SENATE THIRD READING

STR Bill Id:SJR 4

Author:(Leyva)

As Introduced Ver:March 4, 2019

Majority vote

SUMMARY:

Urges the United States Department of Health and Human Services (HHS) to rescind the new Title X regulations that will impede access to essential, time-sensitive health care for low-income individuals across California and the nation.

Major Provisions

1. Makes various findings regarding the federal Title X family planning program, including:
   1. Title X was established in 1970 by the United States Congress with broad bipartisan support to provide high-quality family planning services and other preventive care to low-income and uninsured individuals who may otherwise lack access to health care, and is the sole federal program dedicated to funding family planning services, including birth control, pregnancy testing, and the prevention and treatment of sexually transmitted diseases (STDs);
   2. California's Title X provider network, which is the largest and most diverse in the nation, served more than 1 million low-income Californians in 2017 and over 25% of all Title X patients nationwide;
   3. Over $1 billion is saved annually in California because of public investment in family planning and related services provided at Title X health care centers across the state;
   4. The new federal Title X regulations interfere with the provider-patient relationship and gag Title X funded agencies by directing providers to withhold full and accurate medical information from patients about pregnancy options or by prohibiting providers from giving patients referrals for abortion care; and,
   5. The federal government's harmful Title X regulations are likely to force many health care organizations and qualified family planning providers in California to choose between a critical funding source and accepting onerous and unnecessary regulations, resulting in reduced access to quality, time-sensitive care for low-income individuals across the state.
2. Resolves, by the Senate and the Assembly of the State of California, jointly, the following:
   1. The Legislature respectfully urges HHS to rescind the new Title X regulations that will impede access to essential, time-sensitive health care for low-income individuals across California and the nation; and,
   2. The Secretary of the Senate transmit copies of this resolution to the President and Vice President of the United States, to the Speaker of the House of Representatives, to the Majority Leader of the Senate, to each Senator and Representative from California in the Congress of the United States, to HHS, and to the author for appropriate distribution.

COMMENTS:

HHS final rule. On March 4, 2019, HHS issued a final rule related to Title X to take effect on May 3, 2019. According to Office of Population Affairs, it issued this final rule to ensure compliance with, and enhance implementation of, the statutory requirement that none of the funds appropriated for Title X may be used in programs where abortion is a method of family planning.

The attorneys general from 23 states (including California), family planning organizations (including the sponsor of this resolution), and the American Medical Association filed legal challenges in federal court to block the implementation of the regulations, claiming the new rules violate the Constitution and federal law, restrict access to critical preventive health care and access to birth control, prohibit doctors from providing accurate information for patients and referrals for abortion, and will cause harm to patients and providers through dramatic alterations to the Title X program.

On April 24, 2019, the U.S. District Court in Yakima, Washington issued a nationwide injunction on President Trump's proposed changes to the Title X program. The injunction was issued by Judge Stanley Bastian in the case brought forward by Attorney General Bob Ferguson's office on behalf of Governor Inslee's Washington State Department of Health, and was effective immediately.

According to the Author:

Title X is a federal program that supports the delivery of family planning and related services to low-income and uninsured patients. Services provided include birth control, pregnancy tests, sexually transmitted disease-related services, breast and cervical cancer screenings, and other essential services. California is home to the nation's largest Title X provider network that serves 1 million low-income Californians annually – more than 25% of all Title X patients served nationwide. Essential Access Health (EAH) distributes Title X funds to more than 350 clinic sites in 38 California counties. Members of EAH's statewide Title X provider network include federally qualified health centers, city and county public health departments, Urban Indian Health Centers, academic medical centers, Planned Parenthood affiliates, and other family planning and women's health centers. To protect these services, this resolution sends a clear message to the federal government that California stands in strong support of comprehensive reproductive health care access and urges the federal government to rescind these harmful new regulations.

Arguments in Support:

EAH, the sponsor of this resolution, states that the Trump Administration's recently released harmful and unlawful Title X regulations represent some of the most extreme policy changes proposed since Title X was established and would affect care delivered at all Title X-funded health centers in the state.

