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Title X (Public Health Service Act) Family
Planning Program
Angela Napili
Information Research Specialist
March 25, 2011
Congressional Research Service
7-5700
www.crs.gov
RL33644
CRS Report for Congress
P
repared for Members and Committees of Congress

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Title X (Public Health Service Act) Family Planning Program

Summary
The federal government provides grants for voluntary family planning services through the
Family Planning Program, Title X of the Public Health Service Act, codified at 42 U.S.C. § 300
to § 300a-6. The program, enacted in 1970, is the only domestic federal program devoted solely
to family planning and related preventive health services. Title X is administered through the
Office of Population Affairs (OPA) under the Office of Public Health and Science in the
Department of Health and Human Services (DHHS).
Although the authorization for Title X ended with FY1985, funding for the program has
continued to be provided through appropriations bills for the Departments of Labor, Health and
Human Services, and Education, and Related Agencies (Labor-HHS-Education). Within DHHS,
Title X receives its funding through the Health Resources and Services Administration (HRSA)
account.
P.L. 112-6, the Continuing Appropriations Act, 2011, as amended, provides temporary FY2011
funding through April 8, 2011, at the FY2010 rate of operations and under the same conditions as
in FY2010. These conditions include 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 must also certify that they encourage
“family participation” when minors decide to seek family planning services, and must certify that
they counsel minors on how to resist attempted coercion into sexual activity. Appropriations
statute also clarifies that family planning providers are not exempt from state notification and
reporting laws on child abuse, child molestation, sexual abuse, rape, or incest. The House-passed
version of H.R. 1, the Full-Year Continuing Appropriations Act, 2011, would eliminate funding
for Title X for the remainder of FY2011.
The President’s FY2012 Budget requests $327.356 million for Title X, the same as the FY2011
Budget Request. It would be a 3% increase over the FY2010 level of $317.491 million.
The law (42 U.S.C. § 300a-6) prohibits the use of Title X funds in programs where abortion is a
method of family planning. According to OPA, family planning projects that receive Title X funds
are closely monitored to ensure that federal funds are used appropriately and that funds are not
used for prohibited activities such as abortion. The prohibition on abortion does not apply to all
the activities of a Title X grantee, but only to activities that are part of the Title X project. A
grantee’s abortion activities must be “separate and distinct” from the Title X project activities.
Several bills addressing Title X have been introduced in the 112thCongress. H.R. 217, the Title X
Abortion Provider Prohibition Act, and S. 96, the Title X Family Planning Act, would prohibit
Title X grants to abortion-performing entities. H.R. 408 and S. 178, both called the Spending
Reduction Act of 2011, would eliminate the Title X program. H.R. 1, as passed in the House,
would eliminate funding for Title X for the remainder of FY2011. It would also prohibit the bill’s
funds from being made available “for any purpose” to the Planned Parenthood Federation of
America or to any of 102 Planned Parenthood affiliates and offices listed in the bill. H.R. 1099,
the Taxpayers’ Freedom of Conscience Act, would prohibit federal officials from expending
federal funds for “any population control or population planning program or any family planning
activity.” H.R. 1135/H.R. 1167, the Welfare Reform Act of 2011, would define “means-tested
welfare” programs to include family planning, and would require an overall spending limit on
means-tested welfare programs.
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Title X (Public Health Service Act) Family Planning Program

Contents
Title X Program Administration and Covered Services ................................................................ 1
Funding ...................................................................................................................................... 3
FY2012 Budget Request ....................................................................................................... 3
FY2011 Funding ................................................................................................................... 4
FY2011 Budget Request.................................................................................................. 4
Congressional Action ...................................................................................................... 4
Continuing Resolutions ................................................................................................... 5
Institute of Medicine Evaluation.................................................................................................. 7
Abortion and Title X ................................................................................................................... 8
Teenage Pregnancy and Title X ................................................................................................. 10
Confidentiality for Minors and Title X ...................................................................................... 10
Planned Parenthood and Title X ................................................................................................ 11
Provider Conscience Rule ......................................................................................................... 12
Overview ............................................................................................................................ 12
2008 Final Rule................................................................................................................... 13
2011 Rule Rescission .......................................................................................................... 15
Legislation in the 112th Congress............................................................................................... 16
Abortion Restrictions .......................................................................................................... 16
Elimination of Title X Funds ............................................................................................... 16
Limits on Means-Tested Welfare Spending.......................................................................... 17
Restrictions on Funding to Planned Parenthood................................................................... 17

Tables
Table 1. Title X Family Planning Program Appropriations ........................................................... 6

Appendixes
Appendix. Summary of Title X of the Public Health Service Act ............................................... 18

Contacts
Author Contact Information ...................................................................................................... 19

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Title X (Public Health Service Act) Family Planning Program

Title X Program Administration and Covered
Services
Title X is administered through the Office of Population Affairs (OPA) under the Office of Public
Health and Science in the Department of Health and Human Services (DHHS). Although the
program is administered by OPA, funding for Title X activities is provided through the Health
Resources and Services Administration (HRSA) in DHHS. Authorization of appropriations
expired at the end of FY1985, but the program has continued to be funded through appropriations
bills for the Departments of Labor, Health and Human Services, and Education, and Related
Agencies (Labor-HHS-Education).
OPA administers three types of project grants under Title X: family planning services;1 family
planning personnel training;2 and family planning service delivery improvement research grants.3
Grants for family planning services fund family planning and related preventive health services,
such as infertility services; natural family planning methods; services to adolescents; adolescent
abstinence counseling; breast and cervical cancer screening and prevention; sexually transmitted
disease (STD) and HIV prevention education, counseling, testing, and referral; preconception
counseling; and counseling on establishing a reproductive life plan. Among the program’s
FY2011 priorities is providing preventive health services “in accordance with nationally
recognized standards of care.”4 The services must be provided “without coercion and with respect
for the privacy, dignity, social, and religious beliefs of the individuals being served.”5
Priority for the provision of services is to be given to persons from low-income families, who
may not be charged for care.6 Clients from families with income between 100% and 250% of the
federal poverty guideline (FPL) are charged on a sliding scale based on ability to pay. Clients
from families with income higher than 250% FPL are charged fees designed to recover the
reasonable cost of providing services.7
Title X clinics provide confidential screening, counseling, and referral for treatment. In this
regard, OPA has indicated that the program is committed to maintaining the integration of HIV-

