Title X (Public Health Service Act) Family
Planning Program
Angela Napili
Information Research Specialist
September 3, 2014
Congressional Research Service
7-5700
www.crs.gov
RL33644
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 (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 2012, Title X-funded clinics served 4.8 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 FY2014 Consolidated Appropriations Act (P.L. 113-76) provides $286 million for Title X,
3% more than the FY2013 funding level of $278 million. The FY2014 Consolidated
Appropriations Act continues 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 continue
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 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 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.
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Title X (Public Health Service Act) Family Planning Program
Contents
Title X Program Administration and Grants .................................................................................... 1
Administration ........................................................................................................................... 1
Family Planning Services Grants .............................................................................................. 1
Services ............................................................................................................................... 1
Client Charges ..................................................................................................................... 2
Client Characteristics .......................................................................................................... 2
Grantees and Clinics............................................................................................................ 3
Family Planning Training and Research Grants ........................................................................ 3
Funding ............................................................................................................................................ 4
FY2015 Budget Request ............................................................................................................ 4
FY2015 Appropriations Activity ............................................................................................... 4
FY2014 Funding ........................................................................................................................ 5
History of Funding .................................................................................................................... 6
Institute of Medicine Evaluation ...................................................................................................... 8
The Patient Protection and Affordable Care Act and Title X ........................................................... 9
Abortion and Title X ...................................................................................................................... 13
Teenage Pregnancy and Title X ..................................................................................................... 15
Confidentiality for Minors and Title X .......................................................................................... 16
Planned Parenthood and Title X .................................................................................................... 17
Figures
Figure 1. Title X Family Planning Program Appropriations, FY1978-FY2014 .............................. 8
Tables
Table 1. Title X Family Planning Program Appropriations, FY1971-FY2014 ................................ 7
Appendixes
Appendix. Summary of Title X of the Public Health Service Act ................................................. 19
Contacts
Author Contact Information........................................................................................................... 20
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Title X (Public Health Service Act) Family Planning Program
Title X Program Administration and Grants
The federal government provides grants for voluntary 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.
Although Title X is the only federal domestic program primarily focused on family planning,
other programs also finance family planning, among their other services. These programs include
Medicaid, the Health Centers program under Section 330 of the Public Health Service Act,
Maternal and Child Health Block Grants, and Social Services Block Grants. In FY2010, Medicaid
accounted for 75% of U.S. public family planning expenditures (including federal, state, and local
government spending). In comparison, Title X accounted for 10%.1
Administration
Title X is administered by the Office of Population Affairs’ (OPA’s) Office of Family Planning
(OFP), under the Office of the Assistant Secretary for Health in the 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;2 family
planning personnel training;3 and family planning service delivery improvement research grants.4
Family Planning Services Grants
Services
Ninety percent of Title X funds are used for clinical services.5 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
1 Adam Sonfield and Rachel Benson Gold, Public Funding for Family Planning, Sterilization and Abortion Services,
FY1980-2010, Guttmacher Institute, March 2012, http://www.guttmacher.org/pubs/Public-Funding-FP-2010.pdf. More
background is in Institute of Medicine (IOM), “Non-Title X Family Planning Funding Sources,” in A Review of the
HHS Family Planning Program: Mission, Management, and Measurement of Results, ed. Adrienne Stith Butler and
Ellen Wright Clayton (Washington: The National Academies Press, 2009), pp. 117-121, http://www.nap.edu/
catalog.php?record_id=12585.
2 Catalog of Federal Domestic Assistance (CFDA), Program number 93.217, http://www.cfda.gov.
3 CFDA, Program number 93.260.
4 CFDA, Program number 93.974.
5 HHS, Health Resources and Services Administration, Fiscal Year 2015 Justification of Estimates for Appropriations
Committees, p. 409, http://www.hrsa.gov/about/budget/budgetjustification2015.pdf.
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education, counseling, testing, and referral; preconception health services; and counseling on
establishing a reproductive life plan. Among the program’s FY2014 priorities is providing
preventive health services “in accordance with nationally recognized standards of care.”6 The
services must be provided “without coercion and with respect for the privacy, dignity, social, and
religious beliefs of the individuals being served.”7
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.8 OPA provides supplemental 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
Title X services offered to males include condoms, education and counseling, STD testing and
treatment, HIV testing, and, in some cases, vasectomy services.10
Client Charges
Priority for services is given to persons from low-income families, who may not be charged for
care.11 Clients from families with income between 100% and 250% of the federal poverty
guideline (FPL) are charged on a sliding scale based on their ability to pay. Clients from families
with income higher than 250% FPL are charged fees designed to recover the reasonable cost of
providing services.12
Client Characteristics
In 2012, Title X-funded clinics served 4.764 million clients, primarily low-income women and
adolescents. Of those clients, 8% were male, 71% had incomes at or below the federal poverty
6 U.S. Department of Health and Human Services (HHS), Office of Population Affairs, Fiscal Year 2014 Program
Priorities, http://www.hhs.gov/opa/title-x-family-planning/title-x-policies/program-priorities/. 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/title-x-family-planning/initiatives-and-resources/documents-and-
tools/opa-09-01.html.
