The Title X Family Planning Program

The Title X Family Planning Program

Order Code 97-1048 EPW
Updated March 22, 2005
CRS Report for Congress
Received through the CRS Web
The Title X Family Planning Program
Sharon Kearney Coleman
Technical Information Specialist
Knowledge Services Group
Summary
The federal government provides grants for voluntary family planning services
through the family planning program, Title X of the Public Health Service Act. The
program, enacted in 1970, is the only federal program devoted solely to family planning
and related preventive health services. Although the authorization for Title X ended
with FY1985, funding for the program has been provided through bills that provide
appropriations for the Departments of Labor, Health and Human Services, and
Education, and Related Agencies. The Title X program received funding of $285.9
million for FY2005 and the Administration has requested the same amount for FY2006.
This report will be updated periodically.
Title X Program Administration and Covered Services
Title X is administered through the Office of Population Affairs (OPA) under the
Office of Public Health and Science in the Department of Health and Human Services
(DHHS). Funding for Title X activities is provided through the Health Resources and
Services Administration, also in DHHS.
OPA administers three types of project grants under Title X: family planning
services;1 family planning personnel training;2 and family planning service delivery
improvement research grants.3 Grants for family planning services include contraceptive
services, infertility services, special services to adolescents, counseling, physical
examinations, STD and HIV prevention education, screening, and referral. Priority for
the provision of these services is to be given to lower-income families; grantees may use
a sliding fee schedule for determining contributions for care, and grantees may not charge
low-income persons for care. The services must be provided without coercion and with
respect for the privacy, dignity, social, and religious beliefs of the individuals being
1 Catalog of Federal Domestic Assistance (CFDA) 93.217, [http://www.cfda.gov].
2 CFDA 93.260
3 CFDA 93.974
Congressional Research Service ˜ The Library of Congress

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served. Grants for family planning personnel training are to be used to provide training
to staff and to improve utilization and career development of paraprofessional and
paramedical manpower in family planning services, particularly in rural areas. The family
planning service delivery improvement research grants are to be used to develop research
studies for the improvement of the delivery of family planning services. With respect to
research funding, Title X grants will be targeted on projects that enhance the effectiveness
and efficiency of the service delivery system in clinical and non-clinical settings.
Title X clinics provide confidential screening, counseling, and referral for treatment.
In this regard, OPA has indicated that the program is committed to maintaining the
integration of HIV-prevention services in all family planning clinics, particularly in areas
with high rates of HIV and where racial and ethnic minorities are disproportionately
affected.
OPA established the Title X Training Center for Male Reproductive Health at
Morehouse Research Institute (part of Morehouse College, Atlanta, Georgia) to provide
science-based information and training to Title X projects that provide services to males.
All Title X service grantees were required by FY2002 to have at least one project that
provides family planning/reproductive health services to males.4 A survey conducted in
1999 concluded that although most clients of family planning agencies are women, a non-
negligible number are men.5 The survey reported that additional efforts are needed to
determine the best way to deliver reproductive health services to men. The survey also
reported that the most common services offered to men were condom provision, sexually
transmitted disease (STD) counseling, contraceptive counseling, and STD treatment and
testing.
During FY2004 there were 85 service grantees. Such grantees included 35 state
health departments, six territorial health departments, four local health departments, nine
Planned Parenthood affiliates (so titled), and 31 other nonprofit organizations such as
hospitals, health centers, and universities. Grantees can delegate Title X monies to other
agencies to provide services or support clinics with Title X funds. Although there are no
matching requirements for grants, regulations specify that no clinics may be fully
supported by Title X funds. Title X served approximately 4.8 million clients, primarily
low-income women and adolescents, and provided services through more than 4,500 Title
X clinics nationwide.
Abortion and Title X
The law prohibits the use of Title X funds in programs where abortion is a method
of family planning. On July 3, 2000, OPA released a final rule with respect to abortion-
4 U.S. Department of Health and Human Services, Office of Population Affairs/Office of Family
Planning, Male Involvement Projects: Prevention Services (July 2000), [http://opa.osophs.dhhs.gov/
titlex/opa_male_projects_review_july2000.pdf].
5 “Services for Men at Publicly Funded Family Planning Agencies, 1998-1999,” Perspectives
on Sexual and Reproductive Health, vol. 35, no. 5, Sept/Oct 2003.

