Title X (Public Health Service Act) Family
Planning Program
Angela Napili
Information Research Specialist
May 6, 2015
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 2013, Title X-funded clinics served 4.6 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 FY2015 Consolidated and Further Continuing Appropriations Act (P.L. 113-235) provides
$286 million for Title X, the same as the FY2014 level. The FY2015 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 ............................................................................................................................................ 3
FY2016 Budget Request ............................................................................................................ 4
FY2015 Funding ........................................................................................................................ 4
History of Funding .................................................................................................................... 5
Institute of Medicine Evaluation ...................................................................................................... 7
The Patient Protection and Affordable Care Act and Title X ........................................................... 8
Abortion and Title X ...................................................................................................................... 12
Teenage Pregnancy and Title X ..................................................................................................... 14
Confidentiality for Minors and Title X .......................................................................................... 15
Planned Parenthood and Title X .................................................................................................... 16
Figures
Figure 1. Title X Family Planning Program Appropriations, FY1978-FY2015 .............................. 7
Tables
Table 1. Title X Family Planning Program Appropriations, FY1971-FY2015 ................................ 6
Contacts
Author Contact Information........................................................................................................... 17
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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) under the Office of the
Assistant Secretary for Health in the U.S. Department of Health and Human Services (HHS).
Although the program is administered through OPA, funding for Title X activities is provided
through the Health Resources and Services Administration (HRSA) in HHS. Authorization of
appropriations expired at the end of FY1985, but the program has continued to be funded through
appropriations bills for the Departments of Labor, Health and Human Services, and Education,
and Related Agencies (Labor-HHS-Education).
OPA administers three types of project grants under Title X: family planning services;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 2016 Justification of Estimates for Appropriations
Committees, p. 408, http://hrsa.gov/about/budget/budgetjustification2016.pdf.
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education, counseling, testing, and referral; preconception health services; and counseling on
establishing a reproductive life plan.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 2013, Title X-funded clinics served 4.558 million clients, primarily low-income women and
adolescents. Of those clients, 8% were male, 70% had incomes at or below the federal poverty
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 2013, 63% of Title X
clients were uninsured.15
6 Title X clinical guidelines are laid out in Loretta Gavin, Susan Moskosky, and Marion Carter, et al., “Providing
Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs,” Morbidity
and Mortality Weekly Report, vol. 63, no. RR-4 (April 25, 2014), pp. 1-29.
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. See also CDC, Testing in Clinical Settings, http://www.cdc.gov/hiv/testing/clinical/
index.html.
10 HHS, OPA, 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.
13 Christina Fowler, Julia Gable, and Jiantong Wang, Family Planning Annual Report: 2013 National Summary, RTI
International, Research Triangle Park, NC, November 2014, pp. 8-9, 21-22, http://www.hhs.gov/opa/pdfs/fpar-2013-
national-summary.pdf.
14 Jennifer J. Frost, U.S. Women’s Use of Sexual and Reproductive Health Services:Trends, Sources of Care and
(continued...)
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Grantees and Clinics
In 2013, there were 95 Title X family planning services grantees. Such grantees included 50 state,
local, and territorial health departments and 45 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 is no fixed matching amount required for
grants, regulations specify that no Title X projects may be fully supported by Title X funds.17 In
2013, Title X provided services through 4,168 clinics located in the 50 states, the District of
Columbia, and the U.S. territories and Freely Associated States.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/.
Funding
The FY2015 Consolidated and Further Continuing Appropriations Act (P.L. 113-235) provides
$286.479 million for Title X, the same as the FY2014 enacted level.22 The President’s FY2016
(...continued)
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: 2013 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: 2013 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/.
22 P.L. 113-235, Division G, Title II; P.L. 113-76, Division H, Title II. Per P.L. 113-76, Division H, Title II §206, the
Administration in FY2014 had limited authority to transfer funds among HHS accounts. After transfers, FY2014 Title
X funding was $285.760 million, according to HHS, HRSA, Operating Plan for FY2014, http://www.hrsa.gov/about/
budget/operatingplan2014.pdf.
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budget proposes to increase Title X funding by 5% to $300.000 million. Table 1 shows Title X
appropriations amounts since FY1971, when the program was created. Figure 1 shows Title X
appropriations amounts since FY1978.