7 CFDA, Program number 93.217. See also 42 C.F.R. §59.5.
8 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/.
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,
Testing in Clinical Settings, http://www.cdc.gov/hiv/testing/clinical/index.html.
10 HHS, OPA/Office of Family Planning, Male Services, http://www.hhs.gov/opa/title-x-family-planning/initiatives-
and-resources/male-services/.
11 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.”
12 42 C.F.R. §59.5.
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level, and 90% had incomes at or below 200% of the federal poverty level.13 For 61% of clients,
Title X clinics are their “usual” or only regular source of health care.14 In 2012, 64% of Title X
clients were uninsured.15
Grantees and Clinics
In 2012, there were 93 Title X family planning services grantees. Such grantees included 49 state,
local, and territorial health departments and 44 nonprofit organizations, such as hospitals,
community health agencies, family planning councils, and Planned Parenthood affiliates.16
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.17 In 2012, Title X
provided services through 4,189 clinics located in the 50 states, the District of Columbia, and the
U.S. territories.18
Family Planning Training and Research Grants
Grants for family planning personnel training are used to train staff and to improve the utilization
and career development of paraprofessionals.19 Staff are trained through five national training
programs for Coordination and Strategic Initiatives; Management and Systems Improvement;
Family Planning Service Delivery; Quality Assurance, Quality Improvement and Evaluation; and
a National Clinical Training Center.20 Family planning service delivery improvement research
grants are used for studies to enhance effectiveness and efficiency of the service delivery
system.21
More information on the Title X program can be found at http://www.hhs.gov/opa/title-x-family-
planning/.
13 Christina Fowler, Julia Gable, Jiantong Wang, and Emily McClure, Family Planning Annual Report: 2012 National
Summary, RTI International, Research Triangle Park, NC, November 2013, pp. 8-9, 21-22, http://www.hhs.gov/opa/
pdfs/fpar-national-summary-2012.pdf.
14 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.
15 Fowler et al., Family Planning Annual Report: 2012 National Summary, pp. 21, 23.
16 Ibid., p. 7.
17 42 C.F.R. §59.7(c).
18 Fowler et al., Family Planning Annual Report: 2012 National Summary, p. 7. A searchable directory of Title X
providers is at HHS, OPA, Title X Grantees List, http://www.hhs.gov/opa/title-x-family-planning/initiatives-and-
resources/title-x-grantees-list/.
19 CFDA, Program number 93.260.
20 HHS, OPA, National Training Centers, http://www.hhs.gov/opa/title-x-family-planning/training/national-training-
centers/.
21 A list of research grant projects is at HHS, OPA, Research, http://www.hhs.gov/opa/title-x-family-planning/research-
and-data/research/.
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Funding
The FY2014 Consolidated Appropriations Act (P.L. 113-76) provides $286.479 million for Title
X.22 The President’s FY2015 Budget proposes to fund Title X at the same amount, $286.479
million. Table 1 shows Title X appropriations amounts since FY1971, when the program was
created. Figure 1 shows Title X appropriations amounts since FY1978.
FY2015 Budget Request
The President’s FY2015 Budget, submitted March 4, 2014, requests $286.479 million for Title X.
This would be the same as the FY2014 enacted level.23 The budget would continue 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.24
According to the HRSA Justification, the proposed FY2015 funding level would support family
planning services for 4.3 million clients. The program’s FY2015 goals include preventing 1,400
cases of infertility through Chlamydia screening and preventing 828,700 unintended pregnancies.
The FY2015 target for cost per client served is $291.94, with the goal of maintaining the cost per
client below the medical care inflation rate.25
HRSA also plans to use FY2015 funds to train and support family planning clinics “to facilitate
full implementation of relevant provisions of the Affordable Care Act (ACA).” According to the
HRSA Justification, the Administration expects that clinics will increase revenue, in part by
raising the proportion of clients who have health insurance and by billing third parties.26
FY2015 Appropriations Activity
On June 10, 2014, the Senate Appropriations Subcommittee on the Departments of Labor, Health
and Human Services, and Education approved its FY2015 Labor-HHS-Education appropriations
bill by voice vote. On July 24, 2014, the Senate Appropriations Committee released a copy of the
subcommittee-approved bill and draft subcommittee report.27
The Senate subcommittee bill would fund Title X at $300 million, a 5% increase over the FY2014
level. The bill would continue previous year’s requirements that Title X funds not be spent on
abortions, all pregnancy counseling be nondirective, and funds not be spent on promoting or
22 P.L. 113-76, Division H, Title II. Per §206, the Administration has limited authority to transfer funds among HHS
accounts. After transfers, FY2014 Title X funding is $285.760 million, according to HHS, HRSA, Operating Plan for
FY2014, http://www.hrsa.gov/about/budget/operatingplan2014.pdf.
