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Title X (Public Health Service Act) Family Planning Program

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Title X (Public Health Service Act) Family Planning Program

February 6May 31, 2017 (RL33644)
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Contents

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 2015, Title X-funded clinics served 4.0 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, 20162017 (P.L. 114-113115-31) provided $286.5 million for Title X, the same as the FY2015FY2016 level. The FY2016FY2017 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.

As of this writing, final full-year appropriations for FY2017 have not yet been enacted. In the 114th Congress, the Senate Appropriations Committee bill S. 3040, the Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2017, would have provided $286 million for Title X, the same as the FY2016 level. The House Appropriations Committee bill H.R. 5926, Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2017, would have provided no funding for Title X in FY2017.

In December 2016, OPA released a final rule to limit the criteria Title X grantees cancould use to restrict subawards: "No recipient making subawards for the provision of services as part of its Title X project may prohibit an entity from participating for reasons other than its ability to provide Title X services." The rule is effective January 18, 2017.

TheOn April 13, 2017, the President signed P.L. 115-23, which nullified the rule under the Congressional Review Act. Federal 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 (Public Health Service Act) Family Planning Program

Title X Program Administration and Grants

The federal government providesprovides 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, and Temporary Assistance for Needy Families. In FY2015. 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

Administration

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).

OPA administers three types of project grants under Title X: family planning services;3 family planning personnel training;4 and family planning service delivery improvement research.5

Family Planning Services Grants

Services

Ninety percent of Title X funds are used for clinical services.6 Grants for family planning services fund family planning and related preventive health services, such as contraceptive services; natural family planning methods; infertility services; services to adolescents; breast and cervical cancer screening and prevention; sexually transmitted disease (STD) and HIV prevention education, counseling, testing, and referral; preconception health services; and counseling on establishing a reproductive life plan.7 The services must be provided "without coercion and with respect for the privacy, dignity, social, and religious beliefs of the individuals being served."8

Title X clinics provide confidential screening, counseling, and referral for treatment. In this regard, OPA has expressed a commitment to integrating HIV-prevention services in all family planning clinics.9 OPA has provided supplemental grants to help Title X projects implement the Centers for Disease Control and Prevention's (CDC's) "Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings."10

Title X services offered to males include condoms, education and counseling, STD testing and treatment, HIV testing, and, in some cases, vasectomy services.11

Client Charges

Priority for services is given to persons from low-income families, who may not be charged for care.12 Clients from families with income between 100% and 250% of the federal poverty guideline (FPL)guidelines are charged on a sliding scale based on their ability to pay. Clients from families with income higher than 250% FPLof the federal poverty guidelines are charged fees designed to recover the reasonable cost of providing services. If a third party (such as a state Medicaid program or a private health insurance plan) is authorized or legally obligated to pay for a client's services, all reasonable efforts must be made to obtain the third-party payment without discounts.13

Client Characteristics

In 2015, Title X-funded clinics served 4.018 million clients, primarily low-income women and adolescents.14 Of those clients, 10% were male, 66% had incomes at or below the federal poverty levelguidelines, and 86% had incomes at or below 200% of the federal poverty level.14guidelines.15 One survey found that for 61% of clients, Title X clinics were their "usual" or only regular source of health care.1516 In 2015, 48% of Title X clients were uninsured.16

17

The number of Title X clients served in 2015 was 3% lower than in 2014 (when there were 4.129 million clients), 12% lower than in 2013 (when there were 4.558 million clients), and 23% lower than in 2010 (when there were 5.225 million clients).1718 The Family Planning Annual Report and the HRSA FY2017 Budget Justification suggested several reasons for grantees' decreased capacity to serve clients,1819 including

  • reduced revenues for family planning projects, such as decreases in funding from state and local government programs, Title X, block grants, and other funding sources.
  • 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,1920 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).20
    • 21
  • recent clinical guideline changes. For example, pap tests are now recommended every three years instead of annually.21

22Grantees and Clinics

In 2015, there were 91 Title X family planning services grantees. Such grantees included 46 state, local, and territorial health departments and 45 nonprofit organizations, such as community health agencies, family planning councils, and Planned Parenthood affiliates.2223

Title X grantees can provide family planning services directly or they can subaward Title X monies to other public or nonprofit entities 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.2324 In 2015, Title X provided services through 3,951 clinics located in the 50 states, the District of Columbia, and the U.S. territories and Freely Associated States.24

25

Family Planning Training and Research Grants

Family planning training grants are used to train staff and to improve the use and career development of paraprofessionals.2526 Staff are trained through a National Training Center for Service Delivery Improvement and a National Clinical Training Center.2627 These programs have produced provider education resources, training tools, podcasts, and webinars on topics such as ACA implementation, the Zika virus, mandated child abuse reporting, and clinical efficiency, among other topics.2728 Family planning service delivery improvement research grants are used for studies to enhance effectiveness and efficiency of the service delivery system.28

29

For more information on the Title X program, see https://www.hhs.gov/opa/title-x-family-planning.

Funding

Title X is a discretionary program, meaning its funding is provided in and controlled by annual appropriations acts. The Consolidated Appropriations Act, 20162017 (P.L. 114-113) provided115-31) provides $286.479 million for Title X in FY2017, the same as the FY2016 enacted level. FY2017 Funding As mentioned previously, P.L. 115-31 provides $286.479 million for Title X in FY2017, the same as the FY2016 enacted level.30 The FY2017 $286.479 million for Title X in FY2016, the same as the FY2015 enacted level. As of this writing, final full-year appropriations for FY2017 have not yet been enacted. In the 114th Congress, the Senate Appropriations Committee bill S. 3040, the Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2017, would have provided $286 million for Title X, the same as the FY2016 level. The House Appropriations Committee bill H.R. 5926, Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2017, would have provided no funding for Title X in FY2017.

FY2016 Funding

As mentioned previously, P.L. 114-113 provided $286.479 million for Title X in FY2016, the same as the FY2015 enacted level.29 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. 114-113115-31, Consolidated Appropriations Act, 20162017").

FY2016FY2017 appropriations wereare 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."3031 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."3132 In the February 23, 2011, Federal Register, HHS stated that potential conflicts would be handled on a case-by-case basis: "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."32

33

Requirements on the Use of Title X Funds in

P.L. 114-113115-31, Consolidated Appropriations Act, 2016

2017

P.L. 114-113115-31 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.33
    • 34
  • 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.

Sources: P.L. 114-113115-31, Division H, Title II, and §207 and §208. (HHS, HRSA, Fiscal Year 2017, Justification of Estimates for Appropriations Committees, p.25.)

; U.S. Office of Management and Budget, The Budget of the U.S. Government, Fiscal Year 2018, Appendix, pp. 418, 480, https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/budget/fy2018/hhs.pdf.

FY2017FY2018 Budget Request

As of this writing, final full-year appropriations for FY2017 have not yet been enacted. President Obama's FY2017President Trump's FY2018 budget, submitted February 9, 2016, requested $300May 23, 2017, requests $286.479 million for Title X, 5% higher than the FY2016the same as the FY2017 enacted level.34 This budget reflected the Obama Administration's priorities; its proposals may differ from what may be enacted by the current Congress and Administration. This budget would have continued35 This budget would continue previous years' provisions in appropriations laws prohibiting the use of Title X funds for abortion, among other requirements (see text box "Requirements on the Use of Title X Funds in P.L. 114-113115-31, Consolidated Appropriations Act, 20162017").

