[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]


                 PROTECTING TITLE X AND SAFEGUARDING 
                      QUALITY FAMILY PLANNING CARE

=======================================================================

                                HEARING

                               BEFORE THE

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             JUNE 19, 2019

                               __________

                           Serial No. 116-47
                           
                           
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]                           


      Printed for the use of the Committee on Energy and Commerce

                   govinfo.gov/committee/house-energy
                        energycommerce.house.gov
                        
                        
                               __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
44-365 PDF                  WASHINGTON : 2021                     
          
--------------------------------------------------------------------------------------
                        

                    COMMITTEE ON ENERGY AND COMMERCE

                     FRANK PALLONE, Jr., New Jersey
                                 Chairman
BOBBY L. RUSH, Illinois              GREG WALDEN, Oregon
ANNA G. ESHOO, California              Ranking Member
ELIOT L. ENGEL, New York             FRED UPTON, Michigan
DIANA DeGETTE, Colorado              JOHN SHIMKUS, Illinois
MIKE DOYLE, Pennsylvania             MICHAEL C. BURGESS, Texas
JAN SCHAKOWSKY, Illinois             STEVE SCALISE, Louisiana
G. K. BUTTERFIELD, North Carolina    ROBERT E. LATTA, Ohio
DORIS O. MATSUI, California          CATHY McMORRIS RODGERS, Washington
KATHY CASTOR, Florida                BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland           PETE OLSON, Texas
JERRY McNERNEY, California           DAVID B. McKINLEY, West Virginia
PETER WELCH, Vermont                 ADAM KINZINGER, Illinois
BEN RAY LUJAN, New Mexico            H. MORGAN GRIFFITH, Virginia
PAUL TONKO, New York                 GUS M. BILIRAKIS, Florida
YVETTE D. CLARKE, New York, Vice     BILL JOHNSON, Ohio
    Chair                            BILLY LONG, Missouri
DAVID LOEBSACK, Iowa                 LARRY BUCSHON, Indiana
KURT SCHRADER, Oregon                BILL FLORES, Texas
JOSEPH P. KENNEDY III,               SUSAN W. BROOKS, Indiana
    Massachusetts                    MARKWAYNE MULLIN, Oklahoma
TONY CARDENAS, California            RICHARD HUDSON, North Carolina
RAUL RUIZ, California                TIM WALBERG, Michigan
SCOTT H. PETERS, California          EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan             JEFF DUNCAN, South Carolina
MARC A. VEASEY, Texas                GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
A. DONALD McEACHIN, Virginia
LISA BLUNT ROCHESTER, Delaware
DARREN SOTO, Florida
TOM O'HALLERAN, Arizona
                                 ------                                

                           Professional Staff

                   JEFFREY C. CARROLL, Staff Director
                TIFFANY GUARASCIO, Deputy Staff Director
                MIKE BLOOMQUIST, Minority Staff Director
              Subcommittee on Oversight and Investigations

                        DIANA DeGETTE, Colorado
                                  Chair
JAN SCHAKOWSKY, Illinois             BRETT GUTHRIE, Kentucky
JOSEPH P. KENNEDY III,                 Ranking Member
    Massachusetts, Vice Chair        MICHAEL C. BURGESS, Texas
RAUL RUIZ, California                DAVID B. McKINLEY, West Virginia
ANN M. KUSTER, New Hampshire         H. MORGAN GRIFFITH, Virginia
KATHY CASTOR, Florida                SUSAN W. BROOKS, Indiana
JOHN P. SARBANES, Maryland           MARKWAYNE MULLIN, Oklahoma
PAUL TONKO, New York                 JEFF DUNCAN, South Carolina
YVETTE D. CLARKE, New York           GREG WALDEN, Oregon (ex officio)
SCOTT H. PETERS, California
FRANK PALLONE, Jr., New Jersey (ex 
    officio)
                             
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Diana DeGette, a Representative in Congress from the State 
  of Colorado, opening statement.................................     2
    Prepared statement...........................................     3
Hon. Brett Guthrie, a Representative in Congress from the 
  Commonwealth of Kentucky, opening statement....................     4
    Prepared statement...........................................     6
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     7
    Prepared statement...........................................     9
Hon. Greg Walden, a Representative in Congress from the State of 
  Oregon, opening statement......................................    10
    Prepared statement...........................................    11

                               Witnesses

Diane Foley, M.D., FAAP, Deputy Assistant Secretary, Office of 
  Population Affairs, Office of the Assistant Secretary for 
  Health, U.S. Department of Health and Human Services...........    13
    Prepared statement...........................................    15
    Answers to submitted questions                                  221
Clare Coleman, the President and Chief Executive Officer of the 
  National Family Planning and Reproductive Health Association...    62
    Prepared statement...........................................    64
Kami Geoffray, the Chief Executive Officer of the Women's Health 
  and Family Planning Association of Texas.......................    72
    Prepared statement...........................................    74
Monica McLemore, Ph.D., MPH, the Chair-Elect of the Sexual and 
  Reproductive Health Section of the American Public Health 
  Association....................................................    81
    Prepared statement...........................................    83
Jamila Perritt, M.D., Fellow, Physicians for Reproductive Health 
  Fellow.........................................................    90
    Prepared statement...........................................    92
Catherine Glenn Foster, President and Chief Executive Officer of 
  the Americans United for Life..................................    96
    Prepared statement...........................................    98
    Answers to submitted questions                                  223

                           Submitted Material

Letter of June 19, 2019, from Michael J. New Ph.D., Associate 
  Scholar, Charlotte Lozier Institute, Visiting Assistant 
  Professor, The Catholic University of America, Mr. Burgess, 
  submitted by Ms. DeGette.......................................   130
Letter of July 30, 2018, from Colleen A. Kraft, M.D., President, 
  American Academy of Pediatrics, and Deborah Christie Ph.D., 
  President, Society for Adolescent Health and Medicine, to Mr. 
  Azar, submitted by Ms. DeGette.................................   132
Letter of July 31, 2018, from Lisa M. Hollier, M.D., President, 
  The American College of Obstetricians and Gynecologists, to Mr. 
  Azar, submitted by Ms. DeGette.................................   143
Letter of July 30, 2018, from James L Madara, M.D., Executive 
  Vice President, CEO, American Medical Association, to Mr. Azar, 
  submitted by Ms. DeGette.......................................   161
Letter of June 18, 2019, from James L Madara, M.D., Executive 
  Vice President, CEO, American Medical Association, to Ms. 
  DeGette, submitted by Ms. DeGette..............................   166
Letter of July 30, 2018, from George C. Benjamin, M.D., Executive 
  Director, American Public Health Association, to Mr. Azar, 
  submitted by Ms. DeGette.......................................   172
Letter of June 19, 2019, from Penny Nanace, CEO and President, 
  Concerned Women for America, to Mr. Pallone and Mr. Walden, 
  submitted by Ms. DeGette.......................................   179
Letter June 18, 2019, from Travis Weber, Vice President, Policy 
  Family Research Council, to Mr. Bilirakis, submitted by Ms. 
  DeGette........................................................   181
Letter of April 3, 2019, from Mr. Estes, et al., to Mr. Azar, 
  submitted by Ms. DeGette.......................................   183
Letter of April 30, 2018, from Mr. Estes, et al., to Mr. Azar, 
  submitted by Ms. DeGette.......................................   194
Letter of July 10, 2018, from Mr. Estes, et al., to Mr. Azar, 
  submitted by Ms. DeGette.......................................   207
Article of February 26, 2019, ``The Final Title X Regulation 
  Disregards Expert Opinion and Evidence-Based Practices,'' by 
  American College of Obstetricans and Gynecologists, et al., 
  submitted by Ms. Degette.......................................   218

 
    PROTECTING TITLE X AND SAFEGUARDING QUALITY FAMILY PLANNING CARE

                              ----------                              


                        WEDNESDAY, JUNE 19, 2019

                  House of Representatives,
      Subcommittee on Oversight and Investigations,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:01 a.m., in 
the John D. Dingell Room 2123, Rayburn House Office Building, 
Hon. Diana DeGette (chairwoman of the subcommittee) presiding.
    Members present: Representatives DeGette, Schakowsky, 
Kennedy, Ruiz, Kuster, Castor, Sarbanes, Tonko, Clarke, Pallone 
(ex officio), Guthrie (subcommittee ranking member), Burgess, 
Griffith, Brooks, Mullin, Duncan, and Walden (ex officio).
    Also present: Representatives Lujan, Veasey, Shimkus, 
Latta, Rodgers, Bilirakis, and Gianforte.
    Staff present: Kevin Barstow, Chief Oversight Counsel; 
Jacquelyn Bolen, Professional Staff; Jesseca Boyer, 
Professional Staff Member; Jeffrey C. Carroll, Staff Director; 
Manmeet Dhindsa, Counsel; Waverly Gordon, Deputy Chief Counsel; 
Tiffany Guarascio, Deputy Staff Director; Zach Kahan, Outreach 
and Member Service Coordinator; Chris Knauer, Oversight Staff 
Director; Una Lee, Senior Health Counsel; Perry Lusk, GAO 
Detailee; Joe Orlando, Staff Assistant; Tim Robinson, Chief 
Counsel; Benjamin Tabor, Staff Assistant; C. J. Young, Press 
Secretary; Jennifer Barblan, Minority Chief Counsel, Oversight 
and Investigations; Mike Bloomquist, Minority Staff Director; 
Adam Buckalew, Minority Director of Coalitions and Deputy Chief 
Counsel, Health; Jordan Davis, Minority Senior Advisor; 
Margaret Tucker Fogarty, Minority Staff Assistant; Theresa 
Gambo, Minority Human Resources/Office Administrator; Peter 
Kielty, Minority General Counsel; Ryan Long, Minority Deputy 
Staff Director; James Paluskiewicz, Minority Chief Counsel, 
Health; Brannon Rains, Minority Staff Assistant; and Natalie 
Sohn, Minority Counsel, Oversight and Investigations.
    Ms. DeGette. The Subcommittee on Oversight and 
Investigations will now come to order.
    Today, the Subcommittee on Oversight and Investigations is 
holding a hearing entitled Protecting Title X and Safeguarding 
Quality Family Planning Care. The purpose of the hearing is to 
examine the Federal Title X Family Planning Program.
    The Chair now recognizes herself for the purposes of an 
opening statement.

 OPENING STATEMENT OF HON. DIANA DeGETTE, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF COLORADO

    Today, this subcommittee is holding the first congressional 
hearing in nearly 25 years on the Title X Family Planning 
Program. Established in 1970 with bipartisan support, Title X 
is the only Federal program solely dedicated to supporting 
family planning and related healthcare services, ensuring 
access to modern methods of birth control for low-income people 
and underserved communities.
    Over the last half century, Title X has provided the gold 
standard of high-quality family planning and sexual healthcare 
to four million women and patients of all genders each year. 
Title X providers serve a racially and ethnically diverse 
population. Most patients are under 30 years old and, for many, 
Title X centers are the only source of their care.
    The nearly 4,000 Title X health centers around the country 
come in all forms. They include local health departments, 
Planned Parenthoods, community health centers, and private and 
nonprofit organizations. My constituents, for example, can 
access Title X services at 15 different health centers in 
Denver, like the Stout Street Health Center and La Casa Family 
Health Center, all part of the Title X network supported by the 
grantee in my State, the Colorado Department of Public Health 
and the Environment.
    These health centers provide a range of life-saving 
preventative health services: including breast and cervical 
cancer screening, HIV and other STI testing and treatment, and 
family planning and contraceptive information, supplies, and 
services. For 5 decades, regardless of the setting, patients 
seeking care at a Title X health center could depend on being 
treated with respect and dignity. Yet, this patient-centered 
care now faces an imminent threat. In March, the Trump 
administration finalized new regulations referred to by experts 
as the quote, ``gag rule that poses significant threats to the 
Title X network and the patients' health and rights.''
    While anti-abortion ideology is fueling the 
administration's action, that motivation has no bearing on the 
Title X program. Using Title X to provide abortions has been 
and is currently statutorily prohibited. In fact, the 
administration cannot point to a single instance in the 
program's entire history, where Title X funds have been 
misapplied for this purpose.
    Efforts to curb abortion providers' participation in Title 
X program is a solution in search of a problem. This rule is 
the administration's absurd effort to equate abortion referral 
as tantamount to the actual provision of abortion services. And 
as a result, the Government is inserting itself into the 
patient-provider relationship. The rule forbids health 
providers from giving complete information to patients on all 
of their pregnancy options. Even further, it would allow 
providers who oppose contraception, and are in favor of 
promoting other forms of family planning, to participate in the 
program.
    The rule also threatens the ability of patients, especially 
young people, to have confidential conversations with their 
providers about their sexual health and well-being.
    The gag rule would force providers to choose between 
offering limited information and care to their patients or to 
close their doors. That seems like a dramatic and unfortunate 
choice to make. And what it would do is lead to a dramatic 
decline in women's and other patients' ability to received high 
quality and timely sexual and reproductive healthcare.
    The long-term health consequences of limiting access to 
care could have dire consequences on critical public health 
priorities, disrupting, for example, the decline of 
historically low unintended pregnancy rates and a skyrocketing 
of HIV and other STI rates; the latter already at the highest 
level in recorded history.
    According to the American Medical Association, the rule 
would, quote, ``radically alter and decimate the Family 
Planning Assistance Program established by Title X with severe 
and irreparable public health consequences across the United 
States.''
    While the Title X gag rule is currently enjoined under 
injunctions, the Trump administration is doubling down on its 
commitment to dismantle this vital public health program, 
indicating last week that it has no intention of enforcing 
longstanding program requirements, like providing patients with 
complete family planning and pregnancy options. Should the 
Trump administration have its way, those who already face 
barriers to voluntary and non-coercive family planning and 
related healthcare, people of color, LGBTQ plus people, low-
income people, young people, and people living in rural areas 
will bear the harshest consequences.
    For five decades, Title X has relied on evidence of best 
practices to center and serve the needs of patients and 
communities. The Trump administration's agenda takes neither 
evidence nor patients into account in its attempts to dismantle 
the Title X network and to devastate access to high-quality 
family planning and sexual health in the United States.
    I want to welcome all of our witnesses here, particularly, 
Dr. Foley. Thank you so much for coming this morning. We are 
going to also hear from some other experts.
    [The prepared statement of Ms. DeGette follows:]

                Prepared Statement of Hon. Diana DeGette

    Today, the Subcommittee is holding the first congressional 
hearing in nearly 25 years on the Title X family planning 
program.
    Established in 1970 with bipartisan support, Title X is the 
only federal program solely dedicated to supporting family 
planning and related healthcare services, ensuring access to 
modern methods of birth control for low-income people and 
underserved communities.
    Over the last half-century, Title X has provided the gold 
standard of high-quality family planning and sexual healthcare 
to four million women and patients of all genders each year.
    Title X providers serve a racially and ethnically diverse 
population.
    Most patients are under 30 years-old and, for many, Title X 
health centers are their only source of care.
    The nearly 4,000 Title X health centers around the country 
come in all forms. They include local health departments, 
Planned Parenthoods, community health centers, and private and 
nonprofit organizations. My constituents, for instance, can 
access Title X services at 15 different health centers in the 
Denver area, such as Stout Street Health Center and La Casa 
Family Health Center, all part of the Title X network supported 
by the grantee in my state, the Colorado Department of Public 
Health and the Environment.
    These health centers provide a range of lifesaving 
preventive health services, including breast and cervical 
cancer screening, HIV and other STI testing and treatment, and 
family planning and contraceptive information, supplies, and 
services. For five decades, regardless of the setting, patients 
seeking care at a Title X health center could depend on being 
treated with respect and dignity.
    Yet, this patient-centered care now faces an imminent 
threat. In March, the Trump Administration finalized new 
regulations, referred to by experts as the ``Gag Rule," that 
poses significant threats to the Title X network and patients' 
health and rights.
    While anti-abortion ideology is fueling the 
Administration's actions, this motivation has no bearing on the 
Title X program. Using Title X funds to provide abortions has 
been and is currently statutorily prohibited. In fact, the 
Administration cannot point to a single instance in the 
program's history where Title X funds have been misapplied for 
abortion.
    Efforts to curb abortion providers' participation in the 
Title X program is a solution in search of a problem. This rule 
is the Administration's absurd effort to equate abortion 
referral as tantamount to the actual provision of abortion 
services.
    And as a result, the government is inserting itself into 
the patient-provider relationship. The rule forbids health 
providers from giving complete information to patients on all 
of their pregnancy options. Even further, it would allow 
providers who oppose contraception and are in favor of 
promoting natural family planning methods and abstinence-
before-marriage to participate in the program. The rule also 
threatens the ability of patients-especially young people-to 
have confidential conversations with their providers about 
sexual health and wellbeing.
    The Gag Rule would force providers to choose between 
offering limited information and care to their patients or to 
close their doors.
    This could lead to a dramatic decline in women's and other 
patients' ability to receive high-quality and timely sexual and 
reproductive healthcare.
    The long-term health consequences of limiting access to 
care could have dire consequences on critical public health 
priorities-disrupting the decline of historically low 
unintended pregnancy rates and a skyrocketing of HIV and other 
STI rates, the latter already at the highest levels in recorded 
history.
    According to the American Medical Association, the rule 
would, [Quote] ``radically alter and decimate the family-
planning assistance program established by Title X with severe 
and irreparable public health consequences across the United 
States."
    While the Title X Gag Rule is currently enjoined under 
nationwide injunctions, the Trump Administration is doubling 
down on its commitment to dismantle this vital public health 
program-indicating last week that it has no intention of 
enforcing long-standing program requirements such as providing 
patients with complete family planning and pregnancy options.
    Should the Trump Administration have its way, those who 
already face barriers to voluntary and noncoercive family 
planning and related healthcare-people of color, LGBTQ+people, 
low-income people, young people, and people living in rural 
areas-will bear the harshest consequences.
    For five decades, Title X has relied on evidence of best 
practices to center and serve the needs of patients and 
communities. The Trump Administration's agenda takes neither 
evidence nor patients into account in its efforts to dismantle 
the Title X network and devastate access to high-quality family 
planning and sexual healthcare in the United States.
    I look forward to hearing from Dr. Diane Foley, the Deputy 
Assistant Director for Population Affairs at the Department of 
Health and Human Services, regarding HHS's actions and their 
effects on healthcare in the United States.
    Additionally, we will be hearing from experts who have 
repeatedly raised concerns about the consequences of these 
actions should the Trump Administration succeed in its efforts.
    While the Administration may claim that the intention of 
the rule is to ensure compliance of Title X statutory 
requirements, it is yet another attempt to take away women's 
basic rights, and it will ultimately block millions of patients 
from high-quality family planning and preventive healthcare.

    Ms. DeGette. I am now pleased to yield five minutes to the 
ranking member of the subcommittee, Mr. Guthrie.

 OPENING STATEMENT OF HON. BRETT GUTHRIE, A REPRESENTATIVE IN 
           CONGRESS FROM THE COMMONWEATH OF KENTUCKY

    Mr. Guthrie. Thank you. Thank you, Chair DeGette, for 
holding this hearing and thank you for yielding the time.
    For nearly 50 years, the Title X program has helped ensure 
that Americans have access to family planning methods and 
related preventative health services. The program has been 
especially important for low-income women. According to the 
most recent family planning annual report data, services were 
provided to more than four million individuals under the 
program in 2017.
    The Title X program has helped a lot of men and women in my 
home State of Kentucky. In 2015, almost 50,000 individuals in 
Kentucky received services at a Title X clinic, including over 
45,000 women. The Kentucky Cabinet for Health and Family 
Services oversees Title X-funded health centers across the 
Commonwealth. During the most recent funding cycle, HHS awarded 
the Kentucky Cabinet for Health and Family Services $5 million 
for fiscal year 2019.
    Many Title X grantees work tirelessly to provide important 
services to families and adolescents. I am concerned, however, 
about the program integrity issues within the Title X program 
and that some guarantees might not always using funds in a way 
that is consistent with the statutory intent. Indeed, I joined 
other Members of Congress in writing a letter to HHS in April 
2018 asking the Department to update the Title X regulations to 
ensure program integrity with respect to abortion.
    When Congress created the Title X program in 1970, we drew 
a line between family planning and abortion. The Title X 
statute specifically states that, and I quote from the statute, 
``none of the funds appropriated under this Title shall be used 
in programs where abortion is a method of family planning,'' 
unquote.
    Unfortunately, the regulations issued by the Clinton 
administration that have governed the Title X program for 
nearly two decades have blurred the line between family 
planning and abortion by requiring Title X grantees to refer 
women for abortion and allowing Title X clinics to co-locate 
within abortion clinics.
    The Trump administration took an important step toward 
improving program integrity and ensuring that Title X funds are 
used consistently with the statutory intent when the 
administration issued the Protect Life Rule.
    Among other things, the Protect Life Rule helps ensure 
compliance with the statutory requirement for the Title X 
program that none of the funds appropriated for Title X may be 
used in programs where abortion is a method of family planning.
    While my colleagues on the other side of the aisle are 
likely to express outrage at the Protect Life Rule, I would 
like to remind them that these changes make the regulatory 
framework governing the Title X program nearly identical to the 
regulatory framework created by the Reagan Era regulations for 
the Title X program.
    Just like there have been lawsuits filed against the 
Protect Life Rule, the Reagan Era regulations were also 
challenged in court. In 1991, the Supreme Court in Russ v. 
Sullivan upheld the Reagan Era regulations and said ``they were 
permissible construction of the Title X statute.''
    One of the concerns I have heard about the Protect Life 
Rule is that it will harm women's access to contraception under 
the Title X program. The Title X statutory language is clear 
and requires the Title X family planning projects, ``provide a 
broad range of acceptable and effective family planning methods 
and related preventative health services.'' The Protect Life 
Rule includes this exact language and the most recent funding 
announcement for the Title X program directly states that each 
Title X project must include a broad range of acceptable and 
effective methods of family planning, including contraception. 
Moreover, the funding announcement notes that a broad range 
does not necessarily need to include all categories of services 
but should include hormonal methods, since these are requested 
most frequently by clients among the methods shown to be the 
most effective in preventing pregnancy.
    Given this language in the funding announcement, I hope to 
hear more today about how, if at all, HHS expects access to 
contraception through the Title X program to change when the 
Protect Life Rule is fully implemented.
    I am also looking forward to hearing from HHS about how 
they felt changes to the Title X program will help ensure 
program integrity with respect to abortion, where necessary.
    I want to thank all the witnesses for being here today.
    And before I yield back, I would like to do a unanimous 
consent to enter the following items into the record: An April 
30, 2018 letter to Secretary Azar signed by myself and more 
than 150 Members of Congress; a July 10 letter to Secretary 
Azar by 140 Members of Congress, including myself; and an April 
3, 2019 letter to Secretary Azar signed by 100 Members, 
including myself; and a June 18, 2019 letter to Representative 
Bilirakis from the Family Research Council.
    Ms. DeGette. Without objection, the documents will be 
entered.
    [The information appears at the conclusion of the hearing.]
    Mr. Guthrie. And I yield back.
    [The prepared statement of Mr. Guthrie follows:]

                Prepared Statement of Hon. Brett Guthrie

    Thank you, Chair DeGette, for holding this important 
hearing.
    For nearly 50 years, the Title X program has helped ensure 
that Americans have access to family planning methods and 
related preventive health services. The program has been 
especially important for low-income women. According to the 
most recent Family Planning Annual Report data, services were 
provided to more than 4 million individuals under the program 
in 2017.
    The Title X program has helped a lot of men and women in my 
home state of Kentucky. In 2015, almost 50 thousand individuals 
in Kentucky received services at a Title X clinic, which 
included over 45 thousand women. The Kentucky Cabinet for 
Health and Family Services oversees Title X-funded health 
centers across the commonwealth. During the most recent funding 
cycle, HHS awarded the Kentucky Cabinet for Health and Family 
Services 5 million dollars for fiscal year 2019.
    Many Title X grantees work tirelessly to provide important 
services to families and adolescents. I am concerned, however, 
about program integrity issues within the Title X program and 
that some grantees may not be always using funds in a way that 
is consistent with the statutory intent. Indeed, I joined other 
Members of Congress in writing a letter to HHS in April 2018 
asking the Department to update the Title X regulations to 
ensure program integrity with respect to abortion.
    When Congress created the Title X program in 1970, we drew 
a line between family planning and abortion. The Title X 
statute specifically states that, and I quote, ``None of the 
funds appropriated under this title shall be used in programs 
where abortion is a method of family planning." Unfortunately, 
the regulations issued by the Clinton Administration that have 
governed the Title X program for nearly two decades have 
blurred the line between family planning and abortion by 
requiring Title X grantees to refer women for abortion and 
allowing Title X clinics to co-locate with abortion clinics.
    The Trump Administration took an important step toward 
improving program integrity and ensuring that Title X funds are 
used consistently with the statutory intent when the 
Administration issued the Protect Life Rule. Among other 
things, the Protect Life Rule helps ensure compliance with the 
statutory requirement for the Title X program that none of the 
funds appropriated for Title X may be used in programs where 
abortion is a method of family planning.
    While my colleagues on the other side of the aisle are 
likely to express outrage at the Protect Life Rule, I'd like to 
remind them that these changes make the regulatory framework 
governing the Title X program nearly identical to the 
regulatory framework created by Reagan era regulations for the 
Title X program.
    Just like there have been lawsuits filed against the 
Protect Life Rule, the Reagan-era regulations were also 
challenged in court. In 1991, the Supreme Court in Rust v. 
Sullivan upheld the Reagan-era regulations and said that they 
were a permissible construction of the Title X statute.
    One of the concerns I have heard about the Protect Life 
Rule is that it will harm women's access to contraception under 
the Title X program. The Title X statutory language is clear 
and requires that Title X family planning projects ``provide a 
broad range of acceptable and effective family planning methods 
and related preventive health services." The Protect Life Rule 
includes this exact language, and the most recent funding 
announcement for the Title X program directly states that that 
each Title X project must include a broad range of acceptable 
and effective methods of family planning, including 
contraception. Moreover, the funding announcement notes that a 
``broad range" does not necessarily need to include all 
categories of services, but should include hormonal methods 
since these are requested most frequently by clients and among 
the methods shown to be the most effective in preventing 
pregnancy.
    Given this language in the funding announcement, I hope to 
hear more today about how, if at all, HHS expects access to 
contraception through the Title X program to change when the 
Protect Life Rule is fully implemented. I am also looking 
forward to hearing more from HHS about why they felt changes to 
the Title X program that will help ensure program integrity 
with respect to abortion were necessary.
    I want to thank all of the witnesses for being here today.

    Ms. DeGette. The Chair now recognizes the ranking member of 
the full committee--I am sorry--the chairman of the full 
committee, Mr. Pallone, for five minutes for purposes of an 
opening statement.

OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Chairwoman DeGette.
    Today's hearing is the latest step in this committee's 
ongoing work to hold the Trump administration accountable for 
the dramatic changes it has proposed to our nation's Title X 
Family Planning Program. The administration's proposal not only 
threatens the purpose of Title X but the health of every low-
income woman and family that the program is intended to serve.
    Title X is a competitive grant program that allows the 
providers who are best equipped to meet the unique health needs 
of a community participate in the program. And this is how the 
program is designed and it is a hallmark for why the program 
has been successful.
    Take my home State, for example. The New Jersey Family 
Planning League operates a network of Title X health centers 
serving nearly 100,000 patients a year, including locations in 
my district operated by Planned Parenthood. Yet, this 
administration is promoting harmful changes to the Title X 
program because this diverse and community-driven network of 
health centers includes abortion providers who offer abortion 
services with non-Title X and non-federal funds.
    Prior to the most recent round of project awards, 40 
percent of all women served by Title X-funded health centers 
were served at Planned Parenthood sites. By targeting entities 
that provide comprehensive reproductive healthcare services, 
the administration's Title X gag rule stands to destroy the 
intent of the Title X program and that is to serve those with 
limited means to access high-quality family planning and 
related healthcare. By denying funding to these providers, the 
Trump administration is making it harder for low-income women 
and families to get the health information and care that they 
need.
    In fact in his ruling preventing the administration from 
implementing its Title X Rule, Judge McShane with the U.S. 
District Court of Oregon stated, and I am quoting, ``the final 
rule would create a class of women who are barred from 
receiving care consistent with accepted and established 
professional medical standards.'' Judge McShane went on to say 
that, if implemented, the final rule will, and I am quoting 
again, ``result in less contraceptive services, more unintended 
pregnancies, less early breast cancer detection, less screening 
for cervical cancer, less HIV screening, and less testing for 
sexually transmitted disease.'' HHS' response to these negative 
health outcomes is one of silence and indifference.
    Now that is damning, in my opinion, and unfortunately, 
indifference is far too common with the Trump administration. 
Under President Trump and Secretary Azar's leadership, HHS has 
repeatedly promoted policies, practices, and proposals intent 
on sabotaging healthcare in our nation and ripping healthcare 
away from millions of Americans. And this administration is 
comfortable putting its divisive ideology over the needs of 
people and families.
    So this committee has repeatedly sought answers on the 
administration's ongoing threats to Title X programs and, to 
date, the responses have been woefully inadequate from nearly 
termination of Title X projects, to funding announcements that 
undermine the value of quality family planning providers, to 
the new rule that would gag providers and limit patients access 
to information and care. The Trump administration has been 
intent on replacing providers' and patients' judgment with 
their own.
    And for nearly 50 years, when you walked in the door of a 
Title X health center, you could trust that every staff member 
would treat you with dignity and respect and that you would 
receive complete and accurate medical information. But the 
Trump administration's actions undermine that longstanding 
commitment, sabotaging not just the Title X program and its 
patients but access to high-quality family planning and related 
healthcare across this country.
    As long as the Trump administration continues its efforts 
to undermine healthcare for millions of Americans, this 
committee will continue to hold it accountable.
    I don't know if anyone wants my minute or so. If not, I 
will yield back, Madam Chair.
    [The prepared statement of Mr. Pallone follows:]

             Prepared Statement of Hon. Frank Pallone, Jr.