23 HHS, HRSA, Fiscal Year 2015, Justification of Estimates for Appropriations Committees, p.405.
24 Ibid., p. 19.
25 Ibid., pp. 408, 412.
26 Ibid., p. 409.
27 U.S. Senate Committee on Appropriations, “FY15 LHHS Subcommittee Reported Bill and Draft Report,” press
release, July 24, 2014, http://www.appropriations.senate.gov/news/fy15-lhhs-subcommittee-reported-bill-and-draft-
report.
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opposing any legislative proposal or candidate for public office. Grantees would continue to be
required to 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. The bill would also clarify that family planning providers are not exempt from state
notification and reporting laws on child abuse, child molestation, sexual abuse, rape, or incest.
The Senate draft subcommittee report expresses continued support for Title X during and after
ACA implementation:
Although health reform will result in the expansion of insurance coverage, patients seeking
family planning and reproductive health services often have privacy concerns that inhibit the
full use of coverage. Many of these patients will turn to safety-net settings, such as title X-
funded health centers, for care. Public funding for family planning remains a cost-effective
means of providing essential health services and will be important to Federal and State
efforts to implement the ACA.28
The Senate draft subcommittee report also expresses support for using Title X funds to invest in
infrastructure, such as health information technology. The report also notes, with regard to Title X
subgrants, that “The Committee expects that funding decisions will be made solely on the ability
of a clinic to achieve the best possible outcomes for the population served.”
The House has yet to take legislative action on their FY2015 Labor-HHS-Education
appropriations bill.
FY2014 Funding
The FY2014 Consolidated Appropriations Act (P.L. 113-76) provides $286.479 million for Title
X, 3% more than the FY2013 funding level of $278.349 million.29 The FY2014 Consolidated
Appropriations Act continues 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 “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.” Grantees
continue to be required to 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. The law also clarifies that family planning providers are not exempt from
28 Ibid., p. 65 of the draft report. Privacy concerns are discussed below in the sections “The Patient Protection and
Affordable Care Act and Title X” and “Confidentiality for Minors and Title X.”
29 P.L. 113-76, Division H, Title II. Per §206, the Administration has limited authority to transfer funds among HHS
accounts. After transfers, FY2014 Title X funding is $285.760 million, according to HHS, HRSA, Operating Plan for
FY2014, http://www.hrsa.gov/about/budget/operatingplan2014.pdf. The FY2013 amount is from HHS, HRSA,
Sequestration Operating Plan for FY2013, http://www.hrsa.gov/about/budget/operatingplan2013.pdf. With limited
exceptions, the FY2013 Consolidated and Further Continuing Appropriations Act (P.L. 113-6) generally funded
discretionary HHS programs at their FY2012 levels, minus an across-the-board rescission of 0.2% per §3004, as
interpreted by the Office of Management and Budget (OMB). FY2013 Title X appropriations were also subject to an
automatic across-the-board spending reduction, known as sequestration, under the Budget Control Act of 2011 (BCA;
P.L. 112-25) and the American Taxpayer Relief Act of 2012 (ATRA; P.L. 112-240). For discretionary nondefense
programs subject to sequestration, OMB calculated a sequester percentage of 5.0%. For more background on
sequestration, see CRS Report R42050, Budget “Sequestration” and Selected Program Exemptions and Special Rules,
coordinated by Karen Spar.
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state notification and reporting laws on child abuse, child molestation, sexual abuse, rape, or
incest.30
FY2014 appropriations are 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.”31 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.”32 In the February 23,
2011, Federal Register, HHS stated of potential conflicts, “The approach of a case by case
investigation and, if necessary, enforcement will best enable the Department to deal with any
perceived conflicts within concrete situations.”33
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 FY2013 dollars (adjusted for medical care inflation).
30 P.L. 113-76, Division H, Title II, §209 and §210.
31 P.L. 113-76, 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)
(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.
32 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).
33 HHS, “Regulation for the Enforcement of Federal Health Care Provider Conscience Protection Laws,” 76 Federal
Register 9973, February 23, 2011.
