures by Selected Entities Involved in Health-Related Activities, 2010–2012, GAO-15-270R, March 20, 2015, pp. 16-18, http://www.gao.gov/products/GAO-15-270R.

HHS, HRSA, Fiscal Year 2017, Justification of Estimates for Appropriations Committees, pp. 389-397.

Loretta Gavin, Susan Moskosky, and Marion Carter, et al., "Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs," Morbidity and Mortality Weekly Report, vol. 63, no. RR-4 (April 25, 2014), pp. 1-29. These guidelines are also discussed in "Institute of Medicine Evaluation."

Title X grantees will be asked to leverage electronic health records (EHR) technology to securely transmit FPAR data on each client encounter, including data on client demographics, services provided, and health outcomes. The information will be de-identified to protect patient privacy. HHS, HRSA, Fiscal Year 2017, Justification of Estimates for Appropriations Committee, pp. 394-395.

Ibid., pp. 391 and 394.

P.L. 114-113, Division H, Title II; P.L. 113-235, Division G, Title II.

P.L. 114-113, Division H, Title V, §507(d). The Weldon Amendment was originally adopted as part of the FY2005 Labor-HHS-Education appropriations law, and has been attached to each subsequent Labor-HHS-Education appropriations law: P.L. 108-447, Division F, §508(d), 118 Stat. 3163 (FY2005); P.L. 109-149, §508(d), 119 Stat. 2879 (FY2006). Under P.L. 110-5, §2, 121 Stat. 8, FY2007 appropriations were subject to the same conditions as during FY2006. P.L. 110-161, Division G, §508(d), 121 Stat. 1844 (FY2008). P.L. 111-8, Division F, §508(d), 123 Stat. 803 (FY2009). P.L. 111-117, Division D, §508(d), 123 Stat. 3280 (FY2010). Under P.L. 112-10, Division B, §§1101 and 1104, FY2011 appropriations were subject to the same conditions as during FY2010. P.L. 112-74, Division F, §507(d), 125 Stat. 111 (FY2012). Under P.L. 113-6 §§1101 and 1105, FY2013 appropriations are subject to the same conditions as during FY2012 under P.L. 112-74. P.L. 113-76, Division H, Title V, §507(d), 128 Stat. 409 (FY2014). P.L. 113-235, Division G, Title V, §506(d), 128 Stat. 2515 (FY2015).

42 C.F.R. §59.5(a)(5). Examples of this argument appear in "Weldon Amendment," Congressional Record, daily edition, vol. 151, no. 51 (April 25, 2005), p. S4222; and "Federal Refusal Clause," Congressional Record, daily edition, vol. 151, no. 52 (April 26, 2005), p. S425. The National Family Planning and Reproductive Health Association (NFPRHA), many of whose members provide Title X services, filed a lawsuit challenging the Weldon Amendment in the U.S. District Court for the District of Columbia. The court found that "While Weldon may not provide the level of guidance that NFPRHA or its members would prefer, may create a conflict with pre-existing agency regulations, and may impose conditions that NFPRHA members find unacceptable, none of these reasons provides a sufficient basis for the court to invalidate an act of Congress in its entirety." Upon appeal, the U.S. Court of Appeals for the District of Columbia Circuit found that the plaintiff lacked the standing to challenge the Weldon Amendment. See National Family Planning and Reproductive Health Association, Inc., v. Alberto Gonzales, et al., 468 F.3d 826 (D.C. Cir. 2006), and 391 F. Supp. 2d 200, 209 (D.D.C. 2005).

HHS, "Regulation for the Enforcement of Federal Health Care Provider Conscience Protection Laws," 76 Federal Register 9973, February 23, 2011.

Clare Coleman and Kirtly Parker Jones, "Title X: A Proud Past, An Uncertain Future," Contraception, vol. 84 (September 2011), pp. 209-211, http://www.arhp.org/publications-and-resources/contraception-journal/september-2011. See also "The Ongoing Need for Title X," in Sonfield, Hasstedt, and Gold, Moving Forward: Family Planning in the Era of Health Reform, Guttmacher Institute, March 2014, pp. 29-30.

Adam Sonfield, Andrea Rowan, and Joseph L. Alifante, et al., Assessing the Gap Between the Cost of Care for Title X Family Planning Providers and Reimbursement from Medicaid and Private Insurance, Guttmacher Institute, New York, NY, January 2016, https://www.guttmacher.org/pubs/Title-X-reimbursement-gaps.pdf.

Michelle Andrews, "Insurance Coverage Might Steer Women To Costlier—But More Effective—Birth Control," Kaiser Health News, February 20, 2012, http://www.kaiserhealthnews.org/Features/Insuring-Your-Health/2012/contraceptives-coverage-022112.aspx. Jonathan M. Bearak, Lawrence B. Finer, and Jenna Jerman, et al., "Changes in out-of-pocket costs for hormonal IUDs after implementation of the Affordable Care Act: an analysis of insurance benefit inquiries," Contraception, February 2016, http://dx.doi.org/10.1016/j.contraception.2015.08.018. Nora Becker and Daniel Polsky, "Women Saw Large Decrease In Out-Of-Pocket Spending For Contraceptives After ACA Mandate Removed Cost Sharing," Health Affairs, vol. 34, no. 7 (July 2015), pp. 1204-1211.

HHS, OPA, Announcement of Anticipated Availability of Funds for Family Planning Services Grants, p. 10, http://www.hhs.gov/opa/pdfs/opa-fy2016-1.pdf.

In FY2014, 13% of female clients used LARC as their primary contraception method; the FY2017 target is 11%. HHS, HRSA, Fiscal Year 2017 Justification of Estimates for Appropriations Committees, p. 396.

Fowler et al., Family Planning Annual Report: 2014 National Summary, p. A-14.

Ibid., p. A-27. Actual dollars.

Ibid., p. A-22.

Ibid., p. A-2.

42 C.F.R. §59.2.

HHS, OPA, Program Requirements for Title X Funded Family Planning Projects, April 2014, p. 13.

Organizations with annual expenditures of federal funds of $500,000 or more are required to have an audit. For several PPFA affiliates that did not meet the expenditure threshold for audits, GAO obtained data directly from the affiliates. GAO, Health Care Funding: Federal Obligations to and Expenditures by Selected Entities Involved in Health-Related Activities, 2010–2012, pp. 2, 39, 40.

Tables 24 and 25, GAO, Health Care Funding: Federal Obligations to and Expenditures by Selected Entities Involved in Health-Related Activities, 2010–2012, pp 39, 40. In their single audits to the Federal Audit Clearinghouse, PPFA affiliates reported spending $58.03 million in Title X funds in FY2012 (Table 24). According to data GAO obtained directly from PPFA, affiliates spent an additional $6.32 million in Title X funds in FY2012 that they were not required to report to the Federal Audit Clearinghouse because the amounts did not meet the reporting threshold (Table 25). These two dollar amounts total $64.35 million. However, the total is approximate, because Table 25 data were reported using affiliates' 12-month fiscal years, which vary.

Congressional Budget Office, Budgetary Effects of Legislation That Would Permanently Prohibit the Availability of Federal Funds to Planned Parenthood, September 22, 2015, p. 2, https://www.cbo.gov/publication/50833.