Family Planning Program Under Title X of the Public Health Service Act

Contents

• Title X Program Administration and Grants
• Administration
• Family Planning Services Grants
• Services
• Client Charges
• Client Characteristics
• Grantees and Clinics
• Family Planning Training and Research Grants
• Funding
• FY2018 Funding
• FY2019 Budget Request
• History of Funding
• Institute of Medicine Evaluation
• FY2018 Funding Opportunity Announcement
• Key Differences Between the FY2017 and FY2018 FOAs
• Rule Nullification on Selecting Subrecipients
• Abortion and Title X
• Teenage Pregnancy and Title X
• Confidentiality for Minors and Title X
• Planned Parenthood and Title X

Summary

The federal government provides grants for family planning services through the Family Planning Program, Title X of the Public Health Service Act (42 U.S.C. §§300 to 300a-6). Title X, enacted in 1970, is the only domestic federal program devoted solely to family planning and related preventive health services. In 2016, Title X-funded clinics served 4 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 in 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).

Title X grantees can provide family planning services directly or subaward Title X monies to other public or nonprofit entities to provide services. In December 2016, OPA released a final rule to limit the criteria Title X grantees could use to restrict subawards: "No recipient making subawards for the provision of services as part of its Title X project may prohibit an entity from participating for reasons other than its ability to provide Title X services." On April 13, 2017, the President signed P.L. 115-23, which nullified the rule under the Congressional Review Act.

On March 23, 2018, the President signed the Consolidated Appropriations Act, 2018 (P.L. 115-141), which provides $286.5 million for Title X, the same as the FY2017 level. The FY2018 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 President's FY2019 budget request, submitted February 12, 2018, proposes $286.5 million for Title X, the same as the FY2018 enacted level.

Under the Title X Family Planning Services FY2017 funding opportunity announcement (FOA), final award selections were made by the applicable Public Health Service Region's regional health administrator, in consultation with the Deputy Assistant Secretary for Population Affairs (DASPA) and the Assistant Secretary for Health or their designees. In contrast, under the FY2018 FOA, final award selections will be made by the DASPA―a political appointee― or the DASPA's designee. This is a change from program practices in place since the 1980s.

Federal law (42 U.S.C. §300a-6) prohibits the use of Title X funds in programs in which 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. The abortion prohibition does not apply to all Title X grantees' activities, but applies only to Title X projects' activities. A grantee's abortion activities must be "separate and distinct" from the Title X project activities.

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Title X Program Administration and Grants

The federal government provides grants for family planning services through the Family Planning Program, Title X of the Public Health Service Act (42 U.S.C. §§300 to 300a-6). Enacted in 1970, Title X is the only domestic federal program devoted solely to family planning and related preventive health services. By law, Title X clients' participation in family planning services is voluntary.¹

Although Title X is the only federal domestic program primarily focused on family planning, other programs also finance family planning, among their other services. These programs include Medicaid, the Health Center program under Section 330 of the Public Health Service Act, Maternal and Child Health Block Grants, Social Services Block Grants, and Temporary Assistance for Needy Families. In FY2015, Medicaid accounted for 75% of U.S. public family planning expenditures (including federal, state, and local government spending). In comparison, Title X accounted for 10%.²

Administration

Title X is administered by the Office of Population Affairs (OPA) under the Office of the Assistant Secretary for Health in the U.S. Department of Health and Human Services (HHS). Although the program is administered through OPA, funding for Title X activities is provided through in HHS's Health Resources and Services Administration (HRSA). Authorization of appropriations expired at the end of FY1985, but the program has continued to be funded through appropriations bills for the Departments of Labor, Health and Human Services, and Education, and Related Agencies (Labor-HHS-Education).

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

Family Planning Services Grants

Services

In FY2017, OPA used approximately 90% of Title X funds for clinical services.⁶ Family planning services grants fund family planning and related preventive health services, such as contraceptive services; natural family planning methods; infertility services; adolescent services; breast and cervical cancer screening and prevention; sexually transmitted disease (STD) and human immunodeficiency virus (HIV) prevention education, counseling, testing, and referral; preconception health services; and reproductive life plan counseling .⁷ These services must be provided "without coercion and with respect for the privacy, dignity, social, and religious beliefs of the individuals being served."⁸

OPA has increased efforts to integrate HIV-prevention services in family planning clinics.⁹ OPA provided supplemental grants to help Title X projects implement the Centers for Disease Control and Prevention's (CDC's) "Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health Care Settings."¹⁰

Although females make up the majority of Title X clients, services offered to males include condoms, education and counseling, STD testing and treatment, HIV testing, and, in some cases, vasectomy services.¹¹

Client Charges

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

Client Characteristics

In 2016, Title X-funded clinics served 4.008 million clients, primarily low-income women and adolescents.¹⁴ Of those clients, 11% were male, 64% had incomes at or below the federal poverty guidelines, and 85% had incomes at or below 200% of the federal poverty guidelines.¹⁵ An earlier survey found that for 61% of clients, Title X clinics were their "usual" or only regular source of health care.¹⁶ In 2016, 43% of Title X clients were uninsured.¹⁷

The number of Title X clients served in 2016 was slightly lower than in 2015 (when there were 4.018 million clients). The 2016 client count was 23% lower than in 2010 (when there were 5.225 million clients).¹⁸ Figure 1 shows the number of Title X clients each year from 2010 to 2016.

Figure 1. Number of Title X Family Planning Clients Served, 2010-2016

Source: Christina Fowler, Julia Gable, Jiantong Wang, and Beth Lasater, Family Planning Annual Report: 2016 National Summary, RTI International, Research Triangle Park, NC, August 2017, Exhibit A-2a, p. A-6, https://www.hhs.gov/opa/sites/default/files/title-x-fpar-2016-national.pdf.

The Family Planning Annual Report and the HRSA FY2017 Budget Justification suggested several reasons for grantees' decreased capacity to serve clients,¹⁹ including

• clinic closures or clinics no longer participating in Title X;
• staffing shortages for family planning projects due to difficulties in provider recruitment and retention; and
• increased unit cost of providing services and upfront costs for infrastructure improvements (such as purchasing new health information technology and entering new contracts with insurers);

Grantees also suggested several potential reasons for a decrease in demand,²⁰ including

• newly insured clients choosing to seek care from other non-Title X providers;
• increased use of long-acting reversible contraception (LARC), which could reduce the frequency of client visits in the long run, compared with some other types of contraception (such as oral contraceptives that require refills);²¹ and
• recent clinical guideline changes, such as pap tests are now recommended every three years instead of annually.²²

Grantees and Clinics

In 2016, there were 91 Title X family planning services grantees. These grantees included 48 state, local, and territorial health departments and 43 nonprofit organizations, such as community health agencies, family planning councils, and Planned Parenthood affiliates.²³

Title X grantees can provide family planning services directly or subaward Title X monies to other public or nonprofit entities to provide services. Although there is no fixed matching amount required for grants, regulations specify that no Title X projects may be fully supported by Title X funds.²⁴ In 2016, Title X provided services through 3,898 clinics located in the 50 states, the District of Columbia, and the U.S. territories and Freely Associated States.²⁵

Family Planning Training and Research Grants

Family planning training grants are used to train staff and improve the use and career development of paraprofessionals.²⁶ Staff are trained through a Family Planning National Training Center and a National Clinical Training Center.²⁷ These programs have produced provider education resources, training tools, podcasts, and webinars on topics such as the Zika virus, caring for women with opioid use disorders, mandated child abuse reporting, human trafficking, and clinical efficiency, among other topics.²⁸ Family planning service delivery improvement research grants are used for studies to improve the service delivery of Title X projects.²⁹

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

Funding

Title X is a discretionary program, meaning its funding is provided in and controlled by annual appropriations acts. It has received appropriations every year since the program started in FY1971.