1 Catalog of Federal Domestic Assistance (CFDA), Program number 93.217, http://www.cfda.gov.
2 CFDA, Program number 93.260.
3 CFDA, Program number 93.974.
4 U.S. Department of Health and Human Services (DHHS), Office of Population Affairs, FY 2011 Program Priorities,
http://www.hhs.gov/opa/familyplanning/policyplanningeval/programpriorities/index.html. OPA also instructed
providers that clinical protocols should reflect recognized standards of care in “OPA Program Instruction Series, OPA
09-01: Clinical Services in Title X Family Planning Clinics – Consistency with Current Practice Recommendations,”
letter from Evelyn M. Kappeler, acting director, Office of Population Affairs, to Regional Health Administrators,
Regions I-X, April 28, 2009, http://www.hhs.gov/opa/familyplanning/toolsdocs/opa09_01.html.html.
5 CFDA, Program number 93.217. See also 42 C.F.R. § 59.5.
6 42 C.F.R. § 59.2 defines “low-income family” as having income at or below 100% of the Federal Poverty Guidelines
(FPL). The regulation states that “‘Low-income family’ also includes members of families whose annual family income
exceeds this amount, but who, as determined by the project director, are unable, for good reasons, to pay for family
planning services. For example, unemancipated minors who wish to receive services on a confidential basis must be
considered on the basis of their own resources.”
7 42 C.F.R. § 59.5.
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prevention services in all family planning clinics.8 OPA provides supplemental funding for grants
to help Title X projects implement the Centers for Disease Control and Prevention’s “Revised
Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care
Settings.”9
In 2009, Title X grantees reported that 7% of their clients were male.10 Common services that
family planning agencies offer to males include condom provision, STD counseling,
contraceptive counseling, and STD treatment and testing.11
Ninety percent of Title X funds are used for clinical services.12 In 2009, there were 89 Title X
family planning services grantees. Such grantees included 50 state, local, and territorial health
departments, and 39 nonprofit organizations, such as hospitals, community health centers, family
planning councils, Planned Parenthood affiliates, and universities.13 Title X grantees can provide
family planning services directly or they can delegate Title X monies to other agencies to provide
services. Although there are no matching requirements for grants, regulations specify that no
clinics may be fully supported by Title X funds.14 Title X provides services through more than
4,500 clinics located in every state and U.S. territory.15
In 2009, Title X-funded clinics served 5.186 million clients, primarily low-income women and
adolescents.16 70% of clients had incomes at or below the federal poverty level; 91% had incomes
at or below 200% of the federal poverty level.17 For more than half of clients, Title X clinics are
their “usual” or only continuing source of health care.18 In 2009, the latest year for which data is
available, 66% of Title X clients were uninsured.19

8 DHHS, Office of Population Affair (OPA), HIV Prevention and Integration in Family Planning, http://www.hhs.gov/
opa/initiatives/hivprevention/.
9 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, http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm. See also CDC, HIV
Testing in Healthcare Settings, http://www.cdc.gov/hiv/topics/testing/healthcare/.
10 Christina Fowler, Julia Gable, Jiantong Wang, and Stacey Lloyd, Family Planning Annual Report: 2009 National
Summary, RTI International, Research Triangle Park, NC, November 2010, pp. 8, 10, http://www.hhs.gov/opa/
familyplanning/toolsdocs/fpar_2009_national_summary.pdf.
11 “Services for Men at Publicly Funded Family Planning Agencies, 1998-1999,” Perspectives on Sexual and
Reproductive Health, vol. 35, no. 5, September/October 2003. For more background see DHHS, OPA/Office of Family
Planning, Title X Male Involvement Prevention Services, http://www.hhs.gov/opa/familyplanning/grantees/
maleinvolvement/.
12 DHHS, HRSA, Fiscal Year 2012 Justification of Estimates for Appropriations Committees, p. 360,
http://www.hrsa.gov/about/budget/budgetjustification2012.pdf.
13Christina Fowler, Julia Gable, Jiantong Wang, and Stacey Lloyd, Family Planning Annual Report: 2009 National
Summary, p. 7.
14 42 C.F.R. § 59.7(c).
15 DHHS, HRSA, Fiscal Year 2012 Justification of Estimates for Appropriations Committees, p. 358. Christina Fowler,
Julia Gable, Jiantong Wang, and Stacey Lloyd, Family Planning Annual Report: 2009 National Summary, p. 7. A
searchable directory of Title X providers is at OPA Clearinghouse, Family Planning Database,
http://www.opaclearinghouse.org/db_search.asp.
16 Christina Fowler, Julia Gable, Jiantong Wang, and Stacey Lloyd, Family Planning Annual Report: 2009 National
Summary, pp. 8-9.
17 Christina Fowler, Julia Gable, Jiantong Wang, and Stacey Lloyd, Family Planning Annual Report: 2009 National
Summary, p. 22.
18 DHHS, Health Resources and Services Administration, Fiscal Year 2012 Justification of Estimates for
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Grants for family planning personnel training are to be used to train staff and “to improve
utilization and career development of paraprofessional and paramedical manpower in family
planning services, particularly in rural areas.”20 Staff are trained through 10 regional general
training programs and three national training programs.21 Family planning service delivery
improvement research grants are to be used to develop studies to improve the delivery of family
planning services. These research grants target projects that enhance effectiveness and efficiency
of the service delivery system.
More information on the Title X program, including regional contacts, can be found on the
Internet at http://www.hhs.gov/opa/familyplanning/.
Funding
FY2012 Budget Request
The President’s FY2012 Budget requests $327.356 million for Title X, the same as the FY2011
Budget Request. It would be a 3% increase over the FY2010 level of $317.491 million.
According to the HRSA Justification, the proposed FY2012 funding level would support family
planning services for 5.247 million persons (24,000 more persons than the FY2010 target). The
program’s FY2012 goals include preventing at least 1,850 cases of infertility through Chlamydia
screening, and preventing 1.008 million unintended pregnancies.22
The FY2012 HRSA Justification states that family planning clinics will be encouraged to use
electronic health records and electronic practice management systems and that the program will
continue to try to increase competition for funds, targeting areas that currently lack access to
family planning services. The Justification states that the program will continue to try to improve
clinic efficiency in response to rising costs for pharmaceuticals, providers, and screening and
diagnostic technologies.23 The FY2012 target for cost per client served is $280.66, with the goal
of maintaining the cost per client below the medical care inflation rate. The Justification also
states that clinics will be encouraged to expand the availability of long-acting reversible
contraceptive methods.24