According to the HRSA Justification, the proposed FY2017FY2018 funding level would have supportedsupport family planning services for 4.26 million clients. The program's FY2017 goals included preventing 1,278 cases of infertility through Chlamydia screening and preventing 977,400 unintended pregnancies.35 The FY2017 target for cost per client served was $328.41, with the goal of maintaining the cost per client below the medical care inflation rate.36

OPA also planned 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."37 OPA planned to 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 planned 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.38

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 expected that clinics' additional investment in third-party billing, along with improved electronic health records adoption, would increase revenue and allow the Title X program to serve more clients.39

FY2017 Senate Appropriations Bill

On June 9, 2016, the Senate Appropriations Committee reported S. 3040. It would have provided $286 million for Title X, the same as the FY2016 level. It would also have continued to contain the Weldon amendment and would have 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").

FY2017 House Appropriations Bill

On July 22, 2016, the House Appropriations Committee reported H.R. 5926. It would have provided no funding for Title X in FY2017. Section 228 of the bill stated that "None of the funds appropriated in this Act may be used to carry out title X of the PHS Act."

FY2017 Continuing Resolutions

As of this writing, final full-year appropriations for FY2017 have not yet been enacted. On September 29, 2016, President Obama signed into law the Continuing Appropriations Act, 2017 (P.L. 114-223, Division C). It funded most discretionary programs through December 9, 2016, at the rate they were funded in the Consolidated Appropriations Act, 2016 (P.L. 114-113), minus an across-the-board reduction of about one-half of one percent (0.496%). On December 10, 2016, President Obama signed P.L. 114-254, Further Continuing and Security Assistance Appropriations Act, 2017. It funds most discretionary programs through April 28, 2017 (or until full-year appropriations are enacted), at the rate they were funded in the Consolidated Appropriations Act, 2016 (P.L. 114-113), minus an across-the-board reduction of about one-fifth of one percent (0.1901%). In general, the temporary funding provided by both continuing resolutions (CRs) is subject to the same authority and conditions as was the case in the FY2016 Consolidated Appropriations Act.40 The CR also directs that the act be "implemented so that only the most limited funding action of that permitted in the Act shall be taken in order to provide for continuation of projects and activities."41 The purpose of these limits on the use of funds is to preserve flexibility in subsequent appropriations decisionmaking.

Funding provided by the CR is not available until it is apportioned by the Office of Management and Budget (OMB). OMB has released instructions to federal agencies on how to calculate automatic apportionments under FY2017 continuing resolutions. OMB notes that automatic apportionments do not apply to accounts for which the House or Senate had passed or reported a bill with zero funding. OMB explains that "This restrictive funding action is to ensure that the agency does not impinge on final funding prerogatives of the Congress." As noted above, on July 22, 2016, the House reported H.R. 5926, which would provide zero funding for the Title X family planning account in FY2017. Thus, OMB instructions exclude the Title X program from the automatic apportionment under the continuing resolutions. 42

million clients. OPA intends to award 90% of available Title X funds for family planning services, including "recommended chlamydia screening, screening for undiagnosed cervical tissue abnormalities, preconception care and counseling, basic infertility services, pregnancy testing and counseling, contraceptive method provision and related education and counseling, including counseling on fertility awareness-based methods."36

The program's FY2018 goals include preventing 905,000 unintended pregnancies, having 11.3% of contraceptive clients use long-acting reversible contraception, and reducing infertility by screening 959,300 young women for chlamydia.37 The FY2018 target for cost per client served is $336.69, with the goal of maintaining the cost per client below the medical care inflation rate.38

OPA also plans to use FY2018 funds to continue supporting a Family Planning Delivery System Improvement Center. The Justification also states that the program will likely continue addressing the Zika virus and other conditions affecting reproductive-age persons, including but not limited to clients at Title X service sites.39

According to the Justification, the Title X program has encouraged clinics to implement electronic health records. The program has also encouraged clinics to improve financial sustainability by having more contracts with insurance plans and by recovering more costs through reimbursements and billing third-party payers.40

History of Funding

Table 1 shows Title X appropriations amounts since FY1971, when the program was created. Figure 1 shows Title X appropriations amounts since FY1978, in current dollars (not adjusted for inflation) and constant FY2016 dollars (adjusted for medical care inflation).

Table 1. Title X Family Planning Program Appropriations, FY1971-FY2016

FY2017

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

FY

Appropriation

FY

Appropriation

FY

Appropriation

1971

$6.0

1987

$142.5

2003

$273.4

1972

$61.8

1988

$139.7

2004

$278.3

1973

$100.6

1989

$138.3

2005

$286.0

1974

$100.6

1990

$139.1

2006

$282.9

1975

$100.6

1991

$144.3

2007

$283.1

1976

$100.6

1992

$149.6

2008

$300.0

1977

$113.0

1993

$173.4

2009

$307.5

1978

$135.0

1994

$180.9

2010

$317.5

1979

$135.0

1995

$193.3

2011

$299.4

1980

$162.0

1996

$192.6

2012

$293.9

1981

$161.7

1997

$198.5

2013

$278.3

1982

$124.2

1998

$203.5

2014

$286.5

1983

$124.1

1999

$215.0

2015

$286.5

1984

$140.0

2000

$238.9

2016

$286.5

1985

$142.5

2001

$253.9

2017

a

$286.5

1986

$136.4

2002

$265.0

 

  

Sources: FY1971-FY2005: Department of Health and Human Services, Office of Population Affairs, Title X Funding History, https://www.hhs.gov/opa/title-x-family-planning/about-title-x-grants/funding-history/index.html; FY2006: Senate Appropriations Committee, S.Rept. 109-287, p. 325; FY2007: Consolidated Appropriations Act, 2008 Committee Print of the House Committee on Appropriations on H.R. 2764/P.L. 110-161, Division G, p. 1793, http://www.gpo.gov/fdsys/pkg/CPRT-110HPRT39564; FY2008-FY2009: "Explanatory Statement Submitted by Mr. Obey, Chairman of the House Committee on Appropriations, Regarding H.R. 1105, Omnibus Appropriations Act, 2009," Congressional Record, daily edition, vol. 155, no. 31 (February 23, 2009), p. H2378. FY2010: P.L. 111-117, 123 Stat. 3239. FY2011: P.L. 112-10, §1810 and §1119. FY2012: HHS, HRSA, Fiscal Year 2013 Justification of Estimates for Appropriations Committees, p. 347. FY2013: HHS, HRSA, Sequestration Operating Plan for FY2013, http://www.hrsa.gov/about/budget/operatingplan2013.pdf. FY2014: P.L. 113-76, Division H, Title II. FY2015: P.L. 113-235, Division G, Title II. FY2016: P.L. 114-113, Division H, Title II.

a. As of this writing, final full-year appropriations for FY2017 have not yet been enacted FY2017: P.L. 115-31, Division H, Title II.

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

FY2017

Sources: Current dollars, see Table 1. Constant (FY2016) 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/.