    Today's hearing is the latest step in this Committee's 
ongoing work to hold the Trump Administration accountable for 
the dramatic changes it has proposed to our nation's Title X 
family planning program. The Administration's proposal not only 
threatens the purpose of Title X, but the health of every low-
income woman and family that the program is intended to serve.
    Title X is a competitive grant program that allows the 
providers who are best equipped to meet the unique health needs 
of a community to participate in the program. This is how the 
program was designed, and is a hallmark for why the program has 
been successful.
    Take my home state for example, the New Jersey Family 
Planning League operates a network of Title X health centers 
serving nearly 100,000 patients a year, including one site in 
my district, Planned Parenthood of Northern, Central and 
Southern New Jersey.
    Yet, this Administration is promoting harmful changes to 
the Title X program because this diverse and community driven 
network of health centers includes abortion providers, namely 
Planned Parenthood, who offer abortion services with non-Title 
X and non-federal funds. Prior to the most recent round of 
project awards, 40 percent of all of women served by Title X-
funded health centers were served at Planned Parenthood sites.
    By targeting entities that provide comprehensive 
reproductive healthcare services, the Administration's Title X 
Gag Rule stands to destroy the intent of the Title X program-to 
serve those with limited means to access high-quality family 
planning and related healthcare. By denying funding to these 
providers, the Trump Administration is making it harder for 
low-income women and families to get the health information and 
care they need.
    In fact, in his ruling preventing the Administration from 
implementing its Title X rule, Judge McShane with the U.S. 
District Court of Oregon stated: [and I'm quoting] ``The Final 
Rule would create a class of women who are barred from 
receiving care consistent with accepted and established 
professional medical standards."
    Judge McShane went on to say that if implemented, the final 
rule will [and I'm quoting again].``result in less 
contraceptive services, more unintended pregnancies, less early 
breast cancer detection, less screening for cervical cancer, 
less HIV screening, and less testing for sexually transmitted 
disease. HHS's response to these negative health outcomes is 
one of silence and indifference."
    That's damning, and unfortunately, indifference is far too 
common with this Administration. Under President Trump and 
Secretary Azar's leadership, HHS has repeatedly promoted 
policies, practices, and proposals intent on sabotaging 
healthcare in our nation and ripping healthcare away from 
millions of Americans.
    This Administration is comfortable putting its divisive 
ideology over the needs of people and families.
    This Committee has repeatedly sought answers on the 
Administration's ongoing threats to the Title X program, and to 
date the responses have been woefully inadequate. From the 
early termination of Title X projects, to funding announcements 
that undermined the value of quality family planning providers, 
to the new rule that would gag providers and limit patients' 
access to information and care, this Administration has been 
intent on replacing providers' and patients' judgement with 
their own.
    For nearly 50 years, when you walked in the door of a Title 
X health center, you could trust that every staff member would 
treat you with dignity and respect, and that you would receive 
complete and accurate medical information. The Trump 
Administration's actionsundermine that long-standing 
commitment, sabotaging not just the Title X program and its 
patients, but access to high-quality family planning and 
related healthcare across the country.
    As long as the Trump Administration continues its efforts 
to undermine healthcare for millions of Americans, this 
Committee will continue to hold it accountable.
    Thank you.

    Ms. DeGette. The gentleman yields back.
    The Chair now recognizes the ranking member of the full 
committee, Mr. Walden for five minutes for an opening 
statement.

  OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF OREGON

    Mr. Walden. Thank you, Madam Chair, and good morning to our 
guests and our witnesses. We appreciate you all being here 
today.
    Title X Family Planning programs played a critical role in 
ensuring access to a broad range of family planning and 
preventive health services for nearly 50 years. While the Title 
X program is the only Federal program dedicated solely to 
supporting the delivery of family planning and related 
preventative healthcare, there are many different Federal 
funding sources for family planning services. Some of these 
other important programs include: Medicaid, the Health Center 
program, Maternal and Children Health Block Grants, and 
Temporary Assistance for Needy Families. In fact, in fiscal 
year 2015, Medicaid accounted for 75 percent of public family 
planning expenditures in the United States; Title X accounted 
for about 10 percent.
    Although the Title X program only accounts for a very small 
percentage of public funding expenditures for family planning 
services, it is an important program, especially for low-income 
women across the country. And according to the most recent 
family planning annual report data, Title X-funded sites in my 
State of Oregon served 44,815 Oregonians in 2017, including 
41,952 women. Of the Oregonians that received Title X services 
in 2017, nearly 42,000 had incomes at or below 250 percent of 
the Federal poverty level. The types of services that 
Oregonians received through the Title X program include but are 
not limited to family planning services, such as: education, 
counseling, contraception, and clinical services, STD testing 
and treatment, and HIV testing.
    I was pleased to see that the HHS awarded the Oregon Health 
Authority Reproductive Health Program more than $3 million in 
Title X funds for fiscal year 2019. OHA sub-grantees include 
community health departments and community health centers 
across my district. Community health centers are an important 
component of the Title X network because these centers provide 
comprehensive primary care for entire families.
    Given the important services Americans receive under the 
Title X program, I am glad that we have HHS here today to learn 
more about the recent actions relating to the Title X program 
and how the administration thinks that these changes will 
impact the program, and the services offered under the 
programs. Dr. Foley, we are glad you are here.
    When Congress created the Title X program, Congress 
explicitly stated, ``none of the funds appropriated under the 
Title shall be used in programs where abortion is a method of 
family planning.'' That is the statute. It is important that 
Federal programs are implemented and operated in ways that are 
consistent with the law. And I am, therefore, interested in 
knowing about any challenges HHS has faced in overseeing the 
Title X program and why the agency decided to make the recent 
changes to the Title X program.
    Many patients and physicians have come to rely on the Title 
X program since it was created in 1970, which is why it is 
critical that changes to the program do not harm patient access 
to the important services that Congress intended be provided 
under this program. I have heard concerns from some groups, 
such as the National Association of Community Health Centers 
that the recent changes to the program could potentially harm 
access to care for some individuals. So, I hope you will be 
able to address that issue as well today, Dr. Foley.
    While major focus of the Title X program is to right grants 
to clinical service providers, the program also supports other 
priorities and initiatives at HHS, such as HHS' initiative to 
identify and provide solutions to reduce substance abuse 
disorders and assisting the Government's response to infectious 
disease outbreaks that impact the ability of individuals to 
achieve healthy pregnancies, viruses like Zika, among others.
    While these elements of the program are not likely to be a 
focus of our conversation today, and I understand that, I am 
interested in hearing more about them and whether there are any 
issues that affect family planning projects that currently are 
not addressed by the Title X program.
    And Madam Chair, as you know, we have a subcommittee 
hearing going on upstairs on important pipeline safety 
legislation concurrent with this one, so I will be going back 
and forth as the ranking member.
    But I appreciate all the witnesses today and the fact that 
we are having this hearing, and look forward to the testimony 
of our witnesses and the opportunity to ask a few questions 
later on.
    With that, Madam Chair, I will yield back the remaining 44 
seconds.
    [The prepared statement of Mr. Walden follows:]

                 Prepared Statement of Hon. Greg Walden

    Thank you, Chair DeGette, for holding this hearing.
    The Title X family planning program has played a critical 
role in ensuring access to a broad range of family planning and 
preventive health services for nearly 50 years. While the Title 
X program is the only federal program dedicated solely to 
supporting the delivery of family planning and related 
preventive healthcare, there are many different federal funding 
sources for family planning services. Some of these other 
important programs include Medicaid, the Health Center Program, 
Maternal and Child Health Block Grants, and Temporary 
Assistance for Needy Families. In Fiscal Year 2015, Medicaid 
accounted for about 75 percent of public family planning 
expenditures in the United States while Title X accounted for 
about 10 percent.
    Although the Title X program only accounts for a small 
percentage of the public funding expenditures for family 
planning services, it is an important program, especially for 
low-income women across the country. According to the most 
recent Family Planning Annual Report data, Title X-funded sites 
in Oregon served 44,815 Oregonians in 2017, including 41,952 
women. Of the Oregonians that received Title X services in 
2017, about 42,000 had incomes at or below 250 percent of the 
federal poverty level. The types of services that Oregonians 
received through the Title X program include, but are not 
limited to, family planning services such as education, 
counseling, contraception, and clinical services, STD testing 
and treatment, and HIV testing.
    I was pleased to see that HHS awarded the Oregon Health 
Authority Reproductive Health Program over 3 million dollars in 
Title X funds for Fiscal Year 2019. OHA's sub-grantees include 
community health departments and community health centers 
across my district. Community health centers are an important 
component of the Title X network-these centers provide 
comprehensive primary care for the entire family.
    Given the important services Americans receive under the 
Title X program, I am glad that we have HHS here today to learn 
more about the recent actions relating to the Title X program 
and how they think these changes will impact the program and 
the services offered under the program.
    When Congress created the Title X program, Congress 
explicitly stated that, and I quote, ``none of the funds 
appropriated under the title shall be used in programs where 
abortion is a method of family planning." It is important that 
federal programs are implemented and operated in ways that are 
consistent with the statutory language, and I am therefore 
interested in knowing about any challenges HHS has faced in 
overseeing the Title X program and why they decided to make the 
recent changes to the Title X program.
    Many patients and physicians have come to rely on the Title 
X program since it was created in 1970, which is why it is 
critical that changes to the program do not harm patient access 
to the important services that Congress intended to be provided 
under the program. I've heard concerns from some groups such as 
the National Association of Community Health Centers that the 
recent changes to the program could potentially harm access to 
care for some individuals, and I hope that HHS can address some 
of those concerns today.
    While a major focus of the Title X program is to provide 
grants to clinical service providers, the program also supports 
other priorities and initiatives at HHS such as HHS' initiative 
to identify and provide solutions to reduce substance abuse 
disorders and assisting the government's response to infectious 
disease outbreaks that impact the ability of individuals to 
achieve healthy pregnancies, like the Zika virus. While these 
elements of the program are not likely to be a focus of our 
conversation today, I am interested in hearing more about them 
and whether there are any issues that affect family planning 
projects that currently are not addressed by the Title X 
program.
    Thank you, and I yield back.

    Ms. DeGette. The gentleman yields back.
    I would ask unanimous consent that the Members' written 
opening statements be made a part of the records. Without 
objection, so ordered.
    I would now like to introduce our first witness for today's 
hearing, Dr. Diane Foley, who is the Deputy Assistant 
Secretary, Office of Population Affairs, with the Office of the 
Assistant Secretary for Health at the U.S. Department of Health 
and Human Services.
    And Dr. Foley, I am particularly happy to welcome you 
because you are from my home State of Colorado. So welcome.
    I am sure you know that the subcommittee is holding an 
investigative hearing. And when doing so, has had the practice 
of taking testimony under oath. Do you have any objections to 
testifying under oath today?
    Dr. Foley. No, I do not.
    Ms. DeGette. The witness has responded no. The Chair then 
advises you that under the rules of the House and the rules of 
the Committee, you are entitled to be accompanied by counsel. 
Do you desire to be accompanied by counsel during your 
testimony today?
    Dr. Foley. Yes.
    Ms. DeGette. And if you could, introduce that counsel, 
please.
    Dr. Foley. I am going to ask them to introduce themselves. 
They are here with us.
    Ms. DeGette. Thank you.
    Mr. Keveney. Sean Keveney with the Office of General 
Counsel, HHS.
    Ms. DeGette. Thank you. So now, if you would please, 
Doctor, rise and raise your right hand so you may be sworn in.
    [Witness sworn.]
    Ms. DeGette. Let the record reflect the witness responded 
yes. You may be seated.
    Dr. Foley, you are now under oath and subject to the 
penalties set forth in Title 18 Section 1001 of the U.S. Code. 
And I will now recognize you for a 5-minute summary of your 
written statement.
    In front of you is a microphone and a series of lights. The 
light turns yellow when you have a minute left and it turns red 
to indicate that your time has come to an end.
    And you are now recognized for five minutes.

                 STATEMENT OF DIANE FOLEY, M.D.

    Dr. Foley. Thank you.
    Chair DeGette, Ranking Member Guthrie, and members of the 
subcommittee, thank you for this invitation to appear before 
you on behalf of the Department of Health and Human Services. I 
welcome the opportunity to discuss the Title X Rule and the 
Title X Family Planning Program.
    I am the Deputy Assistant Secretary for Population Affairs 
under the Office of the Assistant Secretary for Health. Over 
the past year, it has been my privilege to work with 
professional career staff, grantees, and health professionals 
who make it their mission to ensure that Title X funds are used 
to provide quality family planning services to the adolescents, 
women, and men who need them.
    My professional career has been spent practicing pediatrics 
with a focus on adolescent health. While chief resident in 
pediatrics, I was a Title X provider in one of the first 
school-based health clinics in Indiana. After residency, I 
founded and served as medical director of a pediatric practice 
and spent the next 17 years establishing one of the largest 
private pediatric practices in Central Indiana.
    In 2004, I relocated to Colorado and my practice was 
limited, at that time, to adolescent gynecology. At the same 
time, I provided direction to a non-profit organization and 
implemented a federally-funded sex education program in the 
Colorado Springs area. Part of that direction included 
developing a program to teach adolescents about sexually 
transmitted infections and contraception. Most recently, I 
practiced pediatrics in a rural critical access hospital in 
south-eastern Colorado.
    Title X of the Public Health Service Act was enacted in 
1970 and authorized the establishment and operation of 
voluntary family planning projects, offering a broad range of 
acceptable and effective family planning methods and services, 
including natural family planning methods, infertility 
services, and services for adolescents.
    The Title X program serves close to four million clients 
every year in over 3,900 clinic sites. Currently, there are 90 
grantees using Title X funds, including State Health 
Departments, family planning councils, Federally Qualified 
Health Clinics, and private non-profit entities. These grantees 
are located in all 50 States, the District of Columbia, Puerto 
Rico, U.S. Virgin Islands, and the six Pacific jurisdictions. I 
am proud to direct the efforts of dedicated career staff who 
are committed to promoting health across the reproductive life 
span.
    The 2019 Title X Rule ensures program integrity and 
compliance with statutory provisions. And in particular, the 
statutory prohibition on funding programs where abortion is a 
method of family planning. This rule will promote quality 
family planning services to clients, while ensuring that 
taxpayer dollars are spent according to the original intent of 
Congress. This rule provides for clear financial and physical 
separation between Title X and non-Title X activities. This 
will assist grantees and prevent reporting deficiencies. It 
will make it clear to clients and the general public that Title 
X funds are being used according to the law. This rule protects 
the provider-client relationship. It is not a gag rule. Health 
professionals are free to provide non-directive pregnancy 
counseling, including counseling on abortion. This rule 
protects the conscious rights of health professionals, 
including Title X providers, grantees and applicants, by 
eliminating the requirement to counsel about and refer for 
abortion. This rule ensures, consistent with and eliminates any 
confusion about, the Department's longstanding policy to 
respect these rights. The rule does not prohibit health 
professionals from providing medically-necessary information to 
clients. In fact, by requiring referral for those conditions 
where treatment is medically necessary, this rule ensures 
quality healthcare for women.
    In line with statutory requirements, referral for abortion 
as a method of family planning is prohibited. However, referral 
for abortion is permitted in cases where there are emergency 
medical situations. This rule will protect women and children 
by ensuring that every Title X clinic has a plan to report 
abuse, rape, incest, as well as intimate partner violence, and 
sex trafficking. This is in accordance with the individual 
State laws. It requires that all Title X clinics provide annual 
training for staff, not only to recognize those clients who 
have been or are being abused but also to provide appropriate 
follow-up for them.
    This rule provides guidance to grantees to encourage family 
participation in the decision of minors seeking family planning 
services. It will advance meaningful family communication, 
providing important support to adolescents as they make these 
decisions. By expanding criteria for grant applications, this 
rule will increase competition and encourage innovative 
approaches to unserved populations. First and foremost, the 
revisions to the Title X Rule promote the well-being of 
individuals, families, and communities across the nation.
    Thank you once again for having me here today. I look 
forward to discussing how this rule will ensure the Title X 
program remains in compliance but also fulfills the original 
purpose of Congress so that more adolescents, women, and men 
are able to achieve their family planning goals.
    [The prepared statement of Dr. Foley follows:]
    [GRAPHIC] [TIFF OMITTED] T4365.001
    
