Title X Turns 50

1970

Congress creates and authorizes Title X with $6 million in funding.

In 1970, Title X of the Public Health Service Act establishes the National Family Planning Program within the U.S. Department of Health & Human Services (HHS). The Title X program is the only federal program dedicated solely to the provision of family planning-related preventive health care. Congress makes clear that one major goal is to decrease the adverse health and financial effects of inadequately spaced childbearing on children, women, and their families. (S. Rep. 91-1004, 91st Cong., 2d Sess., July 7, 1970; H. Rep. No. 91-1472, 91st Cong., 2d Sess., September 26, 1970; Family Planning Services and Population Research Act of 1970, P.L. 91-572 [1970]).

1972

In Eisenstadt v. Baird, the Supreme Court extends the right to use birth control to unmarried individuals.

Congress mandates that Medicaid cover the costs of family planning services ($62 million in funding).

Congress passes a bill requiring states’ Medicaid programs to cover the costs of family planning services for low-income families. Under this provision, the federal government covers 90% of the states’ expenditures (42 U.S. Code § 1396b).

1973

HHS develops Family Planning Regional Training Centers in each of the 10 HHS regions.

1975

Congress increases reporting requirements, broadens definition of low-income, and requires providers to offer a broad range of family planning methods.

Congress passes a third bill in 1975 authorizing the building of a network of family planning centers across the United States. The bill also increases reporting requirements, clarifies the definition of “low-income family” to maximize inclusiveness, and requires that family planning projects “offer a broad range of acceptable and effective family planning methods (including natural family planning methods)”(P.L. 94-63, 89 Stat. 304, July 29, 1975).

Title X funds five family planning nurse practitioner programs.

These programs prepare nurse practitioners to serve patients in Title X sites and are the predecessors to the Title X Clinical Training Center.

1978

Amendment clarifies that Title X providers must address infertility and provide services to adolescents.

Congress amends the law in 1978 to clarify that providers must provide services to adolescents and address infertility services (P.L. 95-613, 92 Stat. 3093, November 8, 1978). Also in that time period, Congress enacts laws to protect providers who object to abortion or sterilization (P.L. 93-45).

1980

Title X service providers implement a sliding fee scale.

Title X program regulations stipulate that clients at or below 100% of the federal poverty level (FPL) must not be charged and that clients with incomes between 101% and 250% of the FPL can receive discounted services based on ability to pay.

1981

Congress legislates that Title X providers encourage adolescents to talk with parents about family planning.

In 1981, Congress adds a requirement that providers encourage adolescents to talk with their parents about family planning (P.L. 97-35, August 13, 1981). However, Congress specifically rejects requiring parental notification and, significantly, chooses to retain Title X as discretionary rather than block grant program (H. Conf. Rep.97-208).

1983

Title X program moves to Office of Population Affairs (OPA).

The Title X program moves administratively from the Health Services Administration (now Health Resources and Services Administration) to OPA, Office of the Assistant Secretary for Health.

1988

The Reagan Administration proposes new regulations.

On February 2, 1988, the Reagan administration promulgates a final rule prohibiting Title X-funded providers from counseling patients on pregnancy options that include abortion or referring patients to abortion providers. The rule also prohibits Title X-funded health centers from sharing finances, staff, or a physical location with an abortion provider, as well as mandates Title X-funded sites to provide all pregnant patients with information on prenatal care and social services (53 Fed. Reg. 2922).

1993

The Clinton Administration suspends 1988 regulation.

The Clinton Administration rescinds the 1988 Title X regulations and requires Title X-funded sites to provide non-directive options counseling in the event of a client’s positive pregnancy test.

HHS approves first Medicaid waivers.

The Centers for Disease Control and Prevention’s (CDC) Infertility Prevention Project (IPP) mandates half of IPP funds go to Title X agencies.

The CDC-funded IPP mandates that at least 50% of IPP funds go to Title X agencies. This project brings together public (and sometimes private) laboratories, state and local sexually transmitted disease (STD) partners, and Title X agencies to explore and implement best practices related to STD testing and treatment.

1995

OPA begins collecting Title X Family Planning data.

Title X adds HIV, STD, and cancer screening and prevention to program priorities.

OPA emphasizes training and retaining nurse practitioners specializing in women’s health.

1996

OPA publishes the first Family Planning Annual Report (FPAR).

1997

OPA funds first research grants for provision of male services and approves emergency contraception (EC).

The Food and Drug Administration (FDA) approves the use of combined oral contraceptive pills for EC. OPA issues a Program Instruction to Title X grants, indicating that as an FDA-approved contraceptive method, it is appropriate to include EC within the broad range of contraceptive methods offered within the Title X project.

1999

Congress adds new appropriations language stating that Title X grant recipients are not exempt from state mandatory reporting laws.

Beginning in fiscal year 1999, yearly appropriations include a provision stating that Title X grant recipients are not exempt from state laws mandating notification or reporting of child abuse, child molestation, sexual abuse, rape, or incest (H.R. 4328, October 21, 1998).

OPA updates Title X priorities to include expanding and enhancing partnerships.

The Title X priorities include expanding and enhancing partnerships with entities that have related interests and work with similar priority populations.

2000

OPA expands focus on HIV prevention.

OPA begins receiving funds for HIV prevention activities, from what later becomes the Secretary's Minority AIDS Fund, to award supplemental grants to Title X service grant recipients for HIV testing and prevention activities.