Institute of Medicine Evaluation

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).43

41

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 notedargued, 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."4442 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 2001.4543

In response to the IOM recommendations, OPA released new program guidelines in April 2014.4644 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-adolescentsnonadolescents, 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-contraceptivenoncontraceptive health needs). OPA statesstated that the new guidelines have "a foundation of empirical evidence and information supporting clinical practice."4745 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.48

46

The Patient Protection and Affordable Care Act and Title X

Effect of the ACA on Title X The Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended) has numerous provisions impacting Title X clinics. Notably, ACA increases access to health insurance.4947 (In 2015, 48% of Title X clients were uninsured, down from 63% in 2013.)5048 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 FPLthe federal poverty guidelines, effectively 138% FPL with the 5% income disregard.5149 (In 2015, 66% of Title X clients had incomes under 101% of FPLthe federal poverty guidelines; another 14% had incomes between 101% and 150% of FPL.)52
    • the federal poverty guidelines.)50
  • 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.5351
  • 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 26.5452 (In 2015, 45% of Title X clients were younger than 25 years old; another 22% were aged 25 to 29.)5553
  • ACA provides certain individuals and small businesses with access to private health plans through new health insurance exchanges and subsidizes the premiumpremium expenses and cost-sharing out-of-pocket 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.5654
  • ACA's individual mandate provision requires most individuals to have health insurance or pay a penalty.5755

OPA has established FY2017 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 plans and systems for third party billing as well as the ability to facilitate the enrollment of clients into private insurance and Medicaid, optimally onsite; and to report on numbers of clients assisted and enrolled."5856 A survey of publicly funded family planning clinics found that in 2015, 79% of Title X clinics had contracts to bill Medicaid plans (compared with 35% in 2010) and 69% had contracts to bill private health insurance plans (compared with 26% in 2010).59

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.60 57 Title X clinics also provide enrollment assistance to clients eligible for Medicaid or exchange plans under ACA.6158 OPA awarded one-year grants in FY2014 and FY2015 to help Title X clinics enroll uninsured clients in health coverage.62

59 According to the FY2017 HRSA Justification, the Obama Administration expected that Title X clinics would increase revenue, in part by raising the proportion of clients who have health insurance and by billing third parties.60

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 under the ACA:

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.63

61

Some Title X supporters argue that Medicaid and private health insurance reimbursements do not cover the full cost of providing care.6462 Some advocates also noteargue that even with ACA's health coverage expansions, family planning services will still be sought by uninsured persons6563 and dependents who, for confidentiality reasons, might not wish to bill reproductive health services to their parent's or spouse's health insurance.6664 Advocates maintain that even with the ACA, there is still strong demand for safety net providers, such as many Title X clinics, that provide health care to underserved populations.6765

ACA requires most private health plans to cover certain preventive services for women without cost-sharing.6866 HHS commissioned the Institute of Medicine to recommend preventive services to be included in this requirement.6967 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.7068 Some have notedstated 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.7169 OPA has identified "Patientpatient access to a broad range of contraceptive options, including long acting reversible contraceptives (LARC)" as one of the key Title X issues in FY2017.7270 HHS has also added Title X clients' rate of LARC use to the list of outcome measures for assessing program performance.73

71

The Family Planning Annual Report: 2015 National Summary contains Title X program data from 2015, the second year that ACA's major coverage provisions were in effect. Clients' insurance coverage rates have risen: 50% of Title X clients had health insurance in 2015, compared with 43% in 2014, 35% in 2013, and 31% in 2010.7472 Projects that received Title X funds also reported increased revenues from private third-party payers such as private health insurance plans: $104.0 million in 2015, compared with $95.1 million in 2014, $69.2 million in 2013, and $50.4 million in 2010.7573 Projects that received Title X funds had Medicaid revenues of $501.4 million in 2015, compared with $481.3 million in 2010.76

74

The number of Title X clients served in 2015 (4.018 million) was 3% lower than in 2014 (when there were 4.129 million clients), 12% lower than in 2013 (when there were 4.558 million clients), and 23% lower than in 2010 (when there were 5.225 million clients).7775 As noteddiscussed 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 2015 was 11% higher than in 2014, 16% higher than in 2013, and 50% higher than in 2010.78

76

ACA has also impacted the Title X program in other ways. For example, because ACA increased the Medicaid rebate percentage paid by drug makers, Title X clinics receive larger discounts on drugs purchased through the 340B drug pricing program. As a result of receiving larger drug discounts through the 340B program, Title X clinics receive more revenue on drugs dispensed to clients.7977

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).8078 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.8179 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."8280 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.83

Legislation has been introduced to amend, repeal, or replace some or all of the ACA.84 President Trump's Administration may also use the executive branch to change ACA regulations, guidance, and/or enforcement activities.85 Such legislative and executive branch actions could further impact Title X in the future. Depending on what these actions are, and because many of ACA's effects on Title X are indirect, the potential consequences for Title X are unclear at this point.

Final81 Current Legislative and Executive Actions Potentially Impacting Title X

President Trump's Administration may use the executive branch to change ACA regulations, guidance, or enforcement activities.82 For example, on May 4, 2017, President Trump signed an executive order on "Promoting Free Speech and Religious Liberty," which directs the Treasury, Labor, and HHS Secretaries to consider amending regulations. These changes would address conscience-based objections to the requirement that most health plans cover certain women's preventive services, such as contraception.83

Legislation has also been introduced to amend, repeal, or replace some or all of the ACA.84 For example, on May 4, 2017, the House passed H.R. 1628, the American Health Care Act of 2017. H.R. 1628 has several provisions that could potentially impact the insurance status of some Title X clients, including provisions to zero out the individual mandate penalty, provisions to restructure ACA exchange subsidies, and provisions that are projected to reduce Medicaid enrollment compared with current law.85 Such changes could potentially affect demand for Title X's free and discounted services.

The Congressional Budget Office (CBO) estimates that H.R. 1628 would reduce federal Medicaid spending compared with current law,86 thus H.R. 1628 could also potentially impact Title X projects' Medicaid revenue. Federal regulations specify that no Title X projects may be 100% supported by Title X funds.87 That is, Title X projects must have some revenues from non-Title X sources. In 2015, Title X projects reported that Medicaid accounted for 40% of their total revenues. In comparison, Title X funds accounted for 19%.88 Among the major changes to Medicaid, H.R. 1628 would convert Medicaid financing to a per capita cap model (i.e., per enrollee limits on federal payments to states) starting in FY2020 and would provide states with the option to receive block grant funding (i.e., a predetermined fixed amount of federal funding) instead of per capita cap funding for certain populations starting in FY2020. Some statutory requirements would not apply under the block grant option. One of the mandatory benefits that would no longer be required under the block grant option is family planning services and supplies.89 According to the CBO, H.R. 1628 would also restrict federal Medicaid funding to Planned Parenthood Federation of America (PPFA) and its clinics for one year.90 (The Guttmacher Institute found that in 2015, 13% of Title X clinics were affiliated with PPFA.)91

H.R. 1628 could also affect Title X clinics' revenues from the federal health center program administered by the U.S. Bureau of Primary Health Care (BPHC) under Section 330 of the Public Health Service Act. The federal health center program supports a wide range of outpatient health services, not just family planning.92 H.R. 1628 would provide an additional $422 million for FY2017 for the Community Health Center Fund, which appropriates mandatory funds to the federal health center program. Although H.R. 1628 does not require it, some health centers could opt to use the additional funds to provide family planning services.93 In 2015, 26% of clinics receiving Title X funds participated in the federal health center program as well.94 In 2015, Title X clinics reported that 1% of their Title X family planning project revenues came from programs administered by BPHC including the federal health centers program.95

Such executive and legislative branch actions could further impact Title X in the future. Depending on what these actions are, and because many of ACA's effects on Title X are indirect, the potential consequences for Title X are unclear at this point.