    [GRAPHIC] [TIFF OMITTED] T4365.002
    
    [GRAPHIC] [TIFF OMITTED] T4365.003
    
    [GRAPHIC] [TIFF OMITTED] T4365.004
    
    [GRAPHIC] [TIFF OMITTED] T4365.005
    
    [GRAPHIC] [TIFF OMITTED] T4365.006
    
    [GRAPHIC] [TIFF OMITTED] T4365.007
    
    [GRAPHIC] [TIFF OMITTED] T4365.008
    
    Ms. DeGette. Thank you so much, Dr. Foley.
    The Chair now recognizes herself for five minutes for 
questions.
    On June 1, 2018, as we noted, HHS published a proposed rule 
to revise Title X and HHS received over 500,000 comments on the 
rule. I just wanted to ask you about a couple of those 
organizations that commented.
    Many of the leading health organizations, over 19 of them 
representing 4.3 million providers, submitted comments that 
opposed the new proposed regulations. The American Medical 
Association, for example, said quote, ``we are very concerned 
that the proposed changes, if implemented, would undermine 
patients' access to high-quality medical care and information, 
dangerously interfere with the physician-patient relationship, 
and conflict with physicians' ethical obligations, exclude 
qualified providers, and jeopardize public health,'' end quote
    Were you aware of that AMA letter when you finalized the 
rule, Dr. Foley?
    Dr. Foley. Yes.
    Ms. DeGette. And in a comment letter, the American Academy 
of Pediatrics stated, ``policy decisions about public health 
must be firmly rooted in science and increased access to safe, 
effective, and timely care. The proposed rule would interfere 
with the patient-provider relationship, exacerbate disparities 
for low-income and minority women, men, and adolescents, and 
harm patient health.''
    Were you aware of this letter by the American Academy of 
Pediatrics when you finalized the rule, Dr. Foley?
    Dr. Foley. Yes.
    Ms. DeGette. And in another letter, the American College of 
Obstetricians and Gynecologists stated, ``the proposed rule 
regulates how providers talk to their patients and restricts 
the provider's ability to offer the patient his or her best 
medical judgment. The proposed rule uses medically inaccurate 
language, placing political ideology over science,'' end quote.
    Were you aware of ACOG's letter when you finalized the 
rule, Dr. Foley?
    Dr. Foley. Yes.
    Ms. DeGette. And in its letter, the American Public Health 
Association stated, ``the proposed rule would significantly and 
detrimentally alter the Title X Family Planning Program, which 
has provided vital sexual and reproductive health services to 
people across the country for more than 40 years.''
    Were you aware of APHA's letter when you finalized that 
rule, Doctor?
    Dr. Foley. Yes.
    Ms. DeGette. Now these are just four of the major medical 
associations that opposed the rule. Also opposing the rule were 
the American College of Physicians, the American Academy of 
Family Physicians, the American Academy of Nursing, and so on.
    Now, I just wanted to ask you with seemingly every major 
national provider organization, the science organizations 
sounding the alarm, that rule was finalized with the most 
disconcerting provisions intact. Would you say you ignored the 
views and analyses of these leading health organizations? And 
if not, how did you take their views into consideration?
    Dr. Foley. The Department would respectfully disagree with 
the premise of the question, in that the rule clearly allows 
for providers to have full and open conversation with their 
clients or patients, according to the statute. There is no----
    Ms. DeGette. Well, let's talk about that statute for a 
second because, as noted by both my colleagues and by you, the 
statute says that abortion cannot be used as a form of birth 
control. Is that right?
    Dr. Foley. As a method of family planning.
    Ms. DeGette. Right. So I guess I wanted to ask you, are you 
aware of Title X money being used for abortions either for as a 
method of family planning or otherwise? Do you have evidence of 
that?
    Dr. Foley. The Department, in writing the rule, had grave 
concerns about the possibility of----
    Ms. DeGette. That's not my question, Doctor. My question 
is, Did the Department have evidence that Title X money was 
being used in violation of the statute to use abortion as a 
method of family planning?
    Dr. Foley. There is evidence of significant confusion 
surrounding what Title X is being used for.
    Ms. DeGette. That is not what the statute says, Doctor. 
That's not what the statute says.
    In order to promulgate a rule, the Department is going to 
have to find that there is some violation of that statute. And 
what I am hearing from you is that there is no evidence that 
you are aware of that Title X money is being used to provide 
abortions as a method of birth control.
    Dr. Foley. If you remember in 1988 the Department also 
promulgated a rule that was very similar to this rule. That 
rule was also reviewed by the Supreme Court and, at that time, 
the Supreme Court stated that that was an acceptable 
interpretation of Section 1008 of the----
    Ms. DeGette. Well----
    Dr. Foley. And so in that case, the Department has the 
ability to place in regulation rules that help to govern and 
make sure that there is statutory compliance in the Title X 
program.
    Ms. DeGette. OK. So I would just point out that that 
regulation was more than 30 years ago and the legislation has 
been clarified that in its prohibition on Title X abortion 
funding, you can still have nondirective counseling of pregnant 
women.
    The Chair now recognizes the ranking member for five 
minutes.
    Mr. Guthrie. Thank you very much and I want to follow on 
what you just said with nondirective pregnancy counseling. One 
of the major provisions of the Protect Life Rule, which was 
proposed in June 2018 and finalized in March 2019 is that it 
permits but no longer requires nondirective pregnancy 
counseling, including nondirective counseling on abortion to be 
provided by physicians, practitioners, and nurses with advanced 
degrees.
    So Dr. Foley, what is nondirective pregnancy counseling, 
and why was such counseling previously required, and why has 
HHS revised it now so that nondirective counseling is permitted 
but not required?
    Dr. Foley. The 2000 regulation discusses the fact that it 
does not require pregnancy counseling. It says if there is 
pregnancy counseling, that it must be nondirective. And 
nondirective is defined in the fact that information is given 
but the provider does not direct the client one way or the 
other, it does not support in one way or an other in their 
counseling. So it is nondirective counseling.
    The Department felt very strongly that it was not 
appropriate for there to be regulations that specifically 
required or specifically prohibited any conversation of 
healthcare providers with their clients; that that needed to be 
up to the discretion of the clients and the provider. And that 
is why in the final rule that it is permitted but it is not 
required.
    Mr. Guthrie. So, all these organizations that letters were 
just quoted from can still have these conversations with Title 
X funds----
    Dr. Foley. Absolutely.
    Mr. Guthrie [continuing]. But they are just not mandated to 
do so.
    Dr. Foley. Exactly.
    Mr. Guthrie. So, we are not interfering with a doctor-
client relationship that the previous law/rule actually does 
that, the law that----
    Dr. Foley. The regulation that we are currently under 
because of the enjoined new rule states that if the patient 
requests it, the provider is required to provide that 
information to them.
    Mr. Guthrie. So, it has to be requested.
    Dr. Foley. Again, that is requiring a physician to talk 
about something and that is, to me, very similar to prohibiting 
them from talking about something, which is why the Department 
felt like that it needed to be very clear.
    Mr. Guthrie. Let me get to another. In your testimony, you 
state the Title X statute says, ``we have said this a couple of 
times, none of the funds appropriated under this Title shall be 
used in programs where abortions are a method of family 
planning. This is different from the traditional Hyde Amendment 
that says none of the funds may be used for abortion or health 
benefits that include abortion.''
    Can you explain why the reference to quote, a program where 
abortion is a method of family planning is so important?
    Dr. Foley. There is a difference between paying for the 
procedure itself and also in any way encouraging or supporting 
that. And that is why in Section 1008, where it said these 
funds may not be used in a program where abortion is considered 
a method of family planning, the Secretary's opinion, the 
Department's opinion, is that if as a part of that you are 
referring a client for a service of family planning, you 
indeed, are violating Section 1008.
    Mr. Guthrie. Thanks. I want to get another question.
    There has been some concern that the new rule about the 
access to contraception, which is different from the issue we 
just discussed. As you noted, in the Title X Family Planning 
must offer a broad range of acceptable effective family 
planning methods and services. The broad range doesn't need to 
include all categories but, according to fiscal year 2019 
funding announcement, should include hormonal methods of 
contraception, which is probably the most commonly requested I 
understand.
    So why does the funding announcement say Title X grantees 
should include hormonal methods of contraception?
    Dr. Foley. Because that is an important part of providing a 
broad range of effective and acceptable family planning methods 
and services. It is interesting to note that the 2000 
regulation does not mention contraception as a requirement. It 
simply states the acceptable and effective.
    This regulation, the new regulation specifically includes 
contraception in the requirements for what a grantee must 
provide within their project.
    Mr. Guthrie. So that must be provided in that project.
    So how does the--so we are going back to the previous issue 
on funding of family planning in relation to abortion, how does 
that provision of the rule interact with the Weldon Amendment, 
which prevents HHS funding recipients from discriminating 
against healthcare providers because they refuse to provide, 
pay for, or refer to abortion?
    Dr. Foley. There is support there and that is because there 
are Federal statutes that support the ability for someone to 
not refer for abortion or counsel about abortion as a result of 
a conscience for them.
    Mr. Guthrie. Thank you.
    My time has expired, and I yield back.
    Ms. DeGette. I thank the gentleman.
    The Chair now recognizes the gentle lady from Illinois, Ms. 
Schakowsky, for five minutes.
    Ms. Schakowsky. So in 1967, an eager supporter of 
federally-funded family planning wrote to Congress and said, 
``no American woman should be denied access to family planning 
assistance because of her economic condition,'' and that 
supporter was President Richard Nixon. And the next year, the 
Title X Family Planning Program was finally enacted into law 
with broad support. Co-sponsors of the legislation that 
established the program included several Republican members, 
including then-Congressman George H. W. Bush. And at the time, 
there was an understanding on both sides of the aisle that many 
Americans, and especially low-income women, were having more 
unintended pregnancies than they wanted.
    And both Democrats and Republicans understood that the 
primary driver of this phenomenon was inequitable access to 
contraception and reproductive health services.
    Researchers suggest that unintended child-bearing increases 
poverty, limits education, reduces women's ability to 
participate in the workforce, and was an overall detriment to 
the health of women and girls. And so, the United States 
listened to the experts, considered the facts, followed the 
science, and established Title X. And almost 50 years later, 
what we are looking at is the Trump administration deciding to 
turn back the clock and really, in many ways, decimate for many 
people the robust network of family planning providers across 
every State-so far, still Missouri has availability of full 
range of reproductive health-in our nation.
    So here is, I think this is all about abortion. The name of 
the bill, the rule that was passed,--what is it--Protect Life, 
something like that. This is about abortion. This is about 
trying to limit women from having their full reproductive 
rights. Because what doctors, then, have the option of is 
either withholding critical information and limiting care to 
their patients, leaving the program and scaling back clinic 
services, laying off staff, or closing their doors due to the 
limited resources. And all of these options are completely 
unacceptable.
    The chairwoman of the subcommittee listed all of the 
groups, literally all of the health provider groups, that 
oppose this rule and have written very carefully what they 
said. Nineteen leading women's healthcare provider groups, 
medical organizations, and physician leaders have stated, and 
here is a quote, ``this regulation will do indelible harm to 
the health of Americans and to relations between patients and 
their physicians by forcing providers to omit critical 
information about health, healthcare, and resources available. 
The final regulation directly undermines patient confidence in 
their care. There is no room for politics in the exam room.'' 
This is the politics of abortion that we are dealing with right 
now.
    And I want to just state for the record women are not going 
back. Women are not going back. This is not going to be 
tolerated right now. And what I don't understand--are you 
saying that any clinic now that provides comprehensive 
healthcare, comprehensive scientific healthcare, can no longer 
co-locate with any clinic that itself separately provides 
abortion?
    Dr. Foley. Yes, that is what the new rule states.
    Ms. Schakowsky. So the many, I don't know what the number 
is, but the many clinics that do provide the whole range of 
healthcare, those clinics, some that are the only provider in a 
community, will have to somehow change their way of functioning 
entirely. Do you not think that is going to be a difficult 
process?
    Dr. Foley. Again, it is not whether or not it is going to 
be difficult, that is not the issue that this regulation is 
addressing. It is addressing the fact that the statute says 
that these funds may not be used in a program where abortion is 
a method of family planning. And that, again, has been part of 
the statute since it was developed.
    Ms. Schakowsky. This is not going to stand and women around 
this nation are not going to tolerate that.
    Thank you. I yield back.
    Ms. DeGette. I would just point out that is not what the 
statute says. We can get to that later.
    I would now recognize the ranking member of the full 
committee, Mr. Walden, for five minutes.
    Mr. Walden. Thank you, Madam Chair.
    Again, Dr. Foley, thank you for being here.
    What can physicians operating in a Title X clinic do under 
the 2000 regulations that they can no longer do under the 
Protect Life Rule? I think that is the heart of the matter 
here.
    Dr. Foley. There is nothing that physicians, healthcare 
providers, nothing that they cannot do except refer for 
abortion.
    Mr. Walden. For family planning purposes or for any 
purposes?
    Dr. Foley. For family planning purposes--no, for family 
planning purposes. They are permitted to refer for abortion in 
the case of a medical situation or in the case of rape or 
incest.
    Mr. Walden. OK.
    Dr. Foley. However, for family planning services, the 
prohibition against referral for abortion as a method of family 
planning.
    Mr. Walden. And is it your position that the underlying 
statute already precludes that?
    Dr. Foley. Yes.
    Mr. Walden. So why did HHS make these changes? What you 
were asked earlier, you didn't really have a chance to respond 
in depth. Was there any evidence of misuse of program dollars?
    Dr. Foley. The Secretary felt that there was significant 
opportunity for commingling of funds when there was co-location 
of family planning provided services in a single location where 
abortion was provided. There was opportunity for commingling of 
funds.
    He also went on to state that if, by being co-located, a 
Title X provider was able to benefit from economy of scale, 
fungibility of funds in any way, that also would be in 
violation with Section 1008, which required that these funds 
may not be used in a program where abortion is a method of 
family planning.
    And based on his opinion, based on the opinion of the 
Supreme Court finding that, again, this was a reasonable 
interpretation, they also found those regulations to be 
completely clear from any violation, statutory or 
constitutional as a result of that.
    Mr. Walden. OK. Some Community Health Centers are concerned 
the changes to Title X will interfere with the patient-provider 
relationship by limiting the provider's ability to give their 
patients comprehensive information, even when the patient 
directly asks for that specific information.
    So, my question is, once the Protect Life Rule is fully 
implemented, is there any information that a physician 
operating in a Title X clinic will no longer be able to share 
with his or her patient?
    Dr. Foley. There is not.
    Mr. Walden. None?
    Dr. Foley. No, they are completely free, in a nondirective 
way, which is mandated by Congress, that any counseling must be 
nondirective. However, they are not prohibited from having full 
conversations, answering those questions that their clients 
have.
    Mr. Walden. So if a client came in and they had a child 
that they were expecting determined to have a medical problem 
that could be fatal, could that doctor say here are your 
options: you could terminate the pregnancy today; you could do 
compassionate care; or you might do some extraordinary activity 
after birth?
    Dr. Foley. Yes, they are free to provide counseling on all 
of the options, including the options of abortion for their 
client.
    Mr. Walden. OK. Now as I mentioned earlier, my district 
is--well, it's bigger than any State east of the Mississippi, 
so getting access to care for Oregonians is really essential in 
these very rural, underserved areas. They have three counties 
with no doctors and hospitals, hundreds of miles in-between.
    So, talk to me, given your experience as a pediatrician, as 
somebody who has served in these sorts of areas, are a change 
to the rules going to adversely affect my constituents' ability 
to access reproductive health services and healthcare in these 
Community Health Centers?
    Dr. Foley. One of the other changes in this regulation and 
rule is to encourage grantees to apply who have shown 
innovative ways to address services for those particularly in 
unserved or underserved areas, particularly rural areas. And we 
are hopeful that there will be grantees that will provide those 
services that currently are not being provided in some areas.
    Mr. Walden. Because I understand under perhaps the existing 
contract grant application process, one of the criteria is to 
look at total number of people served. And as I said, I have 
got counties with less than 2,000 people and hundreds, and 
hundreds, and hundreds of square miles. And it seems to me, 
under the current rules, they could be excluded.
    Dr. Foley. Again, those criteria are not exclusionary. It 
is one of the factors that we look at to determine who provides 
the best coverage for a broad range. Those are not 
exclusionary.
    However, I agree with you that if there is increased rural 
coverage, there may be a decrease in the total number of 
patients serviced. However, the opinion of the Department is 
that----
    Mr. Walden. Un-accessed.
    Dr. Foley [continuing]. In urban areas, there are other 
access areas for them.
    Mr. Walden. Thank you. My time has expired.
    Thank you, Madam Chair.
    Ms. DeGette. Thank you so much.
    The Chair now recognizes Dr. Ruiz for five minutes.
    Mr. Ruiz. Thank you, Chairwoman.
    Dr. Foley, my name is Dr. Raul Ruiz and doctor to doctor, I 
want to tell you I am very concerned about the proposed changes 
to the Title X Family Planning Program.
    I represent the constituents of California's 36th District 
to rely on the services of seven health centers that are Title 
X-funded and most of them function in underserved, hard to 
reach communities.
    The Title X program has been in place for 50 years and 
helps around four million people very year by providing them 
with essential services like birth control, HIV/STD testing, 
men's healthcare, and pregnancy testing. And Dr. Foley, as you 
mentioned, you are a former Title X provider. You and I know 
that the program helps low-income, uninsured individuals, and 
individuals who live in rural areas.
    The administration's recently published final rule on Title 
X will harm the four million people it is intended to help. One 
of the provisions in the final rule prohibits Title X providers 
from referring their patients for abortion services, even if 
specifically requested.
    Now you just heard an example about an extreme case, where 
somebody's health is on the line but how about the 13/14-year-
old made, a mistake, comes into the clinic, says ``I want to 
know my different options.'' Mother is there with her and says, 
``What are my options? Can you refer me to an abortion 
clinic?'' Just for family planning, saying ``it is not my time, 
I am not prepared, I am in a dysfunctional situation.'' Can 
that doctor refer that patient to an abortion service clinic?
    Dr. Foley. According to the statute, abortion cannot be 
used--the funds cannot be used in that.
    Mr. Ruiz. So no.
    And the other thing that this bill does is that it leaves 
doctors to decide whether or not to follow certain guidelines, 
whether or not to even refer them, even if they ask as well. 
And that is a problem, you see.
    We all know that Title X funds do not go towards abortion. 
It never has. And you cannot even give us one example of any 
violation of that statute or one example of Title X money going 
towards abortion. You can't even give us an example. That fear 
is unfounded.
    Last year, the New England Journal of Medicine published a 
perspective that stated that this rule, in fact, changes 
implemented in April 2017 already allow grantees to shift Title 
X funds away from sites that also provide abortion. It already 
does. Several statute and appropriation restrictions already 
protect providers who refuse on the basis of conscience to 
refer clients for abortion service. They already have that 
option.
    These proposed regulations go farther by restricting 
providers' ability to deliver sound patient care in, 
essentially, dismantling the well-established, well-functioning 
Title X care system, disregarding local community care systems 
and policy preferences. The consequence changes in the Title X 
system are likely to increase unintended pregnancy rates in the 
most vulnerable segments of the population and are, thus, more 
likely to increase than to reduce the incidence of abortions.
    I represent a district with rural and underserved areas and 
this rule would create barriers that disproportionately impact 
low and rural communities and augment the unsafe use of 
abortions.
    Given your training and background as a pediatrician, do 
you agree that the patient-provider relationship must be built 
on trust?
    Dr. Foley. Yes.
    Mr. Ruiz. Numerous medical associations have strongly 
opposes the rule for this very reason, including the American 
Medical Association, the American Academy of Pediatrics, the 
American College of OB/GYN, and the American Nurses 
Association. In fact, the AMA, says ``the ability of physicians 
to have open, frank, and confidential communications with their 
patients has always been a fundamental tenet of high-quality 
medical care. The proposed rule would violate these core 
principles by restricting the counseling and referrals that can 
be provided to patients and by directing clinicians to withhold 
information critical to patient decisionmaking.''
    The exact same example that I told you of a young 
adolescent, maybe 18-year-old, 17-year-old coming in saying I 
want to know all my options. If that doctor cannot give that 
patient the full spectrum and help that patient understand the 
full risks and benefits of that clinical case of all the 
different options available to that woman or girl, then they 
are violating their patient trust relationship. And that's why 
many organizations and many doctors, including myself, are 
opposed to this rule.
    I yield back my time.
    Ms. DeGette. The gentleman yields back.
    The Chair now recognizes Dr. Burgess for five minutes.
    Mr. Burgess. Dr. Foley, let me just give you a chance to 
respond to what you just heard.
    Dr. Foley. There is nothing in the rule that prohibits a 
healthcare provider from giving the full range of information 
about all the options, including everything you just said. 
There is nothing that prohibits them from giving all of that 
information to their clients.
    Mr. Ruiz. You told me----
    Mr. Burgess. Actually, reclaiming my time, Doctor, now, it 
was also asserted that the rule creates barriers to care. Can 
you address that?
    Dr. Foley. The new rule?
    Mr. Burgess. The new rule.
    Dr. Foley. The barriers to care that it may create, there 
are many providers that avoid being a part of the Title X 
program because of the current regulation that states that they 
are required to refer for abortion and that they are required 
to have counseling about that. And so there are a number of 
providers that don't participate, as a result of that.
    Mr. Burgess. Very well. And I know Mr. Guthrie asked you 
some questions on the nondirective counseling part. And just to 
follow-up on that a bit, you did say that it was up to the 
discretion of the client and the provider. Can you clarify 
that?
    Dr. Foley. The counseling is client-directed, based on the 
questions they are asking and what they have. The nondirective 
counseling is there is instruction that you provide the 
options, a full discussion of the options that they have and 
explain that to them. There is no prohibition on having that 
conversation.
    Mr. Burgess. Now we also heard that the nondirective 
counseling was equivalent to a gag rule. Can you address that?
    Dr. Foley. If you were prohibited from counseling about a 
certain area or prohibited from having that conversation, that 
would be a gag rule. The fact of the matter is, this new rule 
gives providers, does not prohibit them, in fact it allows them 
to have that conversation, whatever conversation they would 
like to have with their clients.
    Mr. Ruiz. Would the gentleman yield?
    Mr. Burgess. No. The other issue, of course, is co-location 
and how is this rule addressing the co-location, commingling 
aspect?
    Dr. Foley. There is great concern that co-location 
increases the opportunity for commingling of funds for 
fungibility for use of the funds for infrastructure and other 
things. That was a significant concern; enough of a concern for 
the regulation to be changed. What is interesting is that that 
concern was upheld by the number of comments we receiving 
showing significant misunderstanding of what the rule actually 
states; and talking about the need for abortion to be a part of 
what is covered, and significant confusion not only from 
commenters but as well as the general public.
    So in order to have statutory compliance with integrity, 
the final rule was engaged in the way that it was.
    Mr. Burgess. So let me ask you this. State flexibility and 
competition don't seem like they have always been given a high 
priority within the Title X program. How does the new rule aim 
to increase diversity amongst grant applicants?
    Dr. Foley. Part of the priorities are to look for 
innovative ways to, again, address areas that are underserved 
or unserved as a result of the Title X program and funding. So 
with those changes, that is encouraged and grantees are 
encouraged to provide those types of services, as they apply 
for this.
    Again, this is a competitive grant process. And so part of 
that competition is looking to see what provides the best 
coverage and into the areas of priority.
    Mr. Burgess. So you noted that the 2019 final rule requires 
medically-necessary referrals, such as referrals for prenatal 
care, for the health of the mother, as well as the baby. Was 
medically-necessary care for prenatal care not required under 
the previous rule?
    Dr. Foley. That is right, it was not required.
    Mr. Burgess. So what prompted you to add this portion to 
this rule?
    Dr. Foley. The idea of medical necessity was very 
important, particularly with the changing climate that we have 
seen with increased maternal mortality. And we know that the 
earlier someone who is pregnant is referred for prenatal care, 
the more likely they are to have a better outcome, both for 
them and for the child. And so in that case, that was the 
reason that this was considered a medical necessity that they 
would be referred.
    Mr. Burgess. And you may mark me down as being supportive 
of that change.
    So I will be happy to yield the last 16 seconds to Dr. 
Ruiz. Now, he's absent. Absent without leave.
    So Dr. Foley, just thank you for being here and testifying 
today. It has, I think, added a positive measure to the 
discussion.
    And I will yield back.
    Ms. DeGette. The gentleman yields back.
    The Chair would just note that the rule says that medical 
professionals can have a full conversation, including about 
abortion but only--even if the patients asks, but only in the 
situation of medical necessity, rape, or incest. So at other 
times, they would be prohibited from having those 
conversations.
    The Chair will now recognize the chair of the full 
committee for five minutes.
    Mr. Pallone. Thank you, Madam Chair.
    I am obviously opposed to this rule but the thing that 
strikes me is how it is totally unnecessary. Just as an 
example, the proposed rule sets about requiring onerous 
physical and financial separation between Title X programs and 
those from abortion services, including referral, counseling, 
and any activity related to abortion. And the justification 
given by HHS is that it will, and I quote, ``protect against 
the intentional or unintentional commingling of resources.'' 
Yet, I don't see any evidence that this is actually happening, 
that there actually is commingling of resources.
    So I wanted to ask Dr. Foley, isn't it true that the Office 
of Population Affairs already had robust grantee reporting 
program reviews and auditing process in place before the 
proposed rule? Yes or no. You can just say yes or no if you 
want.
    Dr. Foley. There are provisions for that in place, however, 
that is not spelled out in the current regulation.
    Mr. Pallone. Now you said, I guess in response to Dr. Ruiz, 
that there has been confusion whether Title X funds have been 
inappropriately used to perform abortions. I think that is what 
you said. If you disagree, you can say.
    But are there formal OIG audits? And if so, can you point 
to any in this regard that lead with regard to your statement 
about the confusion?
    Dr. Foley. The purpose of this was, again, to make sure 
that there was integrity and that the original intent was 
followed.
    Mr.Pallone. But I mean were there any OIG audits?
    Dr. Foley. Not that I am aware of.
    Mr. Pallone. All right. In his order granting a preliminary 
injunction on the implementation of the Title X rule, Judge 
McShane, who I quoted earlier, said, ``despite the nearly 50-
year history of Title X, HHS cannot point to one instance where 
Title X funds have been misapplied under past or current 
rules.''
    And I guess perhaps this explains why the American Medical 
Association said in their comments on the rule, and I quote, 
that ``HHS fails to justify why physical separation is 
needed.'' So Dr. Foley, can you understand why the AMA and 
other medical and public health organizations point to a lack 
of justification for the new rule when HHS itself can't provide 
evidence that the additional physical separation requirements 
are necessary?
    Dr. Foley. Again, the program integrity is the purpose of 
this rule. It was--that was the motivation for writing that, to 
make sure that according to statute that these funds are not 
used in a program where a program is a method of family 
planning.
    Mr.Pallone. Well I understand what you are saying but I 
mean the problem is you know you go in to do these proposed 
rules, you are trying to say, accomplishing something which we 
don't even know whether or not there is a problem, and you 
yourself are saying there is some confusion about whether there 
really is a problem.
    So I mean it is all very nice to say you are trying to 
accomplish something but you create all this mischief at the 
same time. I don't mean you but, you know the Department.
    I mean because HHS' Title X rule has been enjoined by the 
judge, the longstanding requirements for Title X remain in 
place and this includes a requirement that all pregnancy 
counseling must be nondirective, including information on all 
available options: including adoption, prenatal care, abortion. 
Yet, last week HHS has stated that it will not enforce this 
requirement with regard to abortion referrals.
    So Dr. Foley, does HHS intend, in your opinion or if you 
know, does HHS intend to enforce other requirements for Title X 
projects, namely, that they must provide the full range of 
medically-approved contraceptives, including hormonal and long-
acting options, do you know?
    Dr. Foley. What they were referring to in that specific 
situation was the protection that is provided under a number of 
Federal laws for conscious protection.
    Mr. Pallone. Well, I understand that, but what I am----
    Dr. Foley. And what they were not going to be able to 
enforce----
    TMr.Pallone [continuing]. Concerned about though is that if 
HHS doesn't enforce these other requirements, that they have to 
provide the full range of contraceptives, hormonal, long-acting 
options; I am just afraid that you know they are just going to 
give out Title X funds to some group that you know just wants 
to narrowly focus their medical advice or whatever, or their 
advice on just a few things and not the full range of options 
in terms of family planning. And that is not what we intend 
with Title X.
    Dr. Foley. The Title X will continue to, as it has, require 
that grantees provide a broad range of effective and acceptable 
family planning methods and services. That will continue to be 
required.
    Mr. Pallone. Well, I hope so because I am very concerned 
that what we may get into is very narrowly focused clinics or 
healthcare services that don't allow these, and then that 
becomes the full range, and then that becomes ideological in 
itself, which this administration is known for.
    In any case, I think that I certainly agree with healthcare 
leaders that say that the administration should retract its 
regulation because family planning policies shouldn't be--
should be driven by facts, evidence, and necessity, not 
politics and ideology. And I think this is headed towards an 
ideological program, which is the last thing we need.
    But thank you for being here. I appreciate it.
    Ms. DeGette. The gentleman yields back.
     The Chair now recognizes the gentle lady from Indiana, 
Mrs. Brooks, who, by the way, we are all very saddened about 
your news that you are leaving us.
    Mrs. Brooks. Thank you. Eighteen months to go, important 
work to do, and I will certainly miss this committee and the 
fine work that we are doing together.
    I do want to ask you, Dr. Foley, you lead the office that 
oversees these grants. Is that correct?
    Dr. Foley. That is correct.
    Mrs. Brooks. And in your written testimony, in addition to, 
because there is much being talked about with respect to the 
nondirective counseling, in your written testimony you have 
indicated that this final rule places a high priority on 
preserving the provider-client relationship and the regulation 
permits but does not require nondirective pregnancy counseling, 
including nondirective counseling on abortion. Is that correct?
    Dr. Foley. That is correct.
    Mrs. Brooks. And that is what you have said today. So this 
means--and I would also like to point out that the Federal 
Register, which has tried to explain a lot of this, and it is 
like 103 pages long, but it talks about nondirective counseling 
does not mean that the counselor is uninvolved in the process 
or that counseling and education offer no guidance but, 
instead, that the clients take the active role in processing 
their experiences and identifying the direction of the 
interaction. And they may provide, still, what I am reading. A 
Title X provider may provide a list of licensed, qualified, 
comprehensive primary healthcare providers, some of which may 
provide abortion. Is that correct?
    Dr. Foley. That is what the rule states.
    Mrs. Brooks. That is what the rule states. And so while 
yes, there is much discussion about this, it does not mean that 
nondirective counseling--what does nondirective counseling mean 
to you, as a doctor?
    Dr. Foley. Nondirective counseling means that the 
information is provided, the questions are answered, but I do 
not direct them one way or another towards a decision.
    Mrs. Brooks. It seems very clear but yet still, as a 
provider, you must and may lay out all of the options.
    Dr. Foley. That is correct.
    Mrs. Brooks. That is correct but you may not tell the 
patient what is best for them, or what is appropriate, or what 
you like, or don't like? What does that mean? Let's talk about 
that a little bit.
    Dr. Foley. When you look at the statute, what it says is, 
again, these funds cannot be used in a program where abortion 
is a method of family planning. So any encouragement of, 
promotion of, support of, referral for abortion would violate 
that standard.
    Mrs. Brooks. And that is Section 1008----
    Dr. Foley. That is right.
    Mrs. Brooks [continuing]. Of the law that is in place.
    Dr. Foley. That is correct.
    Mrs. Brooks. I want to shift a moment to make sure that 
people understand that in the 2000 Title X rule, it did not 
mention contraception but the new rule does explicitly list 
contraception. Because I want to make sure people realize this 
rule is not trying to take away contraception.
    Why did you add a direct mention of contraception in the 
rule?
    Dr. Foley. By definition, when the statute requires that 
these grantees provide a broad range of effective and 
acceptable family planning methods and services, contraception 
is a very critical part of that and that needs to be included. 
And it was to clarify the fact that the intent of the 
Department was not to remove contraception as an option for the 
women, and men, adolescents that are seeking that.
    Mrs. Brooks. Can an entity that provides only one method of 
family planning service receive funding as a Title X grantee?
    Dr. Foley. This was actually part of the 2000 regulation as 
well, where it states that each sub-recipient is not required 
to provide all of the methods; however, within a project, all 
of those must be provided.
    So this has been something that has been in place since the 
