Figure 1. Title X Family Planning Program Appropriations, FY1978-FY2016

Sources: Current dollars, see Table 1. Constant (FY2015) dollars, calculated by CRS using a fiscal year inflation adjustment based on monthly data for the Consumer Price Index All - Urban Consumers for Medical Care published by the Bureau of Labor Statistics, http://data.bls.gov/timeseries/CUUR0000SAM/.

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/programs/93.217.

CFDA,, Program number 93.260, http://www.cfda.gov/programs/93.260.

CFDA,, Program number 93.974, http://www.cfda.gov/programs/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; and Loretta Gavin and Karen Pazol, "Update: Providing Quality Family Planning Services — Recommendations from CDC and the U.S. Office of Population Affairs, 2015," Morbidity and Mortality Weekly Report, vol. 65, no. 9 (March 11, 2016), pp. 231-234.

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

HHS, Office of Population Affairs (OPA), HIV Prevention in Family Planning, http://www.hhs.gov/opa/title-x-family-planning/initiatives-and-resources/hiv-prevention-and-integration/.

Centers for Disease Control and Prevention (CDC), "Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings," MMWR Recommendations and Reports, vol. 55, no. RR-14 (September 26, 2006), pp. 1-17. See also CDC, HIV Testing in Clinical Settings, http://www.cdc.gov/hiv/testing/clinical/index.html.

HHS, OPA, Male Services, http://www.hhs.gov/opa/title-x-family-planning/initiatives-and-resources/male-services/.

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: 20145 National Summary, RTI International, Research Triangle Park, NC, August 20152016, pp. 8-9, 21-22, http://www.hhs.gov/opa/pdfs/title-x-fpar-2014-national2015.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: 20145 National Summary, pp. 21 and 23.

Ibid., p. A-26.

Fowler et al., Family Planning Annual Report: 20145 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: 20145 National Summary, pp. ES-3 and C-2. HRSA, Fiscal Year 2017 Justification of Estimates for Appropriations Committees, p. 392.

Fowler et al., Family Planning Annual Report: 20145 National Summary, pp. A-1620 to A-1822.

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: 20145 National Summary, p. A-1923.

Fowler et al., Family Planning Annual Report: 20145 National Summary, p. 7.

42 C.F.R. §59.7(c).

Fowler et al., Family Planning Annual Report: 20145 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/researchFamily Planning National Training Centers, http://fpntc.org/.

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

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

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.

OPA has explained that "grantees may provide as much factual, neutral information about any option, including abortion, as they consider warranted by the circumstances, but may not steer or direct clients toward selecting any option, including abortion, in providing options counseling." (65 Federal Register 41273).

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.

Institute of Medicine (IOM), Committee on a Comprehensive Review of the HHS Office of Family Planning Title X Program, A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results, ed. Adrienne Stith Butler and Ellen Wright Clayton (Washington, DC: The National Academies Press, 2009), http://www.nap.edu/catalog/12585/a-review-of-the-hhs-family-planning-program-mission-management.

Ibid., pp. 4, 70. See also Jennifer J. Frost, Adam Sonfield, and Mia Zolna, et al., "Return on Investment: A Fuller Assessment of the Benefits and Cost Savings of the US Publicly Funded Family Planning Program," Milbank Quarterly, vol. 92, no. 4 (December 2014), pp. 696-749, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4266172/pdf/milq0092-0667.pdf.

IOM, A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results, pp. 13, 15, 240; the 2001 guidelines are reprinted in Appendix D.

HHS, OPA, Program Guidelines, http://www.hhs.gov/opa/program-guidelines/. The new guidelines are comprised of two documents: HHS, OPA, Program Requirements for Title X Funded Family Planning Projects, April 2014; and 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.

HHS, HRSA, Fiscal Year 2017 Justification of Estimates for Appropriations Committees, p. 394.

IOM, Standing Committee on Family Planning, http://iom.nationalacademies.org/Activities/Women/FamilyPlanning.aspx.