Annual appropriations acts have also specified certain program guidelines, such as requiring all Title X pregnancy counseling to be nondirective and prohibiting the use of Title X funds for abortion. This section describes recent funding amounts and proposals.³⁰

FY2018 Funding

On March 23, 2018, the President signed the Consolidated Appropriations Act, 2018 (P.L. 115-141). P.L. 115-141 provides $286.479 million for Title X in FY2018, the same as the FY2017 enacted level.³¹ The FY2018 act continues previous years' requirements that Title X funds not be spent on abortions, among other requirements (see the text box below).

FY2018 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."³² Some groups have argued that the Weldon amendment conflicts with regulations that require Title X family planning services projects to give pregnant women the opportunity to receive information, counseling, and referral upon request for several options, including "pregnancy termination."³³ In the February 23, 2011, Federal Register, HHS stated that potential conflicts would be handled on a case-by-case basis: "The approach of a case by case investigation and, if necessary, enforcement will best enable the Department to deal with any perceived conflicts within concrete situations."³⁴

FY2019 Budget Request

President Trump's FY2019 budget request, submitted February 12, 2018, includes $286.479 million for Title X, the same as the FY2017 enacted level.³⁶ The FY2019 budget would continue previous years' provisions in appropriations laws prohibiting the use of Title X funds for abortion, among other requirements (see text box above).

According to the HRSA Justification of Estimates for Appropriations Committees, the proposed FY2019 funding level would support family planning services for 4 million clients, of which 90% would have family incomes at or below 200% of the federal poverty guidelines.³⁷ The program's FY2019 goals include preventing 903,000 unintended pregnancies and reducing infertility by screening 1.2 million young women for chlamydia.³⁸ The FY2018 target for cost per client served is $345.11, with the goal of maintaining the increase in cost per client below the medical care inflation rate.³⁹ According to the Justification, the Title X program has encouraged clinics to improve financial sustainability by having more contracts with insurance plans and by recovering more costs through reimbursements and billing third-party payers.⁴⁰ The Justification emphasizes that family planning projects should "optimally" have primary health services onsite or "in close proximity."⁴¹ The Justification also states that the program will likely continue addressing the Zika virus and other conditions affecting reproductive-age persons.⁴²

The FY2019 budget states that it "includes provisions prohibiting certain abortion providers from receiving Federal funds from HHS, including those that receive funding under the Title X Family Planning program and Medicaid, among other HHS programs."⁴³ One such provision would block HHS discretionary funds from being made available to a prohibited entity "either directly, through a State (including through managed care contracts with a State), or through any other means[.]" This prohibition would apply "[n]otwithstanding any other provision of law[.]" The provision defines prohibited entity as an entity, including its affiliates, subsidiaries, successors, and clinics, that meets the following criteria at the time of enactment:

(1) It is a nonprofit organization under Internal Revenue Code Section 501(c)(3);⁴⁴

(2) It is an essential community provider primarily engaged in family planning services, reproductive health, and related medical care;⁴⁵

(3) It performs, or provides any funds to any other entity that performs, abortions (other than in cases of rape, incest, and certain physician-certified cases in which the woman is in danger of death unless an abortion is performed);

(4) Total federal Title X grants to the entity (including affiliates, subsidiaries, or clinics) exceeded $23 million in FY2017.

The prohibited entity definition would no longer apply to an entity that certifies that it will no longer perform, nor fund any other entity that performs, an abortion (other than in cases of rape, incest, and when the woman is in danger of death unless an abortion is performed). The HHS Secretary would be required to seek repayment of any federal assistance if the certification's terms are violated.

The proposed provision does not mention Planned Parenthood Federation of America (PPFA). However, PPFA may meet the criteria for a prohibited entity.⁴⁶ In March 2017, the New York Times reported that, in response to congressional proposals to restrict federal funds to PPFA, the White House informally proposed to preserve federal funding if PPFA stopped providing abortions. PPFA rejected that informal White House proposal.⁴⁷

History of Funding

Table 1 shows Title X appropriations amounts since FY1971, when the program was created. Figure 2 shows Title X appropriations amounts since FY1978, in current dollars (not adjusted for inflation) and constant FY2017 dollars (adjusted for medical care inflation).

Figure 2. Title X Family Planning Program Appropriations, FY1978-FY2018

Sources: Current dollars, see Table 1. Constant (FY2017) dollars, calculated by CRS using a fiscal year inflation adjustment based on monthly data for the Consumer Price Index All - Urban Consumers for Medical Care published by the Bureau of Labor Statistics, http://data.bls.gov/timeseries/CUUR0000SAM/.

Institute of Medicine Evaluation

In 2009, at the request of OPA's Office of Family Planning, the Institute of Medicine (IOM, now the National Academy of Medicine) 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.⁴⁸

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 argued, 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."⁴⁹ IOM made specific recommendations to increase program funding and improve program management, administration, and evaluation.

Among IOM's recommendations was that OPA's Office of Family Planning "review and update the Program Guidelines to ensure that they are evidence-based." IOM noted, for example, that the guidelines required female Title X clients, including adolescents, to have pelvic and breast examinations within six months of their initial visit, though "relevant abnormalities are rarely found in adolescents." At the time of the IOM report, Title X program guidelines had not been updated since 2001.⁵⁰

In response to IOM's recommendations, OPA released new program guidelines in April 2014.⁵¹ The new guidelines draw on systematic literature reviews and existing recommendations from organizations, such as the CDC, the U.S. Preventive Services Task Force, the American College 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, screening for cancer of nonadolescents, assessing gestational age after a positive pregnancy test, if the client has certain STD symptoms, as part of infertility care, or to address other noncontraceptive health needs). OPA stated that the new guidelines have "a foundation of empirical evidence and information supporting clinical practice."⁵² In addition, 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.⁵³

FY2018 Funding Opportunity Announcement

The Title X funding opportunity announcement (FOA), which is released by OPA, lays out grant application requirements, program priorities, and other key issues. A significant delay in the FOA for FY2018 Title X Family Planning Services grants raised concern.⁵⁴ Some current grantees feared services could be interrupted because of a potential lapse in grant funding.⁵⁵ A press release accompanied the FOA: "Recognizing the announcement has been delayed, HHS is committed to ensuring that services continue unabated. Current grantees received notification today inviting them to submit a request for grant extension, so there is no gap in services."⁵⁶

Key Differences Between the FY2017 and FY2018 FOAs

There are several differences between the FY2018 FOA and the FY2017 FOA that was posted under the previous Administration.⁵⁷ Key differences are as follows:

The FY2018 FOA has a new requirement for clients under the age of consent. A client under the age of consent will be subject to a preliminary screening to rule out victimization after he or she presents with an STD, pregnancy, or any suspicion of abuse.⁵⁸

The FY2018 FOA states that Title X projects should communicate the benefits of avoiding sexual risk, delaying sex, and returning to "sexually risk-free status," especially for adolescents.⁵⁹ The FY2017 FOA did not use the phrase "sexually risk-free." The FY2017 FOA required projects to have written clinical protocols in accordance with "Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs and Program Requirements for Title X Funded Family Planning Projects" (QFP).⁶⁰ The QFP document states, "Providers should give comprehensive information to adolescent clients about how to prevent pregnancy. This information should clarify that avoiding sex (i.e., abstinence) is an effective way to prevent pregnancy and STDs."⁶¹

Both FOAs require that projects encourage family participation with respect to services to minors.⁶² But unlike the FY2017 FOA, the FY2018 FOA additionally states that this requirement applies to all clients, not just to minors.⁶³ Under the FY2018 FOA, successful projects will use "counseling techniques that encourage family participation for all clients, including the involvement of parents, spouses or family where practicable."⁶⁴