2000 regulation was in place and this has just been continued 
into the new regulation.
    Mrs. Brooks. And how do you and your Department that is 
overseeing this entire project and the grantees, how do you 
determine whether or not they have provided a broad range of 
family planning methods?
    Dr. Foley. They are required to list the sub-recipients and 
what services they are going to be offering. And we look at 
those, look at the geographic area that they have indicated 
that they will cover, and make sure that a broad range is 
available in that area, as much as is possible.
    Mrs. Brooks. Thank you. I yield back.
    Ms. DeGette. The Chair now recognizes the gentleman from 
Maryland, Mr. Sarbanes, for five minutes.
    Mr. Sarbanes. Thank you, Madam Chair.
    Thank you, Dr. Foley, for being here, as we discuss the 
implementation of the Title X gag rule, which seems to have 
occurred not just without any real scientific or medical input, 
in my view, but in spite of those things.
    I want to echo what has been pointed out by my colleagues, 
many patients seeking care at Title X clinics have no other 
source of care. This is really critical. In fact, there is a 
2016 nationally-representative study that showed that 60, six-
zero, percent of Title X patients had no other source of 
healthcare in the prior year.
    I am very proud that in Maryland, we have been a leader in 
expressing our opposition and taking action against the gag 
rule and the negative impacts that it would have on Maryland 
communities. As a State, Maryland receives about $3.2 million 
in annual funding from Title X. Almost half of that, $1.43 
million, goes to the City of Baltimore, which I represent, 
which uses it to provide a range of services to more than 
16,000 patients annually.
    In the Federal lawsuit that was filed against HHS to 
prevent the rule from taking effect, Baltimore City outlines 
that many Title X grantees would lose funding under this rule 
and the city would be then responsible for replacing that lost 
funding. If not replaced, the public health impacts would 
include an increase in unintended pregnancies, an increase in 
sexually transmitted infections, an increase in undetected 
cancers, and a decrease in access to prenatal care. Each of 
these issues is associated with increased healthcare costs for 
patients and for the city.
    Now you know that Title X was enacted by Congress in 1970, 
correct? And that represented a commitment at the Federal level 
to provide funding for family planning services and to make 
that, in part, a Federal responsibility.
    What I am curious about is when this rule was being 
developed, were considerations given to how the grantees would 
inevitably lose Federal funding; many of the ones who are 
currently receiving Title X, and how this would impact the 
communities that they are located in? In other words, did 
anyone in your office consider how State and local funding 
would have to be diverted from other sources to support the 
family planning activities that would no longer be receiving 
Federal support? Was that part of the analysis?
    Dr. Foley. There is nothing about the new rule that intends 
to keep providers from being part of the Title X program. The 
purpose of the rule was to make sure that there was statutory 
compliance with the regulations, the mandates that are in place 
in the statute.
    And the decision for grantees--again, this is a competitive 
grant process, the decision for grantees is their decision to 
make. There was nothing in this rule that would preclude anyone 
from being a part of our Title X program, as long as they 
complied with the regulations, and the statute, and the 
mandates, bringing things back into compliance with the intent 
of Congress in establishing this rule.
    Mr. Sarbanes. I understand but you are sort of putting 
blinders on. I mean you can stick to that narrative and I 
understand why you are doing it but, in terms of continuing to 
meet the Federal Government's responsibility and intention of 
making sure that these kinds of services are available, 
particularly in low-income communities, others who have 
difficulty accessing this kind of care, instances where it is 
the only source of care, it seems to me that your office ought 
to have given consideration to what the practical impact would 
be, what the ripple effect would be. That's the kind of 
perspective that when you are developing a new regulation ought 
to be in the mix. There is no evidence that that happened here.
    And the impact that is being predicted from implementing 
this gag rule is it will have a tremendous effect on access to 
care and all of the services that I referred to a moment ago. 
So, I would recommend that you broaden the lens here and look 
seriously at how the effects of this rule cut against what 
Congress intended when it put the program in place back in 
1970; and I think that that commitment represents the 
expectations of the broad majority of Americans across the 
country.
    With that, I will yield back my time. Thank you.
     Ms. DeGette. The Chair now recognizes the gentleman from 
Oklahoma, Mr. Mullin, for five minutes.
    Mr. Mullin. Thank you, Madam Chair.
    Just there is a lot of confusion about what the rule does 
and doesn't do. And first of all, it seems like people are 
thinking that it makes a change to the law itself, especially 
when it is pertaining to abortions. But underneath Section 108 
it says, very specifically, it says none of the funds 
appropriated under this title shall be used in programs where 
abortion is a method of family planning. Is that correct?
    Dr. Foley. Yes.
    Mr. Mullin. Does your rule make any changes to that?
    Dr. Foley. No, it did not.
    Mr. Mullin. So this is current law that has been there 
since 1970. Is that what we just referred to?
    So there is no changes to that. So some of my colleagues on 
the other side of the aisle now want to add to it and say that 
that should be an option now offered but, underneath current 
law, that can't be an option. Is that correct?
    Dr. Foley. Yes, that is correct.
    Mr. Mullin. And let's just say because Planned Parenthood 
seems to be brought up here a lot, there isn't any services 
that Planned Parenthood currently offers underneath the clinics 
that are operating underneath Title X that changes, right? They 
just can't perform abortions but they have never been able to 
perform abortions out of the same building. Is that correct?
    Dr. Foley. The co-location--currently, there is co-location 
of a number of clinics that provides abortions as well as 
providing Title X services. The change in what Title X funds 
can pay for has not changed.
    Mr. Mullin. Right, so that doesn't change. You are just 
saying that they can't perform them out of the same building.
    Dr. Foley. The idea that there is the opportunity to 
commingle funds, there is the perception, certainly, by the 
public, by grantees, by other people that Title X covers that 
because it is in the same location, these----
    Mr. Mullin. As a business, sure.
    Dr. Foley [continuing]. Are all of the things that we were 
concerned.
    Mr. Mullin. Absolutely. Well, as a business owner, the way 
I can cut costs from business, to business, to business, 
because my wife and I own multiple businesses, is that we can 
utilize the resources by bringing them underneath one building. 
We can utilize the electric. We can utilize the cost of 
overhead. We can utilize personnel and they can coexist 
underneath one umbrella and it brings down the cost. It is 
cost-sharing among the companies. And what we are saying is 
that because it is 100 percent prohibited underneath Title X 
from 1970, we just got to make sure that isn't happening. And 
underneath the new rule, you are trying to clarifying that, 
correct?
    Dr. Foley. That is correct.
    Mr. Mullin. Because it has been kind of a gray area because 
we have some on the left that think that tax dollars should be 
used for abortions but, yet, the law doesn't say that. The law 
is very, very clear.
    So those on the other side of the aisle, if they wanted to 
try to change that, then they need to change the law but your 
rule doesn't make a change to this. So the gag order, to 
whatever they are saying, they are calling it, that's actually 
just a myth. Is that correct?
    Dr. Foley. The gag rule--it is not a gag rule.
    Mr. Mullin. Which they refer to as a gag rule.
    Dr. Foley. It is not a gag rule.
    Mr. Mullin. Right, it is just clarification.
    Does the new rule help with rural areas, as far as trying 
to get services to family planning?
    Dr. Foley. It is a priority of the Department and it is 
made specifically in the new regulation that part of the grant 
application process will place a priority on serving 
underserved or unserved areas and many of those are rural 
areas.
    Mr. Mullin. Because a lot of times rural areas are you know 
overlooked because they are rural but it still is very 
important. My district is extremely rural and we do need 
resources down there. We need to make sure that we are not 
overlooking it, that disproportionately, the dollars are going 
to major metropolitan areas. It needs to be proportionately 
spread out to the rural. So I do appreciate that.
    How does it encourage parent and child communication in 
family planning decisions?
    Dr. Foley. The mandates from Congress, for a number of 
years, have stated that there needs to be family involvement 
when it comes to, particularly, adolescents in their 
decisionmaking. And while that has been in the mandate, there 
has been nothing in current regulations that actually 
operationalize that or explain how that should be done and how 
that needs to be reported back to the Federal Government if 
Title X funds are going to be used in that situation.
    Mr. Mullin. And adolescent is age--what do you consider an 
adolescent?
    Dr. Foley. Adolescent, that varies depending on who you are 
talking to but, typically, it is a minor, someone who is 
considered a minor.
    Mr. Mullin. Under 18.
    Dr. Foley. And that may change. That may change depending 
on the State laws and that type of thing.
    Mr. Mullin. Just like we have tobacco laws, just like we 
have drinking laws, age appropriate. This is still the same 
thing and this doesn't change it. It just clarifies it that it 
needs to--we need to do more to encourage family participation 
when an adolescent is facing a very, very tough decision.
    Dr. Foley. Right. And again, it also does clarify that 
there are situations if the adolescent is in danger that that 
is not required.
    Mr. Mullin. Right.
    Dr. Foley. For example, if we know that there is abuse 
going on or if it has already been reported to the State and 
local authorities, then the encouragement to include family is 
not a part of what will be done through this regulation.
    Mr. Mullin. Thank you.
    Madam Chair, I yield back. Thank you.
    Ms. DeGette. The Chair now recognizes the gentle lady from 
New York for five minutes.
    Ms. Clarke. Thank you, Madam Chairwoman, and I thank the 
ranking member for convening this very important hearing on 
what can be done or should be done to safeguard quality family 
planning care.
    I am deeply concerned that, at a time when we should be 
discussing how to dramatically increase Title X funding and 
bring reproductive healthcare to millions of women in need, we 
are instead being forced to focus our oversight authority on 
how to protect Title X from the Trump administration's recent 
assault on women's reproductive rights and women's health and 
well-being.
    Despite the important mission of Title X, Federal funding 
has decreased by $31 million nationally since fiscal year 2010. 
Over $1 million of this decrease in funding has occurred in my 
home State of New York. Even with this decrease, Title X has 
remained a critical source of funding throughout New York City. 
Between years 2012 and 2015, 22 different organizations in New 
York City received Title X funding, enabling these 
organizations to provide comprehensive primary and reproductive 
healthcare services to an average of 148,000 New Yorkers 
annually.
    Three of these clinics that rely on Title X funding are 
situated right in my congressional district within Brooklyn, 
where I was born, raised, and live to this day. All three 
health centers provide essential sexual and reproductive 
healthcare to low-income women, women of color, and other 
underserved patients every day. They also provide patients with 
a range of preventative care services that might otherwise be 
out of reach, including breast and cervical cancer detection.
    Now, through its proposed gag rule, the Trump 
administration is directly undercutting Title X by forcing 
health centers to make the impossible choice between proper 
healthcare on the one hand and Federal funding on the other. 
The Trump administration's recent proposal is nothing more than 
an effort to undermine women in our human right to preventative 
healthcare. We must, therefore, safeguard Title X to ensure 
that all patients, regardless of their background, social 
status, or whether they have health insurance, has access to 
quality healthcare.
    What I find interesting is the wordsmithing that has been 
taking place here today. None of what you are trying to preempt 
has even occurred. You have yet to state anything that says 
that you have evidence that people are commingling dollars, 
that any of this is taking place. And so we are only left to 
what we see and know has been an ongoing assault on women's 
reproductive rights.
    So Title X serves a disproportionately high number of black 
and Latinx patients, compared to national rates. In fact, 
nearly one-third of the Title X patients are people of color. 
Public health professionals and leaders within communities of 
color have raised serious concerns regarding the potential 
impact of Trump administration's new Title X rule.
    Dr. Foley, why has HHS disagreed with the American Public 
Health Association's assessment of the impact of the new rule 
as it relates to health inequities within the United States? 
What the American Public Health Association says is that 
``increased health inequities widen the gap between women who 
are able to access healthcare services and those who are not.''
    Dr. Foley. There, again, is nothing in the new regulation 
that precludes any of our current Title X grantees from 
receiving funding as we move forward. Again, when we are 
talking about the ability for a healthcare provider to provide 
a full range of information to their clients, there is no 
restriction on that.
    Earlier----
    Ms. Clarke. I understand what you are saying but here is 
the thing. Most organizations are able to segregate their 
funding streams. And you are making it seem as though there has 
been this mass issue of commingling of funds. This has never 
been the case. You failed to document it. And it would seem to 
me that you would be proceeding based on fact. What you are 
doing is proceeding based on speculation.
    So my next question, Dr. Foley, is: According to black 
women leaders of Our Own Voice, a partnership of five black 
women-led organizations serving communities across the country, 
Title X, the gag rule, would be especially detrimental to low-
income women and women of color. We already face heighten 
barriers to family planning resources. HHS is gambling with our 
lives, putting black women at an even greater risk.
    Dr. Foley, do you share those concerns?
     Dr. Foley. I disagree with the premise of your question in 
that this new regulation is a gag rule. I also disagree with 
the premise that healthcare providers are going to be forced to 
provide--limit the information that they give to their clients 
that are there. There is nothing in this rule that will 
preclude that from happening and that is not the intent. The 
intent is simply to maintain and make sure that this rule is 
following, is compliant with the statute that has been in 
place, and with the intent.
    Ms. Clarke. I yield back.
    Ms. DeGette. The gentle lady's time has expired.
    The Chair now recognizes the gentle lady from Florida, Ms. 
Castor, for five minutes.
    Ms. Castor. Thank you, Madam Chair.
    You know almost 50 years ago America established an 
important public policy through Title X that birth control, and 
contraceptives, and family planning should be just as available 
to working class and uninsured women as they are to every other 
woman across the country. And despite all the progress we have 
made and all of the new modern types of birth control that have 
become available, many women and families still struggle with 
access to contraceptives, preconception care, and vital health 
screenings.
    Now, the Trump administration wants to pass a rule that 
takes America backwards, that deemphasizes contraceptives, and 
birth control, promotes abstinence and the rhythm method. This 
is something of a battle we fought 50 years ago, isn't it? And 
what strikes me is that it is clear that this Trump 
administration proposed rule is going to increase the number of 
unintended pregnancies. And don't just take it from me, that's 
what all of our trusted health groups have said; the American 
Medical Association, the American College of Obstetricians and 
Gynecologists, the American Public Health Association. Why are 
they wrong, Dr. Foley?
    Dr. Foley. I disagree with the premise that this new 
regulation is going to not emphasize contraceptives and 
emphasize other methods are more important. That is not what it 
says.
    Ms. Castor. Well, America is always at its best when we 
base policy on science. And Title X--that is particularly true 
for Title X because it has always been seen as the gold 
standard for family planning care in this country, based on the 
best standards of care.
    Now this proposed rule is going to change that. Since the 
year 2000, Title X regulations have stated that services are 
going to be a broad range of acceptable, and effective, 
medically-approved family planning methods and services, 
including natural family planning, right? That's what the 
regulations have said.
    Dr. Foley. The current regulation states that.
    Ms. Castor. So your final rule now would remove the 
requirement that methods of family planning include those that 
are, ``medically approved.'' Instead, the rule emphasizes the 
provision of natural family planning over other methods.
    Now America's College of Obstetricians and Gynecologists 
have said about that, this modification appears to be diluting 
long-standing Title X program requirements, lowering the 
standards governing the services that must be offered. These 
changes threaten the quality of family planning available to 
Title X patients.
    Now, don't just take it from those experts. The American 
Academy of Family Physicians advised you that in removing 
medically approved from current requirements, the rule, 
``allows Title X grantees to exclude certain forms of FDA-
approved contraceptives, restricting access to safe and 
effective contraception.''
    Did you look at how many more unintended pregnancies will 
result from this rule?
    Dr. Foley. I would disagree with the premise that medically 
approved is an issue.
    Ms. Castor. Can you just say--can you answer directly? Did 
you examine how many more unintended pregnancies will result 
because of the change in policy?
    Dr. Foley. The----
    Ms. Castor. Yes or no?
    Dr. Foley. In the estimation of that, there would not be a 
change based on any changes made to the rule.
    Ms. Castor. Well why do you disagree with all of the--I 
mean who are we going to trust out there, American 
Obstetricians and Gynecologists, the AMA, the American Family 
Physicians? They are the ones that have said that this rule 
will lead to negative health outcomes, it will lead to more 
unintended pregnancies. That is, unfortunately, going to be the 
result when you have less contraceptive services, medically--
approved, that are available to women and families across the 
country. You have elevated ideology over evidence in the public 
health and you have done so to the detriment of women and 
families.
    And I yield back at this time.
    Ms. DeGette. The gentle lady yields back.
    The Chair now recognizes the gentleman from Virginia for 
five minutes.
    Mr. Griffith. Thank you very much, Madam Chair.
    Dr. Foley, this does not make it so that there are less 
contraceptive services unless you include abortion. Isn't that 
correct?
    Dr. Foley. That is correct.
    Mr. Griffith. So the premise that somehow there is less 
contraceptive services, unless you are counting abortion, it is 
just not accurate.
    Dr. Foley. There is nothing in the rule that would lead to 
that.
    Mr. Griffith. And in fact when I read the code section, it 
seems pretty clear that if they were doing what the other side 
of the aisle seems to think they were doing, they were already 
in violation of the law. Am I misreading the law there? I know 
you are not a lawyer. You can say I am not a lawyer. It is all 
right.
    Dr. Foley. I am not a lawyer.
    Mr. Griffith. All right. Well, I am a lawyer and that is 
the way I read it. It looks like to me if what they are saying 
is accurate, they were--somebody was violating the law all 
along.
    Speaking about that, there has been a lot of discussion 
about the co-location requirements. What percentage of Title X 
clinics are currently in violation of the co-location 
requirements in the new rule?
    Dr. Foley. The estimate by a congressional report was that 
approximately ten percent of the Title X service sites are in 
co-location. If you look in the preamble, the discussion and 
the calculations that the Department made to look at economic 
impact with a physical separation made an estimate that 
possibly there would be 20 percent. So they increased that to 
make sure that there was enough of a balance to really properly 
look at what economic impact there might be for requiring 
physical separation.
    Mr. Griffith. Out of all the thousands of locations, we are 
talking about somewhere between 10 and 20 percent may be 
impacted by this. Is that correct?
    Dr. Foley. That is the estimation, yes.
    Mr. Griffith. And my understanding is that co-location 
requirement is not heavy or heavily onerous. So it is something 
that most of these locations can probably fix fairly easily. 
Isn't that also correct?
    Dr. Foley. Again, that is a determination for those 
particular entities. I----
    Mr. Griffith. But the rule was not interpreted or it was 
not intended to be overly burdensome, just trying to follow the 
law. Isn't that correct?
    Dr. Foley. It is trying to make sure that we are in 
compliance with the statute, yes.
    Mr. Griffith. Amazing an administration wants to follow the 
statute. Just amazing.
    Let me ask you some other questions, if I might. Can you 
describe the program reviews that HHS uses to audit Title X 
grantee compliance with the terms of their Title X grants?
    Dr. Foley. We currently have a number monitoring processes 
in place. One of them is an extensive program review that 
occurs once every funding period, where there is an extensive 
administrative, clinical, and financial audit and review of the 
grantee, as well as a number of sub-recipients.
    Mr. Griffith. So these program reviews do extend to the 
sub-recipients?
    Dr. Foley. They do.
    Mr. Griffith. OK and----
    Dr. Foley. Not all of the sub-recipients but there are one 
or two that are chosen for site visits.
    Mr. Griffith. And how frequently does HHS conduct program 
reviews or other audits of the Title X grantees?
    Dr. Foley. They are done once a project period. So 
typically, a grantee would be reviewed once every 2 to 3 years.
    Mr. Griffith. OK, so we are not talking about monthly, or 
quarterly, or anything like that? No.
    And what are some of the common findings these audits have 
had over the last 5 to 10 years?
    Dr. Foley. When those have been reviewed, there are a 
number of administrative types of things that have shown up, as 
far as not reporting different kinds of things. There have been 
situations where there have been instances where funds have 
been commingled that have been a citation, again, not to the 
level of--when something--when we find a citation, typically, 
we notify the grantee of that. And then they are required to 
fix whatever that was, and then get back to us about how they 
have done that, and then we follow up again.
    So there have been a number of instances, over the past 
five years, that have shown misunderstanding with grantees and 
some sub-recipients as far as what the funds can be used for 
and not used for.
    Mr. Griffith. Now my time is almost up but can you 
elaborate on your written testimony and tell me how the Protect 
Life Rule would expand innovation?
    Dr. Foley. Part of what the requirements in the new rule 
are that we would extend as part of the application process, 
that there would be priority given to grantees that show 
innovation in reaching underserved or unserved populations. And 
so looking to try to expand beyond maybe where we are having 
services or we are providing services already.
    Mr. Griffith. So the hope is that you will have a greater 
impact on the communities, particularly the lower income 
communities.
    Dr. Foley. Yes.
    Mr. Griffith. Yes.
    I yield back.
    Ms. DeGette. The Chair now recognizes the gentleman from 
New York, Mr. Tonko, for five minutes.
    Mr. Tonko. Thank you, Madam Chairwoman.
    Dr. Foley, just a point of clarification before I begin my 
questions. You keep on saying that the rule does not prohibit 
discussion about abortions. That may be true. However, isn't it 
true that under the rule a provider can choose to withhold that 
information?
    Dr. Foley. That protection is given under the Federal 
statutes that protect conscience protection.
    Mr. Tonko. But so is it true that the provider can choose 
to withhold that information?
    Dr. Foley. Under their Federal--yes, under their Federal 
rights.
    Mr. Tonko. Well how you can say the rule preserves open 
communication if a provider can decide what information to 
share or which information to withhold from the patient?
    Dr. Foley. That is actually no different than the way 
things are currently. Providers still, for a conscience 
ability, are able to withhold that information now, even under 
the current regulation. The Department, since those Federal 
conscience regulations were put into place in 2006-2009, the 
Department has not held grantees or providers to the standard 
of having to refer or talk about abortion if they have a 
conscience objection to it.
    Mr. Tonko. So as we are discussing the Title X Family 
Planning Program today, I think it is imperative that we focus 
on the fact that the program was created to ensure that low-
income women had access to the family planning method of their 
choice, that they had access to related preventative 
healthcare, and that they had access to care. Yet, if the 
administration's new rule were to proceed, according to the 
American Congress of Obstetricians and Gynecologists, and I 
quote, ``more than 40 percent of Title X patients at risk of 
losing access to critical primary and preventative care 
services.''
    So those at risk include many in my home State of New York, 
where Title X supported 187 Health Centers that provide care to 
306,000 plus New Yorkers. Some of these patients shared their 
stories with me.
    Emily, for instance, from the Capital Region in my 
district, and I quote, says ``the only care that I could 
receive was from Planned Parenthood. Planned Parenthood was 
there for me with no judgment. They provided the necessary and 
affordable medical care that I needed when no one else would.''
    Jasmine, another constituent, and I quote, ``as someone who 
has benefitted from Title X, my ability to continue seeing the 
healthcare provider I know and trust is on the line. My 
healthcare is not a political game. It should not matter who 
you are, or where you live, or what kind of insurance you have; 
every single person should be able to make their own decisions 
about their healthcare.''
    I couldn't agree more.
    So, Dr. Foley, in your testimony you indicate that a 
purpose of the rule is to expand coverage and increase the 
number of clients served within the Title X programs. So, 
Doctor, has HHS conducted an analysis to estimate the number of 
patients who stand to lose or gain access to care under your 
new rule?
    Dr. Foley. Again, the primary purpose of the rule is to 
ensure that there is compliance.
    Mr. Tonko. No, have they conducted an analysis? I just want 
that answered.
    Dr. Foley. There has been a careful analysis of looking at 
coverage.
    Mr. Tonko. Is it a formal analysis? Can you share it with 
us?
    Dr. Foley. It is analysis that has been done as the rule 
was being written. It is analysis that is ongoing. We have 
every hope----
    Mr. Tonko. Well wait a minute. If it is ongoing, why would 
you go forward with the rule?
    Dr. Foley. We have every hope that we will not lose 
grantees already.
    Mr. Tonko. You have hope and you have an ongoing analysis. 
Did you conduct an analysis before you inducted the rule?
    Dr. Foley. There was analysis done that looked to see, 
again, what was going to be the effect of this. And our hope 
was, again, as I mentioned in answering another question, if 
the grantees that currently co-locate, that they refuse to 
follow that regulation, that is approximately ten percent of 
the sites we have currently, in looking at that, there are 
other clinics in those areas that would be able to take those 
patients. And so yes, there was that type analysis done.
    Mr. Tonko. OK. Well, it doesn't seem like a strong enough 
analysis, as you described it.
    The American College of Physicians, along with other 
leading medical and health organizations believes that the 
provisions of the Title X gag rule threaten patients' access to 
care. They state clearly that, and I quote, ``the significant 
changes to Title X will jeopardize access to healthcare for 
vulnerable, often working, low-income patients who may have 
limited to no access to health insurance.''
    So Doctor, do you still contend that the rule does not 
place patients' access to care at risk?
    Dr. Foley. Again, the rule does not preclude full 
conversation with clients about what they have----
    Mr. Tonko. But why are they wrong? Why are these people 
wrong in their analysis?
    Dr. Foley. In their analysis, I am not sure. I have not 
seen that analysis or talked with them. So I am not sure what 
they are talking about in this situation. However, there is 
nothing in the rule that forces physicians or healthcare 
providers to withhold information. There is nothing in the rule 
that would preclude the full range, broad range of effective 
and acceptable contraception, family planning methods to be 
given. It is stated in the rule that is the requirement, that 
is the expectation of grantees under this new rule.
    Mr. Tonko. Well, I have used up my time. I would hope you 
would provide evidence to back that claim. And with that, I 
yield back.
    Ms. DeGette. The Chair now recognizes the gentleman from 
South Carolina for five minutes.
     Mr. Duncan. Thank you, Madam Chair.
    You know Republicans are being painted that we are anti-
Title X and nothing could be further from the truth. In fact, I 
am a fan of Title X. There are about 4,000 service sites, I 
think, in the country that Title X funds. Only about 500 of 
them are Planned Parenthood.
    The argument from the other side is that with this Title X 
funding, after this rule, that many low-income Americans will 
no longer have access to the health resources available to 
them. That is just wrong because there are only 500 Planned 
Parenthood sites, 4,000 Title X sites. These are Federally 
Qualified Health Centers, which I am a big fan of. In fact, I 
think we should have expanded the Federally Qualified Health 
Centers before we allowed the Affordable Care Act to pass. We 
should have looked at where the rubber meets the road, where 
low-income Americans have access to health services on a wide 
spectrum at the Federally Qualified Health Centers across this 
country. We should have expanded the Federally Qualified Health 
Centers across this country, not expanding Planned Parenthood, 
per se, but places that are meeting the needs of the poor folks 
in our country.
    But when the Government confiscates the tax dollars from 
Americans, and I think the abortion issue in this country is 
probably about 50-50, that is just guessing off the cuff here, 
so 50 percent of the country doesn't want their tax dollars to 
go to pay for abortion services. And Government takes that 
money and then uses it to pay for abortions. In fact, Planned 
Parenthood gets about $50-60 million in Title X funds. Now not 
100 percent of that goes to abortion. In fact, I think it is 
very difficult to determine how much of that tax dollars go to 
abortion because the money is commingled at Planned Parenthood 
and some of that money pays for regular health services that 
Planned Parenthood provides, but some of it pays, commingled 
money they get from private donors, money they get from tax 
dollars commingled and they use to pay for all the services 
that Planned Parenthood provides. And so it is very difficult.
    Does the HHS have any concerns about the financial 
oversight of Title X Planned Parenthood sites and that 
commingling that I am talking about?
    Dr. Foley. That is the reason that one of the--that a part 
of this rule is that there is going to be physical and 
financial separation in the case where there is co-location 
because of the--to make sure that there is no commingling of 
funds, to make sure that there isn't fungibility that is used, 
and to make sure that there isn't a benefit based on economy of 
scale, which, again, would be against the Section 1008 of the 
statute.
    Mr. Duncan. All right. Do you agree with me that the 
Federally Qualified Health Centers--take Planned Parenthood out 
of it for just a second, but the other Federally Qualified 
Health Centers actually meet the needs of folks around the 
country?
    Dr. Foley. There are a lot of Federally Qualified Health 
Centers that are part of our Title X network that we work with 
and that do provide great service.
    Mr. Duncan. Right. Many have been calling this final rule a 
gag rule. In a statement released in March by Planned 
Parenthood, it referred to the final rule as the Trump-Pence 
administration's unethical, illegal, and harmful Title X gag 
rule. This could not be further from the truth. It is not the 
banning of abortion or abortion referral in the private sector, 
it is only governing programs that the Federal Government funds 
with tax dollars. As I mentioned earlier, Planned Parenthood 
chooses to prioritize their abortion services over the rest of 
the services they provide.
    The final rule is very clear, if Title X sites want to 
continue receiving Federal dollars, they simply must comply 
with the provisions of the final rule, which are consistent 
with the original statute. Go back to the original statute. It 
requires that none of the funds, quote, ``in Section 1008 of 
Title X says that none of the funds appropriated under this 
program shall be used in programs where abortion is a method of 
family planning.'' That is in the statute. That is not my 
words. That is in the statute.
    And so the rule is clear. It says that if Title X sites 
want to continue receiving Federal dollars, they simply must 
comply with the provisions of the final rule, which are 
consistent with the original statute. Wouldn't you agree with 
that? If not, they will have to seek their own private funding 
to continue the services, wouldn't they?
    Dr. Foley. I am not aware of what their financial situation 
is.
    Mr. Duncan. Right. Also under the final rule, grantees are 
permitted, just no longer required, to provide nondirective 
pregnancy counseling, including nondirective counseling on 
abortion to their patients. Isn't that right under the rule?
    Dr. Foley. That is a stamp yes.
    Mr. Duncan. And can you go into further detail on how this 
is different from the original 1988 policy?
    Dr. Foley. The 1988 regulation actually was more 
restrictive, in that it prohibited any counseling about 
abortion and it also prohibited referral for abortion. Again, 
the Supreme Court upheld that as consistent, both from a 
statutory as well as a constitutional standpoint, that that 
particular one stood that test.
    However, we believe, as we were looking at this rule, that 
we needed to make sure that health professionals were able to 
have conversations with their clients that they wanted to have.
    Ms. DeGette. The gentleman's time has expired.
    Mr. Duncan. Thank you very much. I yield back.
    Ms. DeGette. The Chair now recognizes the gentleman from 
Massachusetts, Mr. Kennedy, for five minutes.
    Mr. Kennedy. Thank you, Madam Chair.
    And Dr. Foley, you said that the goal of this proposed rule 
is to maintain and make sure that the rule is compliant with 
the statute. Is that right?
    Dr. Foley. To maintain the statutory integrity.
    Mr. Kennedy. OK. So on the Office of Public Affairs--Office 
of Population Affairs Web site, your office measures 
performance based on the effectiveness of contraceptive care 
and the access to long-acting reversible contraceptive care, 
LARCs. Do you have any evidence whatsoever that imposing a rule 
that will likely shutter essentially family planning clinics, 
which you have estimated to be 10 to 20 percent of them and 
largely in underserved communities, would force others to 
forego Title X funding and increase access to LARCs?
    Dr. Foley. The idea that----
    Mr. Kennedy. Any evidence?
    Dr. Foley. The evidence that we have is from the 500,000 
comments that we received. And of those comments, there were a 
number of them, providers, who stated that part of the reason 
why they were not involved with Title X was based on the 
requirement to refer for abortion.
    Mr. Kennedy. So you read----
    Dr. Foley. And if that was----
    Mr. Kennedy. Ma'am, reclaiming my time. How many of those 
500,000 comments did you look at?
    Dr. Foley. I looked at most of them.
    Mr. Kennedy. And you didn't have time, based off of your 
testimony to Mr. Tonko, didn't have time to look at a letter 
from the American College of Obstetricians and Gynecologists, 
or the AMA, or the American Academy of Family Physicians. You 
didn't look at those?
    Dr. Foley. I did read those letters.
    Mr. Kennedy. You did. So when you indicated to Mr. Tonko 
that you weren't aware of why every one of these groups is 
against it, you said you weren't familiar with their analysis, 
did you look at them or did you not?
    Dr. Foley. I read the letters.
    Mr. Kennedy. And so are you familiar with why they are 
against the analysis, why they are strongly, according to the 
AMA, strongly opposed to the final rule?
    Dr. Foley. What I said was that I disagreed with the 
premise upon which that they base their statement.
    Mr. Kennedy. And so those three leading organizations are 
not--have not approached--there is an issue with the way in 
which they, all three of them, conducted their studies?
    Dr. Foley. The issue that this was a gag rule, 
specifically.
    Mr. Kennedy. The issue that--and that is the only reason 
why you believe that they are against the existing--this rule 
is because of the gag rule function. It has nothing to do with 