HHS issues regulation and guidance on abortion prohibition

On July 3, 2000, OPA issues a final rule entitled Standards of Compliance for Abortion-Related Services in Family Planning Services Projects (65 Fed. Reg. 41270) and an accompanying Federal Register Notice entitled Provision of Abortion-Related Services in Family Planning Services Projects (65 Fed. Reg. 41281). The regulation clarifies that Title X funds cannot used for abortion care, to support advocacy for abortion access, or to facilitate a patient obtaining such care.

2001

Title X adds clinical services for difficult-to-reach populations to program priorities.

OPA updates program priorities to include clinical services for difficult-to-reach populations, such as the uninsured or under-insured, substance users, migrant workers, and the homeless.

2003

Title X adopts additional priorities including abstinence education, limited English proficiency (LEP), and family participation.

Abstinence education is added to the list of program priorities, and persons with LEP are added to the difficult-to-reach populations that grant recipients are to address. In 2003, grant applicants are directed to encourage family participation in the decisions of minors to seek family planning services by including activities that promote positive family relationships.

HHS encourages faith-based organizations to apply for Title X funding.

2004

OPA establishes the Family Planning Male Reproductive Health Training Center.

The Center provides science-based information and training to Title X projects and family planning clinics to help develop and test outreach models, and to improve the quality of family planning and reproductive health information and services provided to males.

2005

OPA expands the FPAR.

The FPAR expands aggregate data collected from all Title X grant recipients on a range of family planning and related preventive health services, including services provided by age, contraceptive method, gender, race/ethnicity, family income, breast and cervical cancer screening, STI and HIV testing, and other data elements (insurance coverage and limited English proficiency).

2006

Title X adds mandatory reporting and counseling on resisting sexual coercion to program priorities.

OPA adds ensuring compliance with state laws requiring notification or reporting of child abuse, child molestation, sexual abuse, rape, or incest to Title X program priorities. The office also adds counseling to minors on how to resist attempts to coerce them into engaging in sexual activities to program priorities.

2008

OPA funds Male Research Cooperative Agreements.

The projects aim to reassess and modify the physical and administrative environment of clinics, provide staff training in methods that best serve males, and conduct focused outreach and make linkages with other community-based organizations that serve males. The “Getting Ready for Male Reproductive Health Services: An Assessment and Implementation Toolkit” resulted from this research.

OPA forms Federal Training Center Collaborative.

The Federal Training Center Collaborative brings together the AIDS Education & Training Centers, STD/HIV Prevention Training Centers, Addiction Technology Transfer Centers, Viral Hepatitis Education and Training Projects, and Tuberculosis Regional Training and Medical Consultation Centers from each HHS region. These groups work toward the common goal of building capacity for training and resource sharing on topics related to HIV/STD prevention, care, and treatment for racial and ethnic minority communities disproportionately affected by HIV/AIDS.

2010

Congress passes the Affordable Care Act (ACA), mandating contraceptive coverage and expanding other health coverage.

Within OPA, a number of Title X grant recipients receive funds to conduct Outreach and Enrollment activities. In addition, OPA funds an “ACA Research Collaborative” to investigate the ways in which the ACA impacts Title X services.

2012

OPA restructures Family Planning Regional Training Centers.

The Federal Training Centers Collaborative is replaced with five nationally focused family planning training centers focused on management and systems improvement, quality assurance, quality improvement and evaluation, service delivery, and clinical training.

2014

OPA and CDC publish Quality Family Planning Recommendations.

Providing Quality Family Planning Services: Recommendations of CDC and the U.S. Office of Population Affairs (QFP) is released in CDC’s Morbidity and Mortality Weekly Report. These are the first national evidence-based and evidence-informed recommendations that outline how to provide QFP services and are intended for Title X and other public or private providers of family planning services. CDC and OPA collaboratively developed the QFP.

2015

Title X adds Zika virus response to program priorities.

In 2015 and 2016, large outbreaks of Zika virus occur in the Americas, and local transmission is seen in parts of the United States. Given that infection during pregnancy can cause certain birth defects, family planning providers are a critical part of the response. OPA develops a Zika toolkit that is widely used by federal, state, and local organizations. In June 2016, OPA convenes a meeting with public health representatives from eight southern states at high risk for mosquito-borne transmission of Zika virus, federal agency representatives, and national stakeholders with the goal of building capacity for family planning care in the context of Zika.

2016

OPA transitions regional centers to one Family Planning National Training Center and one National Clinical Training Center for Family Planning.

National Quality Forum (NFQ) endorses contraceptive care performance measures.

NQF, a nonprofit organization that establishes health care performance measurements and standards, endorses the contraceptive care performance measures. These measures are the first reproductive health-related measures that NQF endorses, and they are intended to increase access to and use of the most- and moderately effective methods of contraception across a range of health care settings, including primary care settings. OPA awards a research grant to begin work on a patient-reported outcome performance measure as a balancing measure to the contraceptive care performance measures.

2019

OPA releases the Decision-Making Guide for the Provision of PrEP Services in Title X-Funded Family Planning Service Sites.

This evidence-based algorithm is piloted in 2018 and disseminated to Title X program sites in early 2019 to help them determine the appropriate level of pre-exposure prophylaxis (PrEP) services they can provide.

HHS issues Title X Final Rule.

On March 4, 2019, OPA issues a final rule entitled “Compliance with Statutory Program Integrity Requirements” (84 Fed. Reg. 7714). This rule, which is almost identical to the 1988 regulations, prohibits the use of Title X funds to perform, promote, refer for, or support abortion as a method of family planning.

2020

The Title X Family Planning Program celebrates its 50^th anniversary, having provided family planning services to some 190 million individuals since its establishment in 1970.