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Table 1. Title X Family Planning Program Appropriations, FY1971-FY2014
(in millions, current dollars, not adjusted for inflation)
FY Appropriation FY Appropriation FY Appropriation
1971 $6.0
1986
$136.4 2001 $253.9
1972 $61.8
1987 $142.5
2002 $265.0
1973 $100.6
1988 $139.7
2003
$273.4
1974 $100.6
1989 $138.3
2004
$278.3
1975 $100.6
1990 $139.1
2005
$286.0
1976 $100.6
1991 $144.3
2006
$282.9
1977 $113.0
1992 $149.6
2007
$283.1
1978 $135.0
1993 $173.4
2008
$300.0
1979 $135.0
1994 $180.9
2009
$307.5
1980 $162.0
1995 $193.3
2010
$317.5
1981 $161.7
1996 $192.6
2011
$299.4
1982 $124.2
1997 $198.5
2012
$293.9
1983 $124.1
1998 $203.5
2013
$278.3
1984 $140.0
1999 $215.0
2014
$286.5
1985 $142.5
2000 $238.9
Source: FY1971-FY2005: Department of Health and Human Services, Office of Population Affairs, Title X
Funding History, http://www.hhs.gov/opa/title-x-family-planning/title-x-policies/title-x-funding-history/; 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.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.
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Figure 1. Title X Family Planning Program Appropriations, FY1978-FY2014
Sources: Current dol ars: See Table 1. Constant (FY2013) dol ars: Calculated by CRS using a fiscal year inflation
adjustment based on monthly data for the Consumer Price Index Al - 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 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).34
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.”35 IOM made specific recommendations to increase program funding and to
improve program management, administration, and evaluation.
Among IOM’s recommendations was that OFP “review and update the Program Guidelines to
ensure that they are evidence-based.” IOM noted, for example, that the guidelines required female
34 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.
35 Ibid., pp. 4, 70.
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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 2001.36
In response to the IOM recommendations, OPA released new program guidelines in April 2014.37
The new guidelines draw on systematic literature reviews and existing recommendations from
organizations, such as the Centers for Disease Control and Prevention, the U.S. Preventive
Services Task Force, the American Congress of Obstetricians and Gynecologists, the American
Academy of Pediatrics, the American Society for Reproductive Medicine, and the American
Urological Association. For example, the new guidelines state that pelvic exams and clinical
breast exams are “not needed routinely to provide contraception safely to a healthy client”
(though they may be recommended for some cases, such as inserting an intrauterine device,
fitting a diaphragm, cancer screening for non-adolescents, assessing gestational age after a
positive pregnancy test, if the client has certain STD symptoms, as part of infertility care, or to
address other non-contraceptive health needs). OPA states that the new guidelines have “a
foundation of empirical evidence and information supporting clinical practice.”38 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.39
The Patient Protection and Affordable Care Act and
Title X
The Patient Protection and Affordable Care Act (ACA) has numerous provisions that may impact
Title X clinics.40 Notably, ACA increases access to health insurance.41 (In 2012, 64% of Title X
clients were uninsured.)42 Federal ACA regulations and guidance also require most health plans
and health insurers to cover contraceptive services without cost-sharing.
36 Ibid., pp. 13, 15, 240; the 2001 guidelines are reprinted in Appendix D.
37 HHS, OPA, Program Guidelines, http://www.hhs.gov/opa/program-guidelines/. The new guidelines are comprised of
two documents: HHS, OPA, Program Requirements for Title X Funded Family Planning Projects, April 2014; and
Loretta Gavin, Susan Moskosky, and Marion Carter, et al., “Providing Quality Family Planning Services:
Recommendations of CDC and the U.S. Office of Population Affairs,” Morbidity and Mortality Weekly Report, vol. 63,
no. RR-4 (April 25, 2014), pp. 1-29.
38 HHS, HRSA, Fiscal Year 2015 Justification of Estimates for Appropriations Committees, p. 409.
39 IOM, Standing Committee on Family Planning, http://www.iom.edu/Activities/Women/FamilyPlanning.aspx.
40 The Patient Protection and Affordable Care Act (P.L. 111-148, March 23, 2010) was amended by the Health Care
Education and Reconciliation Act of 2010 (P.L. 111-152, March 30, 2010). These acts will be collectively referred to in
this report as “ACA.”
41 The Congressional Budget Office (CBO) and Joint Committee on Taxation (JCT) estimate that “12 million more
nonelderly people will have health insurance in 2014 than would have had it in the absence of the ACA. They also
project that 19 million more people will be insured in 2015, 25 million more will be insured in 2016, and 26 million
more will be insured each year from 2017 through 2024 than would have been the case without the ACA.” CBO,
Updated Estimates of the Effects of the Insurance Coverage Provisions of the Affordable Care Act, April 2014, April
14, 2014, p. 3, http://www.cbo.gov/publication/45231.