the closure of the 10 to 20 percent of the hospitals--of the 
clinics across the country.
    Dr. Foley. That, in addition.
    Mr. Kennedy. In addition but you have also spent the last 
hour-plus saying that there is no major change in this existing 
rule from the existing law that is already out there. Yet, you 
indicated that the prior, the violation of this commingling, of 
which you have offered zero evidence of, zero evidence, the 
evidence of that was such a grave violation of that before and 
prior to this rule you offered a letter to work with them to 
try to address the commingling, and now we are closing 10 to 20 
percent of the clinics across the country? That is the remedy? 
We are shifting from a letter to closure. That is the 
appropriate response?
    Dr. Foley. The choice to close is not of the Department. 
The choice to close is of the individual----
    Mr. Kennedy. Aside from the fact, ma'am, let's address that 
next point as well. You have indicated that you are not aware 
of the financial circumstances of these clinics, yet Kaiser 
Family Foundation has pointed out that it would cost up to a 
quarter of the existing budget of the entire program to come 
into compliance with the rule, a quarter.
    So are you familiar with that analysis?
    Dr. Foley. We disagreed with the premise of that 
discussion.
    Mr. Kennedy. So you disagree with Kaiser, ACOG, AMA, and 
American Academy of Family Physicians. Let's see who else you 
disagree with.
    You indicated that you were unaware of the financial 
circumstances provided by these clinics. Are you aware of the 
financial circumstances of the American public, yes or no?
    Are you aware of the fact that 40 percent of the American 
public cannot come up with money to spend $400 for an emergency 
medical bill? Yes or no?
    Dr. Foley. Can you repeat that question for me?
    Mr. Kennedy. Did you know that 40 percent of American 
families cannot afford an unexpected $400 medical bill?
    Dr. Foley. Yes.
    Mr. Kennedy. Did you know how many Americans would drop 
below 150 percent of the Federal poverty line if you subtracted 
out the cost of medical care?
    Dr. Foley. I am not aware of that.
    Mr. Kennedy. Seven million.
    Do you know the percentage of clients who rely on Title X 
sites are now either poor or low income?
    Dr. Foley. At our last report, approximately 60 percent of 
our----
    Mr. Kennedy. The data I have is 87 percent.
    Dr. Foley. That----
    Mr. Kennedy. And so your data is 60 percent. My data is 87 
percent. We are closing a rule that you say doesn't actually 
address any major change in law, that four major medical 
associations are against, that targets directly low-income 
individuals' access to critical family care, you are saying is 
just not that big a deal.
    Dr. Foley. We are not aware nor in the 500,000 comments 
that we got was there sufficient evidence to show that these 
would all close as well. Again, it was----
    Mr. Kennedy. Aside from the studies that I pointed out. 
No----
    Dr. Foley. Again, it was an estimation of what might happen 
and there was not sufficient evidence to show what would happen 
as a result of this.
    Mr. Kennedy. So ma'am, does your organization take a 
position on repealing the ACA mandate that contraception be 
available with no patient out-of-pocket costs and do you have 
an analysis as to how that would impact access to LARCs?
    Dr. Foley. The statute requires that for clients who are 
100 percent or below the Federal poverty level, that the 
contraceptive broad range are given to them at no cost.
    Mr. Kennedy. You support the mandate. You support the 
mandate.
    Dr. Foley. And then again, there is a sliding fee scale for 
those above 100 percent.
    Mr. Kennedy. Do you support the mandate, yes or no?
    Dr. Foley. We support what is in the statute, as well as 
required by Title X.
    Mr. Kennedy. And how about a $1.5 trillion cut to Medicaid, 
do we think that that increases women's access to long-term 
planning or long-term contraception care or no?
    Dr. Foley. That again, is beyond the scope of the Title X 
program.
    Mr. Kennedy. And how about the 14 States that have not yet 
expanded Medicaid? Would expanding Medicaid actually help women 
gain long-term access to care, yes or no?
    Dr. Foley. Again, that is out of the scope of what the 
Title X program is in charge of.
    Mr. Kennedy. I am sure it is.
    Ms. DeGette. The Chair now recognizes the gentle lady from 
New Hampshire, Ms. Kuster, for five minutes.
    Ms. Kuster. Thank you, Madam Chair and thank you to our 
witness for appearing before us today.
    You have talked about confusion. And frankly, I think you 
are adding to the confusion, if you will. But I want to know, 
because it seems to me that this would require a physician to 
be omniscient, in a sense. Tell me the protocol for determining 
whether an abortion is sought, ``for purposes of family 
planning.'' Walk me through. What would the question be? And 
just let's use as an example, a 13-year-old raped by her 
father.
    Dr. Foley. Again, the regulation allows for referral for 
abortion in the case of----
    Ms. Kuster. I am just asking you as a physician.
    Dr. Foley [continuing]. Rape or incest.
    Ms. Kuster. As a physician--okay, so let's say it wasn't 
rape and it wasn't her father, it was the neighbor. The 
neighbor having sex with the 13-year-old resulting in a 
pregnancy. And walk me through, as a physician, the protocol 
for you to make the omniscient determination that this is for 
the purposes of family planning.
    Dr. Foley. What the rule states and, again, the statute 
states in regulation----
    Ms. Kuster. Just walk me through the protocol.
    Dr. Foley [continuing]. It does say that if it is not a 
medical emergency----
    Ms. Kuster. Right, and how would you determine----
    Dr. Foley [continuing]. Then it is a method of family 
planning.
    Ms. Kuster [continuing]. This for the purposes of family 
planning?
    Dr. Foley. If it is----
    Ms. Kuster. This is the first abortion, the second 
abortion, the third abortion, what is using abortion for family 
planning?
    Dr. Foley. For anything other than medical emergencies or 
in the case of rape or incest.
    Ms. Kuster. OK. And in those cases, it is prohibited to 
make a recommendation. You said--you talked about this 
nondirective. You said if the patient asks. I am talking about 
a 13-year-old. Like she probably doesn't even know how the 
pregnancy occurred. Why would she ask? What would she know to 
ask?
    Dr. Foley. Following what the statute says in Title X 
clinics--again, this doesn't restrict anything that a doctor 
can do outside of Title X-funded programs.
    Ms. Kuster. Well, frankly----
    Dr. Foley. And what that says----
    Ms. Kuster [continuing]. They are going to close without 
the Title X funding. I mean you have taken care of that.
    Dr. Foley. There is no evidence that shows that they will 
close.
    Ms. Kuster. So in my--I have a rural community. They would 
not be able to. They can't afford--this whole question of 
commingling, and we have heard a number of times today that 
there is virtually zero evidence. You have not cited any 
evidence of commingling of funds.
    So meanwhile, they can't afford to have two different 
sites. So trust me, they are going to close. And there is no 
other option in my district. These are rural communities. They 
cannot get there.
    Are you aware that in a rural community where I live there 
is no childcare up to 6 months? Are you familiar with that?
    Dr. Foley. I am not familiar with New Hampshire, no.
    Ms. Kuster. And are you familiar that when you have a 
child, and you live in a rural area, and most of the people 
working there do not have any paid medical leave, so they do 
not have any place for the child to be cared for by someone 
else, nor can they probably afford it if they are working on 
the typical wage there and the childcare is going to cost them 
40, 50, 60 percent of their monthly wage.
    So what about the circumstance where they just simply can't 
afford to have a child? Is that a conversation? Say it is an 
older person. Say it is someone in their 20s. Say it is one of 
my nieces, working, unable to afford to have a child, or unable 
to find childcare for that child, can that conversation include 
how to make a determination about the pregnancy? Does it 
include adoption? Does it include terminating the pregnancy? 
What are the options that you can discuss?
    Dr. Foley. You can discuss with that client all of the 
options that are available to them as the pregnancy----
    Ms. Kuster. But only in a nondirective way. So only if the 
client asks the right questions----
    Dr. Foley. No.
    Ms. Kuster [continuing]. Not if you think that this is----
    Dr. Foley. Nondirective means that you can--you give the 
options to them and then you answer the questions they have. 
Directive means--you don't direct them, support, encourage one 
or the other. That is nondirective.
    Ms. Kuster. Let me ask you about that because does this new 
rule include, say for example, a church program and the only 
options that they offer are the rhythm method or abstinence. Is 
that appropriate under this rule?
    Dr. Foley. Only if they also----
    Ms. Kuster. They would get Federal funding?
    Dr. Foley. Only----
    Ms. Kuster. They could get my tax dollars in Federal 
funding?
    Dr. Foley. Only if they are associated within their project 
with other locations that provide the rest of the broad range.
    Ms. Kuster. So that would be OK.
    Dr. Foley. The rest of the broad range.
    Ms. Kuster. A church that only offered the rhythm method 
and abstinence, that would be sufficient counseling for a 
person. And is there a medical exception to that or we will go 
back to the rape and incest?
    Dr. Foley. That, again, is under the current regulation, 
the 2000 regulation allows for entities to provide only one 
method, as long as they are associated----
    Ms. Kuster. I think there is a lot of confusion.
    Ms. DeGette. The gentle lady's time has expired.
    Ms. Kuster. I think this is more confusion but I yield 
back.
    Ms. DeGette. The Members of the subcommittee now have 
finished their questioning. And so we thank other members for 
coming to waive on and for their interest in this topic.
    And the first I will recognize is Mr. Shimkus for five 
minutes.
    Mr. Shimkus. Thank you, Madam Chair. I am appreciate you 
letting us waive on. And for the record, Diane DeGette and I 
are pretty good friends. Sometimes we disagree but in this era 
of tenseness in Washington, I think that's important to put on 
the table.
    Dr. Foley, thank you for your service. And Joe Kennedy is a 
good friend of mine, too, but I would ask you, do you know that 
we have the lowest unemployment since 1969 in this economy? We 
do. Do you know that the tax cuts passed provided almost $3,000 
for a family with two kids? We do. Do you know that 
unemployment is at 3.6 percent, which is almost, by economists' 
standards, full employment? The answer is that is a fact. So 
better wealth, income for our citizens helps across the board.
    I also want to take this time, because I had to pull up 
your bio or parts of it, because you are a compassionate doctor 
in this field. Originally from Indiana, Dr. Foley founded and 
served as medical director of Northpoint Pediatrics. Shortly 
after completing a residency in pediatrics, Dr. Foley's areas 
of special interest are adolescent gynecology, prevention and 
treatment of sexually transmitted diseases, healthy family 
formation, and global health.
    Most recently, she was in part-time clinical practice at 
Certified Centers for CMS, a critical access hospital in Lamar, 
Colorado. At the same time Dr. Foley served as Director of 
Medical Ministries for Global Partners of the Wesleyan Church, 
where her responsibilities included oversight of mission 
hospitals in Sierra Leone, Zambia, and Haiti. Dr. Foley is a 
graduate of Marion College, now Indiana Wesleyan University, 
and the Indiana University School of Medicine.
    Sometimes I think it is important to know people's 
background. We get in a hyper partisan event, although this 
hearing has been conducted respectfully and I attribute that to 
the Chair and her demeanor.
    A couple questions. What is the--what are some of the--
because this commingling of funds and this co-location issue 
has always been a debate in this arena. What are some of the 
ways Title X grantees may spend the funds available to them?
    Dr. Foley. The funds that are used in Title X programs must 
be used to provide a broad range of effective and acceptable 
family planning methods and including associated preventative 
services as well. So in addition to providing contraception, to 
providing training on natural family planning methods, they 
also can be used for screenings that are related to health, 
such as screening for sexually transmitted infections, such as 
cancer screenings--
    Mr. Shimkus. Let me ask, because I filibustered and used a 
lot of my time, how are these types of expenses tracked?
    Dr. Foley. They are reported to the Federal Government and 
there are reports that have to be turned into the grant office.
    Mr. Shimkus. Let me ask another question. May Title X 
grantees count clients as Title X clients and also bill 
Medicaid for services provided to the client?
    Dr. Foley. Yes.
    Mr. Shimkus. In the Clinton era, Title X regulations put an 
emphasis on privacy to the exclusion of parental involvement, 
despite the statute and annual appropriation bills putting 
emphasis on parental involvement. How does this rule improve 
family involvement and communication?
    Dr. Foley. Again, the statutory and the appropriations have 
mandated that there needs to be family involvement. And what we 
have done is just require that there is a way within the 
patient record that it is notified that they encourage that. 
Again, we cannot require that there is parental consent. That 
is not within our purview. However, using the best adolescent 
development information we know now, and in fact there was a 
study that was just released----
    Mr. Shimkus. OK, let me go. You are doing great. I have got 
one more I need to get in.
    You mentioned 2009 in this conscience protection discussion 
we had earlier. Who was the President at that time? President 
Barack Obama.
    Dr. Foley. It was the last administration.
    Mr. Shimkus. So conscience protection is very important in 
this whole debate and it shouldn't be discarded.
    With that, Madam Chair, I will yield back my time.
    Ms. Castor. [presiding]. Mr. Lujan, you are recognized for 
five minutes.
    Mr. Lujan. Thank you, Madam Chair. I want to thank you and 
the ranking member for this important hearing.
    Dr. Foley, thank you for being with us today. Dr. Foley, 
yes or no, are you a medical doctor?
    Dr. Foley. I am.
    Mr. Lujan. Are you familiar with both AMA's Code of Medical 
Ethics and the AMA's comments on the rule?
    Dr. Foley. Yes.
    Mr. Lujan. Do you agree with the AMA that this rule will 
cause doctors to violate medical ethics by limiting their 
ability to counsel their patients about all of their options 
and to provide referrals?
    Dr. Foley. What I--I do not agree that this rule limits 
their options to be able to talk with the patients about all. 
It does not limit their ability to talk about all of the 
options.
    According to the statute, referral is not--is prohibited. 
However, all along, Congress, as well as other bodies, have 
separated, and the AMA also separates out counseling from 
referral. Those are two different types of things.
    And so from a medical/ethical standpoint, I firmly believe 
physicians need to be fully able to have full and open 
conversations with their clients about all of the different 
options and provide that information to their patients in an 
ethical way. It is mandated, again by Congress, that that is 
done non-directively, in that information is given, questions 
are answered, however, one method is not--we don't direct them 
to make one method over another. There is not one that is 
encouraged more than another.
    Mr. Lujan. Dr. Foley, would you agree that the American 
Medical Association essentially wrote the book on medical 
ethics? Is that a fair statement?
    Dr. Foley. I would say that there are--there may be--it 
certainly is the medical body association. There are a number 
of people, and we found that from the 500,000 comments that we 
got, that disagree that this rule is in violation of medical 
ethics.
    Mr. Lujan. Do you disagree with the AMA's Code of Medical 
Ethics? You said you were familiar with them.
    Dr. Foley. I disagree with the premise of the question that 
this rule violates that.
    Mr. Lujan. No, no, that is not what I am asking. That is 
not what I am asking.
    Do you disagree with AMA's Code of Medical Ethics? You said 
you were familiar with them when I asked the question 
initially.
    Dr. Foley. Yes, I do not disagree with that.
    Mr. Lujan. You do not disagree with AMA's Code of Medical 
Ethics.
    Dr. Foley. Yes.
    Mr. Lujan. I heard you say yes. Is that correct?
    Dr. Foley. Yes.
    Mr. Lujan. Well here is what the AMA said about this rule, 
and I quote, ``the inability to counsel patients about all of 
their options in the event of a pregnancy and to provide any 
and all appropriate referrals, including for abortion services 
are contrary to the AMA's Code of Medical Ethics.''
    Dr. Foley. And what I would say is I disagree with the 
premise that this rule violates that.
    Mr. Lujan. Dr. Foley, the folks that wrote the rule, that 
have a responsibility to make sure that these medical ethics 
are not being violated are talking about the concerns that they 
have. I think it is the premise of the question that you have 
been asked by several of our colleagues today. And so if you do 
not object to the AMA's Code of Medical Ethics, I think that we 
should listen to the experts from the AMA when they say that 
they have a concern that the AMA's Code of Medical Ethics are 
going to be violated. That is what you are requiring doctors to 
do.
    So my concern is that it would appear that HHS would be 
putting providers in the impossible position of choosing 
between their patients' rights or what the Government dictates. 
According to the AMA, before HHS issued the final rule, Title X 
providers were required to advise their patients about their 
healthcare options according to the patient's interests. That 
is medical practices and accepted standards of professional 
ethics under the final rule. However, Title X providers are no 
longer held to such standards, closed quote.
    Why is this administration comfortable lowering the 
standards of provider care and dictating what can and cannot be 
said in a doctor's office?
    Dr. Foley. I disagree with the premise of that. There is 
nothing in the final rule that will not allow a physician to 
have that full conversation with their clients. That is not 
part of what the rule states.
    Mr. Lujan. So you stand by saying that the gag order that 
is being put in place by this administration does not restrict 
the conversation that doctors can have. That is what you are 
saying. That is your interpretation.
    Dr. Foley. That is true.
    Mr. Lujan. And you would fight to protect that in court? So 
if you a doctor violated your rule and had a conversation in 
court, you are saying that they are not in violation?
    Dr. Foley. I am not a lawyer. I am here representing what 
the rule says.
    Mr. Lujan. You are the expert. This is your responsibility.
    Dr. Foley. I am an expert as a physician and you asked me 
about the ethics.
    Mr. Lujan. All right.
    Dr. Foley. I would say to you that this rule does not 
violate those ethics.
    Mr. Lujan. Well, Madam Chair, as my time expired, I think 
there is a bit of a conflict here because what I just heard was 
that the rule does not restrict any physicians from having 
these conversations. I hope I can get that in writing so that 
we can give that direction. Because the way that I read this 
and the AMA reads this, there is a gag order that is being put 
in place and restrictions being put in place.
    And with that, I yield back.
    Ms. DeGette. [presiding.] The Chair now recognizes the 
gentleman from Ohio----
    [Disturbance in hearing room.]
    Ms. DeGette. The committee will come to order.
    The Chair will now recognize Mr. Latta from Ohio for five 
minutes.
    Mr. Latta. Well thank you very much, Madam Chair and thanks 
very much for allowing me to participate in the hearing. I 
really appreciate it. And thanks to our witness for being here 
today.
    Dr. Foley, the final rule requires that all Title X clinics 
provide annual training for staff to ensure compliance with 
State reporting laws for child abuse, child molestation, sexual 
abuse, rape, incest, intimate partner violence, and 
trafficking.
    Are the new rape and abuse reporting requirements different 
from those in the old Title X rule?
    Dr. Foley. The current regulation does not state what Title 
X providers or grantees are required to do to show that they 
followed the mandate that says that they need to be reporting 
according to State laws.
    So what this new regulations has done is put into place the 
process requiring annual training and then requiring the 
recording of the fact that they are following that mandate.
    Mr. Latta. You know when you say the annual training, has 
there been a requirement for annual training in the past?
    Dr. Foley. No, that has not been in regulation. That has 
been a practice that the Title X program has had and is 
recommended in quality family planning but has never been put 
in as far as something that is required that would need to be 
reported upon.
    Mr. Latta. OK, thank you.
    We had a little discussion here about the gag rule and some 
have called this a gag rule, which implies that freedom of 
speech is being impinged. Does this rule impact what grantees 
may do at locations not funded by Title X programs?
    Dr. Foley. Not at all.
    Mr. Latta. And do grantees who don't agree with the Protect 
Life Rule have the freedom to forego taxpayer dollars and seek 
private funding instead and elsewhere?
    Dr. Foley. Yes, it simply is putting restrictions on how 
Federal funds can be used.
    Mr. Latta. OK. In 2015, Planned Parenthood served 2.4 
million clients and 1.6 million of these clients received Title 
X--were Title X patients, meaning that 67 percent of Planned 
Parenthood clients were Title X clients served by a program 
that makes up just four percent of their total $1.46 billion in 
revenue.
    How do we or you reconcile these numbers? Is there a way to 
reconcile that and is it possible that clients are counted as 
receiving Title X services when they are also receiving 
services funded under other federally or privately funded type 
programs?
    Dr. Foley. Most of our grantees--we do not have enough 
funding to fund family planning services that our grantees and 
our sub-recipients need. And so most of them have a variety of 
other funds that help to fund the services that they have. So 
that is likely what has happened as a result of that.
    Mr. Latta. Just backing up, would there be any other 
federal dollars out there did you say?
    Dr. Foley. Medicaid is the primary, actually would be the 
primary funding source for most of our Title X clients because 
it is a service reimbursement.
    Mr. Latta. OK.
    Well thank you very much, Madam Chair, and I yield back.
    Ms. DeGette. The Chair now recognizes Mr. Bilirakis for 
five minutes.
    Mr. Bilirakis. Thank you, Madam Chair. I appreciate it so 
very much.
    And I want to thank the chair, Ms. DeGette, and also my 
good friend from Florida, my neighbor, Ms. Castor.
    But Dr. Foley, I have a couple questions. Title X is the 
only Federal program dedicated solely to the provision of 
family planning and related preventative healthcare. What 
services are encompassed under the Title X program?
    Dr. Foley. The Title X program is authorized to provide 
voluntary family planning projects. They must offer a broad 
range of acceptable and effective family planning methods and 
services and, in addition, related preventative services, those 
that relate to family planning, which is to help prevent 
pregnancy or to help to achieve a pregnancy. So that would 
include or could include things that might affect infertility, 
sexually transmitted infection screening, cancer screening, 
those types of things; basic infertility services.
    Mr. Bilirakis. OK, very good.
    While Title X is the only program dedicated solely to this 
purpose, as you said, what other federal programs also provide 
services for family planning and related preventative 
healthcare?
    Dr. Foley. There----
    Mr. Bilirakis. If you could give me an example or give me a 
few. Yes.
    Dr. Foley. There aren't any that strictly provide just 
family planning services. Again, Medicaid is a reimbursement 
service, so that would be another Federal program that would 
help to cover that.
    Mr. Bilirakis. OK, but there are alternatives out there and 
Medicaid does cover those programs.
    Under the proposed Title X rule, the amount of funding 
available for family planning would not diminish. I am pretty 
sure that is correct. It would only be redirected away from 
providers so determined to provide abortion that they refused 
to comply with the new rules.
    Under the Clinton era regulation, Title X grantees were 
required to refer for abortion. Is that correct?
    Dr. Foley. If the patient requested that, they were 
required to refer for abortion.
    Mr. Bilirakis. OK, what does this mean for entities that 
want to provide care without referring for abortion because it 
goes against their moral convictions or religious beliefs, and 
how would the new rule change that, the Trump rule?
    Dr. Foley. The new rule that is currently enjoined states 
that because--that referrals for abortion are prohibited, 
except in the case of medical emergencies, or rape, or incest. 
So for family planning, for the purpose of family planning, 
referral for abortion is prohibited as a part of that program.
    Mr. Bilirakis. So we are basically going back to prior 
2000. Is that correct, to a certain extent?
    Dr. Foley. Consistent with the 1988 regulations.
    Mr. Bilirakis. To 1988, OK, very good.
    I yield back, Madam Chair. I appreciate it very much.
    Ms. DeGette. The Chair thanks the gentleman.
    And now the Chair recognizes the gentleman from Montana for 
five minutes.
    Mr. Gianforte. Thank you, Madam Chair.
    And Dr. Foley, thank you for being here today. You 
testified earlier that, under this new rule, providers would 
not be restricted from fully counseling their clients on the 
range of options. Is that correct?
    Dr. Foley. That is correct.
    Mr. Gianforte. Yes, and I just wanted--there was some 
dispute here earlier with some of the interaction. I just I was 
looking at the rule itself. And just reading directly from the 
rule it says Title X provider may provide a list of licensed, 
qualified, comprehensive primary healthcare providers, 
including providers of prenatal care, some of which may provide 
abortion, in addition to comprehensive primary care. So it 
seems that the actual rule verifies what you testified in front 
of this committee. So I just wanted to set that clear in the 
record that it does not restrict doctors in any way from 
discussing a full range of options.
    As you know, Montana is an incredibly rural State. Most 
parts of Montana are still considered frontier areas. Providing 
medical care there is more difficult because of just the 
expanse. This makes accessing family planning services 
incredibly difficult for the women in our State.
    So one of the goals, as I understand, in the Protect Life 
Rule, is to increase innovation, expand diversity of grantees, 
and to clarify the flexibility the program directors have to 
provide services. Do you think that this new rule will help 
promote a diversity of grantees under Title X?
    Dr. Foley. That is what we are hoping for. In addition, 
again, this is a competitive grant application. And so it 
depends on the people who apply for this grant to provide 
services. However, what the new rule does allow for is 
innovation in providing services to areas that are unserved or 
underserved and increasing the emphasis on those areas, looking 
for grantees who are willing, or who are located in those 
areas, and would like to provide service.
    Mr. Gianforte. So what, specifically, would this new rule, 
what impact would it have on rural areas in the United States?
    Dr. Foley. The idea would be that if there are--if current 
grantees even would look for sub-recipients that maybe in more 
rural areas and expand their services in that area, that would 
impact the access for rural areas.
    Mr. Gianforte. So this new rule, in your opinion, would 
expand access to services for women in rural areas.
    Dr. Foley. With that emphasis, yes.
    Mr. Gianforte. OK. So what impact, if any, will this 
diversity in grantees have on helping ensure the Title X 
program is serving patients in these underserved areas?
    Dr. Foley. Again, by emphasizing those that are providing 
or suggesting innovative ways to provide services to 
underserved areas, we would be able to focus our funding in 
those areas.
    Mr. Gianforte. OK. And this is a real priority for me, 
particularly in a rural State like Montana.
    So a question of the difference between the prior rule and 
this new rule, could an entity that had a conscience objection 
to certain Title X services required under the 2000 regulation 
participate in the program?
    Dr. Foley. They could participate in the program. In fact, 
the Department has issued guidelines that because--the 
regulation was written before some of these conscience 
guidelines came into effect. And so when the Federal conscience 
guidelines were in effect, the Department has stated, and it 
has been long-standing, that they cannot require someone to 
refer for abortion, counsel about abortion, if they have a 
moral objection to that.
    Mr. Gianforte. OK. And how does that change under the new 
rule?
    Dr. Foley. Well in the new rule, the referral for abortion 
is prohibited. Again, the same conscience protection. The 
Federal conscience protections don't change but there has been 
confusion surrounding the fact that if it states it in the 
regulation that you must refer for abortion and you must 
counsel about abortion, even if you have conscience concerns 
about it. There has been confusion that they would still be 
able to participate.
    Mr. Gianforte. OK.
    Dr. Foley. And so I think that clarifies and makes that--
brings those into line.
    Mr. Gianforte. OK, thank you, Dr. Foley. I would just say, 
based on what we have heard here today from your testimony, 
also from a reading of the rule, this new rule does not 
restrict a doctor's ability to provide all options to their 
patients and, in fact, the rule will help particularly in 
bringing additional services to women in rural areas of the 
country. So I thank you for your work on it and I appreciate 
your being here.
    With that, Madam Chair, I yield back.
    Ms. DeGette. The gentleman yields back.
    Dr. Foley, I want to thank you for coming today. I just 
have one last piece of housekeeping that I hope you can help me 
with.
    This committee has sent four letters to Secretary Azar 
starting January 29, 2018 regarding the Title X program. We got 
a response, finally, on April 17th of this year, and thank you. 
Your agency started providing documents.
    But here is the problem. These are the kinds of documents 
we are getting. You can see I have page after page of documents 
that have been completely redacted. And we understand there is 
some pending litigation but we haven't gotten justification on 
why each particular document was redacted.
    And so I bring this up because it has been a pattern with 
HHS in general of not getting documents and then getting 
documents that are redacted. And so since you signed the 
initial letter producing documents and most of the documents 
lie within your agency, will you commit to working with this 
committee to provide as many unredacted documents as possible 
and to explaining why certain documents have been redacted?
    Dr. Foley. We will be able to provide explanation for you. 
What we have done is we have followed the Federal laws as far 
as information that is privileged and information that might be 
involved with litigation and that has been the reason for it. 
However----
    Ms. DeGette. That is----
    Dr. Foley [continuing]. We will look at that again and we 
will get back with you.
    Ms. DeGette. I appreciate that. You know that is the reason 
that was given but, again, it wasn't given for each particular 
document. And so if you can work with us, that would be great.
    I do see that Mr. Veasey has joined us and I will, since I 
have given comity to all of the witnesses, I thank you for 
coming, Mr. Veasey. And we will just recognize him for five 
minutes and then we will let you go.
    Mr. Veasey. Thank you, Madam Chair.
    Dr. Foley, with seemingly every major national provider 
organization sounding the alarm, HHS finalized the rule with 
the most disconcerting provisions intact.
    Nineteen leading women healthcare provider groups, medical 
organizations, and physicians have stated that, ``this 
regulation will do indelible harm to the health of Americans 
and to the relationship between the patients and their 
providers by forcing providers to omit critical information 
about their healthcare resources and current requirements that 
Title X sites--excuse me--and for the reasons discussed in more 
detail and in our court complaint, the AMA strongly opposes the 
final rule. We are very concerned that the proposed changes, if 
implemented, would undermine patients' access to high-quality 
medical care and information, dangerously exclude qualified 
providers, and jeopardize public health.''
    ``In addition to the legal arguments that the final rule be 
permanently overturned by the Federal courts, the AMA urges 
Congress to swiftly take legislative action to prevent further 
attempts by the administration to jeopardize the critical 
Federal healthcare program.''
    Dr. Foley, I wanted you to weigh in, when it comes to the 
patients' confidence and some of the things that I have just 
mentioned earlier, to please tell us why this rule would not 
interfere with the patient-provider relationship, will not 
cause providers to violate ethical standards, and will not put 
improper restrictions on the practice of medicine, and does not 
put ideology over science, and will not jeopardize public 
health as experts have stated.
    Are all of these medical organizations wrong?
    Dr. Foley. What I would say is that the rule was written 
and revised to allow complete full conversation, allow 
physicians, healthcare providers, to have complete conversation 
with the clients about the options that they have. There is no 
restriction on that.
    I would also say that this rule was written very similar to 
the 1988 rule that was written and that rule was then upheld by 
the Supreme Court that it did not violate statutory or 
constitutional standards. And in addition, that they did not--
they also stated that it did not violate the Code of Medical 
Ethics based on what this--based on their interpretation of 
that.
    Mr. Veasey. Dr. Foley, I think that this is--so, are you 
saying that they are wrong?
    Dr. Foley. What I am saying is----
    Mr. Veasey. You really didn't answer my question. So, are 
they wrong?
    Dr. Foley. What I am saying is that this rule, this new 
regulation, does not force physicians to omit information. 
There is nothing in this new rule that omits them--that causes 
them to force--to omit information.
    Mr. Veasey. OK, so you are not saying--you are not 
answering the question about whether they are wrong.
    Ms. DeGette. Will the gentleman yield?
    Mr. Veasey. Yes.
    Ms. DeGette. It doesn't force them to omit it but allows 
them to omit it, correct?
    Dr. Foley. And the allowing them to omit is based on the 
Federal conscience statutes that, again, preclude the law. And 
that is what is important to understand.
    Mr. Veasey. Dr. Foley, it is just hard to put a lot of 
stock into what you are saying today. Numerous medical and 
public health organizations have detailed how this rule will 
lead to negative health outcomes. They have stated that the 
rule will result in less contraceptive services, more 
unintended pregnancies, which is a big problem in the district 
that I represent in Dallas right now. We are seeing rates go 
down in other parts of the country but we have seen a steep 
increase in STDs and unplanned pregnancies in the Dallas area. 
And I just think that HHS is putting ideology over evidence and 
public health.
    I yield back my time.
    Ms. DeGette. I thank the gentleman. And again, Dr. Foley, I 
thank you for joining us today. We will look forward to getting 
your documents. And with that, you are dismissed.
    The Chair will call up the next panel.
    Dr. Foley. Thank you.
    Ms. DeGette. The committee will come to order and the 
witnesses will take their seats.
    The Chair will advise members, while we are waiting for Dr. 
McLemore, that we are expecting a series of votes around 1:00 
or 1:15 and it will be, unfortunately, a very long series of 
votes. I had hoped to be able to finish this panel but I think 
that probably we may have to have the member questions after we 
return. So I just wanted to let you know that.
    The Chair will now introduce our second panel of witnesses 
and welcome all of you. Thank you so much for your patience. 
Ms. Clare Coleman, the President and Chief Executive Officer of 
the National Family Planning and Reproductive Health 
Association; Ms. Kami Geoffray, the Chief Executive Officer of 
the Women's Health and Family Planning Association of Texas; 
Monica McLemore, the Chair-Elect of the Sexual and Reproductive 
Health Section of the American Public Health Association; 
Jamila Perritt, M.D., Fellow, Physicians for Reproductive 
Health; and Ms. Catherine Glenn Foster, President and Chief 
Executive Officer of the Americans United for Life.
    Thanks and welcome to all of the witnesses. As all of you 
are aware, we are holding an investigative hearing and so, when 
doing so, we have the practice of taking testimony under oath. 
Do any of you have any objections to testifying under oath 
today? Let the record reflect the witnesses responded no.
    The Chair will then advise you, under the rules of the 
House and the rules of the committee, you are entitled to be 
accompanied by counsel. Do any of you desire to be accompanied 
by counsel today? Let the record reflect the witnesses 
responded no.
    And so if you would, could you please rise and raise your 
right hand so you may be sworn in?
    [Witnesses sworn.]
    Ms. DeGette. You may be seated. Let the record reflect the 
witnesses have responded affirmatively.
    And you are now under oath and subject to the penalties set 
forth in Title 18, Section 1001 of the U.S. Code.
    The Chair will now recognize our witnesses for a 5-minute 
summary of their written statements. As I explained to the last 
panel, you have a microphone and then you have lights. And the 
light turns yellow when you have one minute and red when your 
time is at the end.
    And so first I would like to recognize Ms. Coleman for 
purposes of an opening statement, five minutes.