(...continued)
Appropriations Committees, p. 358. See also Figure 2.3, “The large majority of women who obtain care at a family
planning center consider it their usual source of care,” 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, p. 14, http://www.guttmacher.org/pubs/
NextSteps.pdf.
19 Christina Fowler, Julia Gable, Jiantong Wang, and Stacey Lloyd, Family Planning Annual Report: 2009 National
Summary, pp. 21, 23.
20 CFDA, Program number 93.260.
21 DHHS, Health Resources and Services Administration, Fiscal Year 2012 Justification of Estimates for
Appropriations Committees, p. 358.
22 DHHS, HRSA, Fiscal Year 2012 Justification of Estimates for Appropriations Committees, pp. 359-360.
23 DHHS, HRSA, Fiscal Year 2012 Justification of Estimates for Appropriations Committees, p. 360.
24 DHHS, HRSA, Fiscal Year 2012 Justification of Estimates for Appropriations Committees, pp. 359-361.
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The FY2012 HRSA Justification describes plans to continue a contract with the Institute of
Medicine (IOM) to form a Standing Committee to advise the Title X program. The Standing
Committee will examine the role of family planning and reproductive health in health reform and
will address recommendations made in the independent IOM report, A Review of the HHS Family
Planning Program: Mission, Management, and Measurement of Results (2009). (The IOM report
is discussed further in the section “Institute of Medicine Evaluation.”)
FY2011 Funding
FY2011 Budget Request
The President’s FY2011 Budget requested $327.356 million for Title X, which would be a 3%
increase over the FY2010 level of $317.491 million. The HRSA Justification explained that at
least 90% of the increase would be used to implement recommendations made by the IOM 2009
report, A Review of the HHS Family Planning Program: Mission, Management, and Measurement
of Results.25 (The IOM report is discussed further in the section “Institute of Medicine
Evaluation.”)
The FY2011 HRSA Justification stated that family planning clinics would be encouraged to use
electronic health records, and that the program would continue to try to increase competition for
funds, targeting areas that currently lack access to family planning services. The HRSA
Justification also stated that the program would continue to try to improve efficiency in response
to rising costs for pharmaceuticals, providers, and screening and diagnostic technologies. 26
Congressional Action
On July 15, 2010, the House Appropriations Subcommittee on Labor-HHS-Education approved a
draft FY2011 bill, but did not release a committee report with funding figures for Title X.
On July 29, 2010, the Senate Appropriations Committee approved S. 3686, the FY2011 Labor-
HHS-Education appropriations bill. The bill would have provided the Title X program with
$327.356 million, the same as the Budget Request and 3% higher than the FY2010 level, but the
bill received no further action. In the committee report, DHHS was encouraged to use the funding
increase “to provide technical assistance to grantees to be prepared for healthcare reform,
including the expansion of Medicaid, technology upgrades and participating as essential
community providers.” The committee also urged HRSA to augment existing grantees’ awards to
offset the increasing costs of providing health care.27




25 DHHS, HRSA, Fiscal Year 2011 Justification of Estimates for Appropriations Committees, p. 322,
http://www.hrsa.gov/about/budgetjustification/budgetjustification11.pdf.
26 DHHS, HRSA, Fiscal Year 2011 Justification of Estimates for Appropriations Committees, p. 323.
27 S.Rept. 111-243, pp. 61-62.
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Continuing Resolutions
P.L. 112-6, the Continuing Appropriations Act, 2011, as amended, provides temporary FY2011
funding through April 8, 2011, at the FY2010 rate of operations and under the same conditions as
in FY2010.28 These conditions are laid out in P.L. 111-117, the Consolidated Appropriations Act,
2010. The conditions include that Title X funds not be spent on abortions, that all pregnancy
counseling be nondirective, and that funds not be spent on “any activity (including the publication
or distribution of literature) that in any way tends to promote public support or opposition to any
legislative proposal or candidate for public office.”29 Grantees are also required to certify that
they encourage “family participation” when minors decide to seek family planning services, and
to certify that they counsel minors on how to resist attempted coercion into sexual activity.30 The
appropriations statute also clarifies that family planning providers are not exempt from state
notification and reporting laws on child abuse, child molestation, sexual abuse, rape, or incest.31
The Consolidated Appropriations Act, 2010, contained 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.”32 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.”33 In the February 23, 2011, Federal Register, DHHS stated of potential

28 P.L. 112-6 is the sixth FY2011 continuing appropriations law that continues funding for most federal programs at
FY2010 levels. Previously, P.L. 111-242 continued funding through December 3, 2010; P.L. 111-290 continued
funding through December 18, 2010; P.L. 111-317 continued funding through December 21, 2010; P.L. 111-322
continued funding through March 4, 2011; and P.L. 112-4 continued funding through March 18, 2011.
29 P.L. 111-117, Division D, Departments of Labor, Health and Human Services, and Education, and Related Agencies
Appropriations Act, 2010, Title II, Department of Health and Human Services, Health Resources and Services
Administration, 123 Stat. 3239-3240.
30 P.L. 111-117, Division D, Departments of Labor, Health and Human Services, and Education, and Related Agencies
Appropriations Act, 2010, Title II, Department of Health and Human Services, General Provisions, § 209, 123 Stat.
3256.
31 P.L. 111-117, Division D, Departments of Labor, Health and Human Services, and Education, and Related Agencies
Appropriations Act, 2010, Title II, Department of Health and Human Services, General Provisions, § 210, 123 Stat.
3256-3257.
32P.L. 111-117, Division D, Departments of Labor, Health and Human Services, and Education, and Related Agencies
Appropriations Act, 2009, Title V, General Provisions, § 508(d), 123 Stat. 3280. 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).
33 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
(continued...)
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conflicts, “The approach of a case by case investigation and, if necessary, enforcement will best
enable the Department to deal with any perceived conflicts within concrete situations.”34 This
issue discussed further in “Provider Conscience Rule” below.
H.R. 1, the Full-Year Continuing Appropriations Act, 2011, passed the House on February 19,
2011. It would eliminate funding for Title X for the remainder of FY2011. During House debate
on H.R. 1, three amendments were submitted that would have struck the language eliminating
funds for Title X. One of those amendments would have also maintained FY2011 Title X
funding at the FY2010 level of $317.491 million. These amendments did not see floor action.
During Senate debate on H.R. 1, S.Amdt. 149 was defeated; it was a substitute amendment that
would have continued funding Title X for the remainder of FY2011 at the same rate of operations
as in FY2010.
Table 1. Title X Family Planning Program Appropriations
(in millions)
FY Appropriation FY Appropriation FY Appropriation
1971 $6.0
1985 $142.5 1999 $215.0
1972 $61.8
1986 $136.4 2000 $238.9
1973 $100.6
1987 $142.5
2001 $253.9
1974 $100.6
1988 $139.7
2002 $265.0
1975 $100.6
1989 $138.3
2003 $273.4
1976 $100.6
1990 $139.1
2004 $278.3
1977 $113.0
1991 $144.3
2005 $286.0
1978 $135.0
1992 $149.6
2006 $282.9
1979 $135.0
1993 $173.4
2007 $283.1
1980 $162.0
1994 $180.9
2008 $300.0
1981 $161.7
1995 $193.3
2009 $307.5
1982 $124.2
1996 $192.6
2010 $317.5
1983 $124.1
1997 $198.5
2011
a
1984 $140.0
1998 $203.5
2012 $327.4b
Source: FY1971-FY2005: Department of Health and Human Services, Office of Population Affairs, Funding
History, http://www.hhs.gov/opa/about/budget/; 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, p. 1793, http://www.gpoaccess.gov/congress/house/appropriations/08conappro.html;
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.