Nullification of Rule on Selecting Subrecipients

As mentioned earlier, Title X grantees can provide family planning services directly or they can subaward Title X funds to other government or nonprofit entities (subrecipients) to provide services. In December 2016, OPA promulgated the final rule "Compliance With Title X Requirements by Project Recipients in Selecting Subrecipients."8696 It isbecame effective January 18, 2017. The rule appliesP.L. 115-23 (April 13, 2017) nullified the rule.97 The rule would have applied to grantees that make subawards; it does not affectwould not have affected grantees that provide all their Title X services directly. It addswould have added the following language to Title X Family Planning Services grant program regulations:

No recipient making subawards for the provision of services as part of its Title X project may prohibit an entity from participating for reasons other than its ability to provide Title X services.87

In the rule's preamble, OPA explained that some states have98

On April 13, 2017, the President signed P.L. 115-23, "Providing for congressional disapproval under chapter 8 of title 5, United States Code, of the final rule submitted by Secretary of Health and Human Services relating to compliance with title X requirements by project recipients in selecting subrecipients." P.L. 115-23 nullified the rule under the Congressional Review Act.99 As a result, the rule "shall be treated as though such rule had never taken effect."100 That is, the rule is deemed not to have had any effect at any time. Furthermore, HHS is prohibited from reissuing the nullified rule in "substantially the same form" or issuing a "new rule that is substantially the same" as the nullified rule.101

In the December 2016 preamble accompanying the rule, OPA explained that some states had taken actions to limit Title X participation by certain types of providers.102 taken actions to limit Title X participation by certain types of providers. For example, some states have enacted laws to prohibit state and local agencies from giving Title X subawards to abortion providers.88103 Some other states havehad established a priority system for allocating Title X subawards, for example by giving preference to state health departments, primary care providers, and community health centers over specialized family planning clinics.89104 OPA argued that "Thesethese policies, and varying court decisions on their legality, have led to uncertainty among recipients, inconsistency in program administration, and reduced access to services for Title X priority populations."90105

The final rule limitsrule would have limited the criteria a grantee cancould use to restrict entities from Title X subawards, disallowing "reasons other than [the entity's] ability to provide Title X services." The preamble explains that under this rule, explained that applicants for new and continuing91106 Title X grants willwould be required to describe their criteria for choosing subrecipients. The preamble notes that HHS will reviewstated that, under this rule, HHS would have reviewed these submissions for rule compliance, and that "the Department will make and would have made "every effort to help entities come into compliance, and will award replacement grants to other providers when necessary to minimize any disruption of services."92

107

Supporters of the rule have argued that it protectswould have protected funding to specialized family planning providers, such as Planned Parenthood,93108 and that it protectswould have protected vulnerable individuals' access to family planning services.94109 Critics of the rule have argued that states should have the discretion to administer Title X funds consistently with state policy,95110 and that the rule violateswould have violated the conscience rights of voters and states that object to public funding of abortion providers.96111

Abortion and Title X

The law prohibits the use of Title X funds in programs where abortion is a method of family planning.97112 On July 3, 2000, OPA released a final rule with respect to abortion services in family planning projects.98113 The rule updated and revised regulations that had been promulgated in 1988.99114 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."100

115

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.101116 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-allowablenonallowable 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.102

117

It is unclear precisely how many Title X clinics also provide abortions through their non-Title X activities. In 2015, the Guttmacher Institute surveyed a nationally representative sample of publicly funded family planning clinics. Respondents included 535 clinics that received Title X funds. Based on that survey, an estimated 10% of clinics that received any Title X funding reported offering abortions separately from their Title X project.103

118

In 2004, following appropriations conference report directions, HHS surveyed its Title X grantees on whether their clinic sites also provided abortions with nonfederal funds.104119 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 nonfederal funds, and 34 indicated that none of their clinic sites provided abortions with nonfederal 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.105 HHS 120 HHS estimates that Title X services helped avert 901,838 unintended pregnancies in FY2015, and the Guttmacher Institute estimateestimates that Title X family planning services helped avert more than 900,000822,300 unintended pregnancies in 2014.106calendar year 2015.121 It is unclear exactly how many unintended pregnancies would have ended in abortion; however, the Guttmacher Institute estimates that in 20142015, clinics receiving Title X funds helped avert 326,000277,800 abortions, including 54,000500 abortions among teens.107

122

On the other hand, Title X critics argue that federal funds should be withheld from any organization that performs abortions, such as the Planned Parenthood Federation of America. These critics argue that federal funding for non-abortionnonabortion activities frees up Planned Parenthood's other resources for its abortion activities.108123 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.109

124

Teenage Pregnancy and Title X

In 2015, 18% of Title X clients were aged 19 or younger.110125 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.111126 (See CRS Report RS20301, Teenage Pregnancy Prevention: Statistics and Programs.)

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 2014The Guttmacher Institute estimates that in 2015, Title X family planning services helped avert an estimated 171,800188,700 unintended teen pregnancies.112127 The Guttmacher Institute estimates that without Title X clinics' services, the 20142015 U.S. teen pregnancy rate would have been 3044% higher.113128 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 declines in U.S. teen birth rates can be explained in part by changes in teen contraceptive use.114

129

Confidentiality for Minors and Title X

By law, Title X providers are required to "encourage" family participation when minors seek family planning services.115130 However, confidentiality is required for personal information about Title X services provided to individuals, including adolescents.116131 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.117

132

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.118

133

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.119134

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.120

135

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."121136 Program requirements instruct that "Eligibility for discounts for unemancipated minors who receive confidential services must be based on the income of the minor."122137

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.123

138

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."124

139

Planned Parenthood and Title X

The Planned Parenthood Federation of America (PPFA) operates through a national office and 57 affiliates, which operate approximately 650 local health centers.125140 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.126141 The Guttmacher Institute found that in 20102015, Planned Parenthood clinics made up 13% of Title X clinics, but served 37% of 41% of female Title X clients.127

142

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.128

143

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.129144 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.130145 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.131146

On September 22, 2015, the Congressional Budget Office estimated that PPFA and its affiliates receive approximately $60 million annually through the Title X program.132147

Author Contact Information

[author name scrubbed], InformationSenior Research SpecialistLibrarian ([email address scrubbed], [phone number scrubbed])

Footnotes

Fowler et al., Family Planning Annual Report: 2015 National Summary, pp. 9, 21-22, https://www.hhs.gov/opa/sites/default/files/title-x-fpar-2015.pdf.

HHS, HRSA, Fiscal Year 2018, Justification of Estimates for Appropriations Committees, pp. 289-290. . 41. 61. The rule would have amended 42 C.F.R. §59.3 and revisedhttp://fpntc.org/topics/affordable-care-act.

OPA noted 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 91853, footnote 8).

1.

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."
2.

Kinsey Hasstedt, Adam Sonfield and Rachel Benson Gold, Public Funding for Family Planning, Sterilization and Abortion Services, FY1980-20102015, Guttmacher Institute, March 2012, httpApril 2017, https://www.guttmacher.org/pubs/Public-Funding-FP-2010.pdfreport/public-funding-family-planning-abortion-services-fy-1980-2015. 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.
3.