   STATEMENT OF CLARE COLEMAN, PRESIDENT AND CHIEF EXECUTIVE 
   OFFICER, NATIONAL FAMILY PLANNING AND REPRODUCTIVE HEALTH 
 ASSOCIATION; KAMI GEOFFRAY, CHIEF EXECUTIVE OFFICER, WOMEN'S 
    HEALTH AND FAMILY PLANNING ASSOCIATION OF TEXAS; MONICA 
  McLEMORE, PH.D., MPH, CHAIR-ELECT, SEXUAL AND REPRODUCTIVE 
  HEALTH SECTION, AMERICAN PUBLIC HEALTH ASSOCIATION; JAMILA 
PERRITT, M.D., MPH, FELLOW, PHYSICIANS FOR REPRODUCTIVE HEALTH; 
   AND CATHERINE GLENN FOSTER, PRESIDENT AND CHIEF EXECUTIVE 
              OFFICER, AMERICANS UNITED FOR LIFE.

                   STATEMENT OF CLARE COLEMAN

    Ms. Coleman. Thank you, Chairwoman DeGette. Thank you, 
Ranking Member Guthrie and the members of the subcommittee for 
the opportunity to testify.
    I am Clare Coleman. For nearly 10 years--closer--for nearly 
10 years, I have been the President and CEO of the National 
Family Planning and Reproductive Health Association, known as 
NFPRHA. Founded the year after Title X's enactment, NFPRHA 
advances and elevates the importance of family planning in the 
Nation's healthcare system. NFPRHA represents the vast majority 
of Title X providers, with members in all 50 States, DC, and 
the territories.
    Title X plays an essential role in ensuring access to high-
quality family planning and sexual healthcare in our country. 
Congress created Title X to equalize access to biomedical 
contraceptives and related medical care, and to ensure that 
those services were voluntary and confidential. These purposes 
remain Title X's focus 50 years on.
    Today, Title X helps more than four million people access 
contraception and related health services at nearly 4,000 
Health Centers across the country. For many, Title X services 
are the only source of healthcare of any kind, offering 
patients healthcare they need, exams and contraceptives, 
sexually transmitted disease testing and treatment, cancer 
screenings, and information and counseling, including referrals 
to care outside the scope of Title X.
    Title X provider networks are designed by communities for 
communities to facilitate access to care in the service area 
covered by the Title X grant. So the network includes State, 
city, and local health departments, Federally Qualified Health 
Centers, freestanding family planning providers, Planned 
Parenthood affiliates, hospitals, and school-based and 
university-based health centers.
    But because Title X is a funding stream, there is no Title 
X sign on a health center door. Instead, patients know they are 
in a Title X center by the patient-centered and culturally 
responsive care they receive from a broad range of FDA-approved 
methods available on-site to the thorough and nondirective 
counseling offered.
    Title X standards of care are the gold standard in family 
planning. Despite this, Title X is facing the fight of a 
generation. In March, the administration published a final rule 
which, if enacted, would destroy the quality and integrity of 
Title X.
    NFPRHA's opposition to this rule is well-documented and 
here are just some of our reasons why. The new rule undermines 
the Federal Government's own standard of care and opens the 
door to fund providers that will not offer a broad range of 
FDA-approved contraceptive methods. It eliminates the 
requirement that providers offer pregnancy options counseling 
at the patient's request, while requiring that all pregnant 
patients be referred for prenatal care, regardless of what the 
patient wishes. And it bars, absolutely, referrals for 
abortion, no matter the patient's wishes.
    It requires that Title X-funded activities be physically 
separated from any non-Title X activity that touches on 
abortion and this would include health education and public 
health initiatives.
    By limiting the services and the information available 
through Title X agencies, the rule undermines the trust and 
confidentiality that is so important when it comes to this most 
intimate and personal care.
    If the rule is implemented, all Title X providers in every 
single location would be forced into only bad choices. They can 
withhold critical information and limit care to patients or 
they can leave the program and be less able or unable to care 
for low-income people in their community. This rule shows no 
respect and no regard for the millions of low-income people who 
today rely on Title X for their primary and often only 
healthcare.
    Title X centers are located in 60 percent of U.S. counties 
but that is where 90 percent of women in need live. So these 
services are located where people need it and our services are 
intended to meet them where they live, focused on their needs 
and their values.
    In addition to this rule, over the last decade, Title X has 
endured funding cuts that have led to more than a million 
people losing access to care and recent repeated funding 
announcements that have dismissed the expertise of so many 
longstanding providers. These attacks are wholly unwarranted 
and they are unjustifiable.
    Title X has demonstrated, over 49 years, both quality and 
integrity. It is a true public health success story and it 
deserves strong bipartisan support.
    I appreciate the opportunity to speak about the essential 
value that Title X plays in our nation's healthcare system.
    Ms. DeGette. The lady's time has expired.
    Ms. Coleman. I welcome any questions you have.
    [The prepared statement of Ms. Coleman follows:]

    [GRAPHIC] [TIFF OMITTED] T4365.009
    
    [GRAPHIC] [TIFF OMITTED] T4365.010
    
    [GRAPHIC] [TIFF OMITTED] T4365.011
    
    [GRAPHIC] [TIFF OMITTED] T4365.012
    
    [GRAPHIC] [TIFF OMITTED] T4365.013
    
    [GRAPHIC] [TIFF OMITTED] T4365.014
    
    [GRAPHIC] [TIFF OMITTED] T4365.015
    
    [GRAPHIC] [TIFF OMITTED] T4365.016
    
    Ms. DeGette. The Chair now recognizes Ms. Geoffray for five 
minutes.

                   STATEMENT OF KAMI GEOFFRAY

    Ms. Geoffray. Chairwoman DeGette, Ranking Member Guthrie, 
and members of the subcommittee, thank you for holding this 
hearing and inviting me to testify today.
    As Chief Executive Officer of the Women's Health and Family 
Planning Association of Texas, I oversee the administration of 
the second largest Title X Family Planning Services grant award 
in the nation. I am here today to tell you about the serious 
challenges faced by the family planning safety-net providers in 
my State and the clients they serve, and to share my concerns 
that, if implemented, the changes the current administration 
seeks to impose on the Title X Family Planning program will 
reduce access to critical reproductive health services in 
communities across the country, mirroring what we experienced 
in Texas in recent years.
    I also am here to tell you about the role Title X grantees 
and sub-recipients play in providing high-quality family 
planning services that are informed by the unique needs of each 
community and delivered with respect and dignity for each 
individual.
    The Texas experience serves as a cautionary tale of the 
deeply harmful consequences that can result when policymakers 
target particular family planning providers. In 2011, State 
lawmakers made a series of funding and policy decisions that 
ultimately resulted in 82 family planning clinics, one out of 
every four in our State, closing or reducing hours, restricting 
access to critical reproductive health services across the 
State. The intended target was family planning providers that 
also provide abortion services or affiliate with abortion 
service providers; but the consequences reached much further. 
Two-thirds of the clinics impacted were family planning 
providers that had no affiliation with abortion service 
providers and tens of thousands of Texans lost access to 
services.
    The impact was quickly observed. Contraceptive use 
decreased, while the rates of unintended pregnancies and 
abortions increased. Overall, the Texas experience teaches us 
that once lost, access to critical reproductive health services 
is difficult or impossible to reestablish. Over the last eight 
years, significant funding has been invested to bolster a 
family planning safety-net that was weakened by a series of the 
Texas legislature's decisions. Yet, it appears that State-
funded programs still are not serving as many individuals today 
as they did in 2011.
    The Title X rule finalized by the current administration 
seeks to implement several of the misguided policies piloted in 
Texas, forcing family planning providers that also provide 
abortion services from the program, and prioritizing primary 
care providers over those focused on reproductive healthcare. 
If implemented, these policy proposals will reduce access to 
family planning services and likely result in similarly 
negative outcomes as those seen in Texas in recent years.
    Finally, I would like to speak about the qualified 
providers of high-quality family planning services that make up 
the Title X grantee and sub-recipient network.
    We develop healthcare networks that are informed by our 
communities that we serve and that are as diverse as the 
geography and demographics of the States in which we work. We 
work diligently to ensure that the Federal dollars that we have 
been entrusted with administering are used to support evidence-
based, client-centered family planning care of the highest 
quality. We implement detailed systems to ensure compliance 
with program statutes, regulations, and legislative mandates at 
the grantee and sub-recipient levels. Collectively, we provide 
critical reproductive health services and a full range of 
contraceptive methods to four million individuals each year but 
we have the capacity to do so much more if additional funding 
were made available.
    In closing, I urge you to learn from Texas and ensure that 
Title X funding continues to be administered by those most 
qualified and committed to providing a full package of family 
planning services in an evidence-based, client-centered manner, 
helping to advance the reproductive health and well-being of 
millions of low-income, uninsured, and underinsured individuals 
who turn to Title X for care every year.
    Thank you for the opportunity to testify today. I look 
forward to answering any questions you may have.
    [The prepared statement of Ms. Geoffray follows:]
    [GRAPHIC] [TIFF OMITTED] T4365.017
    
    [GRAPHIC] [TIFF OMITTED] T4365.018
    
    [GRAPHIC] [TIFF OMITTED] T4365.019
    
    [GRAPHIC] [TIFF OMITTED] T4365.020
    
    [GRAPHIC] [TIFF OMITTED] T4365.021
    
    [GRAPHIC] [TIFF OMITTED] T4365.022
    
    [GRAPHIC] [TIFF OMITTED] T4365.023
    
    Ms. DeGette. Thank you so much.
    The Chair now recognizes Dr. McLemore for five minutes for 
purposes of an opening statement.

              STATEMENT OF MONICA McLEMORE, Ph.D.

    Dr. McLemore. Chair DeGette, ranking members, and the 
entire committee, I really appreciate you providing me an 
opportunity to be able to provide my expertise for you and with 
you. It has been interesting we have been hearing about 
scientific experts and it is kind of ironic that I am the first 
one to speak.
    I am grateful to provide clinical, scientific, and research 
expertise to the committee. I have been a licensed registered 
nurse since 1993 and for most of my career, I worked clinically 
in facilities that receive Title X funding. Since 2002, I have 
worked clinically at Zuckerberg San Francisco General Hospital 
and Trauma Center, a place with co-located services.
    I am an expert nurse in the provision of sexual and 
reproductive health services. I sit before you as the incoming 
chair for Sexual and Reproductive Health for the American 
Public Health Association.
    Ensuring all people of reproductive age can achieve their 
reproductive life goals is an essential component of 
reproductive health and public health. Additionally, 
reproductive justice is essential to bodily autonomy, human 
rights principles, and existential liberation for all humans. 
Simply put, reproductive justice posits that every person has 
the right to decide if, when, and how to become pregnant, and 
to determine the conditions under which they will birth and 
create families.
    Next, every person has the right to decide that they will 
not become pregnant, and have all options for preventing and/or 
ending pregnancies, and have those means be accessible and 
available.
    Third, individuals have the right to parent their children 
they already have with dignity and without fear of violence 
from individuals of the Government.
    And finally, individuals have the right to disassociate sex 
from reproduction and that health, healthy sexuality, and 
pleasure are essential components to a whole and full human 
life.
    Academicians, activists, clinicians, researchers, and 
scholars like me believe that Title X and Title V are essential 
components to achieving reproductive justice. There are 
currently 4,000 entities designated as Title X grantees and 40 
percent are Planned Parenthood health facilities. I wanted to 
correct that incorrection from earlier. Half the people served 
at Title X clinics are people of color.
    I also want to correct the record that nurses, nurse 
practitioners, nurse midwives, and public health nurses have 
been the mainstay of the sexual reproductive healthcare 
workforce, including in Title X and Planned Parenthood centers 
and we provide a crucial access for vulnerable and low-income 
populations. These clinics also provide essential training for 
nursing and medical students and potential clinic closures can 
reduce the pipeline of appropriately trained clinicians.
    The proposed rule change violates the American Nurses 
Association Code of Ethics that reads, and I quote, ``the ANA 
has historically advocated for the healthcare needs of all 
patients, including services related to reproductive health. 
The American Nurses Association also believes that healthcare 
clients have the right to privacy and the right to make 
decisions about personal healthcare based on full information 
and without coercion.''
    As a nurse scientist, this work is personal for me. Let me 
tell you how Title X has helped me earn three degrees from 
public institutions, and become a visible scholar and thought 
leader on black maternal health. I am a member of the 
populations most served by Title X. As a poor post-doc in 2011, 
I almost bled out in my car, due to fibroids, driving into San 
Francisco to see my mentor. My sister, my mom, and like many 
black Americans, fibroids is a huge problem. And I was able to 
receive a Mirena IUD at a Title 10 clinic that I still have to 
this day.
    This allowed me to complete my studies, to generate and 
publish 48 papers, including 17 op-eds, two of which were about 
the protection of Title X. And in those publications, I also 
was able to optimize information to the public during Black 
Maternal Health Awareness Week, sponsored by the Black Mamas 
Matter Alliance.
    I have been able to provide clinical care to the public, 
which I still do, and am soon to becoming the incoming chair 
for Sexual and Reproductive Health at the American Public 
Health Association.
    In November, I will be fortunate enough to be inducted as a 
fellow of the American Academy of Nursing, who also signed on 
against this rule change. And I am still waiting to hear if I 
will become the fifth tenured black person in a 113-year 
history of the University of California San Francisco School of 
Nursing.
    Achieving my reproductive goals has allowed me to become 
the scholar, and the reproductive justice has been 
operationalized in my life, and all the people served by Title 
X clinics and providers deserve the same opportunity.
     Thank you.
    [The prepared statement of Dr. McLemore follows:]
    [GRAPHIC] [TIFF OMITTED] T4365.024
    
    [GRAPHIC] [TIFF OMITTED] T4365.025
    
    [GRAPHIC] [TIFF OMITTED] T4365.026
    
    [GRAPHIC] [TIFF OMITTED] T4365.027
    
    [GRAPHIC] [TIFF OMITTED] T4365.028
    
    [GRAPHIC] [TIFF OMITTED] T4365.029
    
    [GRAPHIC] [TIFF OMITTED] T4365.030
    
    Ms. DeGette. Thank you so much, Doctor.
    Dr. Perritt, I am now pleased to recognize you for five 
minutes for purposes of an opening statement.

               STATEMENT OF JAMILA PERRITT, M.D.

    Dr. Perritt. Thank you so much, Chairman Pallone, Chair 
DeGette, Ranking Member Guthrie, and members of the 
subcommittee.
    My name is Dr. Jamila Perritt and I am a board-certified, 
fellowship-trained obstetrician and gynecologist, and a fellow 
with the Physicians for Reproductive Health. I am here today to 
give voice to the people I take care of, a voice that is often 
missing from the rhetoric in the political theater that we see 
during these debates.
    Whether rural or urban, young or old, all of my patients 
share one thing in common. They are making thoughtful and 
sometimes difficult decisions about their health and about 
their well-being. The patient-provider relationship relies on 
trust and open and honest communication. These rules will 
compromise that trust and result in substandard care for the 
communities that already experience discrimination and 
inequities in healthcare and healthcare delivery, like the 
communities I serve. It goes against everything I know as a 
physician and against the oath that I took when I began this 
work.
    As a kid, I dreamed of becoming a doctor and, in fact, I 
have never wanted to be anything else. I studied for 20 plus 
years to do this work and I was taught in medical school to 
respect the agency and the autonomy of my patients. A shared 
understanding and communication of the risks, benefits, and 
alternatives to any options for care undergirds this process 
and is my professional duty.
    We heard Congressman Lujan mention the American College of 
Obstetricians and Gynecologists Code of Professional Ethics, 
which states, and I quote, that ``the patient-physician 
relationship is essential to the focus of all ethical 
concerns.'' ACOG also requires OB/GYNs to serve as the 
patient's advocate and exercise all reasonable means to ensure 
that appropriate care is provided to the patient.''
    This new rule directly violates these principles and that 
is why leading medical organizations oppose it.
    Whether I am talking with my patients about options for 
birth control, prenatal care and birth care, or pregnancy, I am 
ethically bound to make sure that they have all the information 
they need to understand and access their options. When speaking 
about pregnancy, that means answering questions about carrying 
a pregnancy to term and parenting, putting the child up for 
adoption, or ending a pregnancy. My patients trust me to give 
them the information they need and request; and I trust them to 
make the decisions that are right for them.
    These new rules will not allow me to deliver ethical and 
quality care. The Federal Government is telling providers what 
we can and cannot say to our patients. It is telling my 
patients what they can and cannot hear from their doctors. It 
is ordering me to deprive my patients of information they need, 
even if they request it. It is an attempt to strip from my 
patients their basic human rights.
    I share Chairman Pallone's earlier voiced concern regarding 
the equally as problematic focus of this rule on organizations 
that may offer one method of family planning disguised as 
comprehensive coverage, such as fertility awareness-based 
methods at the expense of others. Although fertility awareness 
methods may be right for some, any women's health provider can 
tell you that birth control and pregnancy prevention is not one 
size fits all. Everyone deserves access to the full range of 
contraceptive methods. And it is only through having a choice 
of methods that someone can decide what is right for them and 
avoid the pressure and coercion that comes with being offered 
only one class of methods.
    I can remember a patient I cared for who was seeking birth 
control. She was a mother of small children and worked at night 
so she could provide care for her children during the day and 
be home when her oldest got in from school. She was seeking a 
birth control option but was concerned because she had tried 
just about everything and nothing worked. Her high blood 
pressure prevented her from using some method like pills. She 
had side effects from other methods like the shot. And 
ultimately, she settled, like Dr. McLemore, on an IUD because 
it helped to prevent pregnancy; and also had the benefit of 
helping manage her heavy periods.
    My patient would not have been able to afford this method 
without being seen at a clinic where I provide care and she 
received funding through the Title X program.
    Dr. McLemore discussed reproductive justice, a vision where 
the lives of historically marginalized communities and 
individuals are essential to the fight for equity and justice. 
It is grounded in an understanding of reproductive health and 
autonomy as basic human rights.
    What I want us all to understand is that no one is making 
decisions about their reproductive health in a vacuum. Our 
lives are intersectional. These new rules not only contradict 
professional ethics and practice guidelines, they perpetuate a 
system of injustice. They make it clear that if you are an 
individual with a low income in need of services, you will be 
getting substandard care. They tell me if you are poor, you are 
less deserving. When you desire information, you won't get it. 
This is not healthcare. This is manipulation, punishment, and 
coercion.
    Please protect individuals in the Title X program and their 
access to high-quality care. My patients deserve it.
    [The prepared statement of Dr. Perritt follows:]
    [GRAPHIC] [TIFF OMITTED] T4365.031
    
    [GRAPHIC] [TIFF OMITTED] T4365.032
    
    [GRAPHIC] [TIFF OMITTED] T4365.033
    
    [GRAPHIC] [TIFF OMITTED] T4365.034
    
    Ms. DeGette. Thank you, Doctor.
    And I would now like to recognize for five minutes, for 
purposes of an opening statement, Ms. Foster.

              STATEMENT OF CATHERINE GLENN FOSTER

    Ms. Foster. Thank you, Chairwoman DeGette, Ranking Member 
Guthrie, and members of the committee.
    I am Catherine Glenn Foster, President and CEO of Americans 
United for Life; America's original national pro-life 
organization and leader in life-affirming law and policy.
    I want to emphasize two key points today, both of which I 
elaborate on in greater depth in my written testimony. First, 
Congress acted intentionally when it excluded abortion from 
Title X. Second, challenges to the HHS rule are rooted in the 
desire to cast aside congressional intent and use Title X 
funding for abortion-related services.
    First, Congress enacted Title X of the Public Health 
Service Act in 1970 to provide financial support for healthcare 
organizations offering pre-pregnancy family planning services. 
Since 1970, the Act, through Section 1008, has explicitly 
excluded abortion from the scope of family planning methods and 
services.
    Let me underscore, Congress has statutorily excluded 
abortion from the scope of Title X projects.
    Consistent with the U.S. Supreme Court's decision in Rust 
v. Sullivan, the HHS rule at issue requires physical and 
financial separation between Title X projects and abortion-
related activities.
    Second, today's challenges to the HHS rule are rooted in 
the desire to cast aside congressional intent and use Title X 
funding for abortion-related services. Any consideration of 
access to abortion should carry no legal weight because Title X 
explicitly excludes abortion from the scope of its projects.
    It is worth asking why Plaintiffs did not raise a legal 
challenge to the HHS rule based on the undue burden rationale. 
The answer is plainly because the scope of the abortion right, 
as discovered in the constitution by seven men in Roe v. Wade, 
includes neither a right to public funding for abortion nor a 
third party's right to provide abortion.
    If you listen to the rhetoric of my sisters sitting beside 
me today, you could be forgiven for thinking that abortion 
represented some public good. The hand-waving, the euphemisms, 
and the, frankly, tired rhetoric that I have heard today not 
only obscures the constitutional realities surrounding Title X 
but worse, it obscures the truth about what they seek to 
promote: abortion.
    Men and women who advocate for abortion share a strange 
kind of faith. They believe that women's own empowerment 
demands the disempowerment of another. We never become 
stronger, as women, when we abort our own children. I know 
this, both because I am a mother and because I lived with the 
regret of having been coerced into an abortion.
    I bear the marks of trauma from abortion. But as a woman, I 
can tell you that my autonomy and empowerment are not a result 
of the violence and self-harm of abortion, a violence and self-
harm which too many seek to perpetuate and to normalize.
    Abortion can never be considered a form of family planning 
because thriving families are characterized by their living 
members and the life they share in common. Abortion can never 
be legitimately considered a form of family planning because 
what defines a successful abortion is a dead member of the 
human family full stop. There is no way around this reality.
    Twenty years ago, a younger Donald Trump appeared on Meet 
the Press and assured Tim Russert that he was, ``pro-choice in 
every respect and as far as it goes.''
    Today, President Trump has been described by some as 
America's most pro-life President. If President Trump can show 
the courage to admit that he was wrong and to embrace life, I 
believe that there is hope that perhaps some here today might 
be similarly willing to look past ideology and to confront the 
reality of abortion, too. Every American, and especially every 
woman, deserves better than abortion.
    In closing, let me underscore: Congress was clear when it 
enacted the Title X program in 1970 and Congress has not 
deviated. The intent was clearly to exclude abortion. The HHS 
rule adds accountability and transparency to the Title X 
program. The HHS rule is sound public policy and the HHS rule 
can withstand constitutional scrutiny.
    Thank you.
    [The prepared statement of Ms. Foster follows:]
    [GRAPHIC] [TIFF OMITTED] T4365.035
    
