Title X (Public Health Service Act) Family Planning Program
Released: 2017-08-31T00:00:00

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, it is the only dom estic federal program devoted solely to family planning and related preventive health services. Participation in family planning services by Title X clients is, by law, voluntary.

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%.

Administration

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

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

Family Planning Services Grants

Services

Ninety percent of Title X funds are used for clinical services. Grants for family planning services fund family planning and related preventive health services, such as contraceptive services; natural family planning methods; infertility services; services to adolescents; breast and cervical cancer screening and prevention; sexually transmitted disease (STD) and HIV prevention education, counseling, testing, and referral ; preconception health services; and counseling on establishing a reproductive life plan. The services must be provided "without coercion and with respect for the privacy, dignity, social, and religious beliefs of the individuals being served."

OPA has expressed a commitment to integrating HIV-prevention services in family planning clinics. OPA has 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."

Title X services offered to males include condoms, education and counseling, STD testing and treatment, HIV testing, and, in some cases, vasectomy services.

Client Charges

Priority for services is given to persons from low-income families, who may not be charged for care. 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.

Client Characteristics

In 2015, Title X-funded clinics served 4.018 million clients, primarily low-income women and adolescents. Of those clients, 10% were male, 66% had incomes at or below the federal poverty guidelines, and 86% had incomes at or below 200% of the federal poverty guidelines. One survey found that for 61% of clients, Title X clinics were their "usual" or only regular source of health care. In 2015, 48% of Title X clients were uninsured.

The number of Title X clients served in 2015 was 3% lower than in 2014 (when there were 4.129 million clients), 12% lower than in 2013 (when there were 4.558 million clients), and 23% lower than in 2010 (when there were 5.225 million clients). The Family Planning Annual Report and the HRSA FY2017 Budget Justification suggested several reasons for grantees' decreased capacity to serve clients, including

reduced revenues for family planning projects, such as decreases in funding from state and local government programs, Title X, block grants, and other funding sources. staffing shortages for family planning projects, for example, due to difficulties in provider recruitment and retention. 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, including

Patient Protection and Affordable Care Act (ACA) insurance coverage expansions, because newly insured clients can choose to seek care from private practitioners and 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). recent clinical guideline changes. For example, pap tests are now recommended every three years instead of annually.

Grantees and Clinics

In 2015, there were 91 Title X family planning services grantees. Such grantees included 46 state, local, and territorial health departments and 45 nonprofit organizations, such as community health agencies, family planning councils, and Planned Parenthood affiliates.

Title X grantees can provide family planning services directly or they can 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. In 2015, Title X provided services through 3,951 clinics located in the 50 states, the District of Columbia, and the U.S. territories and Freely Associated States.

Family Planning Training and Research Grants

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

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. The Consolidated Appropriations Act, 2017 ( P.L. 115-31 ) provided $286.479 million for Title X in FY2017, the same as the FY2016 enacted level.

The President's FY2018 budget request includes $286.479 million for Title X, the same as the FY2017 enacted level. The House-reported FY2018 Labor-HHS-Education Appropriations bill, H.R. 3358 , would provide no funding for the Title X program in FY2018. The House Rules Committee has announced that H.R. 3354 , the Make America Secure and Prosperous Appropriations Act, 2018, would be the legislative vehicle for several FY2018 appropriations bills, including the House Labor-HHS-Education appropriations bill. H.R. 3354 , as posted on the House Rules Committee website on August 16, 2017, would provide no funding for the Title X program in FY2018. As of this writing, an FY2018 Labor-HHS-Education Appropriations bill has not been introduced in the Senate.

FY2017 Funding

As mentioned, P.L. 115-31 provided $286.479 million for Title X in FY2017, the same as the FY2016 enacted level. The FY2017 act continued previous years' requirements that Title X funds not be spent on abortions, among other requirements (see text box "Requirements on the Use of Title X Funds in P.L. 115-31 , Consolidated Appropriations Act, 2017").

FY2017 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." Some have argued that the Weldon amendment conflicts with regulations that require Title X family planning services projects to give pregnant women the opportunity to receive information, counseling, and referral upon request for several options, including "pregnancy termination." 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."