Catalog of Federal Domestic Assistance (CFDA), Program number 93.217, http://www.cfda.gov/programs/93.217.
4.

CFDA, Program number 93.260, http://www.cfda.gov/programs/93.260.
5.

CFDA, Program number 93.974, http://www.cfda.gov/programs/93.974.
6.

HHS, Health Resources and Services Administration, Fiscal Year 20178 Justification of Estimates for Appropriations Committees, p. 394, http289, https://www.hrsa.gov/about/budget/budgetjustification2017budgetjustification2018.pdf.

7.

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, https://www.cdc.gov/mmwr/volumes/65/wr/mm6509a3.htm.
8.

CFDA, Program number 93.217. See also 42 C.F.R. §59.5.
9.

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/.
10.

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.
11.

HHS, OPA, Title X Male Services, httphttps://www.hhs.gov/opa/title-x-family-planning/initiatives-and-resources//title-x-male-services/index.html. .
12.

42 C.F.R. §59.2 defines "low-income family" as having income at or below 100% of the Federal Poverty Guidelines (FPL)federal poverty guidelines. 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."
13.

42 C.F.R. §59.5.
14.

Christina Fowler, Julia Gable, Jiantong Wang, and Beth Lasater, Family Planning Annual Report: 2015 National Summary, RTI International, Research Triangle Park, NC, August 2016, ppp. 8-, https://www.hhs.gov/opa/sites/default/files/title-x-fpar-2015.pdf. To view a county map with the numbers of female Title X contraceptive clients who were served in 2015, see Jennifer J. Frost, Lori Frohwirth, Nakeisha Blades, et al., Publicly Funded Contraceptive Services At U.S. Clinics, 2015, Guttmacher Institute, April 2017, https://www.guttmacher.org/report/publicly-funded-contraceptive-services-us-clinics-2015. Click "Go to state and county maps," then choose "# of clients served at Title X-funded clinics" from the pull-down menu.

15.
1516.

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.
1617.

Fowler et al., Family Planning Annual Report: 2015 National Summary, pp. 21 and 23.
1718.

Ibid., p. A-6.
1819.

Fowler et al., Family Planning Annual Report: 2015 National Summary, pp. ES-3 and C-2. HRSA, Fiscal Year 2017 Justification of Estimates for Appropriations Committees, p. 391, https://www.hrsa.gov/about/budget/budgetjustification2017.pdf.

1920.

Fowler et al., Family Planning Annual Report: 2015 National Summary, pp. ES-3 and C-2. HRSA, Fiscal Year 2017 Justification of Estimates for Appropriations Committees, p. 392.

2021.

Fowler et al., Family Planning Annual Report: 2015 National Summary, pp. A-20 to A-22.
2122.

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: 2015 National Summary, p. A-23.
2223.

Fowler et al., Family Planning Annual Report: 2015 National Summary, p. 7. A directory of Title X grantees is at HHS, OPA, Title X Grantees, https://www.hhs.gov/opa/title-x-family-planning/title-x-grantees/index.html. A searchable directory of Title X clinics is at https://www.opa-fpclinicdb.com/.

2324.

42 C.F.R. §59.7(c).
2425.

Fowler et al., Family Planning Annual Report: 2015 National Summary, p. 7.

A searchable directory of Title X grantees, subawardees, and clinic sites is at https://www.opa-fpclinicdb.com. For a map with the number of Title X clinics by county in 2015, see Frost et al., Publicly Funded Contraceptive Services At U.S. Clinics, 2015, https://www.guttmacher.org/report/publicly-funded-contraceptive-services-us-clinics-2015. Click "Go to state and county maps," then choose "# of Title X-funded clinics" from the pull-down menu. 26
25.

CFDA, Program number 93.260.
2627.

HHS, OPA, National Training Centers, httphttps://www.hhs.gov/opa/title-x-family-planning/training-and-resources/national-training-centers/index.html.
2728.

Family Planning National Training Center, http://fpntc.org/.

2829.

OPA, Research, https://www.hhs.gov/opa/title-x-family-planning/title-x-research-grants/index.html.

2930.

P.L. 114-113115-31, Division H, Title II; P.L. 113-235114-113, Division GH, Title II.

3031.

P.L. 114-113115-31, 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); P.L. 114-113, Division H, Title V, §507(d), 129 Stat. 2649 (FY2016).
3132.

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).
3233.

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

3334.

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).
3435.

HHS, HRSA, Fiscal Year 20178, Justification of Estimates for Appropriations Committees, p.389 288.
3536.

HHS, HRSA, Fiscal Year 2018, Justification of Estimates for Appropriations Committees, p. 289. Fertility awareness methods are described at HHS, OPA, Natural Family Planning, https://www.hhs.gov/opa/pregnancy-prevention/non-hormonal-methods/natural-family-planning/index.html.

 37.

Outcome measures for the Title X program are also 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.
3638.

HHS, HRSA, Fiscal Year 20178, Justification of Estimates for Appropriations Committees, pp. 389-397289-290.
3739.

HHS, HRSA, Fiscal Year 2018, Justification of Estimates for Appropriations Committees, pp. 289-290.
40.

HHS, HRSA, Fiscal Year 2018, Justification of Estimates for Appropriations Committees, p. 288.

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."
38.

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.
39.

Ibid., pp. 391 and 394.
40.

P.L. 114-223, Division C, Sections 101 and 104. P.L. 114-254, Section 101.
41.

P.L. 114-223, Division C, Section 110.
42.

This OMB guidance does allow for an agency to request an account-specific apportionment in such cases, along with a justification for why funds should be provided. OMB, Circular A-11, Section 123.3, "What do I do if my account receives no funding in the House or Senate bill?," 2016, https://obamawhitehouse.archives.gov/sites/default/files/omb/assets/a11_current_year/s123.pdf. "Apportionment of the Continuing Resolution(s) for Fiscal Year 2017," Letter from Shaun Donovan, Director, OMB, to the Heads of Executive Departments and Establishments, September 29, 2016, p. 2, https://obamawhitehouse.archives.gov/sites/default/files/omb/bulletins/2016/16-01.pdf. As of January 17, 2017, no FY2017 Title X grant funds had yet been distributed (Email from HHS Office of the Assistant Secretary for Legislation, January 17, 2017).
43.

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.
4442.

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.

4543.

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.

4644.

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, https://www.hhs.gov/opa/sites/default/files/ogc-cleared-final-april.pdf; 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.
4745.

HHS, HRSA, Fiscal Year 2017 Justification of Estimates for Appropriations Committees, p. 394.
4846.

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

4947.

The Congressional Budget Office (CBO) and Joint Committee on Taxation (JCT) estimate that 22have estimated that 24 million more nonelderly people willwould have health insurance in 20162017 than would have 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" https://www.cbo.gov/publication/51385. 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, vol. 93, no. 5 (May 2016), pp. 386-391, http://dx.doi.org/10.1016/j.contraception.2016.01.003.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4951091/.
5048.

Fowler et al., Family Planning Annual Report: 2015 National Summary, p. A-19.
5149.

P.L. 111-148, §2001 as modified by §10201; P.L. 111-152, §1004 and §1201. This provision is summarized in CRS In 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 pays 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.
5250.

Fowler et al., Family Planning Annual Report: 2015 National Summary, p. 22.

5351.