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services in family planning projects.6 The rule updates and revises regulations that had
been in effect since 1988.7 The major revision revokes 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 offer pregnant women the opportunity to be provided
information and counseling regarding each of the following options: prenatal care and
delivery; infant care, foster care, or adoption; and pregnancy termination. If requested to
provide such information and counseling, the project must provide 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.
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. Safeguards for such activities 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.
Some Title X critics believe that federal funds should be withheld from any
organization that performs or promotes abortions, such as the Planned Parenthood
Federation of America. Critics believe that if a family planning clinic 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.
Teenage Pregnancy and Title X
Critics of the program question its effectiveness at reducing the rate of unintended
pregnancies, particularly among teenagers. These critics note that although the overall
teen birth rate has declined, the birth rate of unmarried teens has doubled since 1970 and
the creation of Title X. They 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. (See CRS Report RS20873, Reducing Teen Pregnancy: Adolescent
Family Life and Abstinence Education Programs, by Carmen Solomon-Fears for a
broader discussion of teen pregnancy.)
The program’s supporters, on the other hand, believe the program should be
expanded to serve more people in order to reduce the rate of unintended pregnancies.
They say women would have between 1.2 million and 2.1 million unintended pregnancies
a year if publicly funded services were not available.
6 65 Federal Register 41270 and 65 Federal Register 41280 (July 3, 2000).
7 42 C.F.R. Part 59

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Planned Parenthood and Title X
During May 2003, the General Accounting Office (GAO) updated a report on federal
funds provided to several nonprofit organizations and their affiliates involved in health-
related activities during FY2001.8 The report provides information on the Planned
Parenthood Federation of America, the Population Council, the International Planned
Parenthood Federation, the Alan Guttmacher Institute, Advocates for Youth, and the
Sexuality Information and Education Council of the United States (SIECUS).
Information was collected from each organization with respect to their expenditure of
federal funds. Only Planned Parenthood and the Alan Guttmacher Institute reported
spending Title X funds.
Planned Parenthood operates through a national office and 126 affiliates; these
affiliates receive funds directly and indirectly from other Title X grantees, such as their
state or local health departments. Planned Parenthood also operates 865 local health
centers. The Alan Guttmacher Institute is an affiliate of the Planned Parenthood
Federation and provides policy analysis and conducts research. According to the GAO
report, in FY2001 Planned Parenthood spent $58.7 million of Title X funds, and the Alan
Guttmacher Institute spent $315,320 of such funds; together this amounts to
approximately 23% of Title X appropriations for that year.
Funding
FY2005 funding for Title X is contained in the Consolidated Appropriations Act,
2005, P.L. 108-447. Title X was provided $285.9 million for FY2005, $7.6 million more
than FY2004. The conferees to H.Rept. 108-7929 declared that departments and agencies
should be guided by the language and instructions set forth in H.Rept. 108-63610 and
S.Rept. 108-345.11
Under H.Rept. 108-636, the House Committee on Appropriations encouraged HRSA
to work with the Centers for Disease Control and Prevention to implement HIV/AIDS
testing and counseling as part of the services provided in family planning centers. The
committee recommended the same funding as in FY2004: $278.3 million.
The Senate Committee on Appropriations, in S.Rept. 108-345, recognized that
increased availability of new contraceptive methods and screening technologies would
8 U.S. General Accounting Office, Federal Funds: Fiscal Year 2001 Expenditures by Selected
Organizations Involved in Health-Related Activities, GAO-03-527R, May 16, 2003.
9 H.Rept. 108-792, to accompany H.R. 4818, P.L. 108-477, making appropriations for foreign
operations, export financing, and related programs for the fiscal year ending Sept. 30, 2005, and
for other purposes.
10 H.Rept. 108-636, to accompany H.R. 5006, Sept. 7, 2004, making appropriations for the
Departments of Labor, Health and Human Services, and Education, and Related Agencies for
FY2005.
11 S.Rept. 108-345, to accompany S. 2810, Sept. 15, 2004, making appropriations for the
Departments of Labor, Health and Human Services, and Education, and Related Agencies for
FY2005.