The Congressional Budget Office (CBO) and Joint Committee on Taxation (JCT) estimate that 1922 million more nonelderly people will have health insurance in 2016 than would have it without the ACA. They also project that 22 million more will be insured in 2017 and 2018, 23 million more will be insured in 2019, and 24 million more will have insurance each year from 2020 through 2025 than would have it without the ACA. CBO, Budgetary and Economic Effects of Repealing without the ACA. CBO, Federal Subsidies for Health Insurance Coverage for People Under Age 65: 2016 to 2026, March 24, 2016, Table 4, "Effects of the Affordable Care Act on Health Insurance Coverage for People Under Age 65" httpsthe Affordable Care Act, June 19, 2015, Table 3, http://www.cbo.gov/publication/5025251385. One study found that uninsurance rates among reproductive age women declined by almost 40% between 2012 and 2015. Rachel K. Jones and Adam Sonfield, "Health insurance coverage among women of reproductive age before and after implementation of the Affordable Care Act," Contraception, January 2016Insurance Coverage Among Women of Reproductive Age Before and After Implementation of the Affordable Care Act," Contraception, vol. 93, no. 5 (May 2016), pp. 386-391, http://dx.doi.org/10.1016/j.contraception.2016.01.003.

Fowler et al., Family Planning Annual Report: 20145 National Summary, pp. 23, A-14, A-15p. A-19.

P.L. 111-148, §2001 as modified by §10201; P.L. 111-152, §1004 and §1201. This provision is summarized in CRS Report R43564, TheIn Focus IF10399, Overview of the ACA Medicaid Expansion, by [author name scrubbed]. Medicaid, is jointly financed by federal and state governments. All state Medicaid programs are mandated to include family planning services and supplies in their benefit packages, with no cost-sharing. In states that choose to expand Medicaid eligibility, the federal government will paypays 100% of Medicaid expenditures for those in the new eligibility group in 2014 through 2016, including family planning expenditures, gradually declining to 90% in 2020 and thereafter. For all other Medicaid enrollees, the federal government pays 90% of Medicaid family planning expenditures.

Fowler et al., Family Planning Annual Report: 20145 National Summary, p. 22.

P.L. 111-148, §2303. This provision was effective upon enactment. Prior to ACA, states could provide these Medicaid family planning expansions only by obtaining special waivers. This provision is summarized in CRS Report R41210, Medicaid and the State Children's Health Insurance Program (CHIP) Provisions in ACA: Summary and Timeline, by [author name scrubbed] et al. As of FebruarySeptember 1, 2016, 14 states have had state plan amendments approved under this new authority. Guttmacher Institute, State Policies in Brief as of FebruarySeptember 1, 2016: Medicaid Family Planning Eligibility Expansions, http://www.guttmacher.org/statecenter/spibs/spib_SMFPE.pdf. Federal guidance is provided in Cindy Mann, director, Center for Medicaid, CHIP and Survey & Certification, State Medicaid Directors Letter #10-013, Family Planning Services Option and New Benefit Rules for Benchmark Plans, July 2, 2010, http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD10013.pdf, and State Medicaid Directors Letter #14-003, Family Planning and Family Planning Related Services Clarification, April 16, 2014, http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SMD-14-003.pdf.

P.L. 111-148, §1001, as amended by P.L. 111-152, §2301. This dependent coverage provision is effective for plan years beginning on or after September 23, 2010. The provision is summarized in CRS Report R42069, Private Health Insurance Market Reforms in the Patient Protection and Affordable Care Act (ACA), by [author name scrubbed] and [author name scrubbed].

Fowler et al., Family Planning Annual Report: 20145 National Summary, pp. 10-11.

45 C.F.R. §156.235. U.S. Centers for Medicare & Medicaid Services (CMS), Center for Consumer Information and Insurance Oversight (CCIIO), 20152017 Letter to Issuers in the Federally-facilitated Marketplaces, February 29, 2016, p. 32, https, March 14, 2014, p. 22, http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2015-final-issuer-letter-3-14-2014.pdf. CMS, CCIIO, Final 2016 Letter to Issuers in the Federally-facilitated Marketplaces, February 20, 2015, p. 28, http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2016_Letter_to_Issuers_2_20_2015.pdfFinal-2017-Letter-to-Issuers-2-29-16.pdf. 45 C.F.R. §156.235.

P.L. 111-148, §1501 and §10106, as amended by P.L. 111-152, §1002. This provision is summarized in CRS Report R41331, R44438, The Individual Mandate Under the ACAfor Health Insurance Coverage: In Brief, by [author name scrubbed].