FY2016 Budget Request
The President’s FY2016 budget, submitted February 2, 2015, requests $300.000 million for Title
X, 5% higher than the FY2015 enacted level.23 The budget would continue previous years’
requirements that Title X funds not be spent on abortions, all pregnancy counseling be
nondirective, and funds not be spent on promoting or opposing any legislative proposal or
candidate for public office.24
According to the HRSA Justification, the proposed FY2016 funding level would support family
planning services for 4.7 million clients. The program’s FY2016 goals include preventing 1,400
cases of infertility through Chlamydia screening and preventing 894,000 unintended
pregnancies.25 The FY2016 target for cost per client served is $301.14, with the goal of
maintaining the cost per client below the medical care inflation rate.26
OPA also plans to use FY2016 funds to train and support Title X clinics as more clients become
eligible for health insurance under the Patient Protection and Affordable Care Act (ACA). The
program encourages clinics to increase their number of contracts with insurance plans and to
recover more costs through reimbursements and billing third-party payers. OPA expects that
clinics’ additional investment in third-party billing, along with improved electronic health records
adoption, will increase revenue and allow the Title X program to serve more clients.27
FY2015 Funding
As mentioned previously, P.L. 113-235 provides $286.479 million for Title X, the same as the
FY2014 enacted level.28 The FY2015 act continues previous years’ requirements that Title X
funds not be spent on abortions, all pregnancy counseling be nondirective, and 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
23 HHS, HRSA, Fiscal Year 2016, Justification of Estimates for Appropriations Committees, p.404.
24 Ibid., p. 25.
25 Outcome measures for the Title X program are described in “Enclosure II: Department of Health and Human
Services’ Evaluations of Title X Family Planning Program Outcomes,” in U.S. Government Accountability Office
(GAO), Health Care Funding: Federal Obligations to and Expenditures by Selected Entities Involved in Health-
Related Activities, 2010–2012, GAO-15-270R, March 20, 2015, pp. 16-18, http://www.gao.gov/products/GAO-15-
270R.
26 HHS, HRSA, Fiscal Year 2016, Justification of Estimates for Appropriations Committees, pp. 408-411.
27 Ibid., pp. 407-409.
28 P.L. 113-235, Division G, Title II; P.L. 113-76, Division H, Title II. Per P.L. 113-76, Division H, Title II §206, the
Administration in FY2014 had limited authority to transfer funds among HHS accounts. After transfers, FY2014 Title
X funding was $285.760 million, according to HHS, HRSA, Operating Plan for FY2014, http://www.hrsa.gov/about/
budget/operatingplan2014.pdf.
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not exempt from state notification and reporting laws on child abuse, child molestation, sexual
abuse, rape, or incest.29
FY2015 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.”30 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.”31 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.”32 In the explanatory statement accompanying P.L.
113-235, Congress directed the HHS Secretary to respond “expeditiously” to complaints about
Weldon Amendment violations.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 FY2014 dollars (adjusted for medical care inflation).
29 P.L. 113-235, Division G, Title II, §209 and §210.
30 P.L. 113-235, Division G, Title V, §506(d). The Weldon Amendment was originally adopted as part of the FY2005
Labor-HHS-Education appropriations law, and has been attached to each subsequent Labor-HHS-Education
appropriations law: P.L. 108-447, Division F, §508(d), 118 Stat. 3163 (FY2005); P.L. 109-149, §508(d), 119 Stat. 2879
(FY2006). Under P.L. 110-5, §2, 121 Stat. 8, FY2007 appropriations were subject to the same conditions as during
FY2006. P.L. 110-161, Division G, §508(d), 121 Stat. 1844 (FY2008). P.L. 111-8, Division F, §508(d), 123 Stat. 803
(FY2009). P.L. 111-117, Division D, §508(d), 123 Stat. 3280 (FY2010). Under P.L. 112-10, Division B, §§1101 and
1104, FY2011 appropriations were subject to the same conditions as during FY2010. P.L. 112-74, Division F, §507(d),
125 Stat. 111 (FY2012). Under P.L. 113-6 §§1101 and 1105, FY2013 appropriations are subject to the same conditions
as during FY2012 under P.L. 112-74. P.L. 113-76, Division H, Title V, §507(d), 128 Stat. 409 (FY2014).
31 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).