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 September 1, 2016, 14. As of May 1, 2017, 15 states have had state plan amendments approved under this new authority. Guttmacher Institute, State Policies in Brief as of January 1, 2017: Laws and Policies: Medicaid Family Planning Eligibility Expansions, https://www.guttmacher.org/state-policy/explore/medicaid-family-planning-eligibility-expansions. 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.

5452.

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].
5553.

Fowler et al., Family Planning Annual Report: 2015 National Summary, pp. 10-11.
5654.

U.S. Centers for Medicare & Medicaid Services (CMS), Center for Consumer Information and Insurance Oversight (CCIIO), 2018Addendum to 2018 Letter to Issuers in the Federally-facilitated Marketplaces, December 16, 2016, p. 31February 17, 2017, p. 33, https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Final-2018-Letter-to-Issuers-in-the-Federally-facilitated-Marketplaces.pdf. 45 C.F.R. §156.235.

57-and-February-17-Addendum.pdf. For the 2018 plan year, a plan issuer will have satisfied the requirement for a "sufficient number and geographic distribution" of essential community providers (ECPs) if, among other criteria, the issuer contracts with at least 20% of available ECPs in the service area to participate in the plan's provider network. For the 2018 plan year, HHS maintains a list of ECPs, but issuers may identify additional ECPs through a write-in process. HHS, CMS, "Patient Protection and Affordable Care Act; Market Stabilization," 82 Federal Register 18372-18374, April 18, 2017. The HHS ECP list is at https://data.healthcare.gov/dataset/FINAL-PY-2018-ECP-LIST/dwyq-rebe. The ECP regulation is at 45 C.F.R. §156.235. 55.

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

5856.

HHS, OPA, Program Priorities, https://www.hhs.gov/opa/title-x-family-planning/about-title-x-grants/program-priorities/index.html.
5957.

Mia R. Zolna and Jennifer J. Frost, Publicly Funded Family Planning Clinics in 2015: Patterns and Trends in Service Delivery Practices and Protocols, Guttmacher Institute, November 2016, Table 11, p. 44, https://www.guttmacher.org/sites/default/files/report_pdf/publicly-funded-family-planning-clinic-survey-2015_1.pdf. Jennifer J. Frost, Rachel Benson Gold, and Lori Frohwirth, et al., Variation in Service Delivery Practices Among Clinics Providing Publicly Funded Family Planning Services in 2010, Guttmacher Institute, May 2012, Table 8, p. 37, https://www.guttmacher.org/sites/default/files/report_pdf/clinic-survey-2010.pdf.
60.

HHS, HRSA, Fiscal Year 2017 Justification of Estimates for Appropriations Committees, p. 394.
6158.

"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.
6259.

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.
6360.

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

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.
6462.

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.
6563.

CBO and JCT estimate that about 28have estimated that under the ACA, about 27 million people will be uninsured in 20262027. CBO, Federal Subsidies for Health Insurance Coverage for People Under Age 65: 2016 to 2026, March 24, 2016Under the Affordable Care Act for Health Insurance Coverage Related to the Expansion of Medicaid and Nongroup Health Insurance: Tables from CBO's January 2017 Baseline , January 2017, 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, vol. 93, no. 5 (May 2016), pp. 386-391, http://dx.doi.org/10.1016/j.contraception.2016.01.003https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4951091/. See also Euna M. August, Erika Steinmetz, and Lorrie Gavin, et al., "Projecting the Unmet Need and Costs for Contraception Services After the Affordable Care Act," American Journal of Public Health, vol. 106, no. 2 (February 2016), pp. 334-341, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4985850/.

6664.

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. notestate 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.

6765.

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.

6866.

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).

6967.

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.
7068.

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/. For health insurance plan/policy years beginning on or after December 20, 2017, updated guidelines are at HHS, HRSA, Women's Preventive Services Guidelines, https://www.hrsa.gov/womensguidelines2016/index.html. 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].

.
7169.

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.2015.08.018https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4780678/. 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.

However, some studies of ACA's early effects have not found that the ACA caused increased LARC use. See Jonathan Bearak and Rachel K. Jones, "Did Contraceptive Use Patterns Change After the Affordable Care Act?: A Descriptive Analysis," Women's Health Issues, March 2017; and Lydia E. Pace, Stacie B. Dusetzina, and Nancy L. Keating, "Early Impact of the Affordable Care Act on Uptake of Long-acting Reversible Contraceptive Methods," Medical Care, vol. 54, no. 9 (September 2016), pp. 811-817. 70
72.

HHS, OPA, Program Priorities, https://www.hhs.gov/opa/title-x-family-planning/about-title-x-grants/program-priorities/index.html.
7371.

In FY2014, 13FY2015, 15.56% of female clients used LARC as their primary contraception method; the FY2017. The FY2018 target is 11.3%. HHS, HRSA, Fiscal Year 20172018 Justification of Estimates for Appropriations Committees, p. 396290.
7472.

Fowler et al., Family Planning Annual Report: 2015 National Summary, p. A-19.
7573.

Ibid., p. A-32. Actual dollars.
7674.

Ibid., p. A-32. Actual dollars.
7775.

Ibid., p. A-6.
7876.

Ibid., p. A-20. 451,625 female Title X clients used the LARC methods of hormonal implants or intrauterine devices in 2015, compared to 405,310 in 2014, 387,875 in 2013, and 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. Title X guidelines encourage providers to explain to clients that LARC methods are "safe and effective for most women, including those who have never given birth and adolescents." (Gavin et al., "Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs," p. 8.)
7977.

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. A 340B program overview is in Medicare Payment Advisory Commission, Overview of the 340B Drug Pricing Program: Report to Congress, May 2015, p. viii, http://www.medpac.gov/docs/default-source/reports/may-2015-report-to-the-congress-overview-of-the-340b-drug-pricing-program.pdf. It states: "Covered entities can purchase 340B drugs for all eligible patients, including patients with Medicare or private insurance, and generate revenue if the reimbursements for the drugs from payers exceed the discounted prices they pay for the drugs. Because the 340B statute does not restrict how covered entities can use this revenue, entities can use these funds to expand the number of patients served, increase the scope of services offered to low-income and other patients, invest in capital, cover administrative costs, or for any other purpose."
8078.

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.
8179.

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.

8280.

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. HHS, OPA, Affordable Care Act Collaborative, https://www.hhs.gov/opa/title-x-family-planning/affordable-care-act/initiatives/aca-collaborative/index.html.

8381.

National Family Planning Training Centers, Affordable Care Act, https://web.archive.org/web/20161224191445/http://fpntc.org/topics/affordable-care-act.

82.

See, for example, Executive Order 13765, "Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal," 82 Federal Register 8351, January 24, 2017.

83.

Executive Order 13798, "Promoting Free Speech and Religious Liberty," 82 Federal Register 21675, May 9, 2017. See also HHS, "Secretary Price Welcomes Opportunity to Reexamine Contraception Mandate," press release, May 4, 2017, 2017, https://www.hhs.gov/about/news/2017/05/04/secretary-price-welcomes-opportunity-to-reexamine-contraception-mandate.html. Religious accommodations as they existed prior to the executive order are described at 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.

84.

Examples of such legislation can be found in the Legislative Information System (access for congressional offices only), http://lis.gov. From the Topics pull-down menu, choose PPACA (Patient Protection and Affordable Care Act) (111th-) to generate a list of bills with titles or summaries mentioning ACA.