(...continued)
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).
34 DHHS, “Regulation for the Enforcement of Federal Health Care Provider Conscience Protection Laws,” 76 Federal
Register 9973, February 23, 2010.
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a. P.L. 112-6, the Continuing Appropriations Act, 2011, as amended, provides temporary FY2011 funding
through April 8, 2011, at the FY2010 rate of operations and under the same conditions as in FY2010. H.R.
1, as passed in the House, would eliminate funding for the remainder of the fiscal year.
b. Amount based on he President’s FY2012 Budget Request level.
Institute of Medicine Evaluation
At the request of OPA’s Office of Family Planning (OFP), 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).35
IOM found that family planning—“helping people have children when they want to and avoid
conception when they do not—is a critical social and public health goal,” and that the “federal
government has a responsibility to support the attainment of this goal.” IOM noted, for example,
that family planning can prevent unintended and high-risk pregnancies, thereby reducing fetal,
infant, and maternal mortality and morbidity. IOM also stated that the appropriate use of
contraception can reduce abortion rates and cited “ample evidence that family planning services
are cost-effective.”36
IOM recommended that OFP develop and implement a multiyear evidence-based strategic plan .37
IOM also made specific recommendations to improve program management and administration.
For example, IOM recommended that program funding be increased so that statutory
responsibilities can be met, that methods of allocating funds be examined and improved, that drug
purchasing sources be consolidated, that the administrative burden on clinics be reduced, that a
single method be adopted for determining eligibility criteria for services, that transparency be
increased, that workforce needs be assessed, and that program guidelines be evidence-based.38
Finally, IOM made recommendations to improve program evaluation. For example, IOM
recommended that OFP collect additional data on client and system characteristics, the process
and quality of care, and program outcomes. IOM recommended that OFP fund and use a
comprehensive framework for evaluating Title X, that OFP obtain scientific input on its
evaluation efforts, and that evaluation findings be communicated to grantees, clinics, and others.39
In response to the IOM report, DHHS has a contract with IOM to form a Standing Committee to
advise the Title X program. The Standing Committee is expected to help develop a
comprehensive strategic plan and will conduct additional studies on program infrastructure and

35 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.php?record_id=12585.
36 IOM, A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results, pp. 4,
70.
37 IOM, A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results, p. 98.
38 IOM, A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results, pp. 140-
143.
39 IOM, A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results, pp. 166-
170.
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goals.40 According to the FY2012 HRSA Justification, the Standing Committee will advise the
program on the following areas related to report recommendations: strategic planning, workforce
planning, improving data collection on program performance, and improving communication and
transparency.41
The President’s FY2011 Budget requested a $10 million (3%) increase over the FY2010 funding
level for Title X. The HRSA Justification stated that at least 90% of this increase would be used
to implement IOM’s recommendations, “specifically supporting the infrastructure that is currently
needed to meet the demand for care, including the ability to recruit and retain qualified staff, and
to better meet the needs for family planning services among low-income individuals, through
addressing the increasing cost of providing family planning services to low-income individuals,
including uninsured and under-insured.”42
Abortion and Title X
The law prohibits the use of Title X funds in programs where abortion is a method of family
planning.43 On July 3, 2000, OPA released a final rule with respect to abortion services in family
planning projects.44 The rule updated and revised regulations that had been in effect since 1988.45
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.”46
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

40 DHHS, HRSA, Fiscal Year 2012 Justification of Estimates for Appropriations Committees, p. 358.
41 DHHS, HRSA, Fiscal Year 2012 Justification of Estimates for Appropriations Committees, p. 360.
42 DHHS, HRSA, Fiscal Year 2011 Justification of Estimates for Appropriations Committees, p. 322
43 42 U.S.C. § 300a-6. In addition, annual appropriations riders to 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 FY2010, this rider appeared in P.L. 111-117, 123 Stat. 3239). For background on abortion funding restrictions in
general, see CRS Report RL33467, Abortion: Judicial History and Legislative Response, by Jon O. Shimabukuro.
44 DHHS, OPA, “Standards of Compliance for Abortion-Related Services in Family Planning Services Projects,” 65
Federal Register 41270–41280, July 3, 2000, and DHHS, OPA, “Provision of Abortion-Related Services in Family
Planning Services Projects, “ 65 Federal Register 41281-41282, July 3, 2000.
45 42 C.F.R. Part 59, “Grants for family planning services.”
46 On December 19, 2008, DHHS published a provider conscience rule which, according to DHHS, is inconsistent with
the requirement that Title X grantees provide clients with abortion referrals upon request. 73 Federal Register 78087.
This is also discussed below in “Provider Conscience Rule.”
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activities must be “separate and distinct” from the Title X project activities.47 Safeguards to
maintain this separation include (1) careful review of grant applications to ensure that the
applicant understands the requirements and has the capacity to comply with all requirements; (2)
independent financial audits to examine whether there is a system to account for program-funded
activities and non-allowable program activities; (3) yearly comprehensive reviews of the grantees’
financial status and budget report; and (4) periodic and comprehensive program reviews and site
visits by OPA regional offices.
It is unclear exactly how many Title X clinics also provide abortions through their non-Title X
activities. In 2004, following appropriations conference report directions, DHHS surveyed its
Title X grantees on whether their clinic sites also provided abortions with non-federal funds.48
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.
DHHS mailed surveys to 86 grantees and received 46 responses. Of these, nine indicated that at
least one of their clinic sites (17 clinic sites in all) also provided abortions with non-federal funds,
and 34 indicated that none of their clinic sites provided abortions with non-federal funds; three
responses had no numerical data or said the information was unknown.
Title X supporters argue that family planning reduces unintended pregnancies, thereby reducing
abortion.49 DHHS estimates that Title X family planning services helped avert 993,614
unintended pregnancies in FY2009.50 The Guttmacher Institute estimates that clinics receiving
Title X funds helped avert 406,200 abortions in 2008.51
On the other hand, Title X critics argue that federal funds should be withheld from any
organization that performs or promotes abortions, such as the Planned Parenthood Federation of
America. These critics argue that federal funding for non-abortion activities frees up Planned
Parenthood’s other resources for its abortion activities.52 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.53

