Ask the Scholar
Document scope · 1 page
Scholar
Ask about this object, its catalog metadata, its source description, or the page inventory.
For page-specific OCR and visual context, open one of the page chats.
Scholar Source Context
Document identity
localId
55031791
label
Gag Rule
core
doc
dtoType
document
citationUrl
pageCount
1
Source metadata
id
55031791
sourceUrl
contentType
document
title
Gag Rule
citationUrl
collections
Records of the First Lady's Office (Clinton Administration)
Melanne Verveer's Subject Files
imageCount
1
hasImages
yes
source
import
hasTranscription
no
Source extras
naId
55031791
levelOfDescription
fileUnit
otherTitles
2068127-20130534S-097-017-2022
recordType
description
ocrSource
nara-archive
Single page context
seq
1
pageIndex
0
type
document
mediaId
76cc3fa0a6f73cfe
ocrText
fite 908 Rate
STATE OFFICE OF THE THE OF MANAGEN RESIDENT AND W.W. UNITED
EXECUTIVE OFFICE OF THE PRESIDENT
OFFICE OF MANAGEMENT AND budget
WASHINGTON, D.C. 20503
ADMINISTRATOR
OFFICE OF
INFORMATION AND
May 22, 2000
REGULATORY AFFAIRS
MEMORANDUM FOR THE DEPUTY DIRECTOR
FROM:
John T. Spotila
SUBJECT:
Potential Revisions to the Gag Rule
After further review of the draft final rule, we have the following observations:
The draft submission will need some minor rewriting to add the new Section
59.5(a)(5) to the rule and to incorporate minor related changes in the preamble. We
are unclear as to how long HHS would need to make the changes.
Since the rule primarily finalizes the 1993 interim final revocation of the Gag Rule,
the new language must emphasize that it is designed to clarify the Department's
policy in this area, not change it fundamentally. If for any reason the new language
were challenged successfully as going beyond the proposal, the Department would
want to be able to fall back on the basic revocation (which tracks the proposal and the
interim final rule exactly).
It would be difficult to define the phrase "not promote or encourage" narrowly or
with absolute precision. Historically, the Department has defined it by referring to a
guiding principle and then citing examples. The proposed guidance and preamble
reflect this traditional approach (see the attached pages).
The Department's policy on nondirective counseling is identical to the pre-1988
policy. In the guidance, HHS mandates that clinics provide, upon patient request,
comprehensive and balanced counseling on all treatment options.
The Department's policy on referrals is essentially identical to its pre-1988 approach
with one clarification. In discussing referrals to abortion providers, the pre-1988
guidance drew a distinction between making a "mere referral" and taking "further
affirmative action to secure the services". In the former case, the guidance equated a
"mere referral" to giving a patient the name, address and/or telephone number of the
provider. The new guidance preserves this conceptual distinction, but allows the
clinic to give the patient additional information on provider policies (customary
charges; whether Medicaid coverage is accepted; other restrictions).
The new guidance matches the pre-1988 guidance in its discussion of restrictions on
advocacy. It also matches the pre-1988 guidance in its discussion of physical and
financial separation of services, with one minor exception. It eliminates a
confusingly vague reference in the earlier guidance to allowing "impermissible"
abortion-related materials in common waiting rooms.
2
New Section 59.5(a)(5)
(5)
Not provide abortion as a method of family planning. Each project must offer
pregnant women the opportunity to be provided information and counseling regarding:
(A)
Prenatal care and delivery;
(B)
Infant care, foster care, or adoption; and
(C)
Pregnancy termination.
If requested to provide such information and counseling, provide neutral, factual information and
nondirective counseling on each of the options, except for any options about which the pregnant
woman indicates that she does not wish to receive information and counseling.
DRAFT GUIDANCE
Program Policies Regarding the Title X National Family Planning Program and the
Section 1008 Abortion Prohibition
Section 1008 of the Title X statute, 42 U.S.C. 300a-6, states: "None of the funds
appropriated under this title shall be used in programs where abortion is a method of family
planning." This prohibition applies not only to the performance of abortion by a Title X project,
but also to the conduct of certain abortion-related activities by the project. However, the
prohibition does not apply to all the activities of a Title X grantee, but only to those within the
Title X project. This statement summarizes the Department policies and interpretations in
existence prior to the imposition of the 1988 "Gag Rule" with regard to implementation of
section 1008, as modified following the rulemaking of 1993.