85.

CRS Report R44785, H.R. 1628: The American Health Care Act (AHCA). Congressional Budget Office (CBO), Cost Estimate for H.R. 1628, American Health Care Act of 2017, As passed by the House of Representatives on May 4, 2017, May 24, 2017, pp. 16-19, https://www.cbo.gov/publication/52752.

86.

CRS Report R44785, H.R. 1628: The American Health Care Act (AHCA). Congressional Budget Office (CBO), Cost Estimate for H.R. 1628, American Health Care Act of 2017, As passed by the House of Representatives on May 4, 2017, May 24, 2017, p. 13, https://www.cbo.gov/publication/52752.
87.

42 C.F.R. §59.7(c).
88.

Fowler et al., Family Planning Annual Report: 2015 National Summary, Exhibit A-14b, p. A-33.
89.

H.R. 1628 Engrossed in House, May 4, 2017, Section 121, pp. 51-55. See also Kaiser Family Foundation, Summary of the American Health Care Act, May 2017, p. 4, http://files.kff.org/attachment/Proposals-to-Replace-the-Affordable-Care-Act-Summary-of-the-American-Health-Care-Act.
90.

H.R. 1628 Engrossed in House, May 4, 2017, section 103 would restrict certain federal funding for one year to a prohibited entity (including its affiliates, subsidiaries, successors, and clinics) if it meets certain criteria. The Congressional Budget Office expects that, according to the specified criteria, the prohibited entity would be Planned Parenthood Federation of America. The restriction would apply only to mandatory spending (such as Medicaid reimbursements) and would not apply to funds from discretionary spending programs such as Title X. CRS Report R44785, H.R. 1628: The American Health Care Act (AHCA). Congressional Budget Office (CBO), American Health Care Act Budget Reconciliation Recommendations of the House Committees on Ways and Means and Energy and Commerce, March 9, 2017, March 13, 2017, https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/americanhealthcareact.pdf. Subsequent amendments were made to the bill before it was passed by the House, however these amendments did not change the bill's Planned Parenthood provision.

91.

Frost et al., Publicly Funded Contraceptive Services At U.S. Clinics, 2015, pp. 1, 9, https://www.guttmacher.org/sites/default/files/report_pdf/publicly_funded_contraceptive_services_2015_3.pdf.
92.

See CRS Report R44295, Factors Related to the Use of Planned Parenthood Affiliated Health Centers (PPAHCs) and Federally Qualified Health Centers (FQHCs).
93.

H.R. 1628 does not specify which services the additional $422 million may be used for; however, some bill supporters have suggested that the funds may be used for women's health care. In a press conference on an earlier version of the bill, the House Ways and Means Committee chair stated that "we are de-funding Planned Parenthood and redirecting those dollars to community health centers so women have those services where they need them." ("Reps. Brady and Walden Hold News Conference on American Health Care Act," CQ Newsmaker Transcripts, March 7, 2017, http://www.cq.com/doc/newsmakertranscripts-5055592). HHS Secretary Dr. Tom Price has said of the bill: "It's also important to appreciate that through community health centers, the bill that's being proposed right now would allow greater access for women to healthcare in greater numbers of facilities across this land." (White House, "Press Briefing by Press Secretary Sean Spicer, 3/7/2017, #18," press release, March 7, 2017, https://www.whitehouse.gov/the-press-office/2017/03/07/press-briefing-press-secretary-sean-spicer-372017-18). From the House Speaker's web page The American Health Care Act: Your Questions Answered: "Why are you cutting women's health services? We're not. In fact, we're expanding women's access to health services by redirecting Planned Parenthood dollars to community health centers, which vastly outnumber Planned Parenthood clinics." (House Speaker Paul Ryan, The American Health Care Act: Your Questions Answered (Part 3), May 4, 2017, http://www.speaker.gov/general/american-health-care-act-your-questions-answered-part-3).

94.

Frost et al., Publicly Funded Contraceptive Services At U.S. Clinics, 2015, pp. 1, 9.
95.

Fowler et al., Family Planning Annual Report: 2015 National Summary, pp. 59, A-33.
96.

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 91852-91860, December 19, 2016, https://www.federalregister.gov/d/2016-30276. It was preceded by a proposed rule and public comment period, see 81 Federal Register 61639-61646, September 7, 2016, https://www.federalregister.gov/d/2016-21359.

97.

When asked if any actions were taken to implement the rule before its nullification, HHS responded: "No - no actions were taken to implement the rule because of timing. Recipients that would have been impacted were those whose applications were submitted on or after January 18, 2017. All of those applicants would have had funding dates of July 1, 2017, but the rule was nullified prior to that." Email from HHS, Office of the Assistant Secretary for Legislation, May 1, 2017.
98.
84.

Examples of such legislation can be found in the Legislative Information System (access for congressional offices only), http://lis.gov. From the Topics pull-down menu, choose PPACA (Patient Protection and Affordable Care Act) (111th-) to generate a list of bills with titles or summaries mentioning ACA.

85.

See, for example, Executive Order 13765, "Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal," 82 Federal Register 8351, January 24, 2017.
86.

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 91852-91860, December 19, 2016, https://www.federalregister.gov/d/2016-30276. It was preceded by a proposed rule and public comment period, see 81 Federal Register 61639-61646, September 7, 2016, https://www.federalregister.gov/d/2016-21359.

87.

The rule amends 42 C.F.R. §59.3, and also revises 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?"
88.

OPA notes99.

The Congressional Review Act is codified at 5 U.S.C. §§801-808.
100.

5 U.S.C. §801(f).
101.

See CRS Insight IN10660, What Is the Effect of Enacting a Congressional Review Act Resolution of Disapproval? and CRS Report R43992, The Congressional Review Act (CRA): Frequently Asked Questions.
102.

According to the rule preamble, "Since 2011, 13 states have placed restrictions on or eliminated subawards with specific types of providers based on reasons other than their ability to provide Title X services." (81 Federal Register 91852). Some of this state activity is tracked by Guttmacher Institute, State Family Planning Funding Restrictions, https://www.guttmacher.org/state-policy/explore/state-family-planning-funding-restrictions, and Usha Ranji, Alina Salganicoff, and Laurie Sobel, et al., Financing Family Planning Services for Low-income Women: The Role of Public Programs, Kaiser Family Foundation, May 11, 2017, Table 1, http://kff.org/womens-health-policy/issue-brief/financing-family-planning-services-for-low-income-women-the-role-of-public-programs.
103.
89104.

OPA discussesdiscussed the example of the Texas state government's "tiered" system for Title X subaward competition in 2011. (81 Federal Register 91853; 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.
90105.

81 Federal Register 91858.
91106.

Title X family planning services projects have "project periods," typically up to three years, during which HHS does not require the grantee to recompete for funds. Within these project periods, continuing awards are generally funded in annual increments (one-year budget periods). Continuing awards are contingent on factors such as appropriations, program priorities, and grantees' compliance with federal requirements. See HHS, OPA, Announcement of Anticipated Availability of Funds for Family Planning Services Grants, FY2017, p. 11, https://www.hhs.gov/opa/sites/default/files/FY-17-Title-X-FOA-New-Competitions.pdf; HHS, OPA, Program Requirements for Title X Funded Family Planning Projects, April 2014, p. 10.
92107.