47 65 Federal Register 41281-41282, July 3, 2000.
48 DHHS, Report to Congress Regarding the Number of Family Planning Sites Funded Under Title X of the Public
Health Service Act That Also Provide Abortions with Non-Federal Funds, 2004. The DHHS was directed to conduct
the survey by FY2004 appropriations conference report H.Rept. 108-401, pp. 800-801.
49 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.
50 DHHS, HRSA, Fiscal Year 2012 Justification of Estimates for Appropriations Committees, p. 361.
51 Jennifer J. Frost, Stanley K. Henshaw, and Adam Sonfeld, Contraceptive needs and services: national and state
data, 2008 update, Guttmacher Institute, New York, NY, 2010, p. 16, http://www.guttmacher.org/pubs/win/
contraceptive-needs-2008.pdf.
52 Examples of this argument can be found in House debate, Congressional Record, daily edition, vol. 154, no. 112
(July 9, 2008), pp. H6320-H6326. In 2009, 332,278 abortion procedures were performed by Planned Parenthood
affiliates, comprising three percent of Planned Parenthood services that year, according to the Planned Parenthood
Federation of America, Planned Parenthood Services Fact Sheet, February 2011, p. 2,
http://www.plannedparenthood.org/files/PPFA/PP_Services.pdf.
53 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
(continued...)
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Teenage Pregnancy and Title X
In 2009, 24% of Title X clients were aged 19 or younger.54 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.55 (See CRS Report RS20301, Teenage
Pregnancy Prevention: Statistics and Programs, by Carmen Solomon-Fears, for a broader
discussion of teen pregnancy.)
The program’s supporters, on the other hand, argue that the Title X program should be expanded
to serve more people in order to reduce the rate of unintended pregnancies. According to DHHS,
in 2007, Title X family planning services helped avert an estimated 242,480 unintended teen
pregnancies.56 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.57
Confidentiality for Minors and Title X
Confidentiality is required for personal information about Title X services provided to
individuals.58 Regarding services to minors, Title X project guidelines state:
Adolescents must be assured that the counseling sessions are confidential and, if follow-up is
necessary, every attempt will be made to assure the privacy of the individual. However,
counselors should encourage family participation in the decision of minors to seek family
planning services and provide counseling to minors on resisting attempts to coerce minors
into engaging in sexual activities. Title X projects may not require written consent of parents
or guardians for the provision of services to minors. Nor can the project notify parents or

(...continued)
Services, pp. 22-35.
54 Christina Fowler, Julia Gable, Jiantong Wang, and Stacey Lloyd, Family Planning Annual Report: 2009 National
Summary, p. 9.
55 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.
56 Email correspondence between the author and Maurice Huguley, Office of the Assistant Secretary for Legislation,
U.S. Department of Health and Human Services, January 27, 2009. 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.php?record_id=4903.
57 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.
58 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.
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guardians before or after a minor has requested and received Title X family planning
services.59
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.60
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.”61 The project
guidelines instruct that “Eligibility for discounts for minors who receive confidential services
must be based on the income of the minor.”62
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. 63
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.”64
Planned Parenthood and Title X
In May 2010, the Government Accountability Office (GAO) released a report with data on the
obligations and expenditures of federal funds for several nonprofit organizations, including the
Planned Parenthood Federation of America and its affiliates.65

59 DHHS, Office of Family Planning, Program Guidelines For Project Grants For Family Planning Services, January
2001, p. 25, http://www.hhs.gov/opa/familyplanning/toolsdocs/2001_ofp_guidelines_complete.pdf. For an overview of
Title X efforts to encourage family participation, see RTI International, An Assessment of Parent Involvement
Strategies in Programs Serving Adolescents: Final Report, 2007, http://www.hhs.gov/opa/pubs/
parent_involvement_finalreport_9-11-07_psg.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.
60 P.L. 111-117, Division D, Departments of Labor, Health and Human Services, and Education, and Related Agencies
Appropriations Act, 2010, Title II, Department of Health and Human Services, General Provisions, § 210, 123 Stat.
3256-3257.
61 42 C.F.R. § 59.2.
62 DHHS, Office of Family Planning, Program Guidelines For Project Grants For Family Planning Services, January
2001, p. 8.
63 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, p. 5-10.
64 Examples of these arguments appear in Congressional Record, daily edition, vol. 142 (July 11, 1996), pp. H7348-H
7349, 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, 104th Cong., 1st sess., August
10, 1995, S.Hrg. 104-416 (Washington: GPO, 1996), 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.
65 U.S. Government Accountability Office (GAO), Federal Funds: Fiscal Years 2002-2009 Obligations,
Disbursements, and Expenditures for Selected Organizations Involved in Health-Related Activities, GAO-10-533R,
May 28, 2010, http://www.gao.gov/products/GAO-10-533R.
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Planned Parenthood operates through a national office and 85 affiliates, which operate more than
820 local health centers.66 Affiliates participating in Title X can receive funds directly from
DHHS or indirectly from other Title X grantees, such as their state or local health departments.
According to the GAO report, in FY2009, DHHS reported obligating to Planned Parenthood and
its affiliates $18.2 million through the Title X Family Planning Services program and $0.3 million
through Title X Family Planning Service Delivery Improvement Research Grants.67 These figures
reflect funds that DHHS provided directly to these organizations. They do 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 Planned Parenthood’s expenditures of Title X funds. These
expenditures were identified through audit reports that Planned Parenthood and its affiliates
submitted to comply with Office of Management and Budget (OMB) audit requirements.68
Expenditures include federal funds provided directly or indirectly to these organizations. The
most recent expenditure data was from FY2008, when Planned Parenthood and its affiliates
reported spending $53.0 million from the Title X Family Planning Services program.69
Provider Conscience Rule
Overview
Several already existing federal restrictions protect health care providers from being coerced to
provide certain services to which they object. These statutory restrictions prohibit recipients of
certain federal funds from discriminating against such providers. These restrictions include the
Church Amendment (which protects those with religious or moral objections to abortion and
sterilization), Public Health Service (PHS) Act sec. 245 (which protects certain individuals,
medical schools, and training programs that will not provide, perform, make arrangements for, or
refer for abortions or abortion training), and the Weldon Amendment (which protects certain
entities that will not provide, pay for, provide coverage for, or refer for abortions).70