Arguments in Opposition:

None on file.

FISCAL COMMENTS:

This resolution is nonfiscal.

VOTES:

SENATE FLOOR: 26-9-3

YES: Allen, Archuleta, Atkins, Beall, Bradford, Caballero, Dodd, Durazo, Galgiani, Glazer, Hill, Hueso, Hurtado, Jackson, Leyva, McGuire, Monning, Pan, Portantino, Roth, Rubio, Skinner, Stern, Umberg, Wieckowski, Wiener

NO: Bates, Borgeas, Grove, Jones, Moorlach, Morrell, Nielsen, Stone, Wilk

ABS, ABST OR NV: Chang, Hertzberg, Mitchell

ASM HEALTH: 11-2-2

YES: Wood, Aguiar-Curry, Bonta, Burke, Carrillo, Limón, McCarty, Nazarian, Ramos, Rodriguez, Santiago

NO: Bigelow, Flora

ABS, ABST OR NV: Mayes, Waldron

UPDATED:

VERSION: March 4, 2019

CONSULTANT: Lara Flynn / HEALTH / (916) 319-2097 FN: 0001062

Date of Hearing: June 11, 2019

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

SBPCA Bill Id:SJR 4

Author:(Leyva) – As Introduced Ver:March 4, 2019

SENATE VOTE: 26-9

SUBJECT: Title X.

SUMMARY: Urges the United States Department of Health and Human Services (HHS) to rescind the new Title X regulations that will impede access to essential, time-sensitive health care for low-income individuals across California and the nation. Specifically, this resolution:

1. Makes various findings regarding the federal Title X family planning program, including:
   1. Title X was established in 1970 by the United States Congress with broad bipartisan support to provide high-quality family planning services and other preventive care to low-income and uninsured individuals who may otherwise lack access to health care, and is the sole federal program dedicated to funding family planning services, including birth control, pregnancy testing, and the prevention and treatment of sexually transmitted diseases (STDs);
   2. California’s Title X provider network, which is the largest and most diverse in the nation, served more than 1 million low-income Californians in 2017 and over 25% of all Title X patients nationwide;
   3. Over $1 billion is saved annually in California because of public investment in family planning and related services provided at Title X health care centers across the state;
      
   4. The new federal Title X regulations interfere with the provider-patient relationship and gag Title X funded agencies by directing providers to withhold full and accurate medical information from patients about pregnancy options or by prohibiting providers from giving patients referrals for abortion care;
      
   5. The federal government’s harmful Title X regulations are likely to force many health care organizations and qualified family planning providers in California to choose between a critical funding source and accepting onerous and unnecessary regulations, resulting in reduced access to quality, time-sensitive care for low-income individuals across the state; and,
      
   6. Patients rely on and trust their health care providers to provide a comprehensive, accurate, and unbiased evaluation of their condition, along with all available treatment options, and the American Medical Association’s Code of Medical Ethics establishes that withholding information without the patient’s knowledge or consent is ethically unacceptable and that patients should be informed of all burdens, risks, and expected benefits of all medical options.
      
2. Resolves, by the Senate and the Assembly of the State of California, jointly, the following:
   1. The Legislature respectfully urges HHS to rescind the new Title X regulations that will impede access to essential, time-sensitive health care for low-income individuals across California and the nation; and,
      
   2. The Secretary of the Senate transmit copies of this resolution to the President and Vice President of the United States, to the Speaker of the House of Representatives, to the Majority Leader of the Senate, to each Senator and Representative from California in the Congress of the United States, to HHS, and to the author for appropriate distribution.
      

FISCAL EFFECT: None

COMMENTS:

1. PURPOSE OF THIS RESOLUTION. According to the author, Title X is a federal program that supports the delivery of family planning and related services to low-income and uninsured patients. Services provided include birth control, pregnancy tests, sexually transmitted disease-related services, breast and cervical cancer screenings, and other essential services. California is home to the nation’s largest Title X provider network that serves 1 million low-income Californians annually – more than 25% of all Title X patients served nationwide.