42 Fowler et al., Family Planning Annual Report: 2012 National Summary, pp. 21, 23.
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ACA has several provisions that may increase health insurance coverage in the populations
currently served by Title X. These provisions could help free up funds that Title X clinics
currently spend on serving the uninsured. For example,
• States can expand Medicaid eligibility to include most nonelderly,
nonpregnant individuals with income at or below 133% of FPL,
effectively 138% FPL with the 5% income disregard.43 (In 2011, 69% of
Title X clients had incomes under 101% of FPL; another 15% had
incomes between 101% and 150% of FPL.)44
• 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.45
• 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 26.46 (In 2012, 49% of Title X clients were
younger than 25 years old; another 21% were aged 25 to 29.)47
• ACA provides certain individuals and small businesses with access to
private health plans through new health insurance exchanges and
subsidizes the premium costs for certain individuals. To ensure access for
low-income individuals, exchange plans are required to have a sufficient
number and geographic distribution of “essential community providers,”
which include Title X projects.48
43 P.L. 111-148, §2001 as modified by §10201; P.L. 111-152, §1004 and §1201. This provision is summarized in CRS
Report R43564, The ACA Medicaid Expansion, by Alison Mitchell. Medicaid is jointly financed by federal and state
governments. All state Medicaid programs are mandated to include family planning services and supplies in their
benefit packages, with no cost-sharing. In states that choose to expand Medicaid eligibility, the federal government will
pay 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.
44 Christina Fowler, Julia Gable, Jiantong Wang, and Emily McClure, Family Planning Annual Report: 2012 National
Summary, p. 22.
45 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 Evelyne P. Baumrucker et al. As of September 1, 2014, 12 states have had state plan amendments
approved under this new authority. Guttmacher Institute, State Policies in Brief as of September 1, 2014: Medicaid
Family Planning Eligibility Expansion, http://www.guttmacher.org/statecenter/spibs/spib_SMFPE.pdf. Federal
guidance is provided in Cindy Mann, director, Center for Medicaid, CHIP and Survey & Certification, State Medicaid
Directors Letter #10-013, Family Planning Services Option and New Benefit Rules for Benchmark Plans, July 2, 2010,
http://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD10013.pdf, and State Medicaid
Directors Letter #14-003, Family Planning and Family Planning Related Services Clarification, April 16, 2014,
http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SMD-14-003.pdf.
46 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 R41220, Preexisting
Condition Exclusion Provisions for Children and Dependent Coverage under the Patient Protection and Affordable
Care Act (ACA), by Bernadette Fernandez.
47 Fowler et al., Family Planning Annual Report: 2012 National Summary, pp. 10-11.
48 45 C.F.R. §156.235. U.S. Centers for Medicare & Medicaid Services (CMS), Center for Consumer Information and
Insurance Oversight (CCIIO), Affordable Exchanges Guidance, April 5, 2013, pp. 7-10, http://www.cms.gov/CCIIO/
Resources/Regulations-and-Guidance/Downloads/2014_letter_to_issuers_04052013.pdf; CMS, CCIIO, 2015 Letter to
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• Beginning in 2014, ACA’s individual mandate provision requires most
individuals to have health insurance or pay a penalty.49
OPA has established FY2014 Program Priorities to guide the project plans of family planning
services grantees. In response to ACA, one of these priorities is improving Title X clinics’ ability
to bill Medicaid and private health insurance:
Identifying specific strategies for adapting delivery of family planning and reproductive
health services to a changing health care environment including addressing provisions of the
Affordable Care Act (ACA). This includes, but is not limited to, increasing the capacity of
Title X service sites to utilize health information technologies that will enhance their ability
to bill third party payers.50
According to the FY2015 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.51 Title X clinics also provide enrollment assistance to clients eligible for
Medicaid or exchange plans under ACA.52
Title X supporters state that, although clinics currently funded by Title X could see increased
revenues from Medicaid and private insurance in 2014, the Title X program will still be
necessary:
In addition to medical care, Title X supports activities that are not reimbursable under
Medicaid and commercial insurance plans… Title X has made a major contribution to the
training of clinicians; that need remains today… Title X helps to support staff salaries, not
just for clinicians but for front-desk staff, educators and finance and administrative staff.
Title X provides for individual patient education as well as community-level outreach and
public education about family planning and women’s health issues. Title X also helps to
support the infrastructure necessary to keep the doors open—subsidizing rent, utilities and
infrastructure needs like health information technology.53
Some advocates note that even after 2014, family planning services will still be sought by
uninsured persons and dependents who, for confidentiality reasons, might not wish to bill
(...continued)
Issuers in the Federally-facilitated Marketplaces, March 14, 2014, p. 22, http://www.cms.gov/CCIIO/Resources/
Regulations-and-Guidance/Downloads/2015-final-issuer-letter-3-14-2014.pdf.