66 Planned Parenthood Federation of America, Planned Parenthood at a Glance, http://www.plannedparenthood.org/
about-us/who-we-are/planned-parenthood-glance-5552.htm.
67 GAO, Federal Funds: Fiscal Years 2002-2009 Obligations, Disbursements, and Expenditures for Selected
Organizations Involved in Health-Related Activities, p. 16.
68 Organizations with annual expenditures of federal funds of $500,000 or more are required to have an audit. The
GAO report includes expenditure data from 85 Planned Parenthood affiliates. GAO, Federal Funds: Fiscal Years
2002-2009 Obligations, Disbursements, and Expenditures for Selected Organizations Involved in Health-Related
Activities, p. 10 footnote b, p. 22 footnote 1.
69 GAO, Federal Funds: Fiscal Years 2002-2009 Obligations, Disbursements, and Expenditures for Selected
Organizations Involved in Health-Related Activities, p. 25.
70 More background about these and other federal provider conscience provisions is in CRS Report R40722, Health
Care Providers’ Religious Objections to Medical Treatment: Legal Issues Related to Religious Discrimination in
Employment and Conscience Clause Provisions, by Cynthia Brougher and Edward C. Liu, and CRS Report RL34703,
The History and Effect of Abortion Conscience Clause Laws, by Jon O. Shimabukuro. See also DHHS, Office for Civil
Rights (OCR), Overview of Federal Statutory Health Care Provider Conscience Protections, http://www.hhs.gov/ocr/
civilrights/faq/providerconsciencefaq.html, and Federal Health Care Conscience Protection Statutes,
http://www.hhs.gov/ocr/civilrights/understanding/ConscienceProtect/index.html
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In the December 19, 2008, Federal Register, DHHS published a final rule, often called the
provider conscience rule, that was intended to increase awareness of these existing restrictions.71
Some critics argued that the rule would limit patients’ access to contraception, and that it
conflicted with the Title X requirement that grantees provide pregnant women, upon request,
nondirective counseling and referrals on several options including abortion.
The rule became effective January 20, 2009. In the March 10, 2009, Federal Register, DHHS
proposed to rescind the provider conscience rule and invited public comments.72
In the February 23, 2011, Federal Register, DHHS rescinded most of the rule, except for a
provision that the DHHS Office for Civil Rights will handle complaints based on federal health
care provider conscience protection restrictions. DHHS stated that parts of the 2008 rule were
“unclear and potentially overbroad in scope,” and noted that the rescission “does not alter or
affect the federal statutory health care provider conscience protections” that already exist.73
2008 Final Rule
The 2008 provider conscience rule stated that entities carrying out DHHS health service programs
shall not require individuals “to perform or assist in the performance of any part of a health
service program or research activity funded by the Department if such service or activity would
be contrary to his religious beliefs or moral convictions.”74 The rule defined assist in the
performance as participating in any activity with a “reasonable connection” to the objectionable
procedure or health service, including “counseling, referral, training, and other arrangements” for
the procedure or health service.75
The rule prohibited recipients of DHHS appropriations act funds from subjecting institutions or
individuals to discrimination because they did not refer patients for abortions.76 Also, the rule
prohibited recipients of grants under the Public Health Service Act from discriminating against
physicians or other health care professionals because they refused to assist in the performance of
sterilization or abortion based on religious beliefs or moral convictions.77
Before publishing the final rule, DHHS solicited public comments.78 Some commenters argued
that the rule was inconsistent with the Title X regulatory requirement that grantees provide

71 U.S. Department of Health and Human Services, “Ensuring Department of Health and Human Services Funds Do
Not Support Coercive or Discriminatory Policies or Practices in Violation of Federal Law,” 73 Federal Register
78072–78101, December 19, 2008, http://federalregister.gov/a/E8-30134.
72 DHHS, “Rescission of the Regulation Entitled ‘Ensuring That Department of Health and Human Services Funds Do
Not Support Coercive or Discriminatory Support Coercive or Discriminatory Federal Law’; Proposal,” 74 Federal
Register 10207-10211, March 10, 2009, http://federalregister.gov/a/E9-5067. Many of the public comments are posted
at http://www.regulations.gov/#!docketDetail;D=HHS-OPHS-2009-0001.
73 DHHS, “Regulation for the Enforcement of Federal Health Care Provider Conscience Protection Laws,” 76 Federal
Register 9969, February 23, 2011, http://federalregister.gov/a/2011-3993.
74 73 Federal Register 79097, 79098, §88.3(g)(1), §88.4(d)(1).
75 73 Federal Register 78097, §88.2.
76 73 Federal Register78097, 78098, §88.3(c), §88.4(b)(2).
77 73 Federal Register78097, 78098, §88.3(f)(1), §88.4(c)(1).
78 Comments may be viewed at http://www.regulations.gov/#!docketDetail;D=HHS-OS-2008-0011. (Check the “Public
Submissions” box).
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pregnant women, upon request, nondirective counseling and referrals on several options including
abortion.79 The Title X requirement states that 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.”80
DHHS responded that the provider conscience requirement did indeed conflict with the Title X
requirement, so that in certain situations, OPA would not enforce the Title X referral regulation:
With regards to the Title X program, Commenters are correct that the current regulatory
requirement that grantees must provide counseling and referrals for abortion upon request
(42 C.F.R. 59.5(a)(5)) is inconsistent with the health care provider conscience protection
statutory provisions and this regulation. The Office of Population Affairs, which administers
the Title X program, is aware of this conflict with the statutory requirements and, as such,
would not enforce this Title X regulatory requirement on objecting grantees or applicants.81
The final rule did not define the term abortion. Some commenters argued that by not defining
abortion as excluding contraception, the rule could jeopardize Title X programs. DHHS
responded that “questions over the nature of abortion and the ending of a life are highly
controversial and strongly debated,” and so declined to issue a formal definition. DHHS added
that “nothing in this rule alters the obligation of federal Title X programs to deliver contraceptive
services to clients in need as authorized by law and regulation.”82
Some commenters argued that the rule would make it difficult for Title X clinics to screen job
applicants to ensure that staff were willing to provide contraceptive services. DHHS responded
that job applicants would be unlikely to apply for, or be best qualified for, jobs where they object
to the majority of the work. DHHS explained further:
To the extent a health care employer’s adverse decision is based on an applicant’s inability to
perform the essential functions of a job, the decision would not typically constitute
discrimination under the regulation even if the applicant had expressed an unwillingness to
perform those functions on conscience grounds. However, an adverse decision predicated on
an applicant’s alleged ‘‘inability’’ could constitute unlawful discrimination if the employer’s
stated reasons are pretextual; for example, if the employer is using the definition of essential
functions as a pretext for excluding applicants with certain religious beliefs or moral
convictions.83
In response to comments that the rule would restrict patients’ access to contraception, DHHS
responded that “we have found no evidence that these regulations will create new barriers in