FY2018 Budget Request

As mentioned, President Trump's FY2018 budget, submitted May 23, 2017, includes $286.479 million for Title X, the same as the FY2017 enacted level. This budget would continue previous years' provisions in appropriations laws prohibiting the use of Title X funds for abortion, among other requirements (see text box "Requirements on the Use of Title X Funds in P.L. 115-31 , Consolidated Appropriations Act, 2017").

According to the HRSA Justification , the proposed FY2018 funding level would support family planning services for 4 million clients. OPA intends to award 90% of available Title X funds for family planning services, including "recommended chlamydia screening, screening for undiagnosed cervical tissue abnormalities, preconception care and counseling, basic infertility services, pregnancy testing and counseling, contraceptive method provision and related education and counseling, including counseling on fertility awareness-based methods."

The program's FY2018 goals include preventing 905,000 unintended pregnancies, having 11.3% of contraceptive clients use long-acting reversible contraception, and reducing infertility by screening 959,300 young women for chlamydia. The FY2018 target for cost per client served is $336.69, with the goal of maintaining the increase in cost per client below the medical care inflation rate.

OPA also plans to use FY2018 funds to continue supporting a Family Planning Delivery System Improvement Center. The Justification also states that the program will likely continue addressing the Zika virus and other conditions affecting reproductive-age persons, including but not limited to clients at Title X service sites.

According to the Justification , the Title X program has encouraged clinics to implement electronic health records. The program has also 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.

House FY2018 Appropriations Activity

On July 24, 2017, the House Appropriations Committee reported H.R. 3358 , Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2018. H.R. 3358 would provide no funding for the Title X program in FY2018. Section 226 of the bill states, "None of the funds appropriated in this Act may be used to carry out title X of the PHS [Public Health Service] Act."

Title X is also mentioned in a provision restricting funds to certain prohibited entities. Section 529 would block the bill's 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 bill defines prohibited entity as an entity, including its affiliates, subsidiaries, successors, and clinics, that meets all these criteria at the time of enactment:

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

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

(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 where 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 FY2016.

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.

Section 529 of H.R. 3358 does not mention Planned Parenthood Federation of America (PPFA). However, the provision could possibly prohibit the bill's funds, including federal funds from Medicaid and other HHS programs, from going to PPFA and its affiliates and clinics. PPFA could potentially avoid the funding prohibition by certifying that all PPFA affiliates and clinics will not perform abortions (other than in cases of rape, incest, and when the woman is in danger of death unless an abortion is performed).

On August 16, 2017, the House Rules Committee announced that H.R. 3354 , the Make America Secure and Prosperous Appropriations Act, 2018, would be the legislative vehicle for several FY2018 appropriations bills, including the House Labor-HHS-Education appropriations bill. The above provisions (Section 226 and Section 529) are included in H.R. 3354 as posted on the House Rules Committee website on August 16, 2017.

History of Funding

Table 1 shows Title X appropriations amounts since FY1971, when the program was created. Figure 1 shows Title X appropriations amounts since FY1978, in current dollars (not adjusted for inflation) and constant FY2016 dollars (adjusted for medical care inflation).

Institute of Medicine Evaluation

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 (2009).

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." IOM made specific recommendations to increase program funding and to 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.

In response to the IOM recommendations, OPA released new program guidelines in April 2014. 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 Congress of Obstetricians and Gynecologists, the American Academy of Pediatrics, the American Society for Reproductive Medicine, and the American Urological Association. For example, the new guidelines state that pelvic exams and clinical breast exams are "not needed routinely to provide contraception safely to a healthy client" (though they may be recommended for some cases, such as inserting an intrauterine device, fitting a diaphragm, cancer screening for 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." Also in response to the IOM report, HHS contracted with IOM to convene a Standing Committee to advise the Title X program on issues raised by the 2009 report, as well as other emerging family planning issues.

The Patient Protection and Affordable Care Act and Title X

Effect of the ACA on Title X

The Patient Protection and Affordable Care Act (ACA, P.L. 111-148 , as amended) has numerous provisions impacting Title X clinics. Notably, ACA increases access to health insurance. (In 2015, 48% of Title X clients were uninsured, down from 63% in 2013. ) Federal ACA regulations and guidance also require most health plans and health insurers to cover contraceptive services without cost-sharing.