1. General principles. In general, section 1008 prohibits Title X programs from engaging
in activities which promote or encourage abortion as a method of family planning. However,
section 1008 does not prohibit the funding under Title X of activities which have only a
possibility of encouraging or promoting abortion; rather, a more direct nexus is required. The
general test is whether the immediate effect of the activity in question is to promote or encourage
the use of abortion as a method of family planning. If the immediate effect of the activity in
question is essentially neutral, then it is not prohibited by the statute. Thus, a Title X project
may not provide services that directly facilitate the use of abortion as a method of family
planning, such as providing transportation for an abortion, explaining and obtaining signed
abortion consent forms from clients interested in abortions, negotiating a reduction in fees for an
abortion, and scheduling or arranging for the performance of an abortion, promoting or
- 3 -
advocating abortion within Title X program activities, or failing to preserve sufficient separation
between Title X program activities and abortion-related activities.
2. Abortion counseling and referral. According to the 1981 Title X Guidelines:
Pregnant women should be offered information and counseling
regarding their pregnancies. Those requesting information on
options for the management of an unintended pregnancy are to be
given non-directive counseling on the following alternative courses
of action, and referral upon request:
Prenatal care and delivery
Infant care, foster care, or adoption
Pregnancy termination.
There are limitations on what abortion counseling and referral is permissible under the
statute: (a) a Title X project may not provide pregnancy counseling which promotes abortion or
encourages persons to obtain abortion, although the project may provide patients with complete
factual information about all medical options and the accompanying risks and benefits; (b) a
Title X project may provide a referral for abortion. A referral may include providing a patient
with the name, address, telephone number, and other relevant factual information (such as
whether the provider accepts Medicaid, charges, etc.) about an abortion provider. The project
may not take further affirmative action (such as negotiating a fee reduction, making an
appointment, providing transportation) to secure abortion services for the patient; and (c) where a
referral to another provider who might perform an abortion is medically indicated because of the
patient's condition or the condition of the fetus (such as where the woman's life would be
endangered), such a referral by a Title X project is not prohibited by section 1008 and is required
by 42 CFR 59.5(b)(1). The limitations on referrals do not apply in cases in which a referral is
made for medical indications.
- 4 -
3. Advocacy activities. A Title X project may not promote or encourage the use of
abortion as a method of family planning through advocacy activities such as providing speakers
to debate in opposition to anti-abortion speakers. bringing legal action to liberalize statutes
relating to abortion, or producing and/or showing films that encourage or promote a favorable
attitude toward abortion as a method of family planning. Films that present only neutral, factual
information about abortion are permissible. A Title X project may be a dues paying participant
in a national abortion advocacy organization, so long as there are other legitimate program-
related reasons for the affiliation (such as access to certain information or data useful to the Title
X project). A Title X project may also discuss abortion as a backup method of family planning
in a discussion of relative risks of various methods of contraception.
4. Separation. Non-Title X abortion activities must be separate and distinct from Title X
project activities. Where a grantee conducts abortion activities that are not part of the Title X
project and would not be permissible if they were, the grantee must ensure that the Title X-
supported project is separate and distinguishable from those other activities. What must be
looked at is whether the abortion element in a program of family planning services bulks so large
and is so intimately related to all aspects of the program as to make it difficult or impossible to
separate the eligible and non-eligible items of cost.
The Title X project is the set of activities the grantee agreed to perform in the relevant
grant documents as a condition of receiving Title X funds. A grant applicant may include both
project and nonproject activities in its grant application, and, so long as these are properly
distinguished from each other and prohibited activities are not reflected in the amount of the total
approved budget, no problem is created. Separation of Title X from abortion activities does not
- 5 -
require separate grantees or even a separate health facility, but separate bookkeeping entries
alone will not satisfy the spirit of the law. Mere technical allocation of funds, attributing federal
dollars to non-abortion activities, is not a legally supportable avoidance of section 1008.
Certain kinds of shared facilities are permissible, so long as it is possible to distinguish
between the Title X supported activities and non-Title X abortion-related activities: (a) a
common waiting room is permissible, as long as the costs are properly pro-rated; (b) common
staff is permissible, so long as salaries are properly allocated and all abortion related activities of
the staff members are performed in a program which is entirely separate from the Title X project;
a hospital offering abortions for family planning purposes and also housing a Title X project is
permissible, as long as the abortion activities are sufficiently separate from the Title X project;
and (d) maintenance of a single file system for abortion and family planning patients is
permissible, so long as costs are properly allocated.