79 Examples of such comments include Letter from Sharon L. Camp, President and CEO, Guttmacher Institute, to
DHHS, September 24, 2008, http://www.guttmacher.org/media/resources/2008/09/24/GuttmacherInstitute-re-
ConscienceRegulation.pdf, and Letter from Caroline Fredrickson, Director, Washington Legislative Office, American
Civil Liberties Union (ACLU), Louise Melling, Director, Reproductive Freedom Project, ACLU, and Vania Leveille,
Washington Legislative Office, ACLU, et al. to DHHS, September 25, 2008, http://www.aclu.org/images/
asset_upload_file467_36942.pdf.
80 42 C.F.R. § 59(a)(5).
81 73 Federal Register 78087.
82 73 Federal Register 78077.
83 73 Federal Register 78084-78085.
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accessing contraception unless those contraceptives are currently delivered over the religious or
moral objections of the provider.” 84
2011 Rule Rescission
In the February 23, 2011, Federal Register, DHHS rescinded most of the 2008 final rule, except
for a provision that the DHHS Office for Civil Rights (OCR) will coordinate the handling of
complaints based on federal provider conscience statutory restrictions.85 DHHS stated that “No
regulations were required or necessary for the conscience protections contained in the Church
Amendments, PHS Act, sec. 245, and the Weldon Amendment to take effect,” and that the rule
rescission does not affect existing provider conscience statutory restrictions.86
As discussed above in “2008 Final Rule,” some commenters had raised concerns about possible
conflicts between the 2008 Final Rule and requirements governing certain DHHS programs,
including Title X. In the 2011 rule rescission, DHHS stated that such conflicts would be
addressed on a case by case basis:
Health care entities must continue to comply with the long-established requirements of the
statutes above governing Departmental programs. These statutes strike a careful balance
between the rights of patients to access needed health care, and the conscience rights of
health care providers. The conscience laws and the other federal statutes have operated side
by side often for many decades. As repeals by implication are disfavored and laws are meant
to be read in harmony, the Department fully intends to continue to enforce all the laws it has
been charged with administering. The Department is partially rescinding the 2008 final rule
in an attempt to address ambiguities that may have been caused in this area. 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.87
As discussed in “2008 Final Rule,” some commenters had raised concerns that the 2008 rule did
not define “abortion” as excluding contraception. In rescinding the rule, DHHS stated that “The
provision of contraceptive services has never been defined as abortion in federal statute. There is
no indication that the federal health care provider conscience statutes intended that the term
‘abortion’ included contraception.”88
As discussed in “2008 Final Rule,” some commenters had raised concerns that the 2008 rule
could restrict some patients’ access to contraception. DHHS stated that it rescinded the rule in
part because it “had the potential to negatively impact patient access to contraception and certain

84 73 Federal Register 78071-78072.
85 DHHS explained that the enforcement of statutory provider conscience protections would include “normal program
compliance mechanisms.” For example, DHHS is expected to help violating entities come into compliance, and if
entities still fail to comply, DHHS “will consider all legal options,” such as the termination of funds and the return of
funds paid out in violation of the conscience statutes. DHHS also stated that it is starting an initiative to increase
awareness of federal provider conscience protections among grantees and health care providers. OCR includes provider
conscience information in its education and outreach efforts and on its website, and DHHS is amending its grant
documents to clarify that recipients must comply with federal conscience protection laws. DHHS, “Regulation for the
Enforcement of Federal Health Care Provider Conscience Protection Laws,” 76 Federal Register 9972, February 23,
2010.
86 76 Federal Register 9969, 9970.
87 76 Federal Register 9973.
88 76 Federal Register 9973.
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other medical services without a basis in federal conscience protection statutes.” DHHS reiterated
that entities should continue to comply with their Title X obligations.89
Legislation in the 112th Congress
Several bills on the Title X program have been introduced in the 112th Congress.
Abortion Restrictions
H.R. 217, the Title X Abortion Provider Prohibition Act, was introduced January 7, 2011. The bill
would prohibit Title X assistance to any entity unless it certifies that it will not perform, nor
provide funds to any other entity that performs, an abortion during the period of assistance. The
prohibition would not apply to hospitals, unless the hospital provides funds to a non-hospital
entity that performs an abortion. The bill has exceptions for abortions performed in cases of rape,
incest against a minor, or certain physician-certified cases where the woman is “in danger of
death unless an abortion is performed.” H.R. 217 would also require the DHHS Secretary to
provide Congress an annual report listing, for each entity receiving a Title X grant: information
on any abortions it performed, the date that it last certified that it would not perform abortions,
and any other entities to which it makes available funds received through Title X grants. The bill
was referred to the House Committee on Energy and Commerce.
S. 96, the Title X Family Planning Act, was introduced January 25, 2011. It would prohibit Title
X funds from going to entities that perform abortions or whose subgrantees perform abortions,
except in certain physician-certified cases where the woman is “in danger of death unless an
abortion is performed.” This prohibition would not apply to hospitals, unless the hospital
subgrants to a non-hospital entity that performs abortions. S. 96 would require Title X grant
applicants to certify that they and their subgrantees adhere to the abortion prohibition. It would
also require the DHHS to provide Congress with an annual list of Title X grantees that perform
abortions; if an entity appears on the list, it would be ineligible for subsequent fiscal year Title X
funds unless it certifies that it no longer performs abortions. S. 96 was referred to the Senate
Committee on Health, Education, Labor, and Pensions.
Other bills related to abortion are discussed in CRS Report RL33467, Abortion: Judicial History
and Legislative Response, by Jon O. Shimabukuro.
Elimination of Title X Funds
H.R. 1, the Full-Year Continuing Appropriations Act, 2011, passed the House on February 19,
2011. It would eliminate funding for Title X for the remainder of FY2011. During House debate
on H.R. 1, three amendments were submitted that would have struck the language eliminating
funds for Title X.90 One of those amendments would have also maintained FY2011 Title X
funding at the FY2010 level of $317.491 million.91 These amendments did not see floor action.