49 P.L. 111-148, §1501 and §10106, as amended by P.L. 111-152, §1002. This provision is summarized in CRS Report
R41331, Individual Mandate Under ACA, by Annie L. Mach.
50 HHS, OPA, Title X Family Planning Program Priorities, http://www.hhs.gov/opa/title-x-family-planning/title-x-
policies/program-priorities/.
51 HHS, HRSA, Fiscal Year 2015 Justification of Estimates for Appropriations Committees, p. 409.
52 Adam Sonfield, “Implementing the Affordable Care Act: Enrollment Strategies and the U.S. Family Planning
Effort,” Guttmacher Policy Review, vol. 14, no. 4 (Fall 2011), pp. 20-25. Rachel Benson Gold, “The Role of Family
Planning Centers as Gateways To Health Coverage and Care,” Guttmacher Policy Review, vol. 14, no. 2 (Spring 2011),
pp. 15-19. “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.
53 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.
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reproductive health services to their parent’s or spouse’s health insurance.54 Advocates maintain
that even after 2014, there will still be strong demand for safety net providers, such as many Title
X clinics, that provide health care to underserved populations.55
ACA requires most private health plans to cover certain preventive services for women without
cost-sharing.56 HHS commissioned the Institute of Medicine to recommend preventive services to
be included in this requirement.57 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.58 Some have noted that
this requirement, by removing up-front cost barriers, could result in more women switching to
longer-acting contraceptive methods, such as hormonal implants and intrauterine devices.59
HRSA has identified “Patient access to a broad range of contraceptive options, including long
acting reversible contraceptives (LARC)” as one of the key Title X issues in FY2014.60
ACA may also impact Title X clinics in other ways. For example, because ACA increased the
rebate percentage drug makers pay on drugs purchased for Medicaid beneficiaries, Title X clinics
likely will receive larger discounts on drugs obtained through the 340B drug discount program.61
54 CBO and JCT estimate that about 31 million people will be uninsured in 2024. CBO, Updated Estimates of the
Effects of the Insurance Coverage Provisions of the Affordable Care Act, April 2014, April 14, 2014, p. 5.
Confidentiality issues are discussed in Rachel Benson Gold, “Unintended Consequences: How Insurance Processes
Inadvertently Abrogate Patient Confidentiality,” Guttmacher Policy Review, vol. 12, no. 4 (Fall 2009), pp. 12-16,
http://www.guttmacher.org/pubs/gpr/12/4/gpr120412.html; and Adam Sonfield, Kinsey Hasstedt, and Rachel Benson
Gold, Moving Forward: Family Planning in the Era of Health Reform, Guttmacher Institute, March 2014, p. 16.
55 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.
56 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).
57 IOM, Clinical Preventive Services for Women: Closing the Gaps (Washington, DC: The National Academies Press,
2011), http://www.nap.edu/catalog.php?record_id=13181.
58 The requirement is effective for plan years beginning on or after August 1, 2012, with some exceptions and
accommodations for religious objections. Condoms and vasectomies are not included. HHS, HRSA, Women’s
Preventive Services: Required Health Plan Coverage Guidelines, http://www.hrsa.gov/womensguidelines/. HHS,
Centers for Medicare & Medicaid Services, Center for Consumer Information & Insurance Oversight, Fact Sheet:
Women’s Preventive Services Coverage, Non-Profit Religious Organizations, and Closely-Held For-Profit Entities,
http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/womens-preven-02012013.html.
59 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. Kelly Cleland, Jeffrey F. Peipert, and Carolyn Westhoff et al., “Family Planning
as a Cost-Saving Preventive Health Service,” The New England Journal of Medicine, vol. 364 (May 5, 2011), p. e37.
60 HHS, OPA, Title X Family Planning Program Priorities, http://www.hhs.gov/opa/title-x-family-planning/title-x-
policies/program-priorities/.
61 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 Evelyne P.
Baumrucker et al. The 340B program website is http://www.hrsa.gov/opa. There were 3,868 Title X clinic sites
enrolled in the 340B program as of July 1, 2011. U.S. Government Accountability Office, Drug Pricing: Manufacturer
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ACA also increased funding for teen pregnancy prevention efforts, expanded healthcare
workforce programs, and increased funding for community health centers (many of which are
Title X providers).62 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.63 OPA also
announced 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.”64
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.65
Abortion and Title X
The law prohibits the use of Title X funds in programs where abortion is a method of family
planning.66 On July 3, 2000, OPA released a final rule with respect to abortion services in family
planning projects.67 The rule updated and revised regulations that had been in effect since 1988.68
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
(...continued)
Discounts in the 340B Program Offer Benefits, but Federal Oversight Needs Improvement, GAO-11-836, September
23, 2011, p. 39, http://gao.gov/products/GAO-11-836.