The FY2018 FOA emphasizes care coordination by noting that "each Title X project should ensure that family planning is contextualized within a holistic conversation of health, with the project optimally offering primary health services onsite, or having robust referral linkages to primary health providers in close proximity to the Title X site."⁶⁵ The FY2017 FOA did not mention onsite or nearby primary care, but it did list among the program's priorities: "Addressing the comprehensive health care needs of clients through formal, robust linkages or integration with comprehensive primary care providers."⁶⁶

Under the FY2017 FOA, final award selections were made by the applicable Public Health Service Region's regional health administrator (RHA), in consultation with the Deputy Assistant Secretary for Population Affairs (DASPA) and the Assistant Secretary for Health (ASH) or their designees.⁶⁷ In contrast, under the FY2018 FOA, final award selections will be made by the DASPA or designee.⁶⁸ This is a change from program practices in place since the 1980s. The IOM's 2009 report A Review of the HHS Family Planning Program stated that "Although the original language of the Title X statute provides decision-making authority to the DASPA, the Secretary of HHS transferred this authority from the DASPA to the RHAs in the 1980s. This transfer has helped maintain the integrity of the funding processes associated with the Title X program."⁶⁹ The IOM report also stated that "the DASPA's status as a political appointee is one of the most significant issues affecting the Title X program."⁷⁰

The FY2018 FOA encourages applications for "innovative" services and methods that have been "historically underrepresented" in the Title X program.⁷¹ The FY2017 FOA did not use those terms.

Finally, among the program's key issues, the FY2017 FOA explicitly mentioned access to "contraceptive options, including long acting reversible contraceptives (LARC), other pharmaceuticals, and laboratory tests, preferably on site" whereas the FY2018 FOA does not.⁷² A Questions and Answers document accompanying the FY2018 FOA does clarify that projects must provide contraception.⁷³

Rule Nullification on Selecting Subrecipients

As mentioned, Title X grantees can provide family planning services directly or subaward Title X funds to other government or nonprofit entities (subrecipients) to provide services. In December 2016, OPA promulgated the final rule "Compliance With Title X Requirements by Project Recipients in Selecting Subrecipients."⁷⁴ The rule became effective January 18, 2017, but P.L. 115-23 nullified the rule on April 13, 2017.⁷⁵

The rule would have applied to grantees that make subawards; it would not have affected grantees that provide all their Title X services directly. It would have added language that "No recipient making subawards for the provision of services as part of its Title X project may prohibit an entity from participating for reasons other than its ability to provide Title X services" to Title X Family Planning Services grant program regulations.⁷⁶

The President signed P.L. 115-23, "Providing for congressional disapproval under chapter 8 of title 5, United States Code, of the final rule submitted by Secretary of Health and Human Services relating to compliance with title X requirements by project recipients in selecting subrecipients." P.L. 115-23 nullified the rule under the Congressional Review Act.⁷⁷ As a result, the rule "shall be treated as though such rule had never taken effect."⁷⁸ That is, the rule is deemed not to have had any effect at any time. Furthermore, HHS is prohibited from reissuing the nullified rule in "substantially the same form" or issuing a "new rule that is substantially the same" as the nullified rule.⁷⁹

In the December 2016 preamble accompanying the rule, OPA explained that some states had taken actions to limit Title X participation by certain types of providers.⁸⁰ For example, some states enacted laws to prohibit state and local agencies from giving Title X subawards to abortion providers.⁸¹ Some other states had established a priority system for allocating Title X subawards, for example, by giving preference to state health departments, primary care providers, and community health centers over specialized family planning clinics.⁸² OPA argued that "these policies, and varying court decisions on their legality, have led to uncertainty among recipients, inconsistency in program administration, and reduced access to services for Title X priority populations."⁸³

The rule would have limited the criteria a grantee could use to restrict entities from Title X subawards, disallowing "reasons other than [the entity's] ability to provide Title X services." The preamble explained that applicants for new and continuingTitle X grants would be required to describe their criteria for choosing subrecipients.⁸⁴ The preamble stated that, under this rule, HHS would have reviewed these submissions for rule compliance and would have made "every effort to help entities come into compliance, and will award replacement grants to other providers when necessary to minimize any disruption of services."⁸⁵

Supporters of the rule argued that it would have protected funding to specialized family planning providers, such as Planned Parenthood,⁸⁶ and that it would have protected vulnerable individuals' access to family planning services.⁸⁷ Critics of the rule argued that states should have the discretion to administer Title X funds consistently with state policy,⁸⁸ and that the rule would have violated the conscience rights of voters and states that object to public funding of abortion providers.⁸⁹

Abortion and Title X

The law prohibits the use of Title X funds in programs in which abortion is a method of family planning.⁹⁰ On July 3, 2000, OPA released a final rule with respect to abortion services in family planning projects.⁹¹ The rule updated and revised regulations that had been promulgated in 1988.⁹² 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 prenatal care and delivery; infant care, foster care, or adoption; and pregnancy termination. If the woman requests such information and counseling, the project must give "neutral, factual information and nondirective counseling on each of the options, and referral upon request, except with respect to any option(s) about which the pregnant woman indicates she does not wish to receive such information and counseling."⁹³

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 abortion prohibition does not apply to all Title X grantees' activities, but applies only to Title X projects' activities. The grantee's abortion activities must be "separate and distinct" from the Title X project activities.⁹⁴ 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 nonallowable 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.⁹⁵

It is unclear precisely how many Title X clinics also provide abortions through their non-Title X activities. In 2015, the Guttmacher Institute surveyed a nationally representative sample of publicly funded family planning clinics. Respondents included 535 clinics that received Title X funds. Based on that survey, an estimated 10% of clinics that received any Title X funding reported offering abortions separately from their Title X project.⁹⁶

In 2004, following appropriations conference report directions, HHS surveyed its Title X grantees on whether their clinic sites also provided abortions with nonfederal funds.⁹⁷ Grantees were informed that responses were voluntary and "without consequence, or threat of consequence, to non-responsiveness." The survey did not request any identifying information. HHS mailed surveys to 86 grantees and received 46 responses. Of these, 9 indicated that at least one of their clinic sites (17 clinic sites in all) also provided abortions with nonfederal funds, 34 indicated that none of their clinic sites provided abortions with nonfederal funds, and 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.⁹⁸ HHS estimates that Title X services helped avert 901,838 unintended pregnancies in FY2016, and the Guttmacher Institute estimates that Title X services helped avert 822,300 unintended pregnancies in calendar year 2015.⁹⁹ It is unclear exactly how many unintended pregnancies would have ended in abortion; however, the Guttmacher Institute estimates that in 2015, clinics receiving Title X funds helped avert 277,800 abortions, including 54,500 abortions among teens.¹⁰⁰

In contrast, Title X critics argue that federal funds should be withheld from any organization, such as PPFA, that performs abortions. They argue that federal funding for nonabortion activities frees up Planned Parenthood's other resources for its abortion activities.¹⁰¹ 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.¹⁰²

Teenage Pregnancy and Title X

In 2016, 18% of Title X clients were aged 19 or younger.¹⁰³ 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.¹⁰⁴ (See CRS Report RS20301, Teenage Pregnancy Prevention: Statistics and Programs.)

