Title X Family Planning Program
Introduction
The Title X Family Planning Program (Title X) was enacted in 1970 as Title X of the Public Health Service Act (PHSA, codified at 42 U.S.C. §§300 to 300a-6). Title X provides grants to public and nonprofit agencies for family planning services, research, and training. The Office of Population Affairs (OPA) within the Department of Health and Human Services (HHS) administers Title X, which is the only domestic federal program dedicated solely to family planning and related preventive health services. Most Title X regulations are at 42 C.F.R. Part 59. OPA reports there were 3,853 Title X clinics as of 2023. On March 27, 2025, HHS announced an agency restructuring, including reducing the number of HHS employees and eliminating a number of offices and agencies, while consolidating others. It is unclear how these changes may affect the administration of Title X.
Overview of Title X
What Is the Federal Funding Level? Funding for Title X is discretionary and subject to the annual appropriations process. The Continuing Appropriations and Extensions Act, 2025 (P.L. 119-4) provided $286.5 million for Title X in FY2025, continuing funding at the same level, and under the same authority and conditions, as the Further Consolidated Appropriations Act, 2024 (P.L. 118-47). The program has had the same enacted annual discretionary funding level since FY2014. President Trump's FY2026 Budget Request would eliminate funding for the program.
The American Rescue Plan Act of 2021 (ARPA; P.L. 117-2, §2605) also provided Title X with $50 million in one-time mandatory funding. HHS indicated it used some of the ARPA funding for FY2022 grants to address the increased need for Title X family planning services in certain states with "restrictive" policies on reproductive health access, and in certain states that had no or limited Title X services; to improve and expand telehealth infrastructure; and to support training and technical assistance.
What Clinical Services Are Provided? Title X federal regulations require projects to provide "a broad range of acceptable and effective medically approved family planning methods (including natural family planning methods) and services (including pregnancy testing and counseling, assistance to achieve pregnancy, basic infertility services, STI [sexually transmitted infection] services, preconception health services, and adolescent-friendly health services)." The Title X Program Handbook provides additional clinical and programmatic guidance.
Although Title X is the only federal domestic program focused primarily on family planning, other programs also provide or finance family planning services among their other services (see CRS Report R46785, Federal Support for Reproductive Health Services: Frequently Asked Questions).
Does Title X Fund Abortions? Since Title X's enactment, PHSA Section 1008 has prohibited using Title X funds in programs where abortion is a method of family planning. Additionally, annual appropriations laws have stated that Title X funds "shall not be expended for abortions." Program guidance and federal regulations require that a grantee's Title X project activities and its non-Title X abortion activities, should they engage in both, be "separate and distinct." They may share a common facility, a common waiting room, common staff, and a common records system, "so long as it is possible to distinguish between the Title X supported activities and non-Title X abortion-related activities." For example, grantees must clearly delineate clinic staff time spent on project activities and paid for by Title X from non-Title X activities.
Must Title X projects provide abortion referrals upon client request? Current regulations require Title X projects to offer pregnant clients with information and nondirective counseling on prenatal care and delivery; infant care, foster care, or adoption; and abortion (unless a client indicates that they do not want information or counseling about particular options). Projects are also required to provide referrals upon client request, including abortion referrals.
Program guidance states abortion referrals may include providing relevant information (such as the abortion provider's phone number and address), but "the project may not take further affirmative action (such as negotiating a fee reduction, making an appointment, or providing transportation) to secure abortion services for the patient."
Title X providers and grantees with religious or conscientious objections to abortion counseling and referrals are not required to provide such services according to federal regulations (86 Fed. Reg. 56153). Providers with objections "may separately be covered by federal statutes protecting conscience" (42 C.F.R. 59.5, footnote 2).
What Do Clients Pay? Persons with income at or below 100% of the federal poverty level guidelines (FPL) do not pay for care. Clients with income higher than 100% and up to 250% FPL are charged on a sliding scale based on their ability to pay. Clients with income higher than 250% FPL are charged fees designed to recover the reasonable cost of providing services. (In 2025, in the 48 contiguous states and the District of Columbia, the poverty guideline for an individual is an annual income of $15,650; for families of two or more persons, $5,500 is added to the annual income figure for each additional person.) For unemancipated minors who request confidential services, eligibility for discounts is based on the minor's own income. Title X projects may bill health insurers to cover costs of the visit.