ACA has several provisions that may increase health insurance coverage in the populations served by Title X. These provisions could help free up funds that Title X clinics have historically spent on serving the uninsured. For example,

States can expand Medicaid eligibility to include most nonelderly, nonpregnant individuals with income at or below 133% of the federal poverty guidelines, effectively 138% with the 5% income disregard. (In 2015, 66% of Title X clients had incomes under 101% of the federal poverty guidelines; another 14% had incomes between 101% and 150% of the federal poverty guidelines. ) ACA gives states the option, through a Medicaid state plan amendment, of providing targeted Medicaid family planning services and supplies to certain individuals who would otherwise be ineligible for Medicaid. ACA requires most private health plans that offer dependent coverage for children to continue to make such coverage available for young adult children under the age of 26. (In 2015, 45% of Title X clients were younger than 25 years old; another 22% were aged 25 to 29.) ACA provides certain individuals and small businesses with access to private health plans through health insurance exchanges and subsidizes premium expenses and cost-sharing out-of-pocket costs for certain individuals. To ensure access for low-income individuals, exchange plans are required to have a sufficient number and geographic distribution of "essential community providers," which include Title X projects. ACA's individual mandate provision requires most individuals to have health insurance or pay a penalty.

OPA established FY2017 Program Priorities to guide the project plans of family planning services grantees. In response to ACA, one of these priorities is demonstrating Title X clinics' ability to bill Medicaid and private health insurance. Project plans should have "Evidence of contracts with insurance plans and systems for third party billing as well as the ability to facilitate the enrollment of clients into private insurance and Medicaid, optimally onsite; and to report on numbers of clients assisted and enrolled." A survey of publicly funded family planning clinics found that in 2015, 79% of Title X clinics had contracts to bill Medicaid plans (compared with 35% in 2010), and 69% had contracts to bill private health insurance plans (compared with 26% in 2010).

Title X clinics also provide enrollment assistance to clients eligible for Medicaid or exchange plans under ACA. OPA awarded one-year grants in FY2014 and FY2015 to help Title X clinics enroll uninsured clients in health coverage. According to the FY2017 HRSA Justification, the Obama Administration expected that Title X clinics would increase revenue, in part by raising the proportion of clients who have health insurance and by billing third parties.

Title X supporters state that, although clinics funded by Title X could see increased revenues from Medicaid and private insurance, the Title X program is still necessary under the ACA:

In addition to medical care, Title X supports activities that are not reimbursable under Medicaid and commercial insurance plans… Title X has made a major contribution to the training of clinicians; that need remains today… Title X helps to support staff salaries, not just for clinicians but for front-desk staff, educators and finance and administrative staff. Title X provides for individual patient education as well as community-level outreach and public education about family planning and women's health issues. Title X also helps to support the infrastructure necessary to keep the doors open—subsidizing rent, utilities and infrastructure needs like health information technology.

Some Title X supporters argue that Medicaid and private health insurance reimbursements do not cover the full cost of providing care. Some advocates also argue that even with ACA's health coverage expansions, family planning services will still be sought by uninsured persons and dependents who, for confidentiality reasons, might not wish to bill reproductive health services to their parent's or spouse's health insurance. Advocates maintain that even with the ACA, there is still strong demand for safety net providers, such as many Title X clinics, that provide health care to underserved populations.

ACA requires most private health plans to cover certain preventive services for women without cost-sharing. HHS commissioned the Institute of Medicine to recommend preventive services to be included in this requirement. Adopting the IOM recommendations, federal rules and guidelines require that most health plans cover, without cost-sharing, "All Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity," as prescribed. Some have stated that this requirement, by removing up-front cost barriers, could result in more women switching to longer-acting contraceptive methods, such as hormonal implants and intrauterine devices. OPA has identified "patient access to a broad range of contraceptive options, including long acting reversible contraceptives (LARC)" as one of the key Title X issues in FY2017. HHS has also added Title X clients' rate of LARC use to the list of outcome measures for assessing program performance.

The Family Planning Annual Report: 201 5 National Summary contains Title X program data from 2015, the second year that ACA's major coverage provisions were in effect. Clients' insurance coverage rates have risen: 50% of Title X clients had health insurance in 2015, compared with 43% in 2014, and 35% in 2013. Projects that received Title X funds also reported increased revenues from private third-party payers such as private health insurance plans: $104.0 million in 2015, compared with $95.1 million in 2014, and $69.2 million in 2013.