Essential Access Health (EAH) distributes Title X funds to more than 350 clinic sites in 38 California counties. Members of EAH’s statewide Title X provider

network include federally qualified health centers, city and county public health departments, Urban Indian Health Centers, academic medical centers, Planned Parenthood affiliates, and other family planning and women’s health centers. On March 4, 2019, the federal government posted to the Federal Register new regulations for the Title X program that threaten to impede access to vital, time-sensitive health care. To protect these services, this resolution sends a clear message to the federal government that California stands in strong support of comprehensive reproductive health care access and urges the federal government to rescind these harmful new regulations.

1. BACKGROUND.
   1. Title X. According to HHS, for more than 40 years, Title X family planning clinics have played a critical role in ensuring access to a broad range of family planning and related preventive health services for millions of low-income or uninsured individuals and others. Administered by the Office of Population Affairs (OPA), Title X is the only federal program dedicated solely to supporting the delivery of family planning and related preventive health care. The program is designed to provide contraceptive supplies and information to all who want and need them, with priority given to persons from low-income families. In addition to offering a broad range of effective and acceptable contraceptive methods on a voluntary and confidential basis, Title X-funded service sites provide contraceptive education and counseling; breast and cervical cancer screening; STD and HIV testing, referral, and prevention education; and, pregnancy diagnosis and counseling. Federal law prohibits Title X funds from being used to provide abortions.
      
      The program is implemented through competitively awarded grants to state and local public health departments and community health, family planning, and other private nonprofit agencies. For many clients, Title X providers are their only ongoing source of health care and health education. In fiscal year 2017, the Title X program received approximately $286.5 million in federal funding.
   2. Family Planning Annual Report (FPAR). The FPAR provides data on the demographic and social characteristics of Title X clients, their use of family planning and related preventive health services, staffing, and revenue. Key findings from the 2017 FPAR include:
      1. A diverse network of public and private nonprofit health and community service agencies delivers Title X services. Services were implemented through grants to 89 agencies: 47 state and local health departments and 42 nonprofit family planning and community health agencies. Providers served approximately four million family planning users through 6.6 million encounters;
      2. Title X providers serve mostly female, low income, and young clients. About 88% of Title X users were female, 65% were under 30 years of age, and 67% had family incomes at or below the federal poverty level (FPL);
      3. Title X providers serve a racially and ethnically diverse population. Thirty-one percent of users self-identified with at least one of nonwhite race categories (African American, Asian, Native Hawaiian or Pacific Islander, American Indian or Alaska Native, or more than one race) and 33% self-identified as Latino;
      4. Title X providers offer clients a range of safe, effective contraceptive methods. Among the 3.1 million female clients at risk of unintended pregnancy, 70% exited their last encounter with either a most effective (female sterilization, implant, or IUD) or moderately effective (injectable contraception, vaginal ring, contraceptive patch, pills, diaphragm, or cervical cap) contraceptive method;
      5. Title X-funded cervical and breast cancer screenings allow for early detection. Pap testing was conducted on 18% of female users, and 14% of those tests had an indeterminate or abnormal result requiring further evaluation. Providers performed clinical breast exams on 25% of female users and referred 5% of those examined for further evaluation based on abnormal findings;
      6. Title X-funded STD and HIV services provide testing necessary for preventing disease transmission and adverse health consequences. Providers tested 61% of female users under 25 for chlamydia. Providers also performed 2.4 million gonorrhea tests, 1.2 million HIV tests, and 709,161 syphilis tests; and,
      7. Title X projects rely on revenue from a variety of public and private sources. Grantees reported total project revenue of almost $1.3 billion to support their approved Title X services projects. Five sources accounted for 86% of total revenue: Medicaid (38% or $495.2 million), Title X (19% or $244.6 million), state and local governments (15% or $188.2 million), private third-party payers (11% or $140.1 million), and client service fees (4% or $52.4 million).
   3. California Title X. EAH, the sponsor of this resolution, is the sole Title X grantee for California and received $20.5 million in federal fiscal year 2017. These funds were sub-granted to approximately 366 health center and 63 health care agencies. Thirty-eight of California’s 58 counties have Title X funded health care sites. Although California receives only about 8% of the nation’s Title X funding, approximately 25% of the program’s patients receive services in this state. Approximately 86% of California’s Title X patients have income below 150% FPL, 50% are uninsured, and 66% are between the ages of 20 and 34.
   4. HHS final rule. On March 4, 2019, HHS issued a final rule related to Title X to take effect on May 3, 2019. According to OPA, it issued this final rule to ensure compliance with, and enhance implementation of, the statutory requirement that none of the funds appropriated for Title X may be used in programs where abortion is a method of family planning. According to a March 2019 Kaiser Family Foundation Issue Brief, the final rule will make significant changes to the program and will:
      1. Block the availability of federal funds to family planning providers that also offer abortion services;
      2. Prohibit sites that participate in Title X from referring pregnant clients to abortion providers;
      3. Eliminate current requirements for Title X sites to provide non-directive pregnancy options counseling that includes information about prenatal care/delivery, adoption, and abortion;
      4. Prioritize providers that offer comprehensive primary health care services over those that specialize in reproductive health services; and,
      5. Encourage participation by “non-traditional” organizations such as those that only offer one method of family planning, such as fertility awareness-based methods.