Are There Special Requirements for Services to Minors? Annual appropriations have stated that Title X providers are not exempt from state notification and reporting laws on child abuse, child molestation, sexual abuse, rape, or incest. Title X providers must counsel minors on resisting attempted coercion into sexual activity. The Title X statute also requires grantees, "to the extent practical," to encourage family participation. Regulations finalized in October 2021 state that Title X projects may not require parental consent or notify a parent or guardian when a minor has requested or received Title X services.
In 2020, a parent with religious objections sued to challenge this prohibition before the regulations were finalized, arguing that this prohibition violated his constitutional right to direct the upbringing of his children and his rights under the Texas Family Code. In March 2024, the U.S. Court of Appeals for the Fifth Circuit upheld the district court's decision that the prohibition violated the plaintiff's parental rights under relevant Texas law, and that the state law was not preempted by the Title X statute. The appellate court, however, reversed the district court's final judgment to the extent it set aside 42 C.F.R. §59.10(b), since the plaintiff did not directly challenge the regulation, which had not been finalized at the time of suit. In response, OPA issued a Program Policy Notice that it will not enforce confidentiality regulations at projects taking place in the fifth circuit to the extent it conflicts with state law.
Who Are Title X Clients? In 2023, Title X served 2.8 million clients: 85% were women, 60% had incomes at or below FPL, and 27% were uninsured. Of the clients who used insurance to cover their visit, 67% relied on public insurance, such as Medicaid.
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Source: CRS compilation of data from HHS, Title X Family Planning Annual Report: 2023 National Summary, pp. 45, 48, 59. Notes: Income is represented as a percentage of FPL; 36% of clients (all races) identified as Latino/Hispanic. Percentages may not sum to 100% due to rounding. |
Legislative Mandates
What Title X Provisions Are in the Most Recent Appropriations Law? The Continuing Appropriations and Extensions Act, 2025 (P.L. 119-4), continues requirements on the use of Title X funds similar to provisions included in previous years' appropriations laws:
- Title X funds cannot be spent on abortions.
- All pregnancy counseling must be nondirective.
- Funds cannot be spent on "any activity (including the publication or distribution of literature) that in any way tends to promote public support or opposition to any legislative proposal or candidate for public office."
- Grantees must certify that they encourage family participation when minors seek services.
- Grantees must certify that they counsel minors on how to resist attempted coercion into sexual activity.
- Family planning providers are not exempt from state notification and reporting laws on child abuse, child molestation, sexual abuse, rape, or incest.
These requirements are in addition to other statutory mandates, which require family planning participation to be voluntary and prohibit the use of Title X funds in programs where abortion is a method of family planning.
Recent Changes to Funding and Program Requirements Affecting the Title X Network
In recent years, Title X regulations and program guidance have changed, particularly HHS interpretation of Section 1008 of the PHSA. In 2019, HHS issued a final rule prohibiting Title X projects from providing information about and referrals for abortion, resulting in 945 services sites, roughly 25% of the network, to immediately leave the program. In 2018, 3.9 million clients were served by the program, which dropped to 3.1 million in 2019. In 2021, HHS essentially reversed the 2019 rule, and while the network has seen more clients in following years, the program has not served as many clients as it had before 2019.
Additionally, changes to the potential availability of Title X funding may affect Title X service availability. On April 24, 2025, the National Family Planning and Reproductive Health Association (NFPRHA) filed suit in the U.S. District Court, District of Columbia on behalf of Title X projects. NFPRHA alleges that in March 2025, HHS began unlawfully withholding $65.8 million in funding to Title X projects over purported violations of civil rights laws and violations of recent executive orders on diversity, equity, and inclusion, and for providing services to individuals without regard to their immigration status. NFPHRA alleges that the funding freeze conflicts with the terms of Title X grants and federal law. The complaint alleges that 865 service sites of 16 grantees are affected, affecting services to an estimated 842,000 Title X clients. As of the date of publication, this suit is ongoing.