The program's supporters, in contrast, argue that the Title X program should be expanded to serve more people in order to reduce the rate of unintended pregnancies. The Guttmacher Institute estimates that in 2015, Title X family planning services helped avert an estimated 188,700 unintended teen pregnancies.¹⁰⁵ The Guttmacher Institute estimates that without Title X clinics' services, the 2015 U.S. teen pregnancy rate would have been 44% higher.¹⁰⁶ Supporters of expanding family planning services argue that the United States has a higher teen pregnancy rate than some countries (such as Sweden) where a similar percentage of teens are sexually active, in part because U.S. teens use contraception less consistently. Some also argue that recent declines in U.S. teen birth rates can be explained in part by changes in teen contraceptive use.¹⁰⁷

Confidentiality for Minors and Title X

By law, Title X providers are required to "encourage" family participation when minors seek family planning services.¹⁰⁸ However, confidentiality is required for personal information about Title X services provided to individuals, including adolescents.¹⁰⁹ 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.¹¹⁰

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.¹¹¹

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.¹¹²

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.¹¹³ In one study conducted at 17 Title X sites, 4% of family planning visits were by clients who said they had insurance but did not want to use it. Of those, 44% cited confidentiality concerns. Of those citing confidentiality concerns, 39% were under the age of 18.¹¹⁴ According to OPA, Title X clinics "commonly forgo billing" health insurers to maintain confidentiality.¹¹⁵

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."¹¹⁶ Program requirements instruct that "eligibility for discounts for unemancipated minors who receive confidential services must be based on the income of the minor."¹¹⁷

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.¹¹⁸

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."¹¹⁹

Planned Parenthood and Title X

PPFA operates through a national office and 56 affiliates, which operate approximately 600 local health centers.¹²⁰ 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. The Guttmacher Institute found that in 2015, Planned Parenthood clinics made up 13% of Title X clinics, but served 41% of female Title X clients.¹²¹

In March 2018, 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.¹²²

According to the GAO report, in FY2015, HHS reported obligating $23.41 million and disbursing $21.07 million, to PPFA affiliates through the Title X program.¹²³ 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, identified through audit reports that PPFA affiliates submitted to comply with Office of Management and Budget audit requirements. Expenditures included federal funds provided directly or indirectly to these organizations. The most recent expenditure data were from FY2015, when Planned Parenthood and its affiliates reported spending $57.28 million from the Title X Family Planning Services program.¹²⁴

On September 22, 2015, the Congressional Budget Office estimated that PPFA and its affiliates receive approximately $60 million annually through the Title X program.¹²⁵