If implemented, the changes to Title X will shrink the network of participating providers and could reduce the scope of services offered to low-income and uninsured people that rely on Title X-funded clinics for their family planning care.

The attorneys general from 23 states (including California), family planning organizations (including the sponsor of this resolution), and the American Medical Association filed legal challenges in federal court to block the implementation of the regulations, claiming the new rules violate the Constitution and federal law, restrict access to critical preventive health care and access to birth control, prohibit doctors from providing accurate information for patients and referrals for abortion, and will cause harm to patients and providers through dramatic alterations to the Title X program.

The federal government filed a motion to stay the injunction in the Northern District of California, which was denied on May 8, 2019, however an appeal has been filed and the ninth Circuit has not yet issued its ruling.

On April 24, 2019, the U.S. District Court in Yakima, Washington issued a nationwide injunction on President Trump’s proposed changes to the Title X program. The injunction was issued by Judge Stanley Bastian in the case brought forward by Attorney General Bob Ferguson’s office on behalf of Governor Inslee’s Washington State Department of Health, and was effective immediately.

1. SUPPORT. EAH, the sponsor of this resolution, states that the Trump Administration’s recently released harmful and unlawful Title X regulations represent some of the most extreme policy changes proposed since Title X was established. EAH notes that the regulations would affect care delivered at all Title X-funded health centers in the state, affecting more than 25% of all Title patients nationwide, disproportionately affecting communities of color and reversing the progress made reducing unintended pregnancy rates.
2. PREVIOUS LEGISLATION. AJR 42 (Kamlager-Dove) Resolution Chapter 198, Statutes of 2018, urged HHS to reevaluate any proposed rules that are dangerous to women and constitute an international attack on reproductive and women’s health care. AJR 42 also urged that rulemaking be guided by science, data, and humanitarianism.
   

REGISTERED SUPPORT / OPPOSITION:

Support

Essential Health Access (sponsor)
Insurance Commissioner Ricardo Lara
Access Women's Health Justice 
Black Women for Wellness Action Project
Business & Professional Women of Nevada County
California Family Resource Association, A Fiscally Sponsored Project of Community Initiatives
California Health Advocates
California Latinas for Reproductive Justice
California Nurse-Midwives Association
California Pan-Ethnic Health Network
California Women's Law Center
Coalition of Orange County Community Clinics
La Clinica De La Raza, Inc.
Los Angeles LGBT Center
Los Angeles Trust for Children's Health
National Health Law Program
Planned Parenthood Affiliates of California
Training in Early Abortion for Comprehensive Healthcare
Women's Foundation Of California

Opposition

None on file.

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097

 THIRD READING  

Bill No: SJR 4

Author: Leyva (D), et al.

Introduced: 3/4/19

Vote: 21

SENATE HEALTH COMMITTEE: 7-1, 3/20/19

AYES: Pan, Durazo, Hurtado, Leyva, Mitchell, Monning, Rubio

NOES: Stone

NO VOTE RECORDED: Grove

SUBJECT: Title X

SOURCE: Essential Access Health

DIGEST:

This resolution urges the United States Department of Health and Human Services to rescind the new Title X regulations.