Whether a violation of section 1008 has occurred is determined by whether the prohibited
activity is part of the funded project, not by whether it has been paid for by federal or non-federal
funds. A grantee may demonstrate that prohibited abortion-related activities are not part of the
Title x project by various means, including counseling and service protocols, intake and referral
procedures, material review procedures, and other administrative procedures.
Dated: Nov 22,1999
Denese O. Shervington
Deputy Assistant Secretary for Population Affairs
- 6 -
PREAMBLE
With respect to the comments objecting to the revocation of the Gag Rule or the use of
tax dollars for abortion on moral grounds, the Secretary notes that, under the interpretations
adopted in conjunction with the regulations below, the funding of abortion or activities that
promote or encourage abortion with Title X funds has been and will continue to be-prohibited.
Rather, what changes under the interpretations reinstated in conjunction with the regulations
below is which activities are considered to "promote or encourage" abortion. In contrast to the
position taken under the Gag Rule, under the present view (which was also the Department's
view of the statute prior to 1988), the provision of neutral and factual information about abortion
is not considered to promote or encourage abortion as a method of family planning. Thus, the
basic statutory interpretation underlying both the Gag Rule and the specific policies that
governed the Title X program prior to 1988 -- that section 1008 prohibits activities that promote
or encourage abortion as a method of family planning -- remains unchanged.
With respect to the contentions that the Secretary lacks a rational basis for revoking the
Gag Rule and that it must justify each separate part of the Gag Rule that it is discarding, we do
not agree that either contention is sound. Both the pre-1988 interpretations of the statute and the
revised interpretation of the statute embodied in the Gag Rule are legally supportable; they
represent different points on the spectrum of what is legal and, thus, both represent a permissible
exercise of administrative discretion. The crucial difference between the two options is one of
experience. Because of ongoing litigation, the Gag Rule was never implemented on a nation-
wide basis, so that its proponents can point to no evidence that it can and will work operationally
on a national basis in the Title X program. The policies and interpretations reinstituted in
conjunction with the regulations below, on the other hand, have been used by the program for
6
abortions.
D.
Abortion information and counseling. The Gag Rule prohibited the provision of
information other than information directed at protecting maternal and fetal health to women
determined to be pregnant; thus, it prohibited what is generally known as "options counseling",
i.e., the provision to pregnant women in a nondirective fashion of neutral, factual information
about all options for the management of a pregnancy, including abortion. See, 42 CFR 59.8
(1989 ed.). The pre-1988 policies, in contrast, required options counseling, if requested. As
stated in the 1981 "Title X Guidelines" :
Pregnant women should be offered information and counseling regarding their
pregnancies. Those requesting information on options for the management of an
unintended pregnancy are to be given non-directive counseling on the following
alternative courses of action, and referral upon request:
Prenatal care and delivery
Infant care, foster care, or adoption
Pregnancy termination.
The June, 1993 summary of the pre-1988 interpretations also stated that Title X projects were not
permitted to provide options counseling that promoted abortion or encouraged patients to obtain
abortion, but could advise patients of all medical options and accompanying risks.
Most of those comments supporting adoption of the proposed rules appeared to agree
with the pre-1988 policies and interpretations. However, there appeared to be some confusion
among those who agreed with the pre-1988 requirement for options counseling as to how much
information and counseling could be provided. Several of these comments also suggested that
that the "on request" limitation be deleted, particularly where State law requires the provision of
information about abortion to women considering that option.
12
Several comments opposing adoption of the proposed rules and revocation of the Gag
Rule also specifically addressed the issue of counseling. Several of these comments suggested
that counseling on "all options" include the option of keeping the baby, and two comments
suggested that the rules should contain an exception for grantees or individuals who object to
providing such information and counseling on moral grounds.