81 Federal Register 91853-91854.
93108.

See, for example, The Times Editorial Board, "One Obama rule that Trump should keep: Making sure family planning funds reach everyone who needs them," Los Angeles Times, December 27, 2016, http://www.latimes.com/opinion/editorials/la-ed-titlex-new-rule-20161221-story.html; and 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.

94109.

See, for example, Letter from 34 U.S. Senators to President-Elect Donald J. Trump, December 22, 2016, http://www.help.senate.gov/download/title-x-trump; and Letter from 41 U.S. Senators to the Honorable Sylvia Mathews Burwell, Secretary, Department of Health and Human Services, October 7, 2016, https://www.regulations.gov/document?D=HHS-OS-2016-0014-14254.

95110.

See, for example, U.S. House of Representatives, Select Investigative Panel of the Energy and Commerce Committee, Final Report, December 30, 2016, pp. xlii and 408, https://energycommerce.house.gov/sites/republicans.energycommerce.house.gov/files/114/Analysis/20161230Select_Panel_Final_Report.pdf.

96111.

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. Legislation has been introduced to nullify the rule under the Congressional Review Act; see, for example, H.J.Res. 39, H.J.Res. 43, and S.J.Res. 13. For more on the Congressional Review Act, see CRS In Focus IF10023, The Congressional Review Act (CRA), by [author name scrubbed], [author name scrubbed], and [author name scrubbed]. See also CRS Insight IN10611, Can a New Administration Undo a Previous Administration's Regulations?, by [author name scrubbed].

97 112.

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].
98113.

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.

99114.

HHS, Public Health Service, "Statutory Prohibition on Use of Appropriated Funds in Programs Where Abortion is a Method of Family Planning; Standard of Compliance for Family Planning Services Projects," 53 Federal Register 2922, February 2, 1988. The 1988 rule was subsequently challenged in court, and in 1993, the HHS Secretary suspended the rule (HHS, Public Health Service, "Standards of Compliance for Abortion-Related Services in Family Planning Service Projects," 58 Federal Register 7462, February 5, 1993).
100115.

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).

101116.

65 Federal Register 41281-41282, July 3, 2000.
102117.

Email from Barbara Clark, HHS, Office of the Assistant Secretary for Legislation, August 24, 2006May 1, 2017. 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.
103118.

Guttmacher Institute, unpublished tabulations from a 2015 Survey of Publicly Funded Family Planning Clinics. The survey methodology is described in Mia R. Zolna and Jennifer J. Frost, Publicly Funded Family Planning Clinics in 2015: Patterns and Trends in Service Delivery Practices and Protocols, Guttmacher Institute, November 2016, https://www.guttmacher.org/sites/default/files/report_pdf/publicly-funded-family-planning-clinic-survey-2015_1.pdf. For details by abortion type, see Appendix Table A, Questions Q11ee and Q11ii, p. 54.

104119.

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.

105120.

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, 104th Cong., 1st sess., August 10, 1995, S.Hrg. 104-416 (Washington: GPO, 1996), pp. 16-21.
106121.

Title X services helped avert an estimated 941,000 unintended pregnancies in 2014, according to HHS, HRSA, Fiscal Year 20172018, Justification of Estimates for Appropriations Committees, p. 391. Title X clinics' services averted an estimated 904,000 unintended pregnancies in 2014, according to Jennifer J. Frost, Lori Frohwirth, and Mia R. Zolna, Contraceptive Needs and Services, 2014 Update, Guttmacher Institute, September 2016, p. 13, p.290. Jennifer J. Frost, Lori Frohwirth, Nakeisha Blades, et al., Publicly Funded Contraceptive Services At U.S. Clinics, 2015, Guttmacher Institute, April 2017, pp. 1, 10, https://www.guttmacher.org/sites/default/files/report_pdf/contraceptive-needs-and-services-2014_1.pdf.

publicly_funded_contraceptive_services_2015_1.pdf.
107122.

The Guttmacher Institute estimates that in the absence of Title X-funded clinics, the 2014 abortion rate would have been 33% higher than it actually was. Jennifer J. Frost, Lori Frohwirth, and Mia R. Zolna, Contraceptive Needs and Services, 2014 Update, Guttmacher Institute, September 2016, pp. 1, 13, 14, 16, and 32Frost et al., Publicly Funded Contraceptive Services At U.S. Clinics, 2015, pp. 1, 10, 11.
108123.

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, 2015, pp. 29-30, http://www.plannedparenthood.org/about-us/annual-report.
109124.

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.
110125.

Fowler et al., Family Planning Annual Report: 2015 National Summary, p. 9.
111126.

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.
112127.

HHS, HRSA, Fiscal Year 2017 Justification of Estimates for Appropriations Committees, p. 391. Frost et al., Publicly Funded Contraceptive Services At U.S. Clinics, 2015, p. 11. 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.
113.

The Guttmacher Institute estimates that in the absence of Title X-funded clinics, the 2014 teen pregnancy rate would have been 69 pregnancies per 1,000 teens rather than the actual 2014 rate of 53 pregnancies per 1,000 teens. Jennifer J. Frost, Lori Frohwirth, and Mia R. Zolna, Contraceptive Needs and Services, 2014 Update, Guttmacher Institute, September 2016, Figure 5, p. 14, https://www.guttmacher.org/sites/default/files/report_pdf/contraceptive-needs-and-services-2014_1.pdf128. Frost et al., Publicly Funded Contraceptive Services At U.S. Clinics, 2015, p. 1.
114129.

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; 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.
115130.

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.
116131.

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.
117132.

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, https://www.hhs.gov/opa/sites/default/files/ppn2014-01-001.pdf.
118133.

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://web.archive.org/web/20160830233907/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.
119134.

P.L. 114-113, Division H, Title II, §208. 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.
120135.

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 September 1, 2016: Protecting Confidentiality for Individuals Insured as Dependents, http://www.guttmacher.org/statecenter/spibs/spib_CMII.pdf.

121HHS, OPA, Affordable Care Act Collaborative, https://www.hhs.gov/opa/title-x-family-planning/affordable-care-act/initiatives/aca-collaborative/index.html. See also Guttmacher Institute, State Laws and Policies: Protecting Confidentiality for Individuals Insured as Dependents, http://www.guttmacher.org/statecenter/spibs/spib_CMII.pdf. The financial impact on Title X is discussed at National Family Planning & Reproductive Health Association, Confidential and Covered, https://www.confidentialandcovered.com. 136.

42 C.F.R. §59.2.
122137.

HHS, OPA, Program Requirements for Title X Funded Family Planning Projects, April 2014, p. 13, https://www.hhs.gov/opa/sites/default/files/ogc-cleared-final-april.pdf.

123138.

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.

"Adolescent Services – Confidential Services" in Gavin et al., "Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs," pp. 38-39.
124139.

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.
125140.

Planned Parenthood Federation of America, Planned Parenthood at a Glance, http://www.plannedparenthood.org/about-us/who-we-are/planned-parenthood-at-a-glance.
126141.

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

127142.

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.

Frost et al., Publicly Funded Contraceptive Services At U.S. Clinics, 2015, pp. 1, 9, https://www.guttmacher.org/sites/default/files/report_pdf/publicly_funded_contraceptive_services_2015_3.pdf.
128143.

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.
129144.

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.
130145.

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.
131146.

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 expenditure data were reported using affiliates' 12-month fiscal years, which vary.
132147.

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.