ANALYSIS:

This resolution:

1. Makes a number of findings related to the federal Title X family planning program, including:
   1. Title X is the sole federal program dedicated to funding family planning services, including birth control, pregnancy testing, and the prevention and treatment of sexually transmitted diseases (STDs) and it supports outreach and education efforts that link community members to care;
   2. California’s Title X provider network, which is the largest and most diverse Title X system in the nation and an essential part of California’s family planning safety net, served more than one million low-income Californians in 2017 and services provided by clinics that received Title X funding in California helped patients avert over 200,000 unintended pregnancies in 2015;
   3. Over $1 billion is saved annually in California because of public investment in family planning and related services provided at Title X health care centers across the state;
   4. The new federal Title X regulations interfere with the provider-patient relationship and gag Title X funded agencies by directing providers to withhold full and accurate medical information from patients about pregnancy options or by prohibiting providers from giving patients referrals for abortion care;
   5. The federal government’s harmful Title X regulations are likely to force many health care organizations and qualified family planning providers in California to choose between a critical funding source and accepting onerous and unnecessary regulations, resulting in reduced access to quality, time-sensitive care for low-income individuals across the state; and,
   6. Patients rely on and trust their health care providers to provide a comprehensive, accurate, and unbiased evaluation of their condition, along with all available treatment options, and the American Medical Association’s Code of Medical Ethics establishes that withholding information without the patient’s knowledge or consent is ethically unacceptable and that patients should be informed of all burdens, risks, and expected benefits of all medical options.
2. Resolves, by the Senate and the Assembly of the State of California, jointly, the following:
   1. The Legislature respectfully urges the United States Department of Health and Human Services (HHS) to rescind the new Title X regulations that will impede access to essential, time-sensitive health care for low-income individuals across California and the nation; and,
   2. The Secretary of the Senate transmit copies of this resolution to the President and Vice President of the United States, to the Speaker of the House of Representatives, to the Majority Leader of the Senate, to each Senator and Representative from California in the Congress of the United States, to HHS, and to the author for appropriate distribution.

Comments

1. Author’s statement. According to the author, Title X is a federal program that supports the delivery of family planning and related services to low-income and uninsured patients. Services provided include birth control, pregnancy tests, sexually transmitted disease-related services, breast and cervical cancer screenings, and other essential services. California is home to the nation’s largest Title X provider network that serves 1,000,000 Californians annually – more than 25% of all Title X patients nationwide. Title X funds are distributed to 366 clinic sites in 38 California counties. Members of California’s Title X provider network include federally qualified health centers, city and county public health departments, Urban Indian Health Centers, academic medical centers, Planned Parenthood affiliates, and other family planning and women’s health centers. On March 4, 2019, the federal government posted to the Federal Register new regulations for the Title X program that threaten to impede access to vital, time-sensitive health care. To protect these services, this resolution sends a clear message to the federal government that California stands in strong support of comprehensive reproductive health care access and urges the federal government to rescind these new regulations.
2. Title X. According to HHS, The Title X National Family Planning Program, administered by the Office of Population Affairs (OPA), is the only federal program dedicated solely to supporting the delivery of family planning and related preventive health care. The program is designed to provide contraceptive supplies and information to all who want and need them, with priority given to persons from low-income families. In addition to offering a broad range of effective and acceptable contraceptive methods on a voluntary and confidential basis, Title X-funded service sites provide contraceptive education and counseling; breast and cervical cancer screening; STD and HIV testing, referral, and prevention education; and pregnancy diagnosis and counseling. The program is implemented through competitively awarded grants to state and local public health departments and community health, family planning, and other private nonprofit agencies. For many clients, Title X providers are their only ongoing source of health care and health education. In fiscal year 2017, the Title X program received approximately $286.5 million in federal funding.
3. California Title X. Essential Access Health, the sponsor of this resolution, is the sole Title X grantee for California and received $20.5 million in federal fiscal year 2017. These funds were sub-granted to approximately 366 health center and 63 health care agencies. Thirty-eight of California’s 58 counties have Title X funded health care sites. Although California receives only about 8% of the nation’s Title X funding, approximately 25% of the program’s patients receive services in this state. Approximately 86% of California’s Title X patients have income below 150% of the federal poverty level, 50% are uninsured, and 66% are between the ages of 20 and 34.
4. HHS final rule. On March 4, 2019, HHS issued a final rule related to Title X to take effect on May 3, 2019. According to OPA, it issued this final rule to ensure compliance with, and enhance implementation of, the statutory requirement that none of the funds appropriated for Title X may be used in programs where abortion is a method of family planning. According to a March 2019 Kaiser Family Foundation Issue Brief, the final rule will make significant changes to the program and will:
   1. Block the availability of federal funds to family planning providers that also offer abortion services;
   2. Prohibit sites that participate in Title X from referring pregnant clients to abortion providers;
   3. Eliminate current requirements for Title X sites to provide non-directive pregnancy options counseling that includes information about prenatal care/delivery, adoption, and abortion;
   4. Prioritize providers that offer comprehensive primary health care services over those that specialize in reproductive health services; and,
   5. Encourage participation by “non-traditional” organizations such as those that only offer one method of family planning, such as fertility awareness-based methods.

