[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:]
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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:]
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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:]
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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:]
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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:]
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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:]
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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:]
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