HHS, OPA, Announcement of Anticipated Availability of Funds for Family Planning Services Grants, p. 9, http://www.hhs.gov/opa/pdfs/opa-fy2016-1.pdf.

HHS, HRSA, Fiscal Year 2017 Justification of Estimates for Appropriations Committees, p. 394.

"Connecting Clients to Coverage," in Adam Sonfield, Kinsey Hasstedt, and Rachel Benson Gold, Moving Forward: Family Planning in the Era of Health Reform, Guttmacher Institute, March 2014, pp. 34-35, http://www.guttmacher.org/pubs/family-planning-and-health-reform.pdf.

HHS, OPA, FY14 Announcement of Availability of Funds to Enroll Family Planning Clients into Health Insurance Programs, April 3, 2014, http://www.grants.gov/web/grants/view-opportunity.html?oppId=253413. HHS, OPA, FY15 Announcement of Availability of Funds to Enroll Family Planning Clients into Health Insurance Programs, May 13, 2015, http://www.grants.gov/web/grants/view-opportunity.html?oppId=275157. HHS, HRSA, Fiscal Year 2017 Justification of Estimates for Appropriations Committees, p. 393.

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.

CBO and JCT estimate that about 2728 million people will be uninsured in 2025. CBO, Budgetary and Economic Effects of Repealing the Affordable Care Act, June 19, 2015, Table 32026. CBO, Federal Subsidies for Health Insurance Coverage for People Under Age 65: 2016 to 2026, March 24, 2016, Table 1. One study found that as of 2015, uninsurance rates had not declined significantly for Latinas and low-income women in states that did not expand Medicaid. Rachel K. Jones and Adam Sonfield, "Health insurance coverage among women of reproductive age before and after implementation of the Affordable Care Act," Contraception, January 2016, http://dx.doi.org/10.1016/j.contraception.2016.01.003. Confidentiality issues are discussed in Rachel Benson Gold, "Unintended Consequences: How Insurance Processes Inadvertently Abrogate Patient Confidentiality," Guttmacher Policy Review, vol. 12, no. 4 (Fall 2009), pp. 12-16, http://www.guttmacher.org/pubs/gpr/12/4/gpr120412.html; and Adam Sonfield, Kinsey Hasstedt, and Rachel Benson Gold, Moving Forward: Family Planning in the Era of Health Reform, Guttmacher Institute, March 2014, p. 16.

Confidentiality issues are discussed in Kathleen P. Tibb, Erica Sedlander, and Gingi Pica, et al., Protecting Adolescent Confidentiality Under Health Care Reform: The Special Case Regarding Explanation of Benefits (EOBs), Philip R. Lee Institute for Health Policy Studies and Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, June 2014, http://nahic.ucsf.edu/download/protecting-adolescent-confidentiality-under-health-care-reform-the-special-case-regarding-explanation-of-benefits-eobs/; and Adam Sonfield, Kinsey Hasstedt, and Rachel Benson Gold, Moving Forward: Family Planning in the Era of Health Reform, Guttmacher Institute, March 2014, p. 16. Tibb et al. note that as of March 2013, an estimated 15 million young adults aged 15 to 25 were on their parents' health plans, in part due to ACA's dependent coverage provisions.

Kinsey Hasstedt, Yana Vierboom, and Rachel Benson Gold, "Still Needed: The Family Planning Safety Net Under Health Reform," Guttmacher Policy Review, vol. 18, no. 3 (Summer 2015), pp. 56-61, http://www.guttmacher.org/pubs/gpr/18/3/gpr1805615.html. See also Marion Carter, Kathleen Desilets, and Lorrie Gavin, et al., "Trends in Uninsured Clients Visiting Health Centers Funded by the Title X Family Planning Program—Massachusetts, 2005–2012," Morbidity and Mortality Weekly Report, vol. 63, no. 3 (January 24, 2014), pp. 59-62, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6303a3.htm. In 2006, Massachusetts passed its health reform law; subsequently the state's uninsurance rate decreased, to 3% in 2011. The authors found that "Title X program data from 2005–2012 indicate that client volume remained high throughout the period," though the percentage of the state's Title X clients who were uninsured declined from 59% in 2005 to 36% in 2012. In Massachusetts, Title X client volume in 2012 was 90% of what it was in 2005.