If implemented, the changes to Title X will shrink the network of participating providers and could reduce the scope of services offered to low-income and uninsured people that rely on Title X-funded clinics for their family planning care. The attorneys general from 23 states (including California), family planning organizations (including the sponsor of this resolution), and the American Medical Association filed legal challenges in federal court to block the implementation of the regulations, claiming the new rules violate the Constitution and federal law, restricts access to critical preventive health care and access to birth control, prohibits doctors from providing accurate information for patients and referrals for abortion, and will cause harm to patients and providers through dramatic alterations to the Title X program. The courts will likely make a decision on whether to stay the implementation before May 3.

FISCAL EFFECT: Appropriation: No Fiscal Com.: No Local: No

SUPPORT: (Verified 3/20/19)

Essential Access Health (source)

ACCESS Women’s Health Justice

Black Women for Wellness Action Project

California Latinas for Reproductive Justice

California Nurse-Midwives Association

California Pan-Ethnic Health Network

California Women’s Law Center

CaliforniaHealth+ Advocates

Clinica de La Raza

Coalition of Orange County Community Health Centers

Los Angeles LGBT Center

Los Angeles Trust for Children’s Health

National Health Law Program

Planned Parenthood Affiliates of California

TEACH

Women’s Foundation of California

OPPOSITION: (Verified 3/20/19)

None received

ARGUMENTS IN SUPPORT: Supporters of this resolution write that the Trump Administration’s recently released harmful and unlawful Title X regulations represent some of the most extreme policy changes proposed since Title X was established. The regulations would affect care delivered at all Title X-funded health centers in the state. If implemented, the regulations could delay access to comprehensive reproductive health care for low-income patients and devastate California's Title X network by: a) denying women information about their health options; b) disrupting the provider-patient relationship; c) deterring teens from accessing care; and, d) forcing qualified family planning providers to choose between a critical funding source and accepting onerous and unnecessary regulations. The regulations would also disproportionately affect communities of color and reverse the progress California has made in reducing unintended pregnancy rates.

Prepared by: Melanie Moreno / HEALTH / (916) 651-4111

3/20/19 15:47:28

**** END ****

SENATE COMMITTEE ON HEALTH

Senator Dr. Richard Pan, Chair

BILL NO: SJR 4

SUBJECT: Title X

SUMMARY:

Urges the United States Department of Health and Human Services to rescind the new Title X regulations.

