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Federal Register / Vol. 86, No. 192 / Thursday, October 7, 2021 / Rules and Regulations Section 1008s text and subsequent appropriations enactments.
Advancing equity for all, including people from low-income families, people of color, and others who have been historically underserved, marginalized, and adversely affected by persistent poverty and inequality, is a priority for the Department, for OPA, and for the Title X program. By focusing on advancing equity in the Title X
program, we can create opportunities to support communities that have been historically underserved, which benefits everyone. The 2021 rule was written to ensure that the predominantly lowincome clients who rely on Title X
services as their usual source of medical care have access to the same quality healthcare, including full medical information and referrals, that higherincome clients and clients with private insurance are able to access. Key strategies for advancing equity include removing barriers to accessing services, improving the quality of services, and providing services that are clientcentered. Several revisions in the rule focus on improving access to services.
These revisions include clearly defining what constitutes a broad range of acceptable and effective family planning methods and services, requiring service sites not offering a broad range of methods on-site to provide a prescription to the client for their method of choice or referrals, as requested, clarifying required billing practices and income verification for low-income clients, enabling a broader range of clinical services providers to direct Title X services and to provide consultation for medical services, and strengthening client confidentiality.
Several revisions in the 2021 rule focus on improving quality of Title X
services. These revisions include clearly defining quality healthcare as safe, effective, client-centered, timely, efficient, and equitable; incorporating QFPs definition of family planning into the regulation; and requiring all family planning services to be delivered consistent with nationally recognized standards of care. Finally, several revisions in the 2021 rule focus on ensuring client-centered care. These revisions include clearly defining clientcentered care as being respectful of, and responsive to, individual client preferences, needs, and values and where client values guide all clinical decisions, and requiring all family planning services to be client-centered, culturally and linguistically appropriate, inclusive, and traumainformed.

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II. Public Comment and Departmental Response The Department provided a 30-day public comment period for the proposed rule. That period closed on May 17, 2021. A total of 180,266 public comments were submitted to www.Regulations.gov or directly to the Department.
With this 2021 final rule, the Department revokes the requirements of the 2019 regulations 84 FR 7714, March 24, 2019 and readopts the 2000
regulations 65 FR 41270, July 3, 2000
with several revisions. In the section below, the Department discusses the public comments, its responses, and the text of the final rules. The Department first presents a summary of public comments received related to revoking the 2019 regulation and readopting the 2000 regulation. The Department then provides a summary of comments received regarding the revisions and technical corrections proposed in the NPRM to specific provisions of the 2000
regulations. The NPRM proposed 14
revisions, including to 59.2, 59.5a1, 59.5a3, 59.5a8, 59.5a9, 59.5a12, 59.5a13, 59.5b1, 59.5b3, 59.5b8, 59.6, 59.7, 59.10, and 59.11. The NPRM also proposed 10
technical corrections, including to 59.2, 59.5a4, 59.5a5, 59.5a6, 59.5a7, 59.5a11, 59.5b3, 59.6b2, 59.8, and 59.12. The Department received comments on all the revisions proposed in the NPRM and three of the 10 technical corrections.
The Department did not receive comments on the revision to 59.11, nor to the technical corrections to 59.2, 59.5a6, 59.5a7, 59.5a11, 59.5b2, 59.5b3, or 59.8. A
summary of comments and the Departments response are only provided for those revisions and technical corrections that received comments. In addition, the Department received public comments requesting a revision to 59.5b6 that was not proposed in the NPRM, but that is related to the revision that was proposed in the NPRM to 59.5b1. A
summary of these comments and the Departments response are also included below.
After considering the comments, the Department adopts the regulations proposed for public comment on April 15, 2021 at 86 FR 19812 with nine additional revisions and six additional technical corrections to what was proposed in the NPRM.

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General Comments Related To Revoking 2019 Regulations and Readopting the 2000 Regulations A. Compliance With Section 1008 42
U.S.C. 300a6
Comments: Thousands of comments expressed concern that the programs returning to the 2000 regulations violated both the Title X statute and the Courts holding in Rust v. Sullivan, 500
U.S. 173 1991. Many comments stated referral for abortion squarely violated the plain clear text of section 1008.
Many of these same comments also asserted the statute requires separation from abortion activities because they are programs where abortion is a method of family planning. Both comments believing the 2000 rule to be unlawful, and those affirming it to be lawful, cited Rust as well as legislative history in making their arguments.
Those opposing the proposed rule also stressed that private organizations have no right to federal funding, much less to federal funding to perform abortions. These comments stated that money is fungible, and reverting to the 2000 rule will create so-called slush funds and infrastructure for organizations to perform abortions in violation of section 1008. They also suggested that the 2000 rule lacked any mechanism to ensure compliance with the statute, and that the NPRM, in fact, violates the statute because the proposed definition of family planning includes related pregnancy counseling which requires referral for abortion when requested 59.5a5.
Many comments asserted that revoking the 2019 rule would allow grantees to engage in lobbying and other activities encouraging abortion that violate section 1008.
Response: As stated in the NPRM, the Supreme Court held in Rust: We agree with every court to have addressed the issue that the language is ambiguous. The language of 1008
that none of the funds appropriated under this subchapter shall be used in programs where abortion is a method of family planningdoes not speak directly to the issues of counseling, referral, advocacy, or program integrity. Rust at 184. No court adjudicating the 2019 rule found that the separation, referral, or other requirements were required by Rust.
Such a finding would be contrary to the primary holding in Rust. Counseling for abortion, including referral when requested, has never been held to constitute a violation of section 1008.
Interpreting section 1008 to prohibit referrals and require strict separation would also be inconsistent with nearly
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