32 HHS, “Regulation for the Enforcement of Federal Health Care Provider Conscience Protection Laws,” 76 Federal
Register 9973, February 23, 2011.
33 “Explanatory Statement Submitted by Mr. Rogers of Kentucky, Chairman of the House Committee on
Appropriations Regarding Amendment to the Senate Amendment on H.R. 83, Consolidated and Further Continuing
Appropriations Act, 2015,” House of Representatives, Congressional Record, vol. 160, no. 151 Book II (December 11,
2014), pp. H9838-H9839.
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Table 1. Title X Family Planning Program Appropriations, FY1971-FY2015
(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
2015
$286.5
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. FY2015: P.L.
113-235, Division G, Title II.
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Figure 1. Title X Family Planning Program Appropriations, FY1978-FY2015
Sources: Current dollars: See Table 1. Constant (FY2014) 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 OPA’s Office of Family Planning, the Institute of Medicine (IOM) of the
National Academy of Sciences independently evaluated the Title X program and made
recommendations in A Review of the HHS Family Planning Program: Mission, Management, and
Measurement of Results (2009).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.
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. See also Jennifer J. Frost, Adam Sonfield, and Mia Zolna, et al., “Return on Investment: A Fuller
Assessment of the Benefits and Cost Savings of the US Publicly Funded Family Planning Program,” Milbank
Quarterly, vol. 92, no. 4 (December 2014), pp. 696-749.
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Among IOM’s recommendations was that OPA’s Office of Family Planning “review and update
the Program Guidelines to ensure that they are evidence-based.” IOM noted, for example, that the
guidelines required female Title X clients, including adolescents, to have pelvic and breast
examinations within six months of their initial visit, though “relevant abnormalities are rarely
found in adolescents.” At the time of the IOM report, Title X Program Guidelines had not been
updated since 2001.36
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, P.L. 111-148, as amended) has numerous
provisions that may impact Title X clinics. Notably, ACA increases access to health insurance.40
(In 2013, 63% of Title X clients were uninsured.)41 Federal ACA regulations and guidance also
require most health plans and health insurers to cover contraceptive services without cost-sharing.
36 IOM, A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results, pp. 13,
15, 240; the 2001 guidelines are reprinted in Appendix D.
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 2016 Justification of Estimates for Appropriations Committees, p. 408.
39 IOM, Standing Committee on Family Planning, http://www.iom.edu/Activities/Women/FamilyPlanning.aspx.
40 The Congressional Budget Office (CBO) and Joint Committee on Taxation (JCT) estimate that 17 million more
nonelderly people will have health insurance in 2015 than would have had it without the ACA. They also project that
23 million more will be insured in 2016, 24 million more will be insured each year from 2017 through 2019, and 25
million more will be insured each year from 2020 through 2025 than would have been the case without the ACA. CBO,
Insurance Coverage Provisions of the Affordable Care Act—CBO’s March 2015 Baseline, March 9, 2015, Table 2,
http://www.cbo.gov/publication/43900.
41 Fowler et al., Family Planning Annual Report: 2013 National Summary, pp. 21, 23.
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ACA has several provisions that may increase health insurance coverage in the populations
served by Title X. These provisions could help free up funds that Title X clinics have historically
spent on serving the uninsured. For example,
• States can expand Medicaid eligibility to include most nonelderly,
nonpregnant individuals with income at or below 133% of FPL,
effectively 138% FPL with the 5% income disregard.42 (In 2013, 70% of
Title X clients had incomes under 101% of FPL; another 21% had
incomes between 101% and 150% of FPL.)43
• 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.44
• 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 26.45 (In 2013, 47% of Title X clients were
younger than 25 years old; another 22% were aged 25 to 29.)46
• 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.47
42 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.
43 Fowler et al., Family Planning Annual Report: 2013 National Summary, pp. 22.
44 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 May 1, 2015, 13 states have had state plan amendments approved
under this new authority. Guttmacher Institute, State Policies in Brief as of May 1, 2015: 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.
45 P.L. 111-148, §1001, as amended by P.L. 111-152, §2301. This dependent coverage provision is effective for plan
years beginning on or after September 23, 2010. The provision is summarized in CRS Report R42069, Private Health
Insurance Market Reforms in the Affordable Care Act (ACA).
