	Introduction

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. 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. 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. 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." 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. The Title X Family Planning Program

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. 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. Proposed Rule on Statutory Requirements

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. Proposed Rule

The proposed rule would remove the requirement that Title X projects must provide pregnant clients with the opportunity to receive abortion-related information, counseling, and referrals upon request. Therefore, if the rule is finalized, a Title X provider would be prohibited from knowingly referring a pregnant client to an abortion provider. 300a-6 (Section 1008 of the Public Health Service Act), Title X funds may not be used "in programs where abortion is a method of family planning." Under current program guidelines, a grantee's abortion activities must be "separate and distinct" from the Title X project activities; however, in some cases, a grantee's Title X project activities and its abortion activities may have a common facility, a common waiting room, common staff, and a common records system:
Non-Title X abortion activities must be separate and distinct from Title X project activities. In addition, the proposed rule would prohibit the use of Title X funds to build infrastructure for prohibited abortion-related activities. For example, Title X funds enable PPFA-affiliated health centers to provide reproductive health services to an estimated 41% of Title X clients. Title X grantees are subject to several reporting requirements, but they are not laid out in the Title X regulations in the Code of Federal Regulations (42 C.F.R. Respondents included 535 Title X clinics. A core set of family planning services is defined in program guidance, "Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs," which states,
Family planning services include the following:
--providing contraception to help women and men plan and space births, prevent unintended pregnancies, and reduce the number of abortions;
--offering pregnancy testing and counseling;
--helping clients who want to conceive;
--providing basic infertility services;
--providing preconception health services to improve infant and maternal outcomes and improve women's and men's health; and
--providing sexually transmitted disease (STD) screening and treatment services to prevent tubal infertility and improve the health of women, men, and infants.
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. 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. Title X grants enable grantees to establish and operate family planning projects. A family planning project refers to a set of activities that a Title X grantee undertakes under its grant agreement to provide a broad range of family planning methods and services to Title X clients. (In 2016, Title X-funded clinics served 4 million clients.) Examples of Title X activities include provider-to-patient counseling, dissemination of educational materials, and the delivery of clinical services. Clinical services provided through Title X projects include contraceptive services and supplies, sexually transmitted disease testing and treatment, and preconception health care services. All services are confidential.
Title X is administered through the Office of Population Affairs (OPA) in the Department of Health and Human Services (HHS). The program was appropriated $286.5 million for FY2018. Federal law (42 U.S.C. §300a-6) prohibits the use of Title X funds in projects "where 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 such as for performing surgical abortion procedures. Under current program guidance, the abortion prohibition does not apply to all Title X grantees' activities; instead, the prohibition applies only to activities that are part of the Title X project. A grantee's abortion activities must be "separate and distinct" from the Title X project activities.
On June 1, 2018, OPA published a proposed rule in the Federal Register, "Compliance with Statutory Program Integrity Requirements," that would make several changes to federal Title X family planning regulations, including the following:
Title X projects would no longer be required to offer pregnant clients the opportunity to receive abortion information, counseling, and referral upon request. Title X projects would be prohibited from referring patients to abortion services. Title X projects would be required to maintain physical and financial separation between their Title X projects and abortion-related activities. Several terms, including "family planning" and "low-income family," would have new definitions. Criteria for awarding Title X Family Planning Services grants would be revised. Title X grant applicants and grantees would be subject to new reporting requirements.
This proposed rule has sparked a congressional debate about the scope of Title X. The 115th Congress is debating the scope of Title X to determine whether providing an abortion-related service, such as referring a pregnant client to an abortion provider, should be a family planning service under Title X. In addition, Members of Congress are debating whether this proposed rule is a "gag rule": an attempt to prevent some Title X clients from receiving adequate information that would permit them to make an informed decision about their health care treatment.
This report summarizes the proposed rule's major elements and explains how the proposed rule differs from current Title X rules and guidance. In addition, CRS provides HHS's rationale for the components of the proposed rule, as well as selected commentary from key stakeholders in reaction to the proposed rule.