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Federal Register / Vol. 86, No. 192 / Thursday, October 7, 2021 / Rules and Regulations
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increase family planning services to low-income clients. Additionally, 324,776 fewer uninsured clients were served in 2019 compared to 2018. FPAR
data also demonstrate that in 2019
compared to 2018, 128,882 fewer Black or African Americans; 50,039 fewer Asians; 6,724 fewer American Indians/
Alaska Natives; 7,218 fewer Native Hawaiians/Pacific Islanders; and 269,569 fewer Hispanics/Latinos received Title X services.4 Additionally, 151,375 fewer adolescent clients received essential family planning services in 2019. The Department believes these new facts warrant a reconsideration of the 2019 rule.
The mandate of the Title X program is to support access to critical family planning and preventive health services;
unfortunately, the result of the 2019 rule ran counter to that effort. The 2019 rule undermined the mission of the Title X
program by helping fewer individuals in planning and spacing births, providing fewer preventive health services, and delivering fewer screenings for sexually transmitted infections STIs. More specifically, in 2019 compared to 2018, 225,688 fewer clients received oral contraceptives; 49,803 fewer clients received hormonal implants; and 86,008
fewer clients received intrauterine devices IUDs. Additionally, 90,386
and 188,920 fewer Papanicolaou Pap tests and clinical breast exams, respectively, were performed in 2019
compared to 2018. Confidential human immunodeficiency virus HIV tests decreased by 276,109. STI testing decreased by 256,523 for chlamydia, by 625,802 for gonorrhea, and by 77,524 for syphilis. Furthermore, 71,145 fewer individuals who were pregnant or sought pregnancy were served.5
In the 2019 rule, the Department stated that the rule was expected to increase the number of entities interested in participating in Title X as grantees or subrecipient service providers and, thereby, to increase patient access to family planning services focused on optimal health outcomes for every Title X client. 84
FR at 7782 March 24, 2019. However, this expectation proved unwarranted.
Despite several attempts, OPA has been unable to recruit new grantees and new providers into the Title X program to fill the current gaps in services resulting from implementation of the 2019 rule.
4 OPA,
2020. Family Planning Annual Report:
2019 National Summary Report. Accessed on March 9, 2021 from https opa.hhs.gov/sites/default/files/
2020-09/title-x-fpar-2019-national-summary.pdf.
5 OPA, 2020. Family Planning Annual Report:
2019 National Summary Report. Accessed on March 9, 2021 from https opa.hhs.gov/sites/default/files/
2020-09/title-x-fpar-2019-national-summary.pdf.

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First, OPA issued competitive supplemental funding of $33.7 million to 50 existing Title X grantees in fiscal year 2019 to expand their Title X
services. Unfortunately, even with the additional funding, the majority of states were not able to increase the number of service sites in their Title X
networks. From 2018 to 2020, 38 states and territories saw a decrease in the number of service sites in their networks, 12 saw no change in their number of service sites, and only nine saw an increase in the number of service sites. Analyzing users between 2018
2020 for those nine states that gained service sites, six still lost users WV, AZ, DE, NE, CO, and TX while three gained users GA, NV, and Palau. Next, OPA issued a competitive funding announcement in fiscal year 2020 to recruit new grantees to provide Title X
services in unserved or underserved states and communities. The number of applications received was so low eight eligible applications received that the resulting grant awards were for less than the total amount of funding available grant awards for $8.5 million with $20
million available, and OPA was only able to fund grantees to provide services in three states with no or limited Title X services at the time.
The lack of organizations applying for Title X grant funding following implementation of the 2019 rule and the lack of new service sites willing to join existing Title X grantees as providers strongly suggest that the Department was wrong to believe that the 2019 rule would increase the number of grantees and providers. Rather, the 2019 rule appears to have had the opposite effect and resulted in a significant loss of grantees, subrecipients, and service sites, and close to one million fewer clients served from 2018 to 2019. The Department believes that this record warrants a change in course.
The decline in clients served and services provided is devastating. The Title X program is the only federal grant program dedicated to providing comprehensive family planning and related preventive health services. Title X clinics provide services to clients, with priority given to persons from lowincome families. Title X services are voluntary, confidential, and provided regardless of ones ability to pay. For many clients, Title X clinics are their only ongoing source of healthcare and health education. In fact, six in 10
women who go to a publicly funded
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family planning clinic consider it their usual source of medical care.6
While some family planning providers that withdrew from the Title X program were able to continue providing reproductive health services at some level in the absence of Title X
funding, the services provided were not the same as those provided under Title X. Grantees that relinquished their Title X funding at the time made clear that they were not able to provide the same breadth of services as they had been able to under Title X and were not able to provide services using the same schedule of discounts as required in the Title X program. According to several comments received, the loss of Title X
funding meant that organizations had to adjust their fee schedules and push more costs for services to the clients. As a result, organizations saw more clients forgoing recommended tests, lab work, STI testing, clinical breast exams, and pap tests. Further, due to costs, organizations saw some family planning clients outside of the Title X network choose less effective methods of birth control.
The 2019 rule abandoned major portions of Providing Quality Family Planning Services: Recommendations from Centers for Disease Control and Prevention and the U.S. Office of Population Affairs QFP,7 such as nondirective options counseling and referrals, and the client-centered approach recommended by QFP, over the objection of every major medical organization and without any countervailing public health rationale.
QFP recommendations support providers in delivering quality family planning services and define family planning services within a broad context of preventive services, to improve health outcomes for individuals and their future children.
QFP recommendations are based on a rigorous, systematic, and transparent review of the evidence and were developed with input from a broad range of clinical experts, OPA, and the CDC. These recommendations not only improve the quality of care provided to family planning clients, but they foster a supportive and communicative relationship between provider and patient. As evident from grantee relinquishment letters and comments 6 Frost, J., Gold., Hasstedt, K., & Sonfield, A.
2014. Moving Forward: Family Planning in the Era of Health Reform. New York: Guttmacher Institute.
7 CDC. 2014. Providing Quality Family Planning ServicesRecommendations from CDC and the U.S. Office of Population Affairs. Accessed on March 8, 2021 from https opa.hhs.gov/grantprograms/title-x-service-grants/about-title-x-servicegrants/quality-family-planning.

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