46 Fowler et al., Family Planning Annual Report: 2013 National Summary, pp. 10-11.
47 45 C.F.R. §156.235. U.S. Centers for Medicare & Medicaid Services (CMS), Center for Consumer Information and
Insurance Oversight (CCIIO), 2015 Letter to 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.
CMS, CCIIO, Final 2016 Letter to Issuers in the Federally-facilitated Marketplaces, February 20, 2015, p. 28,
http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2016_Letter_to_Issuers_2_20_2015.pdf.
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Title X (Public Health Service Act) Family Planning Program
• Beginning in 2014, ACA’s individual mandate provision requires most
individuals to have health insurance or pay a penalty.48
OPA has established FY2015 Program Priorities to guide the project plans of family planning
services grantees. In response to ACA, one of these priorities is demonstrating Title X clinics’
ability to bill Medicaid and private health insurance. Project plans should have “evidence of
contracts with insurance and systems for third party billing as well as the ability to facilitate the
enrollment of clients into insurance and Medicaid optimally onsite; and to report on numbers
assisted and enrolled.”49
According to the FY2016 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.50 Title X clinics also provide enrollment assistance to clients eligible for
Medicaid or exchange plans under ACA.51 OPA awarded one-year grants in FY2014 to help Title
X clinics enroll uninsured clients in health coverage.52
Title X supporters state that, although clinics funded by Title X could see increased revenues
from Medicaid and private insurance, the Title X program is still necessary:
In addition to medical care, Title X supports activities that are not reimbursable under
Medicaid and commercial insurance plans… Title X has made a major contribution to the
training of clinicians; that need remains today… Title X helps to support staff salaries, not
just for clinicians but for front-desk staff, educators and finance and administrative staff.
Title X provides for individual patient education as well as community-level outreach and
public education about family planning and women’s health issues. Title X also helps to
support the infrastructure necessary to keep the doors open—subsidizing rent, utilities and
infrastructure needs like health information technology.53
Some advocates note that even with ACA’s health coverage expansions, family planning services
will still be sought by uninsured persons and dependents who, for confidentiality reasons, might
not wish to bill reproductive health services to their parent’s or spouse’s health insurance.54
48 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.
49 HHS, OPA, Announcement of Anticipated Availability of Funds for Family Planning Services Grants, p. 9,
http://www.hhs.gov/opa/pdfs/opa-fy2015-1.pdf.
50 HHS, HRSA, Fiscal Year 2016 Justification of Estimates for Appropriations Committees, p. 409.
51 “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.
52 HHS, OPA, FY14 Announcement of Availability of Funds to Enroll Family Planning Clients into Health Insurance
Programs, April 3, 2014, http://www.grants.gov/web/grants/view-opportunity.html?oppId=253413.
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.
54 CBO and JCT estimate that about 27 million people will be uninsured in 2025. CBO, Insurance Coverage Provisions
of the Affordable Care Act—CBO’s March 2015 Baseline, March 9, 2015, Table 2. 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.
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Advocates maintain that even with the ACA, there will still be strong demand for safety net
providers, such as many Title X clinics, that provide health care to underserved populations.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 OPA
has identified “Patient access to a broad range of contraceptive options, including long acting
reversible contraceptives (LARC)” as one of the key Title X issues in FY2015.60 HHS has also
added Title X clients’ rate of LARC use to the list of outcome measures for assessing program
performance.61
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.62
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. CRS Report IF10169,
The Affordable Care Act’s Contraceptive Coverage Requirement: History of Regulations for Religious Objections.
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.
Among teens seeking contraceptive services at Title X clinics, 7.1% used long-acting reversible contraception in 2013,
compared with 0.4% in 2005. Lisa Romero, Karen Pazol, and Lee Warner, et al., “Vital Signs: Trends in Use of Long-
Acting Reversible Contraception Among Teens Aged 15–19 Years Seeking Contraceptive Services—United States,
2005-2013,” Morbidity and Mortality Weekly Report, vol. 64 (April 10, 2015), pp. 363-369.
60 HHS, OPA, Announcement of Anticipated Availability of Funds for Family Planning Services Grants, p. 10,
http://www.hhs.gov/opa/pdfs/opa-fy2015-1.pdf.
61 In FY2013, 8.8% of female clients used LARC as their primary contraception method; the FY2016 target is 9.9%.
HHS, HRSA, Fiscal Year 2016 Justification of Estimates for Appropriations Committees, p. 410.