The number of Title X clients served in 2015 (4.018 million) was 3% lower than in 2014 (when there were 4.129 million clients), and 12% lower than in 2013 (when there were 4.558 million clients). As discussed above in " Client Characteristics ," a decrease in demand might be explained in part by ACA coverage expansions, because newly insured clients can now seek care from private practitioners and other providers. Increased LARC use could also affect demand by reducing the frequency of client visits in the long run, compared with some other contraceptive methods (such as oral contraceptives that require refills). The number of female Title X clients using hormonal implants or intrauterine devices in 2015 was 11% higher than in 2014, 16% higher than in 2013, and 50% higher than in 2010.

ACA has also impacted the Title X program in other ways. For example, because ACA increased the Medicaid rebate percentage paid by drug makers, Title X clinics receive larger discounts on drugs purchased through the 340B drug pricing program. As a result of receiving larger drug discounts through the 340B program, Title X clinics receive more revenue on drugs dispensed to clients.

ACA also increased funding for teen pregnancy prevention efforts, expanded health care workforce programs, and increased funding for community health centers (many of which are Title X providers). HHS contracted with IOM to convene a Standing Committee to advise the Title X program. Among other topics, the IOM Standing Committee was tasked with examining the roles of family planning, reproductive health, and Title X in health reform. OPA also awarded FY2014 research funding to "conduct data analysis and related research and evaluation on the impact of the Affordable Care Act on Title X funded family planning centers." For Title X grantees and clinics, the Title X Family Planning National Training Centers compiled resources and provided training on how ACA may affect Title X.

Recent Legislative and Executive Actions Potentially Impacting Title X

The Trump Administration may use the executive branch to change ACA regulations, guidance, or enforcement activities. For example, on May 4, 2017, President Trump signed an executive order on "Promoting Free Speech and Religious Liberty," which directs the Treasury, Labor, and HHS Secretaries to consider amending regulations. These changes would address conscience-based objections to the requirement that most health plans cover certain women's preventive services, such as contraception.

Legislation has also been introduced to amend, repeal, or replace some or all of the ACA. For example, during the 115 th Congress, H.R. 1628 and some of its amendments have been legislative vehicles for several ACA-related proposals, including but not limited to

the House's American Health Care Act (AHCA), a version of which passed the House as H.R. 1628 on May 4, 2017, the Senate's Better Care Reconciliation Act (BCRA), a version of which was considered and ruled out of order in the Senate as S.Amdt. 270 to H.R. 1628 on July 25, 2017, the Senate's Obamacare Repeal Reconciliation Act (ORRA), a version of which was rejected in the Senate as S.Amdt. 271 to H.R. 1628 on July 26, 2017, and the Senate's Health Care Freedom Act (HCFA), which was rejected in the Senate as S.Amdt. 667 to H.R. 1628 on July 28, 2017.

The above proposals do not explicitly mention Title X, but some of their provisions could affect the program indirectly. For example, AHCA and BCRA have provisions that would potentially impact the insurance status of some Title X clients, including provisions to eliminate the ACA's individual mandate penalty, provisions to restructure ACA exchange subsidies, and provisions projected to reduce Medicaid enrollment compared with current law. Such changes would potentially affect demand for Title X's free and discounted services.

The Congressional Budget Office (CBO) estimated that AHCA and BCRA would reduce federal Medicaid spending compared with current law; thus they would also potentially impact Title X projects' Medicaid revenue. Federal regulations specify that no Title X projects may be 100% supported by Title X funds. That is, Title X projects must have some revenues from non-Title X sources. In 2015, Title X projects reported that Medicaid accounted for 40% of their total revenues. In comparison, Title X funds accounted for 19% of their total revenues.

AHCA, BCRA, ORRA, and HCFA would also restrict federal Medicaid funding to Planned Parenthood Federation of America (PPFA) and its clinics for one year, according to CBO. The Guttmacher Institute found that in 2015, 13% of Title X clinics were affiliated with PPFA.