62 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 C.
Stephen Redhead and Elayne J. Heisler, and CRS Report R41210, Medicaid and the State Children’s Health Insurance
Program (CHIP) Provisions in ACA: Summary and Timeline, by Evelyne P. Baumrucker et al.
63 IOM, Standing Committee on Family Planning, http://www.iom.edu/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.
64 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.
65 National Family Planning Training Centers, Webinar Recording: Affordable Care Act and the Future of Title X,
November 2013, http://www.fpntc.org/training-and-resources/webinar-recording-affordable-care-act-and-the-future-of-
title-x; National Family Planning Training Centers, ACA Basics for Title X, http://www.fpntc.org/resources/affordable-
care-act/aca-basics-for-title-x.
66 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
FY2014, this provision appeared in P.L. 113-76, Division H, Title II). For background on abortion funding restrictions
in general, see CRS Report RL33467, Abortion: Judicial History and Legislative Response, by Jon O. Shimabukuro.
67 HHS, OPA, “Standards of Compliance for Abortion-Related Services in Family Planning Services Projects,” 65
Federal Register 41270–41280, July 3, 2000; and HHS, OPA, “Provision of Abortion-Related Services in Family
Planning Services Projects, “ 65 Federal Register 41281-41282, July 3, 2000.
68 42 C.F.R. Part 59, “Grants for family planning services.”
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any option(s) about which the pregnant woman indicates she does not wish to receive such
information and counseling.”69
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.70 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.71
It is unclear exactly how many Title X clinics also provide abortions through their non-Title X
activities. In 2004, following appropriations conference report directions, HHS surveyed its Title
X grantees on whether their clinic sites also provided abortions with non-federal funds.72
Grantees were informed that responses were voluntary and “without consequence, or threat of
consequence, to non-responsiveness.” The survey did not request any identifying information.
HHS mailed surveys to 86 grantees and received 46 responses. Of these, 9 indicated that at least
one of their clinic sites (17 clinic sites in all) also provided abortions with non-federal funds, and
34 indicated that none of their clinic sites provided abortions with non-federal funds; 3 responses
had no numerical data or said the information was unknown.
Title X supporters argue that family planning reduces unintended pregnancies, thereby reducing
abortion.73 HHS estimates that Title X family planning services helped avert 911,000 unintended
pregnancies in 2012.74 The Guttmacher Institute estimates that clinics receiving Title X funds
helped avert 363,000 abortions in 2012.75
69 On December 19, 2008, HHS published a provider conscience rule which, according to HHS, 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).
70 65 Federal Register 41281-41282, July 3, 2000.
71 Email from Barbara Clark, HHS, Office of the Assistant Secretary for Legislation, August 24, 2006. See also OPA
Program Instruction Series, OPA 11-01: Title X Grantee Compliance with Grant Requirements and Applicable Federal
and State Law, including State Reporting Laws, Letter from Marilyn J. Keefe, Deputy Assistant Secretary for
Population Affairs, to Regional Health Administrators, Regions I-X; Title X Grantees, March 1, 2011,
http://www.hhs.gov/opa/pdfs/opa-11-01-program-instruction-re-compliance.pdf.
72 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.
73 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.
74 HHS, HRSA, Fiscal Year 2015 Justification of Estimates for Appropriations Committees, p. 407.
75 Jennifer J. Frost, Mia R. Zolna, and Lori Frohwirth, Contraceptive needs and services, 2012 Update, Guttmacher
Institute, New York, NY, 2014, p. 21, http://www.guttmacher.org/pubs/win/contraceptive-needs-2012.pdf.
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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.76 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.77
Teenage Pregnancy and Title X
In 2012, 19% of Title X clients were aged 19 or younger.78 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.79 (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 HHS, in
2012, Title X family planning services helped avert an estimated 178,000 unintended teen
pregnancies.80 Supporters of expanding family planning services argue that the United States has
a higher teen pregnancy rate than some countries (such as Sweden) where a similar percentage of
teens are sexually active, in part because U.S. teens use contraception less consistently. Some also
argue that recent trends in U.S. teen birth rates can be explained in part by changes in teen
contraceptive use.81
76 Examples of this argument can be found in House debate, Congressional Record, daily edition, vol. 154, no. 112
(July 9, 2008), pp. H6320-H6326. 327,166 abortion procedures were performed by Planned Parenthood affiliates in
2012, comprising 3% of Planned Parenthood services that year, according to the Planned Parenthood Federation of
America, Planned Parenthood 2012-2013 Annual Report, 2014, pp. 14-15, http://www.plannedparenthood.org/about-
us/annual-report.