62 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
(continued...)
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Title X (Public Health Service Act) Family Planning Program
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).63 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.64 OPA also
awarded FY2014 research funding to “conduct data analysis and related research and evaluation
on the impact of the Affordable Care Act on Title X funded family planning centers.”65 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.66
Abortion and Title X
The law prohibits the use of Title X funds in programs where abortion is a method of family
planning.67 On July 3, 2000, OPA released a final rule with respect to abortion services in family
planning projects.68 The rule updated and revised regulations that had been in effect since 1988.69
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)
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.
63 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.
64 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.
65 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.
66 National Family Planning Training Centers, Webinar Recording: Affordable Care Act and the Future of Title X,
November 2013, http://www.fpntc.org/training-and-resources/webinar-recording-affordable-care-act-and-the-future-of-
title-x; National Family Planning Training Centers, Affordable Care Act, http://fpntc.org/topics/affordable-care-act.
67 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
FY2015, this provision appeared in P.L. 113-235, Division G, Title II). For background on abortion funding restrictions
in general, see CRS Report RL33467, Abortion: Judicial History and Legislative Response, by Jon O. Shimabukuro.
68 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.
69 42 C.F.R. Part 59, “Grants for family planning services.”
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Title X (Public Health Service Act) Family Planning Program
any option(s) about which the pregnant woman indicates she does not wish to receive such
information and counseling.”70
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.71 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.72
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.73
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.74 HHS estimates that Title X family planning services helped avert 870,000 unintended
pregnancies in 2013.75 The Guttmacher Institute estimates that clinics receiving Title X funds
helped avert 363,000 abortions in 2012.76
70 On December 19, 2008, HHS published a provider conscience rule which, according to HHS at the time, was
“inconsistent” with the requirement that Title X grantees provide clients with abortion referrals upon request (73
Federal Register 78087). The rule was later rescinded in 2011 (76 Federal Register 9968).
71 65 Federal Register 41281-41282, July 3, 2000.
72 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.
73 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.
74 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.
75 HHS, HRSA, Fiscal Year 2016 Justification of Estimates for Appropriations Committees, p. 406.
76 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.77 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.78
Teenage Pregnancy and Title X
In 2013, 18% of Title X clients were aged 19 or younger.79 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.80 (See CRS Report RS20301, Teenage
Pregnancy Prevention: Statistics and Programs.)
The program’s supporters, on the other hand, argue that the Title X program should be expanded
to serve more people in order to reduce the rate of unintended pregnancies. According to HHS, in
2013, Title X family planning services helped avert an estimated 160,000 unintended teen
pregnancies.81 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.82
77 Examples of this argument can be found in House debate, Congressional Record, daily edition, vol. 154, no. 112
(July 9, 2008), pp. H6320-H6326. 327,653 abortion procedures were performed by Planned Parenthood affiliates in
2013, comprising 3% of Planned Parenthood services that year, according to the Planned Parenthood Federation of
America, Planned Parenthood 2013-2014 Annual Report, 2014, pp. 14-15, http://www.plannedparenthood.org/about-
us/annual-report.
78 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.
79 Fowler et al., Family Planning Annual Report: 2013 National Summary, p. 9.
80 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.
81 HHS, HRSA, Fiscal Year 2016 Justification of Estimates for Appropriations Committees, p. 406. 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.
82 An example of these arguments can be found in U.S. Congress, Senate Committee on Appropriations, Subcommittee
on Labor, Health and Human Services, Education, and Related Agencies, Threat to Title X and Other Women’s Health
Services, pp. 16-21. See also Jacqueline E. Darroch, et al., “Differences in Teenage Pregnancy Rates Among Five
Developed Countries: The Roles of Sexual Activity and Contraceptive Use,” Family Planning Perspectives, vol. 33,
no. 6 (November/December 2001), pp. 244-251; John S. Santelli and Andrea J. Melnikas, “Teen Fertility in Transition:
Recent and Historic Trends in the United States,” Annual Review of Public Health, vol. 31 (2010), pp. 371-383; and
Heather D. Boonstra, “What Is Behind the Declines in Teen Pregnancy Rates?” Guttmacher Policy Review, vol. 17, no.