In response to the apparent confusion as to the amount of counseling permitted to be
provided under the pre-1988 interpretations, the interpretive summary published in the notices
section of the Federal Register clarifies that Title X grantees are not restricted as to the
completeness of the factual information they may provide relating to all options, including the
option of pregnancy termination. However, the previous restriction as to the "kind" of
information that may be provided about abortion continues: in keeping with the decision to
adhere to the longstanding interpretation of the statute that projects may not "promote or
encourage" abortion as a method of family planning, information and counseling provided by
Title X projects on all options for pregnancy management, including pregnancy termination,
must be nondirective. This interpretation, it should be noted, is also consistent with the
requirement in the program's three most recent appropriations, Pub. L. 104-208 (110 Stat. 3009-
243), Pub. L. 105-78 (111 Stat. 1478) and Pub. L. 105-277 (112 Stat. 2681), that pregnancy
counseling in the Title X program be "nondirective." Thus, grantees may provide as much
factual, neutral information about abortion as they consider warranted by the circumstances, but
may not steer or direct clients toward selecting the option of abortion, or any other option, in
providing options counseling.
The Secretary is retaining the "on request" policy in the interpretive summary published
13
have such objections to provide such counseling. However, in such cases the grantees must
make other arrangements to ensure that the service is available to Title X clients who desire it.
E.
Referral for abortion. The Gag Rule specifically prohibited referral for abortion
as a method of family planning and required grantees to give women determined to be pregnant a
list of providers of prenatal care, which list could not include providers "whose principal
business is the provision of abortion." 42 CFR 59.8(a) (1989 ed.). The Gag Rule permitted
referral to an abortion provider only where there was a medical emergency. 42 CFR 59.8(a)(2)
(1989 ed.). The pre-1988 policies and interpretations, in contrast, permitted Title X projects to
make what was known as a "mere referral" for abortion; a "mere referral" was considered to be
the provision to the client of the name and address and/or telephone number of an abortion
provider. Affirmative actions, such as obtaining a consent for the abortion, arranging for
transportation, negotiating a reduction in the fee for an abortion or arranging for or scheduling
the procedure, were considered to promote abortion as a method of family planning and thus to
be prohibited by section 1008. The pre-1988 rules (§ 59.5(b)(1)) were interpreted by the agency
to require referral for abortion where medically indicated. See, Valley Family Planning V. State
of North Dakota, 489 F.Supp. 238 (D.N.D. 1980), aff'd., 661 F.2d 99 (8th Cir. 1981).
A number of comments, mostly from individuals and organizations supporting
revocation of the Gag Rule, suggested modifications of the proposed referral policies and
interpretations. Most of these comments suggested that the content limitations on referrals be
broadened, with Title X grantees being permitted to provide other relevant information, such as
comparative charges, stage of pregnancy up to which referral providers may under State law or
will provide abortion, the number of weeks of estimated gestation, etc. These comments argued
16
that the provision of such factual information does not "promote or encourage" abortion any
more than does the provision of the abortion providers' names and addresses and/or telephone
numbers. One comment also suggested that the restriction on negotiating fees for clients referred
for abortion conflicts with the requirement to refer for abortion where medically indicated.
Several comments opposing revocation of. the Gag Rule also expressed problems with the
proposed referral policies and interpretations. A few comments urged that referrals to agencies
that can assist clients who choose the "keeping the baby" or adoption options should be required.
Another comment criticized the requirement for referral where "medically indicated" as
confusing. Revisions suggested were that "self-referrals" for abortion be specifically prohibited,
to reduce commercialization and profiteering by Title X grantees who are also abortion providers
and that grantees who objected to abortion on moral or religious grounds be permitted not to
make abortion referrals.
The Secretary agrees with the comments advocating expanding the content of what
information may be provided in the course of an abortion referral. The content (as opposed to
action) restrictions of the "mere referral" policy proceeded from an assumption that the provision
of information other than the name and address and/or telephone number of an abortion provider
might encourage or promote abortion as a method of family planning. The Secretary now agrees,
based on experience and the comments of several providers on this point, that the provision of
the types of additional neutral, factual information about particular providers described above is
likely to do little, if anything, to encourage or promote the selection of abortion as a method of
family planning over and above the provision of the information previously considered
permissible; at most, such information would seem likely to assist clients in making a rational
17
selection among abortion providers, if abortion is being considered. Moreover, it does not seem
rational to restrict the provision of factual information in the referral context, when no similar
restriction applies in the counseling context. Accordingly, the Secretary has revised the policies
and interpretations summarized in the notice section to clarify that grantees are not restricted
from providing neutral, factual information about abortion providers in the course of providing
an abortion referral, when one is requested by a pregnant Title X client.