Author Contact Information

Footnotes

1.	42 U.S.C. §300a-5 states, "The acceptance by any individual of family planning services or family planning or population growth information (including educational materials) provided through financial assistance under this title (whether by grant or contract) shall be voluntary and shall not be a prerequisite to eligibility for or receipt of any other service or assistance from, or to participation in, any other program of the entity or individual that provided such service or information."
2.	Kinsey Hasstedt, Adam Sonfield, and Rachel Benson Gold, Public Funding for Family Planning and Abortion Services, FY1980-2015, Guttmacher Institute, April 2017, https://www.guttmacher.org/report/public-funding-family-planning-abortion-services-fy-1980-2015. (The Guttmacher Institute was originally, but is no longer, part of the Planned Parenthood Federation of America.) More background is in Institute of Medicine (IOM), "Non-Title X Family Planning Funding Sources," in A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results, ed. Adrienne Stith Butler and Ellen Wright Clayton (Washington: The National Academies Press, 2009), pp. 117-121, http://www.nap.edu/catalog/12585/a-review-of-the-hhs-family-planning-program-mission-management.
3.	General Service Administration (GSA), Catalog of Federal Domestic Assistance (CFDA): Family Planning Services, Program number 93.217, https://beta.sam.gov/fal/44fc3928b1aeea872df90344684896fb/view.
4.	GSA, CFDA: Family Planning Personnel Training, Program number 93.260, https://beta.sam.gov/fal/56d42e06dc5344b0668adc0c75143a6b/view.
5.	GSA, CFDA: Family Planning Service Delivery Improvement Research Grants, Program number 93.974, https://beta.sam.gov/fal/1ef4e48c545163457c9f2bd0fc52e51c/view.
6.	U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), Fiscal Year 2018 Justification of Estimates for Appropriations Committees, p. 289, https://www.hrsa.gov/sites/default/files/hrsa/about/budget/budget-justification-2018.pdf.
7.	Title X clinical guidelines are laid out in Loretta Gavin, Susan Moskosky, and Marion Carter, et al., "Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs," Morbidity and Mortality Weekly Report, vol. 63, no. RR-4 (April 25, 2014), pp. 1-29, http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6304a1.htm. To review updates to the Title X clinical guidelines, see HHS, OPA, Quality Family Planning, https://www.hhs.gov/opa/guidelines/clinical-guidelines/quality-family-planning/index.html.
8.	GSA, CFDA, Program number 93.217. See also 42 C.F.R. §59.5.
9.	HHS, Office of Population Affairs (OPA), HIV Prevention in Family Planning, https://www.hhs.gov/opa/title-x-family-planning/preventive-services/hiv-prevention/index.html.
10.	Centers for Disease Control and Prevention (CDC), "Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings," MMWR Recommendations and Reports, vol. 55, no. RR-14 (September 26, 2006), pp. 1-17. See also CDC, HIV Testing in Clinical Settings, http://www.cdc.gov/hiv/testing/clinical/index.html.
11.	HHS, OPA, Title X Male Services, https://www.hhs.gov/opa/title-x-family-planning/preventive-services/title-x-male-services/index.html.
12.	42 C.F.R. §59.2 defines low-income family as having income at or below 100% of the federal poverty guidelines. The regulation states that "'[l]ow-income family' also includes members of families whose annual family income exceeds this amount, but who, as determined by the project director, are unable, for good reasons, to pay for family planning services. For example, unemancipated minors who wish to receive services on a confidential basis must be considered on the basis of their own resources."
13.	42 C.F.R. §59.5.
14.	Christina Fowler, Julia Gable, Jiantong Wang, and Beth Lasater, Family Planning Annual Report: 2016 National Summary, RTI International, Research Triangle Park, NC, August 2017, p. 8, https://www.hhs.gov/opa/sites/default/files/title-x-fpar-2016-national.pdf. To view a map, by county, of the number of female Title X contraceptive clients served in 2015, see Jennifer J. Frost, Lori Frohwirth, Nakeisha Blades et al., Publicly Funded Contraceptive Services At U.S. Clinics, 2015, Guttmacher Institute, April 2017, https://www.guttmacher.org/report/publicly-funded-contraceptive-services-us-clinics-2015. Click "Go to state and county maps," then choose "# of clients served at Title X-funded clinics" from the pull-down menu.
15.	Fowler et al., Family Planning Annual Report: 2016 National Summary, pp. 9, 21-22.
16.	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, May 2013, p. 1 https://www.guttmacher.org/report/us-womens-use-sexual-and-reproductive-health-services-trends-sources-care-and-factors.
17.	Fowler et al., Family Planning Annual Report: 2016 National Summary, p. 23.
18.	Ibid., p. A-6.
19.	Fowler et al., Family Planning Annual Report: 2016 National Summary, pp. C-2 and C-11. HRSA, Fiscal Year 2017 Justification of Estimates for Appropriations Committees, p. 391, https://www.hrsa.gov/sites/default/files/about/budget/budgetjustification2017.pdf.
20.	Fowler et al., Family Planning Annual Report: 2016 National Summary, pp. C-2 and C-11. HRSA, Fiscal Year 2017 Justification of Estimates for Appropriations Committees, p. 392. See also Jennifer Rogers, Halima Ahmadi-Montecalvo, and Julia Fantacone, et al., The Affordable Care Act and Title X Family Planning Services: How the Changing Health Care Landscape Has Affected Service Use and Billing Practices, Altarum Institute and The Urban Institute for HHS OPA, 2017, pp. 3 and 21, https://www.fpntc.org/sites/default/files/resources/altarum_aca_title_x_2014.pdf.
21.	Fowler et al., Family Planning Annual Report: 2016 National Summary, pp. A-21, C-2, C-11.
22.	Loretta Gavin et al., "Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs," Morbidity and Mortality Weekly Report, vol. 63, no. RR-4 (April 25, 2014), p. 20. Fowler et al., Family Planning Annual Report: 2016 National Summary, pp. C-2 and C-11. Christina I. Fowler et al., "Trends in Cervical Cancer Screening in Title X-Funded Health Centers—United States, 2005–2015," Morbidity and Mortality Weekly Report (MMWR), vol. 66, no. 37 (September 22, 2017), https://www.cdc.gov/mmwr/volumes/66/wr/mm6637a4.htm.
23.	Fowler et al., Family Planning Annual Report: 2016 National Summary, p. 7. A directory of Title X grantees is at HHS, OPA, Title X Grantees, https://www.hhs.gov/opa/title-x-family-planning/title-x-grantees/index.html.
24.	42 C.F.R. §59.7(c).
25.	Fowler et al., Family Planning Annual Report: 2016 National Summary, p. 7. Directories of Title X grantees, subawardees, and clinic sites are at https://www.hhs.gov/opa/title-x-family-planning/title-x-grantees/index.html and https://www.opa-fpclinicdb.com. For a map with the number of Title X clinics by county in 2015, see Frost et al., Publicly Funded Contraceptive Services at U.S. Clinics, 2015, https://www.guttmacher.org/report/publicly-funded-contraceptive-services-us-clinics-2015. Click "Go to state and county maps," then choose "# of Title X-funded clinics" from the pull-down menu.
26.	CFDA, Program number 93.260.
27.	HHS, OPA, National Training Centers, https://www.hhs.gov/opa/title-x-family-planning/training-and-resources/national-training-centers/index.html.
28.	For more information, see Family Planning National Training Center, https://fpntc.org. National Clinical Training Center for Family Planning, http://www.ctcfp.org/.
29.	GSA, CFDA, Program number 93.974. To view examples of recent research grant award titles, see HHS, Tracking Accountability in Government Grants, https://taggs.hhs.gov/saved-search/vvvour.
30.	For current information on congressional appropriations activity, see the CRS Appropriations Status Table, http://www.crs.gov/AppropriationsStatusTable/.
31.	P.L. 115-141, Division H, Title II; P.L. 115-31, Division H, Title II.
32.	P.L. 115-141, Division H, Title V, §507(d). The Weldon Amendment was originally adopted as part of the FY2005 Labor-HHS-Education appropriations law, and it has been attached to each subsequent Labor-HHS-Education appropriations law: P.L. 108-447, Division F, §508(d), 118 Stat. 3163 (FY2005); P.L. 109-149, §508(d), 119 Stat. 2879 (FY2006). Under P.L. 110-5, §2, 121 Stat. 8, FY2007 appropriations were subject to the same conditions as during FY2006. P.L. 110-161, Division G, §508(d), 121 Stat. 1844 (FY2008). P.L. 111-8, Division F, §508(d), 123 Stat. 803 (FY2009). P.L. 111-117, Division D, §508(d), 123 Stat. 3280 (FY2010). Under P.L. 112-10, Division B, §§1101 and 1104, FY2011 appropriations were subject to the same conditions as during FY2010. P.L. 112-74, Division F, §507(d), 125 Stat. 111 (FY2012). Under P.L. 113-6 §§1101 and 1105, FY2013 appropriations are subject to the same conditions as during FY2012 under P.L. 112-74. P.L. 113-76, Division H, Title V, §507(d), 128 Stat. 409 (FY2014). P.L. 113-235, Division G, Title V, §506(d), 128 Stat. 2515 (FY2015); P.L. 114-113, Division H, Title V, §507(d), 129 Stat. 2649 (FY2016); P.L. 115-31, Division H, Title V, §507(d) (FY2017).