AHCA, BCRA, ORRA, and HCFA would also affect Title X clinics' revenues from the federal Health Center Program. The Health Center program is administered by the U.S. Bureau of Primary Health Care (BPHC) under Section 330 of the Public Health Service Act. It supports a wide range of outpatient health services, not just family planning. AHCA, BCRA, ORRA, and HCFA would provide an additional $422 million for FY2017 for the Community Health Center Fund, which appropriates mandatory funds to the Health Center program. Although the legislation does not require it, some health centers could opt to use the additional funds to provide family planning services. In 2015, 26% of clinics receiving Title X funds participated in the Health Center program as well. In 2015, Title X clinics reported that 1% of their Title X family planning project revenues came from programs administered by BPHC including the Health Center program.

Such executive and legislative branch actions could further impact Title X in the future. Depending on what these actions are, and because many of ACA's effects on Title X are indirect, potential consequences for Title X are unclear at this point.

Nullification of Rule on Selecting Subrecipients

As mentioned, Title X grantees can provide family planning services directly, or they can 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." It became effective January 18, 2017. P.L. 115-23 (April 13, 2017) nullified the rule.

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 the following language to Title X Family Planning Services grant program regulations:

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 , "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. As a result, the rule "shall be treated as though such rule had never taken effect." 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.

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. For example, some states enacted laws to prohibit state and local agencies from giving Title X subawards to abortion providers. 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. 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."

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 continuing Title X grants would be required to describe their criteria for choosing subrecipients. 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."

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

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 services in family planning projects. The rule updated and revised regulations that had been promulgated in 1988. The major revision revoked the "gag rule," which restricted family planning grantees from providing abortion-related information. The regulation at 42 C.F.R. §59.5 had required, and continues to require, that abortion not be provided as a method of family planning. The July 3, 2000, rule amended the section to add the requirement that a project must give pregnant women the opportunity to receive information and counseling on each of the following options: prenatal care and delivery; infant care, foster care, or adoption; and pregnancy termination. If the woman requests such information and counseling, the project must give "neutral, factual information and nondirective counseling on each of the options, and referral upon request, except with respect to 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. The prohibition on abortion does not apply to all the activities of a Title X grantee, but only to activities that are part of the Title X project. The grantee's abortion activities must be "separate and distinct" from the Title X project activities. 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.

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.

In 2004, following appropriations conference report directions, HHS surveyed its Title X grantees on whether their clinic sites also provided abortions with nonfederal funds. 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, and 34 indicated that none of their clinic sites provided abortions with nonfederal funds; 3 responses had no numerical data or said the information was unknown.

Title X supporters argue that family planning reduces unintended pregnancies, thereby reducing abortion. HHS estimates that Title X services helped avert 901,838 unintended pregnancies in FY2015, and the Guttmacher Institute estimates that Title X services helped avert 822,300 unintended pregnancies in calendar year 2015. 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.

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

Teenage Pregnancy and Title X

In 2015, 18% of Title X clients were aged 19 or younger. 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. (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. The Guttmacher Institute estimates that without Title X clinics' services, the 2015 U.S. teen pregnancy rate would have been 44% higher. 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.

Confidentiality for Minors and Title X

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

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.

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.

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. 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. According to OPA, Title X clinics "commonly forgo billing" health insurers to maintain confidentiality.

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

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.

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."

Planned Parenthood and Title X

PPFA operates through a national office and 56 affiliates, which operate approximately 600 local health centers. 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.

In March 2015, the Government Accountability Office (GAO) released a report with data on the obligations, disbursements, and expenditures of federal funds for several nonprofit organizations, including PPFA and its affiliates.

According to the GAO report, in FY2012, HHS reported obligating $18.67 million, and disbursing $19.08 million, to PPFA affiliates through the Title X program. These figures reflected funds that HHS provided directly to these organizations. They did not include Title X funds that reached Planned Parenthood or its affiliates indirectly through subgrants or that passed through from state agencies or other organizations.

The GAO report also showed PPFA affiliates' expenditures of Title X funds. Most of these expenditures were identified through audit reports that PPFA affiliates submitted to comply with Office of Management and Budget (OMB) audit requirements. Expenditures included federal funds provided directly or indirectly to these organizations. The most recent expenditure data were from FY2012, when Planned Parenthood and its affiliates reported spending $64.35 million from the Title X Family Planning Services program.

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