P.L. 111-148, §1101. This requirement does not apply to grandfathered plans. Grandfathered plans are those that existed on March 23, 2010, and have not made certain specified changes (for example, to benefits and cost-sharing).

IOM, Clinical Preventive Services for Women: Closing the Gaps (Washington, DC: The National Academies Press, 2011), http://www.nap.edu/catalog/13181/clinical-preventive-services-for-women-closing-the-gaps.

The requirement is effective for plan years beginning on or after August 1, 2012, with some exceptions and accommodations for religious objections. Condoms and vasectomies are not included. HHS, HRSA, Women's Preventive Services: Required Health Plan Coverage Guidelines, http://www.hrsa.gov/womensguidelines/. HHS, Centers for Medicare & Medicaid Services, Center for Consumer Information & Insurance Oversight, Fact Sheet: Women's Preventive Services Coverage, Non-Profit Religious Organizations, and Closely-Held For-Profit Entities, http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/womens-preven-02012013.html. CRS In Focus IF10169, The Affordable Care Act's Contraceptive Coverage Requirement: History of Regulations for Religious Objections, by [author name scrubbed].

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: 20145 National Summary, p. A-1419.

Ibid., p. A-2732. Actual dollars.

Ibid., p. A-22.

Ibid., p. A-26.

Ibid., p. A-16. 405,31020. 451,625 female Title X clients used the LARC methods of hormonal implants or intrauterine devices in 20142015, compared to in405,310 in 2014, 387,875 in 2013, and in 300,136 in 2010. A separate CDC study found that among teens seeking contraceptive services at Title X clinics, 7.1% used long-acting reversible contraception in 2013, compared with 0.4% in 2005. Lisa Romero, Karen Pazol, and Lee Warner, et al., "Vital Signs: Trends in Use of Long-Acting Reversible Contraception Among Teens Aged 15–19 Years Seeking Contraceptive Services—United States, 2005-2013," Morbidity and Mortality Weekly Report, vol. 64 (April 10, 2015), pp. 363-369.

P.L. 111-148, §2501. Title X clinics are among the entities eligible to receive discounts on certain drugs' prices under §340B of the Public Health Service Act. The maximum prices that drug manufacturers can charge 340B entities are calculated using the Medicaid rebate formula. The ACA provision is summarized in CRS Report R41210, Medicaid and the State Children's Health Insurance Program (CHIP) Provisions in ACA: Summary and Timeline, by [author name scrubbed] et al. The 340B program website is http://www.hrsa.gov/opa.

These and other ACA provisions that could potentially impact Title X clinics are summarized in CRS Report R41278, Public Health, Workforce, Quality, and Related Provisions in ACA: Summary and Timeline, coordinated by [author name scrubbed] and [author name scrubbed], and CRS Report R41210, Medicaid and the State Children's Health Insurance Program (CHIP) Provisions in ACA: Summary and Timeline, by [author name scrubbed] et al.

IOM, Standing Committee on Family Planning, http://iom.nationalacademies.org/Activities/Women/FamilyPlanning.aspx. HHS, HRSA, Fiscal Year 2013 Justification of Estimates for Appropriations Committees, p. 351, http://www.hrsa.gov/about/budget/budgetjustification2013.pdf.

HHS, OPA, FY14 Announcement of Availability of Funds for Family Planning Affordable Care Act (ACA) Impact Analysis Research Cooperative Agreements, March 7, 2014, http://www.grants.gov/web/grants/view-opportunity.html?oppId=252304.

National Family Planning Training Centers, Webinar Recording: Affordable Care Act and the Future of Title X, November 2013, http://www.fpntc.org/training-and-resources/webinar-recording-affordable-care-act-and-the-future-of-title-x; National Family Planning Training Centers, Affordable Care Act, http://fpntc.org/topics/affordable-care-act.

Office of Population Affairs, Office of the Secretary, U.S. Department of Health and Human Services, "Compliance With Title X Requirements by Project Recipients in Selecting Subrecipients," 81 Federal Register 61639-61646, September 7, 2016, https://www.federalregister.gov/d/2016-21359.