33.	42 C.F.R. §59.5(a)(5). Examples of this argument appear in "Weldon Amendment," Congressional Record, daily edition, vol. 151, no. 51 (April 25, 2005), p. S4222; and "Federal Refusal Clause," Congressional Record, daily edition, vol. 151, no. 52 (April 26, 2005), p. S425. The National Family Planning and Reproductive Health Association (NFPRHA), many of whose members provide Title X services, filed a lawsuit challenging the Weldon amendment in the U.S. District Court for the District of Columbia. The court found that "While Weldon may not provide the level of guidance that NFPRHA or its members would prefer, may create a conflict with pre-existing agency regulations, and may impose conditions that NFPRHA members find unacceptable, none of these reasons provides a sufficient basis for the court to invalidate an act of Congress in its entirety." Upon appeal, the U.S. Court of Appeals for the District of Columbia Circuit found that the plaintiff lacked the standing to challenge the Weldon amendment. See National Family Planning and Reproductive Health Association, Inc., v. Alberto Gonzales, et al., 468 F.3d 826 (D.C. Cir. 2006), and 391 F. Supp. 2d 200, 209 (D.D.C. 2005).
34.	HHS, "Regulation for the Enforcement of Federal Health Care Provider Conscience Protection Laws," 76 Federal Register 9973, February 23, 2011. For recent developments in HHS enforcement of the Weldon amendment and other conscience protections, see HHS, Conscience and Religious Freedom, https://www.hhs.gov/conscience/index.html.
35.	OPA has explained that "grantees may provide as much factual, neutral information about any option, including abortion, as they consider warranted by the circumstances, but may not steer or direct clients toward selecting any option, including abortion, in providing options counseling." (65 Federal Register 41273).
36.	U.S. Office of Management and Budget (OMB), The Budget of the U.S. Government, Fiscal Year 2019, Appendix, pp. 419, 483, https://www.whitehouse.gov/wp-content/uploads/2018/02/hhs-fy2019.pdf.
37.	HHS, HRSA, Fiscal Year 2019, Justification of Estimates for Appropriations Committees, 2018, pp. 304-305, https://www.hrsa.gov/sites/default/files/hrsa/about/budget/budget-justification-fy2019.pdf.
38.	Ibid., pp. 289-290.
39.	Ibid., pp. 305-306.
40.	Ibid., p. 303. Family planning services grant applications should have "Evidence that the applicant has ability to bill third party commercial insurance carriers and Medicaid in accordance with Title X requirements; and the ability to facilitate enrollment of clients into Medicaid," according to HHS, OPA, FY2018 Announcement of Anticipated Availability of Funds for Family Planning Services Grants (Hereafter cited as "FY2018 FOA"), p. 24, https://www.hhs.gov/opa/sites/default/files/FY18%20Title%20X%20Services%20FOA_Final_Signed.pdf. See also Mia R. Zolna, Megan L. Kavanaugh, and Kinsey Hasstedt, "Insurance-related Practices at Title X-funded Family Planning Centers under the Affordable Care Act: Survey and Interview Findings," Women's Health Issues, vol. 28, no. 1 (January-February 2018), pp. 21-28; and also Jennifer Rogers et al., The Affordable Care Act and Title X Family Planning Services: How the Changing Health Care Landscape Has Affected Service Use and Billing Practices, Altarum Institute and The Urban Institute for HHS OPA, 2017, pp. 3 and 21, https://www.fpntc.org/sites/default/files/resources/altarum_aca_title_x_2014.pdf.
41.	HHS, HRSA, Fiscal Year 2019, Justification of Estimates for Appropriations Committees, p. 304.
42.	HHS, HRSA, Fiscal Year 2019, Justification of Estimates for Appropriations Committees, p. 304.
43.	OMB, The Budget of the U.S. Government, Fiscal Year 2019, February 2018, p. 56, https://www.whitehouse.gov/wp-content/uploads/2018/02/budget-fy2019.pdf. OMB, The Budget of the U.S. Government, Fiscal Year 2019, Appendix, pp. 769, https://www.whitehouse.gov/wp-content/uploads/2018/02/appendix-fy2019.pdf.
44.	The criteria are that the entity "is an organization described in section 501(c)(3) of the Internal Revenue Code (IRC) of 1986 and exempt from taxation under section 501(a) of such Code." Section 501(c)(3) organizations are commonly referred to as charitable organizations and are tax-exempt under Section 501(a). See Internal Revenue Service, Exemption Requirements - 501(c)(3) Organizations, https://www.irs.gov/charities-non-profits/charitable-organizations/exemption-requirements-section-501-c-3-organizations. IRC Section 501 is codified in the U.S. Code at 26 U.S.C. 501, http://uscode.house.gov/view.xhtml?req=(title:26%20section:501%20edition:prelim).
45.	The Essential Community Provider (ECP) regulation is 45 C.F.R. §156.235. The ECP list is viewable at https://data.healthcare.gov/dataset/FINAL-PY-2019-ECP-LIST/dwyq-rebe/data.
46.	There are PPFA-affiliated organizations listed in (1) the Internal Revenue Service's "Select Check" database of tax-exempt nonprofit organizations, https://www.irs.gov/charities-non-profits/exempt-organizations-select-check; (2) HHS's list of essential community providers, https://data.healthcare.gov/dataset/FINAL-PY-2019-ECP-LIST/dwyq-rebe/data; and (3) the National Abortion Federation's directory of abortion providers, https://prochoice.org/think-youre-pregnant/find-a-provider/. According to HHS's Tracking Accountability in Government Grants System (TAGGS), total FY2017 Title X awards to Planned Parenthood-affiliated grantees exceeded $23 million, https://taggs.hhs.gov/saved-search/0ycham.
47.	Maggie Haberman, "Trump Tells Planned Parenthood Its Funding Can Stay if Abortion Goes," New York Times, March 6, 2017, https://www.nytimes.com/2017/03/06/us/politics/planned-parenthood.html; PPFA, "Planned Parenthood Statement on New York Times Story," press release, March 6, 2017, https://www.plannedparenthood.org/about-us/newsroom/press-releases/planned-parenthood-statement-on-new-york-times-story.
48.	Institute of Medicine (IOM), Committee on a Comprehensive Review of the HHS Office of Family Planning Title X Program, A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results, ed. Adrienne Stith Butler and Ellen Wright Clayton (Washington, DC: The National Academies Press, 2009), http://www.nap.edu/catalog/12585/a-review-of-the-hhs-family-planning-program-mission-management.
49.	Ibid., pp. 6, 70. See also Jennifer J. Frost 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, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4266172/pdf/milq0092-0667.pdf.
50.	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.
51.	HHS, OPA, Program Guidelines, https://www.hhs.gov/opa/guidelines/program-guidelines/index.html. The new guidelines are composed of two documents: (1) HHS, OPA, Program Requirements for Title X Funded Family Planning Projects, April 2014, https://www.hhs.gov/opa/sites/default/files/ogc-cleared-final-april.pdf; and (2) Loretta Gavin 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. To view updates to the Title X clinical guidelines, see HHS, OPA, Quality Family Planning, https://www.hhs.gov/opa/guidelines/clinical-guidelines/quality-family-planning/index.html.
52.	HHS, HRSA, Fiscal Year 2017 Justification of Estimates for Appropriations Committees, p. 394.
53.	The National Academies, Standing Committee on Family Planning, http://www.nationalacademies.org/hmd/Activities/Women/FamilyPlanning.aspx.
54.	On October 11, 2017, OPA posted a "forecast" on the federal Grants.gov website. The forecast estimated that an FOA would be posted November 1, 2017, with an estimated award date of April 1, 2018. However, OPA did not post the FOA until February 23, 2018, with project periods anticipated to start September 1, 2018. HHS Office of the Assistant Secretary for Health, "Version History," FY 2018 Announcement of Anticipated Availability of Funds for Family Planning Services Grants, https://www.grants.gov/web/grants/view-opportunity.html?oppId=297943.
55.	Sandhya Raman, "States Alarmed by Delay in HHS Family Planning Money," Roll Call, January 12, 2018, https://www.rollcall.com/news/policy/states-frustrated-delay-hhs-family-planning-money. Among current grantees, 60% had grant periods scheduled to end March 31, 2018, and 40% had grant periods scheduled to end June 2018, according to Mattie Quinn, "Months Late, Trump Administration Changes Family Planning Program's Priorities," Governing, February 26, 2018, http://www.governing.com/topics/health-human-services/gov-hhs-abortion-title-x-states-funding-trump.html.
56.	HHS, "HHS Announces the Availability of $260 Million to Fund the Title X Family Planning Program," press release, February 23, 2018, https://www.hhs.gov/about/news/2018/02/23/hhs-announces-availability-260-million-fund-title-x-family-planning-program.html.
57.	HHS, OPA, "FY2017 Announcement of Anticipated Availability of Funds for Family Planning Services Grants," https://www.hhs.gov/opa/sites/default/files/FY-17-Title-X-FOA-New-Competitions.pdf (hereafter cited as "FY2017 FOA"). HHS, OPA, "FY2018 Announcement of Anticipated Availability of Funds for Family Planning Services Grants," https://www.hhs.gov/opa/sites/default/files/FY18%20Title%20X%20Services%20FOA_Final_Signed.pdf (hereafter cited as "FY2018 FOA").
58.	FY2018 FOA, p. 9.
