The Title X Family Planning Program (Title X), enacted in 1970, is the only domestic federal program devoted solely to family planning and related preventive health services. It is administered by the Office of Population Affairs (OPA), under the Office of the Assistant Secretary for Health (OASH) within the Department of Health and Human Services (HHS). On June 1, 2018, HHS published a proposed rule in the Federal Register that would change OPA's administration of the grant program. HHS contends that the program has not been properly administered in accordance with Sections 300 to 300a-6 of title 42 of the U.S. Code (U.S.C). HHS states that the goal of the rule is to ensure that Title X funds are used within the limits set by Congress. According to HHS, family planning projects that receive Title X funds are closely monitored to ensure that federal funds are used appropriately and are not used for prohibited activities, such as for performing surgical abortion procedures. HHS states that the agency has concerns about whether Title X projects that operate in a health care facility where abortions are provided are unintentionally crossing federal funds with funds used to cover the facility's abortion-related expenses. Furthermore, according to the proposed rule's preamble, OPA had previously misinterpreted current law by requiring Title X providers to provide abortion-related services such as counseling and referrals to their patients upon request. The 115 th Congress is debating the scope of the program to determine whether providing an abortion-related service such as an abortion referral should be a family planning service under Title X. For example, some Members of Congress have stated that the service of providing abortion referrals is a family planning service that Title X providers should continue to provide Title X clients upon request. According to some Members of Congress, the proposed rule is a gag rule that "would bar patients from receiving information to support their ability to make informed decisions about their own reproductive health." These Members of Congress are referring to a policy originally put in place by President Reagan in 1988 that was challenged in court but upheld by the Supreme Court in 1991. The court case, Rust v. Sullivan , narrowed the scope of permissible abortion-related activities that are linked to federal funding. Congress subsequently voted to repeal the gag rule but fell short of the two-thirds majority needed to override a President George H.W. Bush veto in 1992. The Clinton Administration suspended the gag rule in January 1993. According to the Clinton Administration, During the first 18 years of the [Title X] program, medical professionals at Title X clinics provided complete, uncensored information, including nondirective abortion counseling. In February 1988, [HHS] adopted regulations, which have become known as the "Gag Rule," prohibiting Title X recipients from providing their patients with information, counseling, or referrals concerning abortion. Subsequent attempts by the [George H.W.] Bush Administration to modify the Gag Rule and ensuing litigation have created confusion and uncertainty about the current legal status of the regulations. Other Members of Congress state that Title X providers should not provide abortion referrals as a method of family planning. According to these Members, current regulations on abortion referrals "undermine" the statutory requirement that no Title X funds shall be used in projects "where abortion is a method of family planning." The Trump Administration has stated that "[c]ontrary to recent media reports, HHS's proposal does not include the so-called 'gag rule' on counseling about abortion that was part of the Reagan Administration's Title X rule." Members on both sides of the issue agree, however, that the proposed rule would make it harder for Planned Parenthood Federation of America (PPFA) to receive Title X funds. To assist Congress as it considers issues related to Title X, this report provides a brief overview of the Title X program; discusses the proposed rule's major elements and explains how the proposed rule differs from current Title X rules and guidance; provides HHS' rationale for the components of the proposed rule, as well as selected commentary from key stakeholders in reaction to the proposed rule; and summarizes HHS's regulatory impact analysis. All 50 states, the District of Columbia, and the U.S. territories and Freely Associated States (collectively referred to as states ) are eligible to apply for Title X grants, as are other public agencies and nonprofit organizations. Grantees may use Title X dollars to establish and operate family planning projects that provide effective methods of family planning services, such as contraception, as well as infertility services. 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. Grants for family planning services fund a range of 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. These services must be provided "without coercion and with respect for the privacy, dignity, social, and religious beliefs of the individuals being served." In FY2017, OPA used approximately 90% of Title X funds for clinical services such as those listed above, and the other 10% for activities such as personnel training and service delivery improvement research in family planning. Current regulations require that Title X's medical services be provided under the direction of a physician with special training or experience in family planning. However, most Title X clinical service staff are not medical doctors. Title X clinical service providers include physicians, nurse practitioners, certified nurse midwives, physician assistants, and registered nurses. In 2016, of Title X's full-time equivalent (FTE) clinical service providers, 22% were physicians; 71% were nurse practitioners, certified nurse midwives, and physician assistants; and 7% were registered nurses with an expanded scope of practice. Title X grantees can provide family planning services directly or subaward Title X monies to other public or nonprofit entities to provide services. Although no fixed matching amount is required for grants, current regulations specify that no Title X projects may be fully supported by Title X funds. In 2016, Title X grantees provided services through 3,898 clinics. That same year, Title X-funded clinics served 4.008 million clients, primarily low-income women and adolescents. 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. An earlier survey found t hat for 61% of clients, Title X-funded clinics were their "usual" or only regular source of health care. Forty-three percent of Title X clients were uninsured in 2016 . Title X is a discretionary program (i.e., its funding is provided in and controlled by annual appropriations acts). It has received appropriations every year since the program started in FY1971. On March 23, 2018, President Trump signed the Consolidated Appropriations Act, 2018 ( P.L. 115-141 ). This law provides $286.479 million for Title X in FY2018, the same as the FY2017-enacted level. The FY2018 act continues previous years' requirements that Title X funds not be spent on abortions, among other requirements. President Trump's FY2019 budget request, submitted February 12, 2018, includes $286.479 million for Title X, the same as the FY2018-enacted level. The FY2019 budget would continue previous years' provisions in appropriations laws prohibiting the use of Title X funds for abortion, among other requirements. On June 28, 2018, the Senate Appropriations Committee reported S. 3158 , Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2019. S. 3158 would fund Title X at the FY2018-enacted level, and would continue previous years' provisions in appropriations laws prohibiting the use of Title X funds for abortion, among other requirements. On July 23, 2018, the House Appropriations Committee reported H.R. 6470 , the Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2019. H.R. 6470 would provide no funding for Title X in FY2019. During the House Appropriations Committee's bill markup, a committee amendment was defeated that would have funded Title X at the FY2018-enacted level and would have prohibited the bill's funds from being used to finalize, implement, administer, or enforce the Title X proposed rule. On June 1, 2018, HHS published a proposed rule in the Federal Register to revise the regulations that implement the Title X Family Planning Program. HHS accepted comments for 60 days, until July 31, 2018. Discussed below are three major elements of the proposed rule that HHS aims to modify: (1) abortion-related activities, (2) grantee requirements, and (3) pertinent definitions. Provided in each discussion of the major elements is an explanation of how the proposed rule differs from current Title X rules and guidance. On July 3, 2000, OPA released a final rule with respect to abortion-related 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.