[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]