    [GRAPHIC] [TIFF OMITTED] T4365.036
    
    [GRAPHIC] [TIFF OMITTED] T4365.037
    
    [GRAPHIC] [TIFF OMITTED] T4365.038
    
    [GRAPHIC] [TIFF OMITTED] T4365.039
    
    [GRAPHIC] [TIFF OMITTED] T4365.040
    
    Ms. DeGette. Thank you, Ms. Foster. I thank the panel.
    In accordance with the chair's previous comments, this 
committee will be recessed pending votes on the floor. They are 
saying we have 12 votes on the floor. It could be an hour to an 
hour and a half. So, I suggest you get some lunch.
    This committee is in recess.
    [Recess.]
    Ms. DeGette. The committee is reconvened and I just can't 
thank all of the witnesses enough for staying around while we 
had our mega vote-a-thon on the floor. I really appreciate it.
    The Chair will recognize herself for five minutes for the 
purposes of questioning. And I would like to start with you, 
Dr. Perritt.
    I know all of you heard Dr. Foley's testimony on the first 
panel. And what I would like you to do is listen to the 
questions that I am going to ask you and answer specifically to 
me what the issues that you have with this rule. And the reason 
is because if you listen to Dr. Foley, then it is really no big 
deal. It is just clarifying the statute that was passed in 
1980. So we hear this dichotomy between what you are saying, 
and she is saying, and I would like to clarify.
    And I would like to start with you, Dr. Perritt. Dr. Foley 
testified that health providers can have a complete 
conversation with their patients about their pregnancy options. 
From your perspective, as a provider, is that an accurate 
statement? And if not, what specifically in this rule would 
prevent providers from having that conversation with their 
patients?
    Dr. Perritt. Thank you so much. You know it absolutely is 
not my understanding of what the rule says and it is 
problematic for a number of reasons.
    Ms. DeGette. And why is that?
    Dr. Perritt. It is absolutely a gag rule. This theoretical 
dispensation of information without actual support to achieve 
these services is not nondirective counseling. So that is a 
global issue with our ability to actually provide care in a 
comprehensive way.
    And so my understanding is this limitation on your ability 
to actually provide counseling about all of the options, 
including providing information regarding referrals, and that 
is an absolute gag of what I am able to say to my patients is 
not nondirective counseling. It is in inhibiting their ability 
to make a decision that is right for them with all of the 
information.
    Ms. DeGette. Dr. McLemore, what is your position on that?
    Dr. McLemore. I agree with what Dr. Perritt said. And I 
also would like to also add that I think it is really important 
that patient-provider relationship is built on trust and trust 
in the public, especially coming from the perspective of a 
nurse, means that we will provide you all of your options that 
are available to you, answer your questions, and be able to 
center you and your needs to get you the care that you need.
    And so if I am having to deal with lying by omission, then 
I think that is really a problematic breach of trust.
    Ms. DeGette. So if a patient, for example, came in and said 
to one of your nurses ``I would like information about 
abortion,'' but that nurse was personally opposed to abortion, 
then would you think that that nurse should have to tell the 
patient all of their options anyway?
    Dr. McLemore. No, we already have protections under the ANA 
Code of Ethics and I didn't get an opportunity to read this 
earlier, because I think it is important that I do because I 
ran out of time, but all nurses have the right to refuse to 
participate in a particular case on ethical grounds. However, 
if a client's life is in jeopardy, nurses are obligated to 
provide for the client's safety and to avoid abandonment.
    Ms. DeGette. And would the nurse also have to, if they were 
opposed, refer them to somebody else so that they could give 
them the information they were asking for?
    Dr. McLemore. Correct.
    Ms. DeGette. And that is what would not happen under this 
rule.
    Dr. McLemore. Correct.
    Ms. DeGette. Is that correct?
    Dr. McLemore. Correct.
    Ms. DeGette. Ms. Coleman, I wanted to ask you, Ms. Foley 
seemed to indicate that there wouldn't really be any problem 
with separating the facilities where there is abortion 
facilities and family planning facilities in one location 
because it was only 10 or 20 percent. Is that the view of your 
members and if not, why not?
    Ms. Coleman. The rule affects all Title X entities, whether 
or not they provide abortion care outside of their Title X 
funds. And the reason that it affects all Title X agencies is 
because, in addition to requiring physical separation, if you 
provide abortion care with non-Title X funds, it also says the 
Title X projects cannot do anything to encourage, promote, 
support, or advocate for any part of abortion.
    So for example, if you are a State Health Department that 
also monitors abortion care and you monitor the Title X 
program, you would have to physically separate the building, 
the staff, the payroll records, the files, everything related 
to your oversight of abortion care in your State.
    Ms. DeGette. So this would be far, far more reaching than 
the Department would seem to indicate.
    Ms. Coleman. Correct, it does not only affect abortion 
providers.
    Ms. DeGette. Ms. Geoffray, I just wanted to ask you very 
briefly, you saw something like this happen in Texas. What did 
this do for the provision of healthcare for lower income and 
rural women?
    Ms. Geoffray. So after the funding cuts and the policy 
changes in 2011, over 50 percent of women that were receiving 
services at the time lost access to services. What we saw was a 
discontinuation of contraceptive methods because people did not 
have access to healthcare services. We saw increases in STI 
rates. We saw increases in unintended pregnancies. We saw 
increases in abortion rates. And we, obviously, saw impacts to 
maternal mortality that had varying causes but there is some 
belief that access to family planning being lost also impacted 
that.
    Ms. DeGette. Thank you so much to all of you.
    The ranking member is now recognized for five minutes.
    Mr. Guthrie. Thank you. And thank you all for being here. 
We appreciate it very much.
    The first thing, I want to ask unanimous consent to include 
in the record a letter from the Concerned Women for America 
Legislative Action Committee. I think it was submitted to your 
staff just previously.
    Ms. DeGette. Without objection.
    [The information appears at the conclusion of the hearing.]
    Mr. Guthrie. Thank you very much. And thank you very much.
    And Ms. Foster, I think I had to learn, started getting 
ready for this hearing, different terms, nondirective 
counseling, directive counseling. As Ms. Foley said, she is not 
a lawyer. I am not a physician as well. We are trying to learn 
and figure the differences and how it complies with what is 
important.
    The congressional statute, and obviously Congress can 
always change the statute if they wanted it to be different, as 
long as you get a majority of the House, the Senate, or a veto-
proof majority, obviously, but that is our system.
    So, in your definition, what is the nondirective counseling 
and how does it differ from directive counseling?
    Ms. Foster. So nondirective counseling would allow for a 
full discussion of all of the options with any pregnancy. It 
includes parenting. It includes adoption. It includes abortion. 
The directive counseling piece would come in when a woman, a 
girl is being urged in one direction. And we know from whistle 
blowers that sometimes that does happen. That is a problem.
    And so one of the goals of this rule is to prevent 
directive counseling, while still allowing women and girls to 
get the full information about their range of options.
    Mr. Guthrie. So, in your opinion, does the change in the 
rule from mandatory nondirective counseling to permitted 
nondirectional counseling better align with the Title X program 
and its statutory frameworks and requirements?
    Ms. Foster. Absolutely. And when you look back at Rust v. 
Sullivan, the 1991 Supreme Court case, what the Supreme Court 
upheld was in fact more restrictive than this Protect Life 
Rule. What they upheld was in fact more of a restriction on 
counseling. This rule says, please, discuss the options, 
discuss all the range of choices before women and girls that 
they have to choose from. Simply, don't be directive about it.
    Mr. Guthrie. OK, thanks. And you know it seems, if you just 
listen to some of the questioning earlier today and some of the 
answers with Dr. Foley, that it seems to be hear some saying 
all we are saying is it is nondirected, nonmandatory, and 
people have the opportunity to speak with their patient. It is 
between the patient and the client. That is who it is between 
and there is nothing directed for them. It is not telling 
anybody what they can do or can't do.
    You know some people were saying this rule tells what they 
can or can't say to their patient. What is your response to 
that? It just seems there is two different--there is one set of 
facts and two different views of the same set of facts.
    Ms. Foster. Yes, I would say that this rule, one of the 
primary goals of it is to in fact increase the diversity of 
providers available to women and girls out there. Because what 
this does is allow providers, who have not previously been 
eligible, I am thinking specifically of Obria, for example, to 
be included within the Title X program.
    And I am thinking also of a dear friend of mine, an 
immigrant, a young woman, came to the United States, fell in 
love, was seeking contraception as she planned her wedding. But 
she is a person of faith and she said you know what, I want a 
healthcare provider who can match my story, match my 
background, a healthcare provider who is likewise a person and 
entity of faith. And you know she had nowhere to turn prior to 
this rule. She didn't know where to go. She didn't want to go 
to Planned Parenthood but she didn't know where in fact she 
could go. And so she really was at a loss under the prior 
regime.
    Now, under the Protect Life Rule, she has options because 
of what you could call the pooling and the ability of a more 
diverse field of providers to engage in Title X, and the 
program, and in the services. So she, thankfully, actually just 
had her second planned child but she encountered such 
resistance at the time. It was very disappointing to try to 
walk with her along that journey and not be able to find a 
provider who could meet her needs as a young immigrant, low-
income woman.
    Mr. Guthrie. Thanks.
     Dr. Perritt, in my opening statement, this has been an 
important program, Title X, to Kentucky. A lot of people have 
benefitted from it.
    And you said that--I am sorry, I am bout out of time so I 
hate to ask you a question and only give you a few seconds but 
you said that this rule tells what you can or cannot say to 
your patients. What do you have to say to your patients because 
of this rule and what can you not say? What does it prevent you 
from doing?
    Dr. Perritt. I think what----
    Mr. Guthrie. Now that you got the question, I really want 
the answer.
    Dr. Perritt. I think what Dr. McLemore said really serves 
it best. These are lies of omission. When we are talking about 
what we can and cannot say in the office with our patients, 
this is not a decision that should be held in a body of 
legislation. These are medical decisions.
    You mentioned earlier you are not a doctor. I am. I studied 
medicine. I practice medicine and I practice in communities 
that deserve the same care that you and I would get, should we 
show up to see our provider.
    Mr. Guthrie. You said it is omission but what can you not 
say? I guess what would you want to be able to share that you 
can't share?
    Dr. Perritt. If someone--sure. If someone says I would like 
an abortion where can I go, I cannot say this is where you can 
go. That is what I can't say.
    Mr. Guthrie. Yes, but that is limited in the statute as 
well, not necessarily the rule. Yes, so it is family planning.
    Dr. Perritt. I disagree.
    Ms. DeGette. The gentleman's time has expired. We will 
clarify this.
    The Chair recognizes the chairman of full committee, Mr. 
Pallone.
    Mr. Pallone. Thank you, Madam Chair.
    It seems to me that the trust between a provider and a 
patient is at the heart of quality family planning and I am 
particularly disturbed by the alarm raised by numerous medical 
associations and in the testimony today about the devastating 
impacts the new Title X rule could have on this relationship, 
if allowed to be implemented.
    So as providers yourself, I will go back to Dr. Perritt and 
Dr. McLemore, I wanted to ask, I will start with Dr. Perritt, 
why is trust essential to the patient and provider relationship 
and what role does trust play in supporting that patient's 
family planning and health needs? I know you talked a little 
bit but if you would, elaborate.
    Dr. Perritt. Absolutely. I could not imagine showing up to 
see my provider and have their hands tied regarding the type of 
counseling for any medical procedure, or any complication, or 
any condition; anything that I show up for.
    So this baseline level of trust means that when a 
provider--when a patient shows up to my office, then I can have 
an honest conversation. They don't have to be concerned that my 
motive is anything different or distracting from what their 
ultimate desire is.
    As a physician, my priority is always my patient. This 
conversation around promoting abortion in one way or another, 
the only thing that I promote and prioritize is the healthcare 
of the community I serve, period.
    Mr. Pallone. And Dr. McLemore, would you agree or do you 
have anything to add? I mean I think what, if I understand what 
she is saying, is that you know even what my previous colleague 
said is true, that you can't even mention or even give 
information about abortion, that in itself is harmful to the 
patient provider relationship that you have to limit what you 
say in any way.
    Ms. McLemore. I do. I mean if that is what patients want 
that is the whole essence of patient-centeredness. It is to be 
able to ascertain and create a situation where patients can 
tell us what they need and, as service providers, we can 
provide them what they need.
    I do want to point out that the patient-provider 
relationship is inherently one of unequal power. And we hold 
that power in the relationships that we have, you know, with 
patients. We have information that the public needs. And so if 
you can't give them the full range of the information that they 
have to make the choices and decisions that they need to make, 
I think it really puts us in a bind with potentially 
catastrophic consequences.
    The Chairman. All right, well, I agree.
    Dr. Foley's testimony stated that the new rule, and I 
quote, ``places a high priority on preserving the provider-
client relationship.'' Ms. Coleman, based on your familiarity 
with both the new rule and Title X providers across the 
country, do you agree with Dr. Foley's and HHS' contention that 
the new rule places a priority on preserving the provider-
patient relationship, and why, or why not?
    Ms. Coleman. Mr. Pallone, I would start with the fact that, 
under this rule, the Title X program which exists to help women 
achieve or prevent pregnancy would not require pregnancy 
counseling at all. The rule would allow it but not require it.
    In the National Family Planning Program, meant by Congress 
to help people prevent or achieve pregnancy, this rule drops 
out the requirement that you discussed medically approved 
contraception that are both acceptable and effective to 
clients. And this rule says that if a patient asked you for a 
contraceptive method that the provider disagreed with or did 
not support offering, the provider does not need to mention, 
the entire entity does not need to include certain types of 
contraception that the entity or an individual provider finds 
objectionable.
    So for all of those reasons, of course this rule steps into 
the relationship between a patient and a provider.
    Mr. Pallone. See one of my concerns, and I don't know if I 
can articulate this, is that this is going to allow so-called 
providers who don't believe in contraception, who don't believe 
in abortion, who don't believe in any of the above, to still 
get Title X funds.
    Ms. Coleman. Well, they don't get them now under the 
current rules.
    Mr. Pallone. No, but they would under the new rule.
    Ms. Coleman. But they will if this rule is applied.
    Mr. Pallone. So you could actually get--you could 
actually--I mean the way I read this thing, I could go there 
and say look, the only thing I do is preach abstinence, right, 
and I want Title X money. They would probably be approved.
    Ms. Coleman. Certainly, a service site could do that.
    It also, I mean the rule itself says a couple of times that 
entities should be allowed to apply conscience in deciding what 
the service mix is. And the rule also says that the referral 
requirements in place now deter qualified providers from 
participating.
    TMr. Pallone. It is just scary.
    Ms. Coleman. So it seems very clear the rule was written to 
open the door to ideological providers and completely walks 
away from our commitment to be client-centered in family 
planning care.
    Mr. Pallone. It is such a scary thing to me that you know 
ideology--it is already a problem but if it gets to that point, 
it is even you know a worse situation.
    Thank you. Thank you, Madam Chair.
    Ms. DeGette. Thank you very much, Mr. Chairman.
    The Chair now recognizes the gentleman from Virginia, Mr. 
Griffith, for five minutes.
    Mr. Griffith. Thank you, Madam Chair.
    Dr. McLemore, you state in your written statement that, and 
I am quoting, ``I employ reproductive justice, RJ, as a theory 
and practice to guide all of my work. And then it goes on to 
define RJ. Simply put, RJ posits that every person has the 
right to decide if and when to become pregnant and to determine 
the conditions under which they will birth and create 
families.''
    In the Virginia legislature this year, there was a bill 
and, in answering questions, Delegate Tran was answering 
questions being put forward by Delegate Gilbert. Delegate 
Gilbert asked if under the bill, as it was put forward, if you 
could have an abortion as late as the time when the mother was 
already dilated. And the bill went on to say that it could be 
for any reason, as long as there was one doctor, even some 
emotional reason at that late stage, and that there could be an 
abortion.
    Does that fit into your definition of RJ or reproductive 
justice?
    Ms. McLemore. I have to say that the question seems a 
little off-putting from the context that we are talking about 
Title X grantees and funding.
    Mr. Griffith. Yes, ma'am, and I would not have asked it if 
you had not included it both in your written statement and in 
your oral statement to this committee. So I agree it is a 
little different but----
    Dr. McLemore. So here is----
    Mr. Griffith [continuing]. You brought it up and so I just 
want to know the answer. Is that a part of what you consider to 
be reproductive justice?
    Dr. McLemore. Here is the interesting thing about 
reproductive justice. It is not necessarily so much about what 
I think. The people who we serve are the experts in their own 
lives and so they get to decide. It is not about what I think 
or what I believe. I have reproductive justice as it is defined 
in my own life. The really great thing about human rights is is 
that people get to determine what rights they want to exercise 
within their lives and that they have the capacity to make the 
decisions that they think are most important.
    Mr. Griffith. But do you think then, under Title X, it 
would be appropriate if somebody had a definition that included 
up to the point of dilation, that they should be counseled to 
where they could go get an abortion in that late third 
trimester? They are already dilated. Should one of the Title X 
clinics then be counseling them to here is where you go to get 
that late-term abortion?
    Dr. McLemore. I don't think that that is a question that I 
can answer, given that Title X grantees do not receive monies 
to be able to provide abortions.
    Mr. Griffith. But the issue here today is whether they can 
make referrals or talk about it. And if reproductive justice, 
as you have defined it, would include, under some individuals' 
philosophy, up to the point of I am dilated, I am getting ready 
to give birth, and I have decided I don't want to.
    I mean I know these are tough questions but it was raised 
by your testimony. That is why I asked.
    Dr. McLemore. Well, I think there is a lot more background 
that would need to be provided. First of all, most abortions, 
almost 90 percent, happen in the first trimester. Late-term 
abortions are very, very rare.
    Mr. Griffith. I don't disagree with that. But is it 
really--either it is allowed under your view or it is not 
allowed.
    Dr. McLemore. It wouldn't be my decision to make.
    Mr. Griffith. All right, Ms. Foster, what do you say about 
that?
    Ms. Foster. I would consider that to be quite concerning, 
of course.
    Mr. Griffith. I thank you very much. I yield back.
    Ms. DeGette. The gentle lady from Illinois is recognized 
for five minutes.
    Ms. Schakowsky. So I wanted to put a few things on the 
record on who actually takes advantage of Title X services. Six 
out of ten women seeking contraceptive care at Title X-funded 
health centers report that center was their only source of care 
that year.
    So this is for comprehensive healthcare that people go to 
these centers. Sixty-seven percent of Title X participants had 
incomes at or below the Federal poverty level in 2017. Ninety 
percent of the Title X patients had incomes at or below 250 
percent of the Federal poverty level, which means that they 
qualified for no-cost or subsidized services. Twenty-two 
percent self-identified as African American. Thirty-three 
percent identified as Hispanic or Latino. And finally, forty-
two percent of the Title X patients are uninsured. So these 
programs provide essential services that go-in their settings-
beyond just contraception.
    But I wanted to ask a couple of things that are really 
unclear to me. So Dr. Foley was saying that the reason you 
couldn't co-locate a clinic with any provider of abortion is 
the opportunity for commingling of funds. And I am wondering 
if, Ms. Coleman, we have any evidence that the current law has 
been violated and that there has been a commingling.
    Ms. Coleman. There is no evidence to support that claim.
    Ms. Schakowsky. I think that is really important to put on 
the record. The opportunity doesn't mean that there has been 
some sort of a violation.
    There was also an example given of a 13- or 14-year-old who 
made a mistake. So we are not talking about rape or incest. We 
are saying this child made a mistake and is pregnant and, then, 
goes to a Title X clinic with her mom, and asks for information 
about getting an abortion because she does not want to be 
pregnant at 13 or 14 years old. The answer was because that was 
a decision about family planning, that the doctor could not 
refer her to an abortion clinic. Does that make----
    Let me ask Ms. Foster. Does that make sense to you, the 
child should have that baby because----
    Ms. Foster. Well, as we discussed previously, Title X was 
enacted to provide financial support for pre-pregnancy family 
planning services. So if there was the desire to expand it to 
family planning services----
    Ms. Schakowsky. Do you think a 13- or 14-year-old should be 
able to be told by the doctor that she went to with her mom 
that there is an abortion available for her?
    Ms. Foster. Well, that would be nondirective counseling and 
would be eligible under this rule.
    Ms. Schakowsky. No, no, no, it wouldn't because that kind 
of referral cannot be made, if the abortion is for family 
planning. That is what this rule says. Am I wrong, Ms. Coleman?
    Ms. Coleman. I think the important thing to think about is 
the national standard, the CDC Office of Population Affairs 
standard says that counseling and referral are part of the same 
action. So when a provider may or may not offer information and 
this rule allows a provider simply to be nonresponsive to that 
adolescent and her parent, the provider would have the 
opportunity to say I can't help you at all.
    So the provider can limit counseling and may not refer. And 
that is in direct contradiction to this country's own clinical 
standard that was put in place in April of 2014 and remains in 
place today.
    Ms. Schakowsky. Is it also possible for that doctor to 
provide a list of places that does not include abortion 
services?
    Ms. Coleman. The rule would allow a provider who chose to 
offer a patient a list for referral. On that list must be 
comprehensive primary care providers. There may or may not be 
an abortion provider included on the list. That would be the 
choice of the provider and the entity. And the provider, in no 
case, could identify to the patient if there were an abortion 
provider listed and if so, which one of the health centers 
listed was the abortion-providing entity.
    Ms. Schakowsky. Thank you.
    I am concerned about this issue of co-locating and the kind 
of disruption, and I don't know who on the panel can best 
describe what that would mean. As I said, most--six out of ten 
women, when they go for contraception, this is their total 
care. They expect the availability of all the services. And if 
they are in a place where abortion is provided, what would 
happen to the clinics around the country if they had to set up 
a whole separate operation?
    Ms. DeGette. The gentle lady's time has expired but----
    Ms. Schakowsky. It did?
    Ms. DeGette [continuing]. We can go back to that.
    Ms. Schakowsky. Oh, I am sorry. OK.
    Ms. DeGette. The Chair will now recognize Dr. Burgess for 
five minutes.
    Mr. Burgess. Thank you.
    And thank you, Ms. Foster, for pointing out that under 
Title X it is pre-pregnancy family planning and that is what we 
are talking about.
    So let me ask you if there are any implications of the 2019 
final rule that would deter grantees from applying for Title X 
grants in the future.
    Ms. Foster. No, and in fact a wider variety, a more diverse 
population of organizations would be able to apply for Title X 
grants.
    Mr. Burgess. So you think it would increase then the 
universe of people offering this service, pre-pregnancy family 
planning?
    Ms. Foster. Absolutely. And in fact, applicants who had a 
conscience objection prior to the 2019 rule, according to the 
prior requirement the Title X grantees must refer for abortion, 
can now in fact apply to receive Title X funds.
    For example, Obria Group operates a chain of clinics 
throughout California and was denied in 2018 but would be 
eligible under the 2019 rule.
    Mr. Burgess. Would you be concerned at all that abortion is 
a large enough percentage of the business of some grantee 
services that they would just simply pull out of Title X?
    Ms. Foster. I would certainly hope not. If an organization 
chose not to apply for a grant, that would be their choice but 
every organization who is currently in compliance with the law, 
would continue to be in compliance with the law.
    Mr. Burgess. So according to the April 2019 Title X 
directory, Texas has two grantees and 34 sub-recipients. Do you 
anticipate that this new rule will attract new grant 
applicants?
    Ms. Foster. I would expect that it would, yes.
    Mr. Burgess. And ultimately, that would be a good thing. Is 
that correct?
    Ms. Foster. Absolutely. If we have a broader diversity of 
grant applicants and hopefully grantees, then that would be a 
good thing. We would have a wider variety of options for women 
to choose from.
    Mr. Burgess. So each State has different needs when it 
comes to the health and well-being of its citizens. Can you 
speak to the importance of allowing States the flexibility to 
choose their own Title X grant recipients?
    Ms. Foster. Certainly. It is absolutely critical that 
States have the ability to choose their Title X grant 
recipients, that we have that diversity and options for women.
    Speaking, again, of the friend that I referenced earlier, 
immigrant low-income women have the same right to access and 
should be able to access life-affirming choices, if that is 
what they so choose. They should be able to access a provider 
that shares their faith background, if they so choose, and that 
really should be available to women in every walk of life.
    Mr. Burgess. Well, thank you for those responses.
    Madam Chair, I would just like to submit for the record a 
letter to me from Dr. Michael New. Dear Dr. Burgess, I would 
like to draw your attention data showing overall positive 
trends in Texas, including a reduction in the number abortions 
year after year. He is talking about 2011-2015. Between that 
time frame, the last year for which data is publicly available, 
the pregnancy rate for minors in Texas fell by 39 percent, the 
birth rate for minors fell by 36 percent, and the number of 
abortions performed on minors fell by 53 percent. Additionally, 
during this time, the overall abortion rates in Texas declined 
by over 29 percent and the State birth rate exhibited little 
change.
    And this is in the background of--I mean we are growing in 
Texas. We are getting bigger. The female population age 15 to 
44 just under 5,400--I am sorry--5,400,000 in 2011 and is now 
5,700,000 in 2015. The female population age 13 to 17 likewise 
increased significantly between 2011 and 2015. So it is not a 
declining population that is resulting in these declining 
numbers. It is providing the timely services, pre-pregnancy 
family planning.
    Thank you very much and I will submit this for the record.
    Ms. DeGette. So I will just say, in terms of admitting this 
to the record, as a former trial lawyer, this would never go 
into the record, since we don't know who Dr. New is or what his 
methodology was. But having said that, we have a general 
practice in this committee of admitting letters that go to 
members.
    And so with the caveat that we don't know if any of this 
data is accurate and, without objection, I will admit it into 
the record.
    [The information appears at the conclusion of the hearing.]
    Mr. Burgess. So happily for you, that is referenced in the 
Department of Health and Human Services----
    Ms. DeGette. We have admitted it.
    Mr. Burgess [continuing]. With the State of Texas. It is 
easily verifiable.
    Ms. DeGette. It has been admitted.
    The Chair will now recognize Ms. Castor from Florida for 
five minutes.
    Ms. Castor. Well, thank you, Chair DeGette.
    In addition to dictating what information Title X providers 
would or wouldn't be allowed to share with their patients, the 
administration's new Title X rule appears to undermine 
evidence-based standards of care. And you heard before 
lunchtime a lot of discussion. The American Medical Association 
opposes this. American College of Obstetricians and 
Gynecologists opposes it. American Family Physicians, American 
Public Health Association, most of our witnesses today, they 
oppose this new rule. For example, ACOG and 18 other leading 
health organizations said of the rule that, ``the final Title X 
regulation disregards expert opinion and evidence-based 
practices.''
    Dr. Perritt, do you agree that the final rule disregards 
evidence-based practices?
    Dr. Perritt. Absolutely. We rely really heavily on the 
evidence to make medical decisions and to help guide our 
patients. It violates it without question.
    Ms. Castor. Do you think that this rule is likely to lead 
to more unintended pregnancies?
    Dr. Perritt. If we decrease access to comprehensive family 
planning services, yes, it will lead to decrease access. We 
heard lots of conversation about hoping that it improves 
access. We hope that it increases access. We hope that more 
people get care.
    The patients that I take care cannot bank on our hope. They 
need actual legitimate services that are comprehensive, that 
are respectful, that respect their agency and autonomy. They 
deserve that.
    Ms. Castor. So let's take a step back for a minute and 
recognize the progress that we have made in the United States 
of America in decreasing the number of unintended pregnancies. 
A lot of that success goes right back to Title X because, for 
about 50 years, we have made every effort to ensure that every 
woman, no matter where she lives, no matter what her income is, 
has equal access to contraceptives and can make those family 
planning decisions with her family, her husband, her faith, the 
doctors, all the healthcare providers. It has been a tremendous 
thing. That is why it is just so mindboggling why the 
administration voices an intent to decrease the number of 
unintended pregnancies is doing the exact opposite of what 
should be done. We should be strengthening the healthcare 
safety-net for women and families.
    The Title X, current Title X guidance specifies that 
projects, ``provide a broad range of acceptable and effective 
medically-approved family planning methods and services.'' Yet, 
the administration's new rule would eliminate the term 
medically-approved.
    Ms. Coleman, what signal is the administration sending by 
eliminating this term?
    Ms. Coleman. Again, the administration has made clear in 
the rule that they believe that entities applying for Title X 
and providers who work in those entities should be able to 
choose according to their own preferences and beliefs what 
range of contraceptive methods and services will be available. 
The rule says that explicitly. And so we have great fear that 
some of the most effective and acceptable methods of 
contraception would simply be eliminated from Title X-funded 
projects. And that would mean you could come in, perhaps with 
no idea of what you would like to have as your method, but want 
to have a full conversation and be told that certain 
conversations are not open; this provider is not willing to 
engage; or those methods aren't available to you.
    Ms. Castor. Then do you also believe that if this rule is 
adopted, it likely will lead to more unintended pregnancies?
    Ms. Coleman. I think that is certainly the case. And I want 
to draw attention again to the fact that the Federal Government 
went through a scientific, clear, 4-year process, involving 
both Government officials and nongovernmental experts. They 
produced a 50-page report that is available to the public that 
is based on evidence from ACOG, evidence from the AMA, evidence 
from the American Cancer Society, evidence from the U.S. 
Preventive Services Task Force. That is the clinical standard 
that is in place today and it is designed to be responsive to 
clients but also to help prevent unintended pregnancy.
    Ms. Castor. And Ms. Geoffray, we don't have to imagine what 
the impacts of this shift might be. You say in your testimony, 
``should this administration be allowed to undermine evidence-
based and client-centered services and interfere with the 
patient-provider relationship in the Title X Family Planning 
Program, our experience in Texas shows that we risk the loss of 
qualified providers and, in turn, reduced access to high-
quality family planning services in communities across the 
country.''
    So based on your experience in Texas, could you go into 
more detail about the impact of undermining evidence-based care 
will have on communities?
    Ms. Geoffray. Absolutely. As I shared this morning, as a 
result of the funding and policy changes that happened in Texas 
in 2011, we saw 82 clinics close, one out of four in our State 
closed; or reduced hours. Two-thirds of those clinics had no 
affiliation with abortion service providers and so it was a 
much larger net than I think was intended to be cast.
    We saw clients lose services. Again, after the 2011 cuts, 
54 percent of clients lost services. Studies have documented 
that thoroughly.
    I think that we also see that whenever we put overly 
burdensome requirements or the Government interferes in the 
patient-provider relationship, that causes providers to 
disengage from these programs. In Texas, we saw providers who 
were not willing to sign attestation forms stating that they 
did not elect--perform elective abortion or affiliate with 
those who perform elective abortion, simply because they did 
not believe that it was something the Government should be 
asking of them and that it might violate their ethics and their 
duties of care.
    Ms. DeGette. The gentle lady's time has expired.
    Ms. Geoffray. And then also, we saw people not want to sign 
into a program that didn't allow the coverage of emergency 
contraception. So again, moving away from evidence-based.
    Ms. DeGette. The gentle lady's time has expired. Thank you.
    The Chair now recognizes the gentle lady from Indiana, Mrs. 
Brooks.
    Mrs. Brooks. Thank you, Madam Chair.
    And I want to thank everybody for a very good discussion 
about an incredibly difficult subject. And I know we certainly 
all might not agree but a couple of things that I want to make 
sure everybody appreciates is the importance of contraception, 
the importance of prevention of unplanned pregnancies; and that 
I think everyone can certainly agree.
    I am curious, though, whether or not each of you were here 
during Dr. Foley's testimony and whether or not you read Dr. 
Foley's testimony. Ms. Coleman, and did you read her testimony?
    Ms. Coleman. I was present and I did review the testimony 
ahead of the hearing.
    Mrs. Brooks. Thank you. Ms. Geoffray?
    Ms. Geoffray. Yes, I was present and I read the testimony.
    Mrs. Brooks. OK, thank you. Dr. McLemore?
    Dr. McLemore. I was present and I read her testimony.
    Mrs. Brooks. Thank you. Dr. Perritt?
    Dr. Perritt. I was present but I did not read her 
testimony.
     Mrs. Brooks. OK, thank you. Ms. Foster?
    Ms. Foster. I was present and read her testimony.
    Mrs. Brooks. And what I have struggled with today is the 
fact that as a physician, and I am a lawyer, I am not a 
physician, so I have gone to the Federal Register to try to 
read what has been written about this rule and I am focused on 
the nondirective counseling piece that I have struggled with 
and you heard me ask those questions before.
    And that is what I cannot quite reconcile today from what 