The proposed language would amend 42 C.F.R. §59.3, and would also revise the section's heading to read "Who is eligible to apply for a family planning services grant or to participate as a subrecipient as part of a family planning project?" The section's current heading is "Who is eligible to apply for a family planning services grant?"

OPA notes the example of Florida law H.B. 1411, 2016 Leg., Reg. Sess. (Fla. 2016). According to OPA, this law was permanently enjoined on August 18, 2016, in an unpublished court order. (81 Federal Register 61641, footnote 9.)

OPA discusses the example of the Texas state government's "tiered" system for Title X subaward competition in 2011. (81 Federal Register 61640-61641; Texas General Appropriations Act, 82nd Leg., R.S., ch. 1355, art. II, rider 77, at II-71, http://www.lrl.state.tx.us/scanned/ApproBills/82_0/82_R_ALL.pdf#page=179.) In FY2013, the Women's Health and Family Planning Association of Texas became the state's Title X grantee; previously it had been the Texas Department of State Health Services.

81 Federal Register 61644.

81 Federal Register 61643. The preamble states that "Under the proposed rule, a tiering structure—described above—would not be allowable unless it could be shown that the top tier provider (e.g., community health center or other provider type) more effectively delivered Title X services than a lower tier provider. In addition, a preference for particular subspecialty providers would have to be justified by showing that they more effectively deliver Title X services. Furthermore, actions that favor `comprehensive providers' would require justification that those providers are at least as effective as other subrecipients applying for funds. The proposed rule does not limit all types of providers from competing for subrecipient funds, but delimits the criteria by which a project recipient can allocate those funds based on the objectives in Title X."

81 Federal Register 61640-61645

81 Federal Register 61643.

See, for example, The New York Times Editorial Board, "A Way to Protect Planned Parenthood Services," New York Times, September 10, 2016, p. A18, New York edition, http://www.nytimes.com/2016/09/10/opinion/a-way-to-protect-planned-parenthood-services.html.

See, for example, Bradford Richardson, "Obama administration 'stunt' would force states to fund Planned Parenthood," Washington Times, September 7, 2016, http://washingtontimes.com/news/2016/sep/7/obama-administration-stunt-would-force-states-to-f/; and Robert King, "Conservative chides feds over protecting Planned Parenthood," Washington Examiner, September 6, 2016, http://www.washingtonexaminer.com/conservative-chides-feds-over-protecting-planned-parenthood/article/2601071.

42 U.S.C. §300a-6. In addition, language in annual Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations bills have also prohibited the use of Title X funds for abortions. (In FY2016, this provision appeared in P.L. 114-113, Division H, Title II)..) For background on abortion funding restrictions in general, see CRS Report RL33467, Abortion: Judicial History and Legislative Response, by [author name scrubbed].

HHS, OPA, "Standards of Compliance for Abortion-Related Services in Family Planning Services Projects," 65 Federal Register 41270–41280, July 3, 2000, https://federalregister.gov/a/00-16758; and HHS, OPA, "Provision of Abortion-Related Services in Family Planning Services Projects, " 65 Federal Register 41281-41282, July 3, 2000, https://federalregister.gov/a/00-16759.

42 C.F.R. Part 59, "Grants for family planning services."

On December 19, 2008, HHS published a provider conscience rule which, according to HHS at the time, was "inconsistent" with the requirement that Title X grantees provide clients with abortion referrals upon request (73 Federal Register 78087). The rule was later rescinded in 2011 (76 Federal Register 9968).

65 Federal Register 41281-41282, July 3, 2000.

Email from Barbara Clark, HHS, Office of the Assistant Secretary for Legislation, August 24, 2006. See also OPA Program Instruction Series, OPA 11-01: Title X Grantee Compliance with Grant Requirements and Applicable Federal and State Law, including State Reporting Laws, Letter from Marilyn J. Keefe, Deputy Assistant Secretary for Population Affairs, to Regional Health Administrators, Regions I-X; Title X Grantees, March 1, 2011, http://www.hhs.gov/opa/pdfs/opa-11-01-program-instruction-re-compliance.pdf. Site visits and comprehensive program reviews are described in IOM, A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results, pp. 349-354.