59.	FY2018 FOA, p. 11. To learn more about "sexually risk-free status," see HHS, OPA, "What Is Meant by 'Returning to a Sexually Risk-Free Status?'" in FY 2018 Title X Family Planning Services Funding Opportunity Announcement: Questions and Answers, February 27, 2018, https://www.hhs.gov/opa/grants-and-funding/grant-opportunities/fy2018-services-questions-answers/index.html.
60.	FY2017 FOA, p. 10.
61.	Gavin et al., "Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs," p. 13.
62.	FY2017 FOA, pp. 6, 7, 20, and 40. FY2018 FOA, pp. 8, 10, and 22.
63.	FY2018 FOA, p. 8.
64.	Ibid., p.22.
65.	FY2018 FOA, pp. 7-8.
66.	FY2017 FOA, p. 10.
67.	FY2017 FOA, p. 43. Links to brief profiles of the Assistant Secretary for Health (ASH) and current regional health administrators (RHAs) are at HHS, Office of the Assistant Secretary for Health, OASH Leadership, https://www.hhs.gov/ash/about-ash/leadership/index.html. A link to a brief profile of the Acting Deputy Assistant Secretary for Population Affairs (DASPA) is at HHS, OPA, Leadership, https://www.hhs.gov/opa/about-opa/leadership/index.html.
68.	FY2018 FOA, p. 44: "The Deputy Assistant Secretary for Population Affairs (DASPA) or Designee Will Make Final Award Selections to be Recommended to the Grants Management Officer for Risk Analysis."
69.	"Effect of Political Issues on Program Administration and Management," in IOM, A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results, 2009, p. 359.
70.	Ibid., p. 358. See also the IOM report's discussion of "Program Leadership," pp. 80-81.
71.	FY2018 FOA, pp. 7 and 9. See also HHS, OPA, FY 2018 Title X Family Planning Services Funding Opportunity Announcement: Questions and Answers, which states, Do I need to have provided family planning, reproductive health, or other related Title X services before to be eligible to apply for or be awarded a Title X family planning service grant? No, there is not a requirement for previous or direct experience in providing family planning, reproductive health, or Title X services to be awarded a grant... We encourage new applicants to submit quality and innovative proposals, expanding subrecipient partnerships in novel ways, and extending services to those areas and clients previously unserved or underserved.
72.	FY2017 FOA, p. 10. Long acting reversible contraceptives (LARCs) include intrauterine devices (IUDs) and hormonal implants.
73.	HHS, OPA, FY 2018 Title X Family Planning Services Funding Opportunity Announcement: Questions and Answers, https://www.hhs.gov/opa/grants-and-funding/grant-opportunities/fy2018-services-questions-answers/index.html.
74.	HHS, OPA, Office of the Secretary, "Compliance With Title X Requirements by Project Recipients in Selecting Subrecipients," 81 Federal Register 91852-91860, December 19, 2016, https://www.federalregister.gov/d/2016-30276. It was preceded by a proposed rule and public comment period, see 81 Federal Register 61639-61646, September 7, 2016, https://www.federalregister.gov/d/2016-21359.
75.	When asked if any actions were taken to implement the rule before its nullification, HHS responded that "No - no actions were taken to implement the rule because of timing. Recipients that would have been impacted were those whose applications were submitted on or after January 18, 2017. All of those applicants would have had funding dates of July 1, 2017, but the rule was nullified prior to that." Email from HHS, Office of the Assistant Secretary for Legislation, May 1, 2017.
76.	The rule would have amended 42 C.F.R. §59.3 and revised the section's heading to read "Who is eligible to apply for a family planning services grant or to participate as a subrecipient as part of a family planning project?" The section's current heading is "Who is eligible to apply for a family planning services grant?"
77.	The Congressional Review Act is codified at 5 U.S.C. §§801-808.
78.	5 U.S.C. §801(f).
79.	See CRS Insight IN10660, What Is the Effect of Enacting a Congressional Review Act Resolution of Disapproval? and CRS Report R43992, The Congressional Review Act (CRA): Frequently Asked Questions.
80.	According to the rule preamble, "Since 2011, 13 states have placed restrictions on or eliminated subawards with specific types of providers based on reasons other than their ability to provide Title X services." (81 Federal Register 91852). Some of this state activity is tracked by Guttmacher Institute, State Family Planning Funding Restrictions, https://www.guttmacher.org/state-policy/explore/state-family-planning-funding-restrictions, and Usha Ranji et al., Financing Family Planning Services for Low-income Women: The Role of Public Programs, Kaiser Family Foundation, May 11, 2017, Table 1, http://kff.org/womens-health-policy/issue-brief/financing-family-planning-services-for-low-income-women-the-role-of-public-programs.
81.	OPA noted the example of Florida law H.B. 1411, 2016 Leg., Reg. Sess. (Fla. 2016). According to OPA, this law was permanently enjoined on August 18, 2016, in an unpublished court order. (81 Federal Register 91853, footnote 8).
82.	OPA discussed the example of the Texas state government's "tiered" system for Title X subaward competition in 2011. (81 Federal Register 91853; Texas General Appropriations Act, 82nd Leg., R.S., ch. 1355, art. II, rider 77, at II-71, http://www.lrl.state.tx.us/scanned/ApproBills/82_0/82_R_ALL.pdf#page=179.) In FY2013, the Women's Health and Family Planning Association of Texas became the state's Title X grantee; previously, it had been the Texas Department of State Health Services.
83.	81 Federal Register 91858.
84.	Title X family planning services projects have "project periods," typically up to three years, during which HHS does not require the grantee to recompete for funds. Within these project periods, continuing awards are generally funded in annual increments (one-year budget periods). Continuing awards are contingent on factors such as appropriations, grantees' compliance with federal requirements, and the best interests of the Government. See HHS, OPA, Announcement of Anticipated Availability of Funds for Family Planning Services Grants, FY2018, pp. 12 and 56, https://www.hhs.gov/opa/sites/default/files/FY18%20Title%20X%20Services%20FOA_Final_Signed.pdf; HHS, OPA, Program Requirements for Title X Funded Family Planning Projects, April 2014, p. 10.
85.	81 Federal Register 91853-91854.
86.	See, e.g., The Editorial Board, "One Obama Rule That Trump Should Keep: Making Sure Family Planning Funds Reach Everyone Who Needs Them," Los Angeles Times, December 27, 2016, http://www.latimes.com/opinion/editorials/la-ed-titlex-new-rule-20161221-story.html; and The Editorial Board, "A Way to Protect Planned Parenthood Services," New York Times, September 10, 2016, p. A18, http://www.nytimes.com/2016/09/10/opinion/a-way-to-protect-planned-parenthood-services.html.
87.	See, e.g., Letter from 34 U.S. Senators to President-Elect Donald J. Trump, December 22, 2016, http://www.help.senate.gov/download/title-x-trump; and Letter from 41 U.S. Senators to the Honorable Sylvia Mathews Burwell, Secretary, Department of Health and Human Services, October 7, 2016, https://www.regulations.gov/document?D=HHS-OS-2016-0014-14254.
88.	See, e.g., U.S. House of Representatives, Select Investigative Panel of the Energy and Commerce Committee, Final Report, December 30, 2016, pp. xlii and 408, https://archives-energycommerce.house.gov/sites/republicans.energycommerce.house.gov/files/114/Analysis/20161230Select_Panel_Final_Report.pdf.
89.	See, e.g., Bradford Richardson, "Obama Administration 'Stunt' Would Force States to Fund Planned Parenthood," Washington Times, September 7, 2016, http://washingtontimes.com/news/2016/sep/7/obama-administration-stunt-would-force-states-to-f/; and Robert King, "Conservative Chides Feds Over Protecting Planned Parenthood," Washington Examiner, September 6, 2016, http://www.washingtonexaminer.com/conservative-chides-feds-over-protecting-planned-parenthood/article/2601071.
90.	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 FY2017, this provision appeared in P.L. 115-31, Division H, Title II). For background on abortion funding restrictions in general, see CRS Report RL33467, Abortion: Judicial History and Legislative Response.
91.	HHS, OPA, "Standards of Compliance for Abortion-Related Services in Family Planning Services Projects," 65 Federal Register 41270-41280, July 3, 2000, https://federalregister.gov/a/00-16758; and HHS, OPA, "Provision of Abortion-Related Services in Family Planning Services Projects," 65 Federal Register 41281-41282, July 3, 2000, https://federalregister.gov/a/00-16759.
92.	HHS, Public Health Service, "Statutory Prohibition on Use of Appropriated Funds in Programs Where Abortion is a Method of Family Planning; Standard of Compliance for Family Planning Services Projects," 53 Federal Register 2922, February 2, 1988. The 1988 rule was subsequently challenged in court, and in 1993, the HHS Secretary suspended the rule (HHS, Public Health Service, "Standards of Compliance for Abortion-Related Services in Family Planning Service Projects," 58 Federal Register 7462, February 5, 1993).
93.	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).
94.	65 Federal Register 41281-41282, July 3, 2000.