all of the associations and what the organizations that we have 
all heard about but yet, I am hearing from the top official who 
oversees the office that oversees these grants. And her 
testimony, both written, and present today, and backing up this 
rule, which is the Federal Register rule, 42 CFR Part 59, 
continues to talk about the fact that nondirective pregnancy 
counseling does provide and allow for providers to give lists 
of qualified comprehensive primary healthcare providers which 
may provide abortion services.
    And so I am really struggling with the assertions that that 
will no longer be allowed under this rule. And I have such 
tremendous respect for the patient-client--not client--I am the 
lawyer-client--the physician-patient relationship and yet why 
would a physician, under this rule, where the rule allows, and 
the Federal Register allows, and the top doc overseeing this 
said it is okay, and in fact it is permitted, why would they 
not be able to provide a list and to have a discussion about 
abortion when the 13-year-old came in with her mother? Why do 
you believe that, when she came out very specifically and said 
that is not what we have written in the rule, that is not how 
the Federal Register is being interpreted, that is not what we 
are stating, that is not what she is testifying to under oath?
    Why do you believe those discussions cannot happen? Dr. 
Perritt, whether you have--you heard what she said, whether you 
read it or not.
    Dr. Perritt. So let----
    Mrs. Brooks. And I respect what you do. I do, I respect 
what all of you do. And so I am confused why everyone is not 
listening to what she said.
    Dr. Perritt. Sure, let me offer some clarification. I think 
Ms. Coleman really spoke to it best when she really stressed 
the linkage between counseling and referral. There is something 
in the medical field called linkage to care. It means that you 
don't just give someone a piece of paper, say good luck, I wish 
you well, be on your way, particularly when we are talking 
about under-resourced communities.
    Being trapped in a cycle of poverty is very--it preoccupies 
you with survival. So what that means is that even 
disconnecting services and moving them out of the same building 
is a barrier for people. It is a barrier for the communities 
that I take care of. So when we offer a list with no context, 
with no additional information, no realistic avenue to access 
those services because it is not tied to a referral, that means 
people cannot get the care that they need. That is not 
nondirective. That is not patient care. That is not how 
medicine works.
    Mrs. Brooks. But would you not agree that a provider can 
have the discussion, even under the rule, and can talk about 
the pros and the cons but, as I read it, now I am a lawyer so I 
am trying to read this rule literally and what the CFR 
literally says, but they can provide counseling and education 
but the client has to take that active role, and then deciding 
that information.
    So why is that not--so that 13-year-old and her mother, a 
provider can answer questions, can say here is the list of 
places that provide all sorts of services, including abortion, 
according to this, they may provide in addition to 
comprehensive primary care. That is what is stated here. And 
that is what I just heard Dr. Foley testify to.
    Now it is not in the same building. That is true. This rule 
does not allow it to be co-located. It does not allow that. But 
I do not see how the rule does not allow, and I think we have a 
fundamental disagreement on what I believe Dr. Foley said can 
happen, and what the rule is stating can happen, and what the 
community you are representing is saying can happen.
    Ms. DeGette. The gentle lady's time has expired.
    Mrs. Brooks. And with that, I yield back.
    Ms. DeGette. The gentle lady from New Hampshire is 
recognized.
    Ms. Kuster. I would like to pick up right here. Maybe 
people who have a different life experience might understand 
these experiences differently. I have been an adoption attorney 
for 25 years. I have literally represented young birth moms who 
had, frankly, no idea even how they got pregnant. And for them 
to be able to direct a conversation with a healthcare provider 
to ask specifically for options, including terminating the 
pregnancy I think is beyond the imagination.
    I think what we are talking about here is breaching the 
confidentiality and the sacred nature of the conversation 
between a healthcare provider and their patient. And for the 
Government--I believe in less Government interference with 
people's personal lives. And for the Government to say what 
that conversation should be is far too much interference.
    And I would love, Ms. Coleman, if you would, to give your 
thoughts on this.
    Ms. Coleman. I think it is first important to again note 
that the provider can choose to have no conversations at all in 
the context of a family planning visit and in the context of a 
positive pregnancy test.
    Ms. Kuster. I apologize for interrupting. Can we just 
clarify for the record? A church can now receive these funds 
for a program that is solely abstinence or rhythm.
    Ms. Coleman. If the rule were implemented, and it is not in 
place today, a church with a health service could participate 
in a Title X program and provide a single service or a limited 
range of services.
    Ms. Kuster. So my tax dollars, against my will, going to a 
church without giving the full range of options that any 
healthcare provider would provide.
    Ms. Coleman. I do want to clarify that under today's law, 
it is permissible under Title X program to have a service site 
offer a single service. It doesn't happen often but it can 
happen and it has long been part of the program.
    So for example, if a State Health Department wanted to 
contract with a Catholic University for a university-based 
health center and that university-based health center said all 
we want to do is fertility awareness methods, that is 
permissible under the current Title X program, as long as the 
other access points in that area, in that project, which may be 
statewide or may be more limited, offers a broad range of 
medically-approved methods and services.
    So it does allow for diversity of a service mix. The law 
allows for that now.
    Ms. Kuster. So a 22-year-old student who, because of her 
own privacy, is not going to pursue a full-blown rape 
allegation, but was in a situation, in a fraternity basement, 
that someone took advantage of her, she goes in to this 
university healthcare and what is she told? She is told that 
adoption is her option?
    Ms. Coleman. No, ma'am.
    Ms. Kuster. I mean how does she get any advice?
    Ms. Coleman. Under the current rules, upon a patient's 
request, you provide full options counseling. So if a patient 
comes in and either knows she is already pregnant or you 
confirm pregnancy at the visit, it is led by the patient. So, I 
often say if the patient says I am thrilled, you don't say let 
me talk to you about giving up your child for adoption or 
abortion. You respond to the client that is in front of you.
    Ms. Kuster. Right but I am saying she is distressed. She 
doesn't remember anything. She was given a Rohypnol pill and 
she finds herself pregnant. She does not want to be pregnant. 
She wants to continue her studies and carry on with her life. 
And in that case of the religious school with the sole source, 
they would say oh----
    Ms. Coleman. Let's separate the offering of the methods 
from the requirements to do full comprehensive options 
counseling upon the patient's request. Those are different.
    So that patient could come, they could offer one method of 
contraception but, if the patient had a positive pregnancy 
test, was in deep distress, and asked for information about a 
single option, termination, or all three options because she 
needed time to think about it, the organization in Title X 
today would be required to furnish her with nondirective 
medically-accurate, neutral information, and referral upon 
request.
    Ms. Kuster. How about after the rule, if this rule goes 
into effect?
    Ms. Coleman. After the rule, neither the counseling nor 
referral for--well, referral for abortion wholly prohibited. 
Directive prenatal referral required.
    So if she was in distress and just said I need some time to 
talk about it, under this rule, you wouldn't give her time. You 
would see, here is a prenatal care referral but you could skip 
all the discussion and the rule doesn't require that your 
counseling be medically accurate.
    Ms. Kuster. I am out of time.
    Ms. DeGette. The gentle lady's time has expired.
    Ms. Kuster. I had some great questions that I will refer to 
the record. Thank you.
    Ms. DeGette. The gentleman from Oklahoma is recognized for 
five minutes.
    Mr. Mullin. Thank you, Madam Chair, and thank you for the 
panel that stayed.
    I am going to ask some tough questions but it is really not 
an `I got you' question, Dr. Perritt, because most of them are 
going to be coming to you. It is not an `I got you' question. 
It is about information. You were very precise on answering 
some questions a while ago, where you said it is about the 
context, and the information to your patient, and providing 
them with their best choices but part of that is actually 
understanding what those options are, and what those options 
include.
    So with that being said, you are an OB/GYN, right?
    Dr. Perritt. I am.
    Mr. Mullin. And you have delivered babies and you have also 
performed abortions or you currently still perform abortions. 
Is that correct?
    Dr. Perritt. Yes.
    Mr. Mullin. What is the latest stage that you have 
performed an abortion?
    Dr. Perritt. So I would love to talk with you a little bit 
about what is happening with my patients but my medical 
practice right now is not what I came here to discuss.
    Mr. Mullin. I know.
    Dr. Perritt. We have a lot of time----
    Mr. Mullin. No, no, this is about--no, no, this is about 
information. I am asking questions.
    Dr. Perritt. Information that is relevant to Title X?
    Mr. Mullin. Yes, it is because it is about information to 
which we are talking about here. If we are going to have these 
options out to the public, then they also got to know what 
their choices are. This is what you are saying, that you want 
to provide your patient with the best information possible. And 
you are saying that under Title X, underneath the new rule, 
that that will be prohibited for you to do so but yet, we have 
had this discussion back and forth saying it wouldn't be.
    So let's talk about the information. You have performed 
abortions, correct?
    Dr. Perritt. I have already said that I do.
    Mr. Mullin. OK, so how many babies have you delivered?
    Dr. Perritt. I don't know the answer to that and once, 
again----
    Mr. Mullin. Just roughly. Just roughly.
    Dr. Perritt [continuing]. We are here talking about--I 
don't know the answer to that.
    Mr. Mullin. OK, so how many abortions have you performed?
    Dr. Perritt. What I--and I don't know the answer to that.
    Mr. Mullin. You don't?
    Dr. Perritt. What I would like to talk with you about----
    Mr. Mullin. No, ma'am, I am asking the questions.
    Dr. Perritt. Sure.
    Mr. Mullin. I am asking the questions here.
    Can you tell me then what the difference is between a baby 
being delivered and performing an abortion?
    Dr. Perritt. I can tell you the difference between taking 
care of low-income people----
    Mr. Mullin. No.
    Dr. Perritt [continuing]. Who need access to reproductive 
services----
    Mr. Mullin. That is not my question that I am asking you.
    You want to provide information to the patient but for some 
reason, you don't want to talk about the abortion, what 
procedures take place.
    My question to you is: What is the difference? When you are 
delivering a baby or you are performing an abortion, what is 
the difference?
    Dr. Perritt. What I would like----
    Ms. DeGette. So I am going to stop this right now. And the 
reason I am going to stop it is because the rules of the House 
say that we have the responsibility to preserve order and 
decorum.
    Mr. Mullin. And so where am I out of order on this?
    Ms. DeGette. Let me finish. The title of this hearing is on 
the Protecting Title X and Safe-Guarding Quality Family 
Planning Care. And it is completely outside the----
    Mr. Mullin. Abortion has been brought up multiple times in 
this hearing.
    Ms. DeGette. Excuse me. The gentleman will come to order. 
It is outside the purview of this----
    Mr. Mullin. No, it is outside the purview because you guys 
don't want to talk about it. And yet anybody else on that side 
can bring up whatever they want to, and they can talk about 
whatever they want to. But when I am asking a question----
    Ms. DeGette. The gentleman will yield back.
    Mr. Mullin [continuing]. And I said it is very clear, I am 
not trying to I got you, it is trying to be information that 
all of a sudden you don't want to talk about it.
    Ms. DeGette. The gentleman will suspend and the Chair will 
explain.
    The title of this hearing is on Protecting Title X and 
Safe-Guarding Quality Family Planning care. It is not on the 
nature of Dr. Perritt's personal medical services.
    Mr. Mullin. It is about information that needs to be given 
out.
    Ms. DeGette [continuing]. And if the gentleman wishes to 
ask about the topic of this hearing, he is more than welcome 
to, as have----
    Mr. Mullin. The topic has been about abortions the whole 
time. Everybody has been talking about the abortions. Yet, when 
I want to discuss it because I want to talk about the 
procedures that want to be done, now all of a sudden we can't 
talk about it?
    Ms. DeGette. The gentleman may proceed to talk about the 
topic of this hearing.
    Mr. Mullin. So then tell me what the topic is, I guess, 
because I have been hearing you guys talk about everything 
underneath the sun but yet we can't talk about abortion now 
that I want to? Because you guys are.
    No, seriously, where is the line? Because I don't know 
where the line is anymore.
    Ms. DeGette. As the Chair has noted, questions to the 
witnesses, the physician and--the medical witnesses about the 
character of their----
    Mr. Mullin. She is here talking about her profession, that 
she is an OB/GYN----
    Ms. DeGette. The gentleman has an answer to that question.
    Mr. Mullin [continuing]. And she is testifying on that 
behalf about her patient and providing her patient information. 
If they are talking about information, then the procedure of 
how that abortion is performed should be part of the 
information that the patient receives.
    Ms. DeGette. Sir----
    Mr. Mullin. Is that not accurate?
    Ms. DeGette [continuing]. You are attacking the witness----
    Mr. Mullin. I am not attacking.
    Ms. DeGette [continuing]. On her personal medical--her 
medical practice.
    Mr. Mullin. How am I attacking? I am asking questions.
    Ms. DeGette. She has a----
    Mr. Mullin. Tell me one thing that has been a personal 
attack.
    Ms. DeGette. The gentleman is out of order. He can ask 
questions about the topic of this hearing.
    Mr. Mullin. That is the topic of the hearing.
    Ms. DeGette. You may proceed.
    Mr. Mullin. On the discussion that I was saying?
    Still wanting to know what the difference between 
performing an abortion and delivering a baby is.
    Dr. Perritt. As I mentioned before, I am happy to talk with 
you about the patients that I take care of and----
    Mr. Mullin. Ma'am, you are here as a professional 
testifying. And I am asking an information question that I am 
not attacking you personally on. I am simply wanting to know 
what the difference is.
    Dr. Perritt. Whether or not----
    Mr. Mullin. I think it is important for the public to know 
because you are talking about choice. You are talking about 
understanding the differences and providing your patient with 
the information. This is prevalent, too.
    Dr. Perritt. My concern is not whether or not you are 
attacking me personally.
    Mr. Mullin. I am not.
    Dr. Perritt. I am not here as a personal individual. I came 
here only to talk about----
    Mr. Mullin. OK, then answer my question.
    Dr. Perritt. I came to talk about the people that I take 
care of.
    Mr. Mullin. And this is part of it.
    Dr. Perritt. We are talking a lot about----
    Mr. Mullin. This is part of it.
    Dr. Perritt. We are talking a lot about providers, the care 
that I provide inside the office, and what Planned Parenthood 
does.
    Mr. Mullin. What----
    Dr. Perritt. There is not one single person here, other 
than the medical providers who are talking about the people 
that are impacted, the patients. That is why I am sitting here.
    Mr. Mullin. This is talking about the patient. The patient 
needs to know the information. So what is the difference 
between delivering a baby and performing an abortion? Ma'am, 
you have done both. You are the best person to ask this 
question to.
    Dr. Perritt. I am the best person to talk about----
    Mr. Mullin. Then answer it.
    Dr. Perritt [continuing]. What happens in the office when 
individuals don't have the care that they need. I am the best 
person to talk about what it means to----
    Mr. Mullin. Then why won't you answer this question?
    Dr. Perritt [continuing]. Be in an urban place, or a rural 
place and not be----
    Mr. Mullin. Why are you avoiding the question?
    Dr. Perritt. I am not avoiding any question.
    Mr. Mullin. Ma'am, you are, too, because I have asked it to 
you three times----
    Dr. Perritt. I am trying to--I would love to----
    Mr. Mullin [continuing]. And you just won't answer it.
    Dr. Perritt [continuing]. Talk about family planning 
services and reproductive healthcare in the context of Title X.
    Mr. Mullin. OK, ma'am, obviously you don't want to talk 
about it. You want to provide every option but you don't want 
to get into the details.
    Do you think those details are important that your patient 
should receive those details when you are making a referral for 
them to go get an abortion? Do you think you should give that 
information to your patient to tell them what it is going to 
entail, that how you are going to kill that baby is going to 
take place, how the abortion is going to be performed, and then 
what the difference is? You don't think that information is 
prevalent?
    Dr. Perritt. What I think is that your rhetoric is 
inflammatory.
    Mr. Mullin. Rhetoric?
    Dr. Perritt. It is not medically-based----
    Mr. Mullin. It's not medically-based?
    Dr. Perritt. [continuing]. And it is absolutely offensive 
because you suggest----
    Mr. Mullin. Do you end the life of the fetus?
    Dr. Perritt [continuing]. That neither or I nor my patients 
know what they are there to talk about or what care that they 
need.
    Mr. Mullin. Do you end the life of the fetus?
    Ma'am, there is no way that I am out of time because you 
and I had a discussion for a minute and a half.
    Ms. DeGette. We stopped the clock.
    Mr. Mullin. I watched it run.
    Ms. DeGette. We stopped the clock.
    The Chair will now recognize the gentleman from New York, 
Mr. Tonko, for five minutes.
    Mr. Tonko. Thank you, Madam Chairwoman.
    We have heard today just how pivotal the role of Title X 
has played over the past 50 years in building a network of 
family planning clinics that ensure access to high-quality 
reproductive care, for low-income, or uninsured individuals, 
many of whom face barriers to care.
    We have also heard today from Dr. Foley that provisions 
within the Trump administration's new Title X rule were, and I 
quote, ``designed to increase the number of clients served 
within the Title X programs.'' In fact, Dr. Foley also contends 
that the rule, and I again, ``focuses on innovative approaches 
to expand Title X services and make inroads into sparsely 
population areas.''
    So Ms. Geoffray--do I have that correct--let me being with 
you, since the Title X network you manage in Texas presumably 
spans some sparsely populated areas.
    Do you believe the provisions in the rule would lead to an 
increase in the number of Title X clients served?
    Ms. Geoffray. I think that the provisions of the rule, as 
they are--if they would be implemented, would allow providers 
that do not provide comprehensive family planning care that is 
evidence-based and client-centered to enter our network. And 
while clients may be served by those providers, we have serious 
concerns about the types of services they would receive.
    I also have concerns that those most qualified providers, 
those who are providing evidence-based client-centered care, 
would be disincentivized from continuing their participation in 
the program, if these rules went into effect, specifically as 
it relates to options counseling and what they could and could 
not say in the context of those counseling sessions.
    Mr. Tonko. And similarly, Ms. Geoffray, I am curious as to 
whether you would characterize the rule as focusing on what 
they call innovative approaches to expand Title X services.
    Ms. Geoffray. I do not. I would like to speak a bit about 
the innovations that the current grantees, including what we 
are doing in Texas, what we are doing now, if that is OK with 
you.
    Mr. Tonko. Sure.
    Ms. Geoffray. So many of our counterparts around the 
country are working to integrate substance use disorder 
treatment into the family planning care that we provide. We are 
using telemedicine and telehealth to deliver family planning 
services to remote and rural locations. We are providing 
outreach in culturally-competent ways across different 
communities, across the country, to ensure that people are 
accessing much-needed care. We are working in school-based 
health centers to help teens understand their sexual and 
reproductive health needs and how to access services.
    So I would say that we are doing a lot of very innovative 
care across the country right now. If what the rule promotes is 
increased access to one method of care, specifically fertility 
awareness-based methods, I would not call that innovation. I 
would actually call that something that our providers are doing 
in the context of the broad range of family planning care right 
now.
    Mr. Tonko. Thank you.
    And Ms. Coleman, you have heard the answers that we 
received here from Ms. Geoffray. Are there reasons to be 
concerned that the administration's rule may in fact result in 
the opposite outcomes, should it be implemented?
    Ms. Coleman. Certainly. So there have been a number of 
State Governments and a number of provider entities that have 
stated publicly that they would not be able to continue to 
participate in Title X-funded care if this rule were 
implemented. There are many, many places in the country where 
the provider network is dominated by one kind of provider, 
whether they be local health departments, for example, in a 
State like South Carolina or Montana. And so we have great 
concerns that there may be wholesale withdrawals or just 
withdrawals in certain parts of a State and that would 
certainly impact access to care.
    I will say something that I said earlier, which is Title X-
provided services are in 60 percent of U.S. counties but that 
is where 90 percent of women in need live. And so when the 
administration persists in saying there are underserved areas, 
there are underserved areas, there is no conversation happening 
with our grantees, at this stage, about where those last ten 
percent of women in need, and I want to recognize that there 
are more than just women who require family planning and sexual 
health services under Title X, but there is no discussion with 
this network about how we might meet that last bit of need that 
is not being attended to by a provider site right now.
    Mr. Tonko. Thank you. Well, I am curious, Ms. Coleman. If 
we were in fact committed to increasing the number of patients 
to Title X program services they could access, even in remote 
areas, what would Congress and the administration be doing to 
realize these goals?
    Ms. Coleman. I am pleased you asked that question. NFPRHA 
came to the Hill this year and asked for $737 million, which is 
derived from a 2016 Health Affairs research study that was a 
CDC Office of Population Affairs and George Washington 
University researchers collaborated. And they said with 
Medicaid expansion, and with the Affordable Care Act somewhat 
in place, they made certain assumptions, that we would need 
$737 million annually appropriated to Title X just to meet the 
needs of women.
    I just want to remark that under our last set of data, 
about 12 percent of the people we see are men in Title X. So we 
probably need more than $737 million a year but that would go a 
long way to meeting the needs of low-income women in this 
country.
    Mr. Tonko. Well, I thank all of you for testifying today.
    And with that, I yield back.
    Ms. DeGette. The gentleman yields back. The Chair now 
recognizes Mr. Bilirakis for five minutes.
    Mr. Bilirakis. Thank you, Madam Chair. I appreciate it so 
much. Thank you for your testimony today and thanks for 
allowing me to sit in. I am not on this subcommittee, so I 
really appreciate you allowing me to sit in.
    Ms. Foster, historically, there have been a limited 
competition among Title X grantees. In 2009, the Institute of 
Medicine, now the National Academies Press, issued a report 
noting that, and I quote, ``competition rarely occurs among 
grantees in the program, since there are few applications for 
any given award, and there is almost no guaranteed turnover, 
less than two percent per year, according to the Institute.'' 
Since at least fiscal year 2010, HHS' congressional budget 
justification has commonly emphasized the importance of 
competition and noted the program's desire to, and I quote, 
``to increase competition for family planning services--service 
funds.'
    So the question is, Why is it important to have competition 
in the Title X program among grant recipients? Does competition 
make for a healthier Title X program?
    Ms. Foster. Absolutely. Competition will make for a 
healthier Title X program. It will increase the diversity among 
the program grantees. It will allow for a broader range of 
grantees, of organizations, of clinics, of services, to include 
the full range of family planning services. And I believe that 
it will make the entire program better, that everyone will rise 
to the challenge.
    We know that, for example, when it comes to family planning 
Federal funding more broadly, things like Medicaid and so on, 
we know that there is evidence of family planning clinics 
billing for abortion-related services. We know that from 
Georgia, from Maine, from Nebraska, from New York, over and 
over, and over, Massachusetts, Washington State. And Maine 
called one instance a clear violation. We know that one New 
York audit found that 42 percent of a sample of billing 
instances were improperly billed as--they were abortion 
services, abortion-related services and 42 of the sample was 
improperly billed to the Federal Government as abortion 
services, when it should not have been.
    So it will work to ensure that that sort of misbilling, of 
waste, and abuse, and improper commingling will not take place; 
and that we will increase the diversity within the program.
    Mr. Bilirakis. So what steps are HHS taking to increase 
competition and diversity in the Title X--for Title X grantees?
    Ms. Foster. Well this rule is about transparency, and 
consistency, and accountability. It is not new. The requirement 
about nondirective counseling is not new. And as we discussed 
earlier, Rust v. Sullivan even upheld a stricter construction 
of counseling.
    So if Congress disagrees with the Title X requirements 
supported by this rule, Congress is free to readdress the Title 
X requirements. But in the meantime, this rule supports those 
requirements and even works to increase diversity, to increase 
the range of providers who will be in the marketplace for 
women.
    Mr. Bilirakis. Okay and that includes ideological 
diversity; if so, why is it important? Why is that an important 
measure for diversity under the Title X program?
    And then also, I have one last question. Does it also 
include geographical diversity and, if so, why is that 
important that we have geographical diversity as well?
    Ms. Foster. Ideological and geographical diversity are both 
critical to the Title X program. Low-income women, immigrant 
women deserve to be able to access providers who match their 
backgrounds, who match their--whether it is a faith background; 
or some other background, they should be able to access the 
services that they desire from the provider that they desire.
    And in the past, we have had issues where, for example, we 
had Title X requirements that went against the Weldon 
Amendment, for example, and would have required referrals 
against the conscience rights of healthcare providers. This 
prevents that and ensures that a broader range of providers, 
who are offering a broad range of services, many of them may be 
offering services that include things like hormonal 
contraception, that include a full range of family planning 
services, but are more ideologically aligned to the women. And 
by increasing the number of providers in the marketplace, we 
would hope to be able to see a greater geographical diversity 
as well and more clinics in women's own neighborhoods, in their 
backyards, so that they are able to easily access.
    Mr. Bilirakis. All right, thank you very much.
    I yield back, Madam Chair.
    Ms. DeGette. The gentleman's time has expired.
    Welcome to Mrs. Rodgers from Washington State. We are glad 
you are here. We recognize you for five minutes.
    Mrs. Rodgers. Thank you Madam Chair, Ranking Member, and 
thank you everyone for being here today.
    Title X of the Public Health Service Act provides family 
planning services to low-income women. Today, there are 
approximately 4,000 Title X service sites in the United States, 
including State and county health departments, Community Health 
Centers, non-profit clinics, and Planned Parenthoods.
    The Protect Life Rule ensures that taxpayer-funded family 
planning centers will serve their intended purpose, to help 
women receive comprehensive, preventative healthcare, while 
ensuring the separation of taxpayer funds from abortion 
services.
    Ms. Foster, I have a couple of questions for you. First, 
how do these centers that are eligible for Title X funding 
under the Protect Life Rule provide comprehensive and primary 
care to women?
    Ms. Foster. Centers that will be eligible under the Protect 
Life Rule will be able to provide the range of family planning 
services. Thanks to pooling, not every center may provide a 
full range, that is true, but within a geographical area, the 
full range of family planning services will be provided.
    Mrs. Rodgers. If abortions only make up a small percentage 
of services offered by Planned Parenthood, it should be no 
problem for them to comply with this rule. If they or 
organizations similar to them were willing to comply with these 
simple rules, would they continue to receive funding?
    Ms. Foster. Any organization that complies with the rule 
which, again, supports Title X as enacted by Congress, will be 
eligible to continue to receiving funding.
    Mrs. Rodgers. So if they choose to prioritize abortion over 
preventative women's healthcare, they would be denying their 
own access to this funding.
    Ms. Foster. I would consider that to be detrimental to 
women and girls.
    Mrs. Rodgers. Who will fill the gap if Planned Parenthood 
refuses to comply with the Protect Life Rule?
    Ms. Foster. We know that there are many organizations in 
the marketplace. Of course we don't know exactly how it will 
impact the market because we don't know who will enter the 
market, who may leave the market, and to whom HHS will award 
grants but we are confident that the market can accommodate 
this change between Community Health Centers, Federally 
Qualified Health Centers, and the range of providers that have 
expressed interest and are applying and in some cases have been 
denied, like Obria Group, but would be eligible under the 
Protect Life Rule to receive Title X funding for family 
planning services.
    Mrs. Rodgers. Out of 4,000 Title X sites, less than 500 are 
Planned Parenthoods. In my district alone, there are 26 
Federally Qualified Health Care Centers, the FQHCs, compared to 
four Planned Parenthoods. So this change would only allow for 
an expansion of coverage to more locations, including all of 
those 26 FQHCs that don't offer abortions, as well as allowing 
faith-based family planning centers to apply for grants without 
slashing access to women's healthcare. By opening the process 
and allowing for religious protections, this will actually 
expand preventative healthcare services for more providers to 
receive funding and provide additional preventative healthcare 
to low-income communities.
    Thank you, Madam Chair, for allowing me to join you today 
and I yield back.
    Ms. DeGette. Thank you so much for coming, Mrs. Rodgers. I 
appreciate it.
    Mr. Guthrie doesn't have anything further. So I just have a 
couple of questions, and a comment, and then some document 
requests.
    Ms. Foster said that programs are billing for--Title X 
programs are billing for abortion services. And Dr. Foley, in 
her testimony, said that she was unable to present any evidence 
of that. And of course, if Title X programs were billing for 
abortion, that would be illegal.
    So Ms. Coleman, I am just wondering if briefly you can let 
me know if that is happening, if you know whether that is 
happening, and just clarify.
    Ms. Coleman. There is no evidence or data to indicate that 
any Title X funds are being used to subsidize abortion care.
    When the proposed rule came out last year, the 
administration made a contention that Medicaid funds, subject 
to OIG audit, had been found with some discrepancies in 
abortion billing. That is completely separate from the Title X 
program and there has been no implication that Title X entities 
or Title X funds are implicated. And the reason why we know the 
administration agrees with that is when they put out the final 
rule, they withdrew the portions about the Medicaid billing 
issues and said we recognize that these are not the same.
    Ms. DeGette. Thank you very much.
    And I just want to close by clarifying. I think there has 
been a little confusion today and I think we need to be really 
clear what we are talking about.
    The first thing is I want to thank all of the witnesses for 
coming today, all five of you, and presenting your 
perspectives. I also want to apologize for some of the 
badgering that you have had to encounter but this is a tough 
issue, and I am proud of you for the answers and for standing 
up.
    Here is what we are dealing with. The law that we have all 
been talking about says none of the funds appropriated under 
this Title shall be used in programs where abortion is a method 
of family planning. Ever since the statute was passed in 1970, 
organizations that provide abortion services do not receive 
Title X funding for family planning. And they keep it 
completely separate. And as we have heard, the evidence is that 
organizations that perform abortions do not get the Title X 
money.
    The confusion is around counseling, pregnancy counseling 
and what that means. And as has been discussed, there was a 
court decision, the Rust decision, where the question was did 
Congress mean organizations that provide counseling for 
abortion services and other types of services or does it mean 
the abortion services themselves. And the court in the Rust 
decision said Congress needs to give direction as to what it 
means, if the statute was intended to not fund abortion or 
abortion counseling.
    So in 1996, Congress passed a law and it said all pregnancy 
counseling shall be nondirective. What that has meant, for over 
20 years, since 1996, is that providers are required to give 
nondirective counseling and they have been given scientific 
nondirective counseling to patients which, as the doctors on 
our panel and the nurses testified, is so important for patient 
health and safety.
    So that is what this new rule that HHS has tried to 
promulgate violates. What it says is we can give Title X money 
to organizations that will not--where the organization will not 
provide the patient with the full range of healthcare 
information that they need, even if the patient requests it. 
That is why Dr. Perritt, and Dr. McLemore, and others have 
pointed out that this interferes with the patient-doctor 
relationship.
    And it is also against public policy to try to prevent 
unwanted pregnancies. This is what just amazes me. If we want 
to prevent unwanted pregnancies, if want to prevent increases 
in abortion, or in unwanted children being born, then we should 
have robust family planning programs that are evidence-based, 
that are targeted at the patient, and that the doctor and 
patient can talk about. And that is why Title X has been so 
effective and that is why we need to keep it.
    And also, P.S., that is why the court has enjoined the 
enactment of this rule because it violates the ethics of 
medicine.
    And so I know this was a tough discussion today; and it is 
always a tough discussion but I am going to say what I always 
say on the floor when we have these bills, if we really want to 
prevent unwanted pregnancies and reduce abortion, I think we 
should all work together on both sides of the aisle to pass 
robust birth control legislation, including long-acting birth 
control, which is wildly successful in my State and all around 
the country.
    So thanks again, everybody, for coming.
    I would ask unanimous consent to put the following 
documents into the record, and the minority has seen them: a 
letter from the AMA opposed to this regulation dated June 18, 
2009; a letter from the American College of Obstetricians and 
Gynecologists dated July 31, 2018; an article entitled The 
Final Title X Regulation Disregards Expert Opinion and 
Evidence-Based Practices dated February 26, 2019; a letter from 
the American Public Health Association dated July 30, 2018 
opposing the regulation; a letter from the American Academy of 
Pediatrics--did I do that one already--dated July 31, 2018; and 
a letter from the AMA dated July 31, 2018.
    Without objection, so ordered.
    Ms. DeGette. Again, I want to thank all the witnesses and 
thank you for waiting for us.
    This hearing is adjourned.
    [Whereupon, at 4:41 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                 [all]