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improve women’s health and result in a decrease in unintended pregnancies nationwide.
The committee instructed DHHS to distribute funds to regional HRSA offices for family
planning services within 60 days of enactment. The committee intends that at least 90%
of Title X funds be for clinical services and that such services are to be provided as
specified by statute. The committee expects the OPA to spend any increased funding on
medical services and supplies. The committee recommended $308.3 million for Title X
activities for FY2005, $30 million more than FY2004.
The conferees included language to reiterate that Title X funds are not to be
expended for abortions, that all pregnancy counseling be nondirective, and that funds are
not to be expended for 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.
The conferees also repeated language that requires the grantees to provide counseling
to minors on how to resist attempts to coerce minors into engaging in sexual activities.
They also clarified that no provider of Title X services is exempt from state law requiring
notification or the reporting of child abuse, child molestation, sexual abuse, rape, or
incest.
Additional Information
More information on the Title X program, including regional contacts, can be found
on the Internet at [http://opa.osophs.dhhs.gov/].
A summary of Title X of the Public Health Service Act, 42 U.S.C. Part 300, is
provided on the last page of this report.
Table 1. Title X Family Planning Program
Appropriation
Appropriation
Appropriation
FY
(millions)
FY
(millions)
FY
(millions)
1971
6.0
1983
124.1
1995
193.3
1972
61.8
1984
140.0
1996
192.6
1973
100.6
1985
142.5
1997
198.4
1974
100.6
1986
136.4
1998
203.4
1975
100.6
1987
142.5
1999
214.9
1976
100.6
1988
139.7
2000
238.9
1977
113.0
1989
138.3
2001
253.9
1978
135.0
1990
139.1
2002
265.1
1979
135.0
1991
144.3
2003
273.3
1980
162.0
1992
149.6
2004
278.3
1981
161.7
1993
173.4
2005
285.9
1982
124.1
1994
180.9
--
--
Source: Department of Health and Human Services, Office of Population Affairs.

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Title X — Population Research and
Voluntary Family Planning Programs
Section 1001. Project Grants and Contracts for Family Planning Services
The Secretary may make grants to and enter into contracts with public or nonprofit private entities
to assist in the establishment and operation of voluntary family planning projects to offer a broad range of
acceptable and effective family planning methods and services (including natural family planning methods,
infertility services, and services for adolescents). Entities which receive grants or contracts must encourage
family participation in their projects.
Section 1002. Formula Grants to States for Family Planning Services
The Secretary may make grants to state health authorities to assist in planning, establishing,
maintaining, coordinating, and evaluating family planning services. The state health authority must have
an approved state plan for a coordinated and comprehensive program of family planning services.
Section 1003. Training Grants and Contracts
The Secretary may make grants to public or nonprofit private entities and to enter into contracts with
public or private entities and individuals to provide the training for personnel to carry out family planning
service programs.
Section 1004. Research
The Secretary may conduct, and make grants to public or nonprofit private entities and enter into
contracts with public or private entities and individuals for projects for research in the biomedical,
contraceptive development, behavioral, and program implementation fields related to family planning and
population.
Section 1005. Informational and Educational Materials
The Secretary may make grants to public or nonprofit private entities and to enter into contracts with
public or private entities and individuals to assist in developing and making available family planning and
population growth information (including educational materials) to all persons desiring such information.
Section 1006. Regulations and Payments
The Secretary may promulgate regulations and must determine the conditions for making payments
to grantees to assure that such grants will be effectively utilized for the purposes they were made.
Grantees must assure that: (1) priority will be given to the furnishing of services to persons from low-
income families; and (2) no charge will be made in such project or program for services provided to any
person from a low-income family except to the extent that payment will be made by a third party (including
a government agency) which is authorized or is under legal obligation to pay the charge.
The Secretary must be satisfied that informational or educational materials developed or made
available under the grant or contract will be suitable for the purposes of this title and for the population or
community to which they are to be made available.
In the case of any grant or contract under Section 1001, such assurances shall provide for the review
and approval of the suitability of such materials, prior to their distribution, by an advisory committee
established by the grantee or contractor in accordance with regulations.
Section 1007. Voluntary Participation
The acceptance by any individual of family planning services or family planning or population growth
information (including educational materials)shall be voluntary and shall not be a prerequisite to eligibility
for or receipt of any other service or assistance from, or to participation in, any other program of the entity
or individual that provided such service or information.
Section 1008. Prohibition of Abortion
None of the funds appropriated under this title shall be used in programs where abortion is a method
of family planning.