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Federal Register / Vol. 86, No. 192 / Thursday, October 7, 2021 / Rules and Regulations
including women whose employers do not cover contraception for religious reasons in the definition of low-income.
One comment expressed support for the NPRMs returned focus on Title Xs priority populationlow-income clientsand removal of the 2019 rules re-definition of low income to use the program to pay for contraceptive services for any people whose employers refuse to include coverage for such services in their employer sponsored insurance due to religious or moral objections. Several comments also expressed support for using more inclusive terminology throughout the NPRM and expressed that client is more reflective of the diverse population of patients served by the Title X program.
Several comments, while supportive of the definitions included in the NPRM, did request specific revisions to many of the new or revised definitions.
Several comments requested that the Department explicitly include systemic racism within the definition of health equity. Another comment requested that the Department revise the definition of health equity by expanding the umbrella term socially determined circumstances to other circumstances that are socially, economically, demographically, or geographically determined. One comment requested that the Department revise the definition of adolescent-friendly services to include developmentally appropriate services that support the healthy cognitive, physical, sexual, and psychosocial development of adolescents as they transition from childhood to adulthood and account for their unique needs, including with respect to confidentiality, legal status, and autonomy. Other comments asked the Department to revise the definition of inclusivity to include non-religious people and the intersex community.
One comment requested that the definition of trauma-informed care be revised to prevent future discrimination of transgender people by clarifying that a trauma-informed program should not result in discrimination against any population.
The Department also received several comments opposing the new or revised definitions. A few comments opposed the definition of client-centered care and felt that it raised conscience concerns. Other comments opposed the definition of family planning services and specifically opposed removing abstinence and preconception health from the definition. One comment opposed the definition and said that medically approved did not include natural family planning. Another
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comment questioned why the definition of family planning services did not emphasize supporting unexpected pregnancies with assistance required by families and mothersincluding emotional, educational, financial, and healthcare supports. Other comments expressed general opposition to the definition of family planning services and felt that the definition included abortion and abortion-related services.
One comment stated that the definition of health equity was vague and undermined the priority for serving low-income clients. Another comment stated that the focus on health equity was targeting minority communities to restrict pregnancy, and another stated that the focus on equity was unnecessary because of protections already included in the Constitution.
One comment opposed the definition of cultural and linguistically appropriate services and expressed that the phrase culturally and linguistically appropriate services may bless health practices, based on cultural norms, that lead to negative health outcomes. One comment opposed the definition of trauma-informed and said it was vague and that it was not clear what was required to be trauma-informed.
One comment opposed the definition of inclusivity and felt that it would drive faith-based providers out of the program. Another comment took issue with the definition of inclusivity and stated that segregation or prioritization of Title X services by protected classes such as race violates the Constitution and several civil rights laws. A few comments opposed the use of the word client instead of woman throughout the NPRM and felt that the change in language was a disservice to women.
Two comments opposed removing women who cannot receive contraception from their employer because they have a religious or moral objection from the definition of lowincome. A few comments opposed the definition of quality healthcare. One comment opposed including clientcentered and equitable within the definition of quality. Still another comment stressed that improving the quality of healthcare is a dynamic process and that this dynamism requires a nimbleness often unattainable by national requirements. The commenter requested that the definition of quality be amended to allow maximum flexibility at the state and local level to establish standards of care.
Response: The Department appreciates the supportive comments regarding the new and revised definitions in the NPRM and believes
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that clear definitions for terms used throughout the regulations are important for consistent implementation. The Department acknowledges comments requested revisions to many of the definitions;
however, the Department believes that it is important to use widely accepted and commonly used definitions from other federal agencies and national medical organizations as the foundation for the regulation. For this reason, the Department will not revise the proposed definitions as requested by several comments.
The Department disagrees that the definition of client-centered care raises conscience concerns. The purpose of the rule and the definitions is to refocus the program as a client-centered one, where well-being of the patient, not the provider, is the primary goal. As stated earlier, providers may avail themselves of existing conscience protections and file complaints with OCR, which will be evaluated on a case-by-case basis as is done with other complaints.
The Department also disagrees with comments objecting to the definition of family planning services. The definition of family planning services within the NPRM is consistent with the definition of family planning services in QFP.
Contrary to some of the comments opposed to the definition of family planning services, the definition does include preconception health, natural family planning, and abstinence as a component of natural family planning.
Family planning services include a broad range of services related to achieving pregnancy, preventing pregnancy, and assisting clients in achieving their desired number and spacing of children. Also, given that the focus of Title X is on helping clients achieve pregnancy, prevent pregnancy, and achieve their desired number and spacing of children, the Department responds to comments requesting that Title X provide support to clients once they become pregnant by noting that this is beyond the scope of the Title X
program. Further, as is clear from section 1008 of the Title X statute, none of the funds appropriated for Title X are used in programs where abortion is a method of family planning. No court has found the decades-long practice of referral upon request to violate that prohibition.
The Department disagrees with comments expressing concern with the definitions of health equity, cultural and linguistic appropriateness, inclusive, low-income, quality, and traumainformed. The definitions proposed in the NPRM are widely used definitions from other federal agencies and major
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