HHS, 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-Federal Funds, 2004. HHS was directed to conduct the survey by FY2004 appropriations conference report H.Rept. 108-401, pp. 800-801.

Examples of this argument can be found in Rachel Benson Gold, Adam Sonfield, and Cory L. Richards, et al., Next Steps for America's Family Planning Program: Leveraging the Potential of Medicaid and Title X in an Evolving Health Care System, Guttmacher Institute, New York, 2009, pp. 16-17, http://www.guttmacher.org/pubs/NextSteps.pdf, and in U.S. Congress, Senate Committee on Appropriations, Subcommittee on Labor, Health and Human Services, Education, and Related Agencies, Threat to Title X and Other Women's Health Services, 104^th Cong., 1^st sess., August 10, 1995, S.Hrg. 104-416 (Washington: GPO, 1996), pp. 16-21.

HHS, HRSA, Fiscal Year 2017 Justification of Estimates for Appropriations Committees, p. 391.

Jennifer J. Frost, Lori Frohwirth, and Mia R. Zolna, Contraceptive Needs and Services, 2013 Update, Guttmacher Institute, July 2015, p. 29, http://www.guttmacher.org/pubs/win/contraceptive-needs-2013.pdf#page=29.

Examples of this argument can be found in House debate, Congressional Record, daily edition, vol. 154, no. 112 (July 9, 2008), pp. H6320-H6326. According to the Planned Parenthood Federation of America's most recent Annual Report, abortions accounted for 3% of Planned Parenthood services. 323,999 abortion procedures were performed by Planned Parenthood health centers from October 1, 2013 through September 30, 2014. During that period, Planned Parenthood health centers provided 9.5 million services to 2.5 million patients during 4 million clinical visits. Planned Parenthood Federation of America, Planned Parenthood 2014-2015 Annual Report, 20142015, pp. 29-30, http://www.plannedparenthood.org/about-us/annual-report.

An example of these arguments can be found in U.S. Congress, Senate Committee on Appropriations, Subcommittee on Labor, Health and Human Services, Education, and Related Agencies, Threat to Title X and Other Women's Health Services, pp. 22-35.

Fowler et al., Family Planning Annual Report: 20145 National Summary,, p. 9.

An example of these arguments can be found in U.S. Congress, Senate Committee on Appropriations, Subcommittee on Labor, Health and Human Services, Education, and Related Agencies, Threat to Title X and Other Women's Health Services, pp. 22-35.

HHS, HRSA, Fiscal Year 2017 Justification of Estimates for Appropriations Committees, p. 391. 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, http://www.nap.edu/catalog/4903/the-best-intentions-unintended-pregnancy-and-the-well-being-of.

An example of these arguments can be found in U.S. Congress, Senate Committee on Appropriations, Subcommittee on Labor, Health and Human Services, Education, and Related Agencies, 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; John S. Santelli and Andrea J. Melnikas, "Teen Fertility in Transition: Recent and Historic Trends in the United States," Annual Review of Public Health, vol. 31 (2010), pp. 371-383; and Heather D. Boonstra, "What Is Behind the Declines in Teen Pregnancy Rates?" Guttmacher Policy Review, vol. 17, no. 3 (Summer 2014), pp. 15-21; and Laura Lindberg, John Santelli, and Sheila Desai, "Understanding the Recent Decline in Adolescent Fertility in the United States, 2007-2013," Journal of Adolescent Health, vol. 58, no. 2, Supplement (February 2016), p. S100–S101..

42 U.S.C. 300(a) states that Title X grantees shall encourage family participation "to the extent practical." P.L. 114-113, Division H, §207 requires Title X grantees to certify that they encourage family participation in minors' decisions to seek family planning services.

42 C.F.R. §59.11. Also, several court cases have interpreted Title X statute as supporting confidentiality for minors; see Glenn A. Guarino, "Provision of family planning services under Title X of Public Health Service Act (42 U.S.C.A. §300-300a-8) and implementing regulations," American Law Reports Federal, 1985, 71 A.L.R. Fed. 961.

HHS, OPA, Clarification regarding "Program Requirements for Title X Family Planning Projects": Confidential Services to Adolescents, OPA Program Policy Notice 2014-1, June 5, 2014, http://www.hhs.gov/opa/pdfs/ppn2014-01-001.pdf.