3 (Summer 2014), pp. 15-21.
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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.83 However, confidentiality is required for personal information about
Title X services provided to individuals, including adolescents.84 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.85
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.86
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.87
83 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.
84 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.
85 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.
86 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.
87 P.L. 113-235, Division G, Title II, §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-program-instruction-re-compliance.pdf.
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Title X (Public Health Service Act) Family Planning Program
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.88
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.”89 Program requirements instruct that “Eligibility for discounts for
unemancipated minors who receive confidential services must be based on the income of the
minor.”90
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.91
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.”92
Planned Parenthood and Title X
The Planned Parenthood Federation of America (PPFA) operates through a national office and 62
affiliates, which operate approximately 700 local health centers.93 Affiliates participating in Title
X can receive funds directly from HHS or indirectly from other Title X grantees, such as their
state or local health departments.
88 Private health insurance policy holders often receive “explanations of benefits” that describe services charged to their
insurance policy. Often policy holders may also view a history of claims made under their policies. These common
health insurance practices may inadvertently breach the confidentiality of dependents who receive care through those
policies. OPA has awarded research funding to study these practices’ effects on Title X clinics’ revenues. HHS, OPA,
FY14 Announcement of Availability of Funds for Family Planning Affordable Care Act (ACA) Impact Analysis
Research Cooperative Agreements, March 7, 2014, pp. 5-6, 10-11, https://www.grantsolutions.gov/gs/preaward/
previewPublicAnnouncement.do?id=49223. See also Abigail English, Rachel Benson Gold, and Elizabeth Nash, et al.,
Confidentiality for Individuals Insured as Dependents: A Review of State Laws and Policies, Guttmacher Institute, July
2012, http://www.guttmacher.org/pubs/confidentiality-review.pdf.
89 42 C.F.R. §59.2.
90 HHS, OPA, Program Requirements for Title X Funded Family Planning Projects, April 2014, p. 13.
91 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.
92 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.
93 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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Title X (Public Health Service Act) Family Planning Program
In March 2015, the Government Accountability Office (GAO) released a report with data on the
obligations, disbursements, and expenditures of federal funds for several nonprofit organizations,
including PPFA and its affiliates.94
According to the GAO report, in FY2012, HHS reported obligating $18.67 million, and
disbursing $19.08 million, to PPFA affiliates through the Title X program.95 These figures
reflected funds that HHS provided directly to these organizations. They did not include Title X
funds that reached Planned Parenthood or its affiliates indirectly through subgrants or that passed
through from state agencies or other organizations.
The GAO report also showed PPFA affiliates’ expenditures of Title X funds. Most of these
expenditures were identified through audit reports that PPFA affiliates submitted to comply with
Office of Management and Budget (OMB) audit requirements.96 Expenditures included federal
funds provided directly or indirectly to these organizations. The most recent expenditure data
were from FY2012, when Planned Parenthood and its affiliates reported spending $64.35 million
from the Title X Family Planning Services program.97
Author Contact Information
Angela Napili
Information Research Specialist
anapili@crs.loc.gov, 7-0135
94 U.S. Government Accountability Office (GAO), Health Care Funding: Federal Obligations to and Expenditures by
Selected Entities Involved in Health-Related Activities, 2010–2012, GAO-15-270R, March 20, 2015,
http://www.gao.gov/products/GAO-15-270R.
95 According to GAO, the term obligation refers to “a definite commitment by a federal agency that creates a legal
liability to make payments immediately or in the future,” while the term disbursement refers to “amounts paid by
federal agencies, in cash or cash equivalents, to satisfy government obligations.” GAO, Health Care Funding: Federal
Obligations to and Expenditures by Selected Entities Involved in Health-Related Activities, 2010–2012, pp. 30, 32..
96 Organizations with annual expenditures of federal funds of $500,000 or more are required to have an audit. For
several PPFA affiliates that did not meet the expenditure threshold for audits, GAO obtained data directly from the
affiliates. GAO, Health Care Funding: Federal Obligations to and Expenditures by Selected Entities Involved in
Health-Related Activities, 2010–2012, pp. 2, 39, 40.
97 Tables 24 and 25, GAO, Health Care Funding: Federal Obligations to and Expenditures by Selected Entities
Involved in Health-Related Activities, 2010–2012, pp 39, 40.
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