The Secretary is not accepting the remainder of the comments on this issue, as they either
proceed from a misunderstanding of, or do not raise valid objections to, the proposed policies
and interpretations. The comment arguing that the restriction on negotiating fees conflicts with
the requirement to refer for abortion where medically indicated is based on a misunderstanding
of that requirement: in such circumstances, the referral is not for abortion "as a method of family
planning" (i.e., to determine the number and/or spacing of one's children) but is rather for the
treatment of a medical condition; thus, the statutory prohibition does not apply, so there is no
restriction on negotiating fees and similar actions. The suggestion that referrals to agencies that
can assist clients who choose the options of "keeping the baby" or adoption be required is
likewise rejected as unnecessary. Under the policy set out in the 1981 "Title X Guidelines"
provision set out in the preceding section, the options of prenatal care and delivery and adoption
are options that are required to be part of the options counseling and referral process; thus,
referral to providers who can assist a client with one of these options is already required, where
that option is selected by the client. The Secretary also rejects the criticism that the provision
requiring referral for abortion where medically indicated is undefined and confusing. It is noted
that this comment came from a law school, not a health care provider. The meaning of the
18
organizations and was negative. Although it was generally agreed that the financial separation of
Title X project activities from abortion-related activities was required by statute and, in the
words of one comment, "absolutely necessary," many of these comments objected that requiring
additional types of separation would be unnecessary, costly, and medically unwise. The
argument was made that the requirement for physical separation is unnecessary, as it is not
required by the statute which, on its face, requires financial separation only. Further, it was
argued that since Title X grantees are subject to rigorous financial audits, it can be determined
whether program funds have been spent on permissible family planning services, without
additional requirements being necessary. With respect to the issue of cost, it was generally
objected that requiring separation of staff and facilities would be inefficient and cost ineffective.
For example, one comment argued that --
The wastefulness and inefficiency of the separation requirements is illustrated by
the
policy which allows common waiting rooms, but disallows "impermissible materials" in
them. This puts grantees in the position of having to continuously monitor health
information for undefined "permissibility" or to build a separate waiting room just to be
able to utilize those materials
It was argued that these concerns were particularly important for small and rural clinics "that
may be the only accessible Title X family planning and/or abortion providers for a large
population of low-income women." Of particular concern for such clinics was the duplication of
costs inherent in the separation requirements, as they --
cannot afford to operate separate facilities or to employ separate staff for these services
without substantially increasing the prices of services. Nor can they offer different
services on different days of the week because so many of their patients are only able
to travel to the clinic on one day.
Many providers also pointed out that requiring complete physical separation of services would be
21
inconsistent with public health principles, which recommend integrated health care, and would
impact negatively on continuity of care. As one comment stated, "women's reproductive health
needs are not artificially separated between services: a woman who needs an abortion may also
need contraceptive services, and may at another time require prenatal care." Several providers
objected in particular that such a separation would, in the words of one comment, "remove
one
of the most opportune time[s] to facilitate the entry of the abortion patient into family planning
counseling, which is at the post-abortion check-up." It was also pointed out that separation of
services would burden women, by making them "make multiple appointments or trips to visit
different staff or facilities." Finally, the separation policy was objected to by several of the
comments that otherwise generally supported the proposed rule as unnecessarily broad,
ambiguous, and vague.
Several of the comments opposing the revocation of the Gag Rule and the adoption of the
proposed rules likewise objected specifically to the separation requirements, generally on the
ground that the pre-1988 policies were vague and unenforceable. Two comments also argued
that, if the pre-1988 requirement of physical separation was to be reinstituted, it made no sense to
revoke § 59.9 of the Gag Rule in its entirety, as that section of the Gag Rule contained specific
standards to implement this requirement; alternatively, it was argued that if the Secretary is going
to use different standards to determine whether the requisite physical separation existed, those
should be published for public comment.
The Secretary agrees that the comments on both sides of this issue have identified
substantial concerns with the pre-1988 policies and interpretations with respect to the issue of
how much physical separation should be required between a grantee's Title X project activities
22
and abortion-related activities. The Secretary agrees with the comments that the pre-1988
interpretation that some physical separation was required was unenforceable. Indeed, since the
pre-1988 interpretations had held that it was permissible to provide abortions on a Title X clinic
site and to have common waiting areas, records, and staff (subject largely to proper allocation of
costs), it was difficult to tell just what degree and kind of physical separation were prohibited.