89 76 Federal Register 9974.
90 Amendment no. 335, House amendments, Congressional Record, daily edition, February 14, 2011, p. H794;
Amendment no. 386, House amendments, Congressional Record, daily edition, February 14, 2011, p. H796;
Amendment no. 505, House amendments, Congressional Record, daily edition, February 15, 2011, p. H929.
91 Amendment no. 335, House amendments, Congressional Record, daily edition, February 14, 2011, p. H794
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During Senate debate on H.R. 1, S.Amdt. 149 was defeated; it was a substitute amendment that
would have continued funding Title X for the remainder of FY2011 at the same rate of operations
and under the same conditions as in FY2010.
H.R. 408, the Spending Reduction Act of 2011, was introduced January 24, 2011. It would
eliminate the Title X program, stating that “No funds appropriated or otherwise available to any
Federal department or agency may be obligated or expended for” a list of programs including
Title X. It was referred to the House Committees on Oversight and Government Reform, Natural
Resources, Transportation and Infrastructure, Budget, Rules, Appropriations, Agriculture,
Administration, Education and the Workforce, Energy and Commerce, Ways and Means,
Financial Services, Judiciary, and Science, Space, and Technology
S. 178, the Spending Reduction Act of 2011, was introduced January 25, 2011. It would eliminate
the Title X program, stating that “No funds appropriated or otherwise available to any Federal
department or agency may be obligated or expended for” a list of programs including Title X. It
was referred to the Senate Committee on Finance.
H.R. 1099, the Taxpayers’ Freedom of Conscience Act of 2011, was introduced March 15, 2011.
It would prohibit federal officials from expending federal funds for “any population control or
population planning program or any family planning activity (including any abortion procedure),
irrespective of whether such program or activity is foreign or domestic.” H.R. 1099 was referred
to the House Committees on Foreign Affairs and Energy and Commerce.
Limits on Means-Tested Welfare Spending
H.R. 1135 and H.R. 1167, both titled the Welfare Reform Act of 2011, would define “means-
tested welfare spending” programs to include family planning, as well as more than 70 other
federal programs. The bills would require a limit on aggregate means-tested welfare spending, no
greater than the FY2007 level, adjusted for inflation. This limit would become effective “after
any monthly rate of unemployment during the immediately preceding fiscal year is below 6.5
percent.” The limit would be enforced through the congressional budget process. Among other
provisions, the bills would also require the President’s Budget to provide information on total
means-tested welfare spending. H.R. 1135 was introduced March 16, 2011, and referred to the
House Committees on Ways and Means, Agriculture, the Budget, Rules, and Energy and
Commerce. H.R. 1167 was introduced March 17, 2011, and referred to the same committees.
Restrictions on Funding to Planned Parenthood
H.Amdt. 95 to H.R. 1, the Full-Year Continuing Appropriations Act, 2011, would prohibit the
bill=s funds from being made available “for any purpose” to the Planned Parenthood Federation of
America or to any of 102 Planned Parenthood affiliates and offices listed in the amendment.92 The
House agreed to the amendment on February 18, 2011. During Senate debate on H.R. 1, S.Amdt.
149 was defeated; it was a substitute amendment that did not mention Planned Parenthood and
that would not have eliminated funds for Planned Parenthood.

92 Amendment no. 11, House amendments, Congressional Record, daily edition, February 14, 2011, pp. H776-H777.
The entities listed in the amendment are the same as those on the website Planned Parenthood Federation of America,
Local & State Offices, http://www.plannedparenthood.org/about-us/affiliate-and-state-offices.htm.
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Title X (Public Health Service Act) Family Planning Program

Appendix. Summary of Title X of the Public Health
Service Act
Below is a summary of Title X of the Public Health Service Act, codified at 42 U.S.C. § 300 to §
300a-6, Population Research and Voluntary Family Planning Programs:
Section 1001. Project Grants and Contracts for Family Planning
Services
The Secretary may make grants to and enter into contracts with public or nonprofit private
entities to assist in the establishment and operation of voluntary family planning projects to offer
a broad range of acceptable and effective family planning methods and services (including natural
family planning methods, infertility services, and services for adolescents). Entities which receive
grants or contracts must encourage family participation in their projects.
Section 1002. Formula Grants to States for Family Planning
Services
The Secretary may make grants to state health authorities to assist in planning, establishing,
maintaining, coordinating, and evaluating family planning services. The state health authority
must have an approved state plan for a coordinated and comprehensive program of family
planning services.
Section 1003. Training Grants and Contracts
The Secretary may make grants to public or nonprofit private entities and enter into contracts
with public or private entities and individuals to provide the training for personnel to carry out
family planning service programs.
Section 1004. Research
The Secretary may conduct and make grants to public or nonprofit private entities and enter into
contracts with public or private entities and individuals for projects for research in the
biomedical, contraceptive development, behavioral, and program implementation fields related to
family planning and population.
Section 1005. Informational and Educational Materials
The Secretary may make grants to public or nonprofit private entities and enter into contracts
with public or private entities and individuals to assist in developing and making available family
planning and population growth information (including educational materials) to all persons
desiring such information.
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Title X (Public Health Service Act) Family Planning Program

Section 1006. Regulations and Payments
The Secretary may promulgate regulations and must determine the conditions for making
payments to grantees to assure that such grants will be effectively utilized for the purposes they
were made.
Grantees must assure that (1) priority will be given to the furnishing of services to persons from
low-income families; and (2) no charge will be made in such project or program for services
provided to any person from a low-income family except to the extent that payment will be made
by a third party (including a government agency) which is authorized or is under legal obligation
to pay the charge.
The Secretary must be satisfied that informational or educational materials developed or made
available under the grant or contract will be suitable for the purposes of this title and for the
population or community to which they are to be made available.
In the case of any grant or contract under Section 1001, such assurances shall provide for the
review and approval of the suitability of such materials, prior to their distribution, by an advisory
committee established by the grantee or contractor in accordance with regulations.
Section 1007. Voluntary Participation
The acceptance by any individual of family planning services or family planning or population
growth information (including educational materials) shall be voluntary and shall not be a
prerequisite to eligibility for or receipt of any other service or assistance from, or to participation
in, any other program of the entity or individual that provided such service or information.
Section 1008. Prohibition of Abortion
None of the funds appropriated under this title shall be used in programs where abortion is a
method of family planning.

Author Contact Information
Angela Napili
Information Research Specialist
anapili@crs.loc.gov, 7-0135

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