77 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.
78 Fowler et al., Family Planning Annual Report: 2012 National Summary, p. 9.
79 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.
80 HHS, HRSA, Fiscal Year 2015 Justification of Estimates for Appropriations Committees, p. 407. 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.
81 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; and 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.
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Confidentiality for Minors and Title X
By law, Title X providers are required to “encourage” family participation when minors seek
family planning services.82 However, confidentiality is required for personal information about
Title X services provided to individuals, including adolescents.83 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.84
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.85
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.86
82 42 U.S.C. 300(a) states that Title X grantees shall encourage family participation “to the extent practical.” P.L. 113-
76, Division H, §209 requires Title X grantees to certify that they encourage family participation in minors’ decisions
to seek family planning services.
83 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.
84 HHS, OPA, Clarification regarding “Program Requirements for Title X Family Planning Projects”: Confidential
Services to Adolescents, OPA Program Policy Notice 2014-1, June 5, 2014, http://www.hhs.gov/opa/pdfs/ppn2014-01-
001.pdf.
85 Gavin et al., “Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of
Population Affairs,” p. 13. For an overview of Title X efforts to encourage family participation, see RTI International,
An Assessment of Parent Involvement Strategies in Programs Serving Adolescents: Final Report, 2007,
http://www.hhs.gov/opa/pdfs/parent-involvement-final-report.pdf. The report found that parent involvement is
associated with several positive outcomes, such as delayed sexual initiation and lower rates of pregnancy and sexually
transmitted infections.
86 P.L. 113-76, Division H, Departments of Labor, Health and Human Services, and Education, and Related Agencies
Appropriations Act, 2014, Title II, Department of Health and Human Services, §210. OPA Program Instruction Series,
OPA 11-01: Title X Grantee Compliance with Grant Requirements and Applicable Federal and State Law, including
State Reporting Laws, Letter from Marilyn J. Keefe, Deputy Assistant Secretary for Population Affairs, to Regional
Health Administrators, Regions I-X; Title X Grantees, March 1, 2011, http://www.hhs.gov/opa/pdfs/opa-11-01-
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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.87
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.”88 Program requirements instruct that “Eligibility for discounts for
unemancipated minors who receive confidential services must be based on the income of the
minor.”89
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.90
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.”91
Planned Parenthood and Title X
The Planned Parenthood Federation of America (PPFA) operates through a national office and 67
affiliates, which operate more than 700 local health centers.92 Affiliates participating in Title X
(...continued)
program-instruction-re-compliance.pdf.
87 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 announced 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.
88 42 C.F.R. §59.2.
89 HHS, OPA, Program Requirements for Title X Funded Family Planning Projects, April 2014, p. 13.
90 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.
91 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.
92 Planned Parenthood Federation of America, Planned Parenthood at a Glance, http://www.plannedparenthood.org/
about-us/who-we-are/planned-parenthood-at-a-glance.
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can receive funds directly from HHS or indirectly from other Title X grantees, such as their state
or local health departments.
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 PPFA
and its affiliates.93
According to the GAO report, in FY2009, HHS 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.94 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 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.95
Expenditures included federal funds provided directly or indirectly to these organizations. The
most recent expenditure data were from FY2008, when Planned Parenthood and its affiliates
reported spending $53 million from the Title X Family Planning Services program.96
93 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.
94 GAO, Federal Funds: Fiscal Years 2002-2009 Obligations, Disbursements, and Expenditures for Selected
Organizations Involved in Health-Related Activities, p. 16.
95 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.
96 GAO, Federal Funds: Fiscal Years 2002-2009 Obligations, Disbursements, and Expenditures for Selected
Organizations Involved in Health-Related Activities, p. 25.
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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. Section
300 to Section 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
Services97
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
97 These formula grants, which were authorized for FY1971-FY1973, were never funded. S.Rept. 101-95, pp. 5, 10.
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planning and population growth information (including educational materials) to all persons
desiring such information.
Section 1006. Regulations and Payments
The Secretary may promulgate regulations and must determine the conditions for making
payments to grantees to assure that such grants will be effectively utilized for the purposes they
were made.
Grantees must assure that (1) priority will be given to the furnishing of services to persons from
low-income families; and (2) no charge will be made in such project or program for services
provided to any person from a low-income family except to the extent that payment will be made
by a third party (including a government agency) which is authorized or is under legal obligation
to pay the charge.
The Secretary must be satisfied that informational or educational materials developed or made
available under the grant or contract will be suitable for the 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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