As a consequence, the agency attempted to enforce this requirement on only a few occasions
prior to 1988. The Secretary does not agree with opponents of the proposed rules, however, who
argued that the "physical separation" requirements in § 59.9 of the Gag Rule should be retained
on the ground that they provide a necessary clarification of this issue. Although $ 59.9 provided
ostensibly more specific standards, the fundamental measure of compliance under that section
remained ambiguous: "the degree of separation from facilities [in which prohibited activities
occurred] and the extent of such prohibited activities," and "[t]he extent to which" certain
materials were present or absent. Furthermore, since under $ 59.9 compliance was to be
determined on a "facts and circumstances" basis, this section of the Gag Rule provided grantees
with less specific advance notice of the compliance standards than did the pre-1988 policies and
interpretations. Moreover, the change in policy from the more concrete policies proposed during
the Gag Rule rulemaking to the less concrete "facts and circumstances" standard ultimately
adopted in the final Gag Rule as a result of the public comment suggests the practical difficulties
of line-drawing in this area. In fact, since the Gag Rule was never implemented on a national
basis, the precise contours of the compliance standards of § 59.9 were never determined. The
Secretary has accordingly not accepted the suggestion from several opponents of the proposed
rule that the policies of § 59.9 be retained.
23
respond to the remaining comments on the issue.
G.
Advocacy restrictions. The Gag Rule, at 42 CFR 59.10 (1989 ed.). prohibited
Title X projects from encouraging, promoting. or advocating abortion as a method of family
planning. This section prohibited Title X projects from engaging in actions to "assist women to
obtain abortions or increase the availability or accessibility of abortion for family planning
purposes," including actions such as lobbying for the passage of legislation to increase the
availability of abortion as a method of family planning, providing speakers to promote the use of
abortion as a method of family planning, paying dues to any group that as a significant part of its
activities advocated abortion as a method of family planning, using legal action to make abortion
available as a method of family planning, and developing or disseminating materials advocating
abortion as a method of family planning. The pre-1988 policies and interpretations likewise
prohibited the promotion or encouragement of abortion as a method of family planning through
advocacy activities such as providing speakers, bringing legal action to liberalize statutes relating
to abortion, and producing and/or showing films that tend to encourage or promote abortion as a
method of family planning. However, under those prior policies and interpretations, it was
considered permissible for Title X grantees to be dues-paying members of abortion advocacy
groups, so long as there were other legitimate program-related reasons for the affiliation.
Very few comments were received concerning these proposed policies and
interpretations. Those received from persons and entities that generally supported the proposed
rules generally argued against the restriction on showing films advocating abortion, on the
ground that it was possible to violate this restriction by showing a film that was purely factual
and detailed relative risks. The few comments on this part of the policies and interpretations
25
received from those who generally opposed revoking the Gag Rule pointed out the similarity
between the advocacy policies articulated in the proposed policies and interpretations and §
59.10 of the Gag Rule and argued that § 59.10 should accordingly be reinstated.
As set out above, the Secretary is of the view that the Gag Rule cannot and should not be
adopted piecemeal, as recommended by these comments. Moreover, the Secretary is of the view
that the prohibition against dues paying contained in $ 59.10 is not required by the statute and
does not represent sound public policy. Accordingly, the suggestion that § 59.10 be reinstated
has not been adopted. With respect to the criticism of the prohibition against Title X grantees
showing films advocating abortion as a method of family planning, it is recognized that the
prohibition should not encompass the kind of neutral, factual information that grantees are
permitted to provide in the counseling context; the policies and interpretations have been
clarified accordingly. To the extent that these comments seek to further liberalize the advocacy
restrictions, however, they are rejected as inconsistent with the Secretary's basic interpretation of
section 1008.
H.
Miscellaneous. A number of comments were received on miscellaneous issues.
Those comments, and the Secretary's responses thereto, are summarized below.
1. Changes outside the scope of the rulemaking. Several comments were received
advocating changes to other sections of the regulations on issues other than the issue of
compliance with section 1008. These comments included the following suggestions: that the
regulations be revised to permit natural family planning providers to be Title X grantees; that the
regulations be revised to prohibit single method providers from participating in Title X projects;
that the footnote in the regulation addressing Pub. L. 94-63 be revised to state that the law also
26