Gavin et al., "Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs," p. 13. For an overview of Title X efforts to encourage family participation, see RTI International, An Assessment of Parent Involvement Strategies in Programs Serving Adolescents: Final Report, 2007, http://www.hhs.gov/opa/pdfs/parent-involvement-final-report.pdf. The report found that parent involvement is associated with several positive outcomes, such as delayed sexual initiation and lower rates of pregnancy and sexually transmitted infections.

P.L. 114-113, Division H, Title II, §208. OPA Program Instruction Series, OPA 11-01: Title X Grantee Compliance with Grant Requirements and Applicable Federal and State Law, including State Reporting Laws, Letter from Marilyn J. Keefe, Deputy Assistant Secretary for Population Affairs, to Regional Health Administrators, Regions I-X; Title X Grantees, March 1, 2011, http://www.hhs.gov/opa/pdfs/opa-11-01-program-instruction-re-compliance.pdf.

Private health insurance policy holders often receive "explanations of benefits" that describe services charged to their insurance policy. Often policy holders may also view a history of claims made under their policies. These common health insurance practices may inadvertently breach the confidentiality of dependents who receive care through those policies. OPA has awarded research funding to study these practices' effects on Title X clinics' revenues. HHS, OPA, FY14 Announcement of Availability of Funds for Family Planning Affordable Care Act (ACA) Impact Analysis Research Cooperative Agreements, March 7, 2014, pp. 5-6, 10-11, https://www.grantsolutions.gov/gs/preaward/previewPublicAnnouncement.do?id=49223. See also Abigail English, Rachel Benson Gold, and Elizabeth Nash, et al., Confidentiality for Individuals Insured as Dependents: A Review of State Laws and Policies, Guttmacher Institute, July 2012, http://www.guttmacher.org/pubs/confidentiality-review.pdf; and Guttmacher Institute, State Policies in Brief as of FebruarySeptember 1, 2016: Protecting Confidentiality for Individuals Insured as Dependents,, http://www.guttmacher.org/statecenter/spibs/spib_CMII.pdf.

42 C.F.R. §59.2.

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

An example of this argument is in Rachel K. Jones, Alison Purcell, and Susheela Singh et al., "Adolescents' Reports of Parental Knowledge of Adolescents' Use of Sexual Health Services and Their Reactions to Mandated Parental Notification for Prescription Contraception," JAMA, vol. 293, no. 3 (January 19, 2005), pp. 340-348. See also the staff quotations in RTI International, An Assessment of Parent Involvement Strategies in Programs Serving Adolescents: Final Report, 2007, pp. 5-10.

Examples of these arguments appear in Congressional Record, daily edition, vol. 142 (July 11, 1996), pp. H7348-H7349, and U.S. Congress, Senate Committee on Appropriations, Subcommittee on Labor, Health and Human Services, Education, and Related Agencies, Threat to Title X and Other Women's Health Services, pp. 22-23. See also the discussion in RTI International, An Assessment of Parent Involvement Strategies in Programs Serving Adolescents: Final Report, 2007, pp. 5-9.

Planned Parenthood Federation of America, Planned Parenthood at a Glance, http://www.plannedparenthood.org/about-us/who-we-are/planned-parenthood-at-a-glance.

The Title X Family Planning Service Site Database currently includes more than 300 Planned Parenthood sites, https://www.opa-fpclinicdb.com/.

Jennifer J. Frost, Mia R. Zolna, and Lori Frohwirth, Contraceptive Needs and Services, 2010, Guttmacher Institute, July 2013, Figure 3 and Table 3, http://www.guttmacher.org/pubs/win/contraceptive-needs-2010.pdf#page=13.

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, http://www.gao.gov/products/GAO-15-270R.

According to GAO, the term obligation refers to "a definite commitment by a federal agency that creates a legal liability to make payments immediately or in the future," while the term disbursement refers to "amounts paid by federal agencies, in cash or cash equivalents, to satisfy government obligations." GAO, Health Care Funding: Federal Obligations to and Expenditures by Selected Entities Involved in Health-Related Activities, 2010–2012, pp. 30, 32.

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 25expenditure 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.