95.	Email from HHS, Office of the Assistant Secretary for Legislation, May 1, 2017. Site visits and comprehensive program reviews are described in IOM, A Review of the HHS Family Planning Program: Mission, Management, and Measurement of Results, pp. 349-354.
96.	Guttmacher Institute, unpublished tabulations from a 2015 Survey of Publicly Funded Family Planning Clinics. The survey methodology is described in Mia R. Zolna and Jennifer J. Frost, Publicly Funded Family Planning Clinics in 2015: Patterns and Trends in Service Delivery Practices and Protocols, Guttmacher Institute, November 2016, https://www.guttmacher.org/sites/default/files/report_pdf/publicly-funded-family-planning-clinic-survey-2015_1.pdf. For details by abortion type, see Appendix Table A, Questions Q11ee and Q11ii, p. 54.
97.	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.
98.	Examples of this argument can be found in Rachel Benson Gold 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.
99.	HHS, HRSA, Fiscal Year 2019, Justification of Estimates for Appropriations Committees, p. 305. Jennifer J. Frost et al., Publicly Funded Contraceptive Services At U.S. Clinics, 2015, Guttmacher Institute, April 2017, pp. 1, 10, https://www.guttmacher.org/sites/default/files/report_pdf/publicly_funded_contraceptive_services_2015_1.pdf.
100.	Frost et al., Publicly Funded Contraceptive Services At U.S. Clinics, 2015, pp. 1, 10, 11.
101.	Examples of this argument can be found in House debate, Congressional Record, daily edition, vol. 154, no. 112 (July 9, 2008), pp. H6320-H6326. According to the Planned Parenthood Federation of America's most recent Annual Report, abortions accounted for 3% of Planned Parenthood services. From October 1, 2015, through September 30, 2016, Planned Parenthood health centers performed 321,384 abortion procedures. During that period, Planned Parenthood health centers provided 9.5 million services to 2.4 million patients during 4 million clinical visits. PPFA, Planned Parenthood 2016-2017 Annual Report, 2017, pp. 29-31, http://www.plannedparenthood.org/about-us/annual-report.
102.	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.
103.	Fowler et al., Family Planning Annual Report: 2016 National Summary, p. 9.
104.	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.
105.	Frost et al., Publicly Funded Contraceptive Services At U.S. Clinics, 2015, p. 11. See also the discussion of publicly funded family planning services in "Programs to Reduce Unintended Pregnancy," in The Institute of Medicine, The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families (Washington: National Academy Press, 1995), p. 220, http://www.nap.edu/catalog/4903/the-best-intentions-unintended-pregnancy-and-the-well-being-of.
106.	Frost et al., Publicly Funded Contraceptive Services At U.S. Clinics, 2015, p. 1.
107.	An example of these arguments can be found in U.S. Congress, Senate Committee on Appropriations, Subcommittee on Labor, Health and Human Services, Education, and Related Agencies, Threat to Title X and Other Women's Health Services, pp. 16-21. See also Jacqueline E. Darroch et al., "Differences in Teenage Pregnancy Rates Among Five Developed Countries: The Roles of Sexual Activity and Contraceptive Use," Family Planning Perspectives, vol. 33, no. 6 (November/December 2001), pp. 244-251; John S. Santelli and Andrea J. Melnikas, "Teen Fertility in Transition: Recent and Historic Trends in the United States," Annual Review of Public Health, vol. 31 (2010), pp. 371-383; Heather D. Boonstra, "What Is Behind the Declines in Teen Pregnancy Rates?" Guttmacher Policy Review, vol. 17, no. 3 (Summer 2014), pp. 15-21; and Laura Lindberg, John Santelli, and Sheila Desai, "Understanding the Recent Decline in Adolescent Fertility in the United States, 2007-2013," Journal of Adolescent Health, vol. 58, no. 2, Supplement (February 2016), pp. S100-S101.
108.	42 U.S.C. 300(a) states that Title X grantees shall encourage family participation "to the extent practical." P.L. 114-113, Division H, §207 requires Title X grantees to certify that they encourage family participation in minors' decisions to seek family planning services.
109.	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.
110.	HHS, OPA, Clarification regarding "Program Requirements for Title X Family Planning Projects": Confidential Services to Adolescents, OPA Program Policy Notice 2014-1, June 5, 2014, https://www.hhs.gov/opa/sites/default/files/ppn2014-01-001.pdf.
111.	Gavin et al., "Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs," p. 13. For an overview of Title X efforts to encourage family participation, see RTI International, An Assessment of Parent Involvement Strategies in Programs Serving Adolescents: Final Report, 2007, http://web.archive.org/web/20160830233907/http://www.hhs.gov/opa/pdfs/parent-involvement-final-report.pdf. The report found that parent involvement is associated with several positive outcomes, such as delayed sexual initiation and lower rates of pregnancy and sexually transmitted infections.
112.	P.L. 114-113, Division H, Title II, §208. HHS, OPA, Clarification regarding "Program Requirements for Title X Family Planning Projects": Confidential Services to Adolescents, OPA Program Policy Notice 2014-1, June 5, 2014.
113.	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. See Guttmacher Institute, State Laws and Policies: Protecting Confidentiality for Individuals Insured as Dependents, https://www.guttmacher.org/state-policy/explore/protecting-confidentiality-individuals-insured-dependents.
114.	Jennifer Yarger et al., Impacts of an Intervention to Improve Screening for Patients' Health Insurance and Need for Payment Privacy in the Title X Network, National Family Planning & Reproductive Health Association, June 2017, pp. 16-18, https://www.confidentialandcovered.com/file/1-research/1.1-research—findings/CC_InterventionReport.pdf.
115.	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. HHS, OPA, Affordable Care Act Collaborative, https://web.archive.org/web/20170702154202/https://www.hhs.gov/opa/title-x-family-planning/affordable-care-act/initiatives/aca-collaborative/index.html. The financial impact on Title X is discussed at National Family Planning & Reproductive Health Association, Confidential and Covered, https://www.confidentialandcovered.com; and Leah E. Masselink et al., "Title X–Funded Health Center Staff Members' Perspectives on Barriers to Insurance Use For Confidential Family Planning Services," Perspectives on Sexual and Reproductive Health, March 5, 2018, https://doi.org/10.1363/psrh.12054.
116.	42 C.F.R. §59.2.
117.	HHS, OPA, Program Requirements for Title X Funded Family Planning Projects, April 2014, p. 13, https://www.hhs.gov/opa/sites/default/files/ogc-cleared-final-april.pdf.
118.	An example of this argument is in Rachel K. Jones 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 "Adolescent Services – Confidential Services" in Gavin et al., "Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs," pp. 38-39.
119.	Examples of these arguments appear in Congressional Record, daily edition, vol. 142 (July 11, 1996), pp. H7348-H7349, and U.S. Congress, Senate Committee on Appropriations, Subcommittee on Labor, Health and Human Services, Education, and Related Agencies, Threat to Title X and Other Women's Health Services, pp. 22-23. See also the discussion in RTI International, An Assessment of Parent Involvement Strategies in Programs Serving Adolescents: Final Report, 2007, pp. 5-9.
120.	Planned Parenthood Federation of America, "Where Does Planned Parenthood Funding Go?" in Facts and Figures, https://www.plannedparenthood.org/about-us/facts-figures.
121.	Frost et al., Publicly Funded Contraceptive Services At U.S. Clinics, 2015, pp. 1, 9, https://www.guttmacher.org/sites/default/files/report_pdf/publicly_funded_contraceptive_services_2015_3.pdf.
122.	U.S. Government Accountability Office (GAO), Health Care Funding: Federal Obligations to and Expenditures by Selected Organizations Involved in Health-Related Activities, Fiscal Years 2013-2015, GAO-18-204R, March 6, 2018, https://www.gao.gov/products/GAO-18-204R.
123.	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." The Title X amounts include the Family Planning Services program and the Family Planning Service Delivery Improvement Research Grants program. GAO, Health Care Funding: Federal Obligations to and Expenditures by Selected Organizations Involved in Health-Related Activities, Fiscal Years 2013-2015, pp. 1, 24, 29, and 30.
124.	Table 30, GAO, Health Care Funding: Federal Obligations to and Expenditures by Selected Organizations Involved in Health-Related Activities, Fiscal Years 2013-2015, p. 53. Expenditure data were reported using affiliates' 12-month fiscal years, which vary. Organizations with annual expenditures of federal funds of $500,000 or more ($750,000 or more for fiscal years beginning on or after December 26, 2014) are required to submit single audit reports to the Federal Audit Clearinghouse. The table excludes expenditures by PPFA affiliates that did not meet the audit threshhold.
125.	Congressional Budget Office, Budgetary Effects of Legislation That Would Permanently Prohibit the Availability of Federal Funds to Planned Parenthood, September 22, 2015, p. 2, https://www.cbo.gov/publication/50833.