Family planning

Rebuilding Title X: New Regulations for the Federal Family Planning Program

On October 4, 2021, the Biden administration released final new regulations for the federal Title X family planning program. The new regulations replace those issued by the Trump administration in 2019, which made significant and well-documented changes to the Title X program, resulting in a significant reduction in the size of the Title X network and the number of low-income and uninsured customers served by the program. This brief presents new state-level data on the state of the Title X network on the eve of the implementation of new regulations and summarizes the impact of Trump-era regulations on the number of customers served. and the participation status of clinics across the country.

The impact of the 2019 Trump settlement

The 2019 Trump administration regulations significantly reduced the Title X family planning network by disqualifying family planning clinics offering co-located abortion services and prohibiting the provision of abortion referrals to clients who do so. wished. In his Family Planning Annual Report 2020the Federal Office for Population Affairs (OPA) documented the impact of Trump administration and pandemic regulations on the number of clients they served, as well as changes in the number of beneficiaries and clinic sites from 2018 to 2020 (Table 1). During this two-year period, the number of clients served increased from 3.9 million to 1.5 million people. The report estimated that the Trump administration’s final rule accounted for nearly two-thirds (63%) of the precipitous reduction in the number of family planning clients served while the COVID-19 pandemic accounted for one-third of the fall (Figure 1).

2018 2019 2020
Customers Served 3.9 million 3.1 million 1.5 million
Family planning visits 6.5 million 4.7 million 2.7 million
Beneficiaries (receive funding from HHS OPA) 99 100 75
Sub-recipients (receive funding from recipients and may distribute to clinical sites or provide services themselves) 1,128 1,060 867
Clinical sites (receiving funding from recipients or sub-recipients) 3,954 3,825 3,031
THE SOURCE: Title X Family Planning Annual Report 2020 National Summary

With the great exodus of clinics from the Title X program in the summer of 2019, there are still five states without Title X-funded clinic sites: Oregon, Washington, Vermont, Maine and Hawaii, while New York currently has only two sub-recipients. sites (Table 2). Seven other states, including New York, have networks of Title X clinics that are currently operating at less than 25% of their original capacity. Based on our analysis of the OPA’s Title X Family Planning Directories, 36 states experienced a decrease in the number of participating Title X clinics from June 2019 to August 2021, while the OPA’s Annual Family Planning Reports between 2018 and 2020 show that 49 states and DC saw a customer reduction ranging from 2% to 100%, with a median customer reduction of 52%.

A small number of entities have joined the Title X network over the past year. One of two Utah grantees, Utah Navajo Health System, joined the Title X program in July 2020 as a subrecipient to Arizona grantee, Arizona Family Health Partnership. The Maryland Department of Health joined the program in October 2020 after the state of Maryland obtained a permanent injunction against enforcement of the 2019 Title X final rule. Most Planned Parenthood clinics left the Title X program after Trump administration rule became final, though few are now in the program, including those in Maryland, Washington DC and Missouri.

The Trump administration’s final rule allowed “non-traditional” Title X recipients to join the network and some of those recipients are no longer part of the program under the Biden administration. Trump administration regulations extended federal family planning funds to organizations that only offered fertility awareness or abstinence options to their clients. The new regulations do not qualify them to participate as beneficiaries if they do not offer a wider range of contraceptive methods to their clients. Notably, Obria Group, Inc., a Southern California-based Christian organization that did not provide contraceptive services based on religious objections to hormonal contraception, left the Title X program in April 2021. Another Christian organization , Beacon Christian Community Health Center, which joined the Title X network as a New York recipient in October 2018, also left the Title X program in April 2021. Two of the three new Title X recipients who joined the Title program X under the Trump administration that are not based on religion, the city of El Paso in Texas and the community health services of Osceola in Florida, remain in the program.

Key Aspects of Title X Settlements of Biden’s Final Administration

the new Biden regulations restore many aspects of the program that were removed by Trump administration regulations, including:

  • Allow co-located abortion services and abortion referrals
  • Require clinics that are unable to provide clients with a wide range of family planning methods to provide a prescription or referral to the client upon request
  • Additional privacy protections for teens – clinics may not require consent from a parent or guardian for the provision of services and may not notify a parent or guardian before or after the provision of any service

The settlement also added new provisions to the program, including:

  • Added telehealth as an option to provide medical services in addition to in-person care
  • Require family planning projects to provide client-centered, culturally and linguistically appropriate, inclusive, and trauma-informed services; protects the dignity of the individual; and ensuring equitable and quality service delivery consistent with a nationally recognized standard of care
  • Added new criteria for funding – applicant’s ability to advance health equity

The final rules will come into effect on November 8, 2021 and clinics will once again be able to offer their clients the care that meets the quality standards set by CDC and OPA, including providing counseling on non-directive pregnancy options with referrals for antenatal care, adoption or abortion services, and confidential services for adolescents, but it will take time to re-establish the network of providers. On October 25, 2021, the State of Ohio, joined by 11 other states (AL, AZ, AK, FL, KS, KY, MO, NE, OK, SC, WV), filed a trial in U.S. District Court for the Southern District of Ohio against HHS to block implementation of Biden administration regulations. These states claim the final settlement violates Section 1008 of the Public Health Services Act which states that none of the funds allocated under Title X may be used in programs where abortion is a method of planning. family. The litigants say that by reinstating regulations that allow co-located abortion services and require participating providers to offer referrals for abortions to clients who request them, HHS is not complying with the spirit of the law. The States request a decision as soon as possible and no later than December 31, 2021. If the Court does not rule before November 8andthe Biden settlement will go into effect.

If the final settlement remains in effect, additional funding that may be awarded to grantees who have left the network is not expected until spring 2022 after grant applications. due January 11, 2022 are reviewed and approved. Funding will likely be granted by April 1, 2022. Recipients who are still part of the Title X program can bring clinics back into their network if they have current funding. The three-year grant cycle for current grantees ends on March 31, 2022.

In response to Texas’ SB 8 banning most abortions, HHS will provide additional funding to Texas’ largest Title X recipient to meet increased demand for emergency contraception and family planning services. The OPA also plans to award an additional $10 million through a new funding opportunity titled “Funding to Address the Critical Need for Family Planning Services” that will provide grants to Title X entities that can demonstrate a need for additional funding for family planning services due to either an influx of clients as a result of Texas’ SB 8 abortion ban or for some other reason. A second funding opportunity the OPA plans to release will provide $45 million in spring 2022 to Title X recipients to expand and improve their telehealth infrastructure and capacity, which will be especially important given the COVID-19 pandemic. 19 ongoing and increased demand for telehealth services.

Looking forward

The Biden administration’s final Title X regulations will make significant changes to sites across the country and allow clinics like Planned Parenthood, which were previously disqualified because they co-located abortion services or provide abortion referrals for people who want them, to ask again for federal support to provide family planning services to low-income and uninsured people. These regulations are being challenged by several states in litigation that could take years to resolve. If fully implemented, however, the real impact of the revised regulations will be when federal funds become available for beneficiaries and clinics to join the program and allow more low-income people to receive health care services. healthcare from Title X sites. While many beneficiaries and clinics who left the network are expected to resume participation in the safety net program, it remains to be seen whether all those beneficiaries and providers who left the program will ask to return. . Some have been able to secure state-level funding to make up for lost federal support. These decisions will likely hinge on whether states will continue to subsidize their family planning providers or whether additional federal funds will be needed to maintain and strengthen state family planning networks and services in communities that have historically been served by these providers.