This resolution:

1. Makes a number of findings related to the federal Title X family planning program, including:
   1. Title X is the sole federal program dedicated to funding family planning services, including birth control, pregnancy testing, and the prevention and treatment of sexually transmitted diseases and it supports outreach and education efforts that link community members to care;
   2. California’s Title X provider network, which is the largest and most diverse Title X system in the nation and an essential part of California’s family planning safety net, served more than one million low-income Californians in 2017 and services provided by clinics that received Title X funding in California helped patients avert over 200,000 unintended pregnancies in 2015;
   3. Over $1 billion is saved annually in California because of public investment in family planning and related services provided at Title X health care centers across the state;
   4. The new federal Title X regulations interfere with the provider-patient relationship and gag Title X funded agencies by directing providers to withhold full and accurate medical information from patients about pregnancy options or by prohibiting providers from giving patients referrals for abortion care;
   5. The federal government’s harmful Title X regulations are likely to force many health care organizations and qualified family planning providers in California to choose between a critical funding source and accepting onerous and unnecessary regulations, resulting in reduced access to quality, time-sensitive care for low-income individuals across the state; and,
   6. Patients rely on and trust their health care providers to provide a comprehensive, accurate, and unbiased evaluation of their condition, along with all available treatment options, and the American Medical Association’s Code of Medical Ethics establishes that withholding information without the patient’s knowledge or consent is ethically unacceptable and that patients should be informed of all burdens, risks, and expected benefits of all medical options.
2. Resolves, by the Senate and the Assembly of the State of California, jointly, the following:
   1. The Legislature respectfully urges the United States Department of Health and Human Services (HHS) to rescind the new Title X regulations that will impede access to essential, time-sensitive health care for low-income individuals across California and the nation; and,
   2. The Secretary of the Senate transmit copies of this resolution to the President and Vice President of the United States, to the Speaker of the House of Representatives, to the Majority Leader of the Senate, to each Senator and Representative from California in the Congress of the United States, to HHS, and to the author for appropriate distribution.

FISCAL EFFECT:

This resolution is keyed nonfiscal.

COMMENTS:

1. Author’s statement. According to the author, Title X is a federal program that supports the delivery of family planning and related services to low-income and uninsured patients. Services provided include birth control, pregnancy tests, sexually transmitted disease-related services, breast and cervical cancer screenings, and other essential services. California is home to the nation’s largest Title X provider network that serves 1,000,000 Californians annually – more than 25% of all Title X patients nationwide. Title X funds are distributed to 366 clinic sites in 38 California counties. Members of California’s Title X provider network include federally qualified health centers, city and county public health departments, Urban Indian Health Centers, academic medical centers, Planned Parenthood affiliates, and other family planning and women’s health centers. On March 4, 2019, the federal government posted to the Federal Register new regulations for the Title X program that threaten to impede access to vital, time-sensitive health care. To protect these services, this resolution sends a clear message to the federal government that California stands in strong support of comprehensive reproductive health care access and urges the federal government to rescind these new regulations.
2. Title X. According to HHS, The Title X National Family Planning Program, administered by the Office of Population Affairs (OPA), is the only federal program dedicated solely to supporting the delivery of family planning and related preventive health care. The program is designed to provide contraceptive supplies and information to all who want and need them, with priority given to persons from low-income families. In addition to offering a broad range of effective and acceptable contraceptive methods on a voluntary and confidential basis, Title X-funded service sites provide contraceptive education and counseling; breast and cervical cancer screening; sexually transmitted disease (STD) and HIV testing, referral, and prevention education; and pregnancy diagnosis and counseling. The program is implemented through competitively awarded grants to state and local public health departments and community health, family planning, and other private nonprofit agencies. For many clients, Title X providers are their only ongoing source of health care and health education. In fiscal year 2017, the Title X program received approximately $286.5 million in federal funding.
3. Family Planning Annual Report. The Family Planning Annual Report (FPAR) provides data on the demographic and social characteristics of Title X clients, their use of family planning and related preventive health services, staffing, and revenue. Key findings from the 2017 FPAR include:
   1. A diverse network of public and private nonprofit health and community service agencies delivers Title X services. Services were implemented through grants to 89 agencies: 47 state and local health departments and 42 nonprofit family planning and community health agencies. Providers served approximately four million family planning users through 6.6 million encounters;
   2. Title X providers serve mostly female, low income, and young clients. About 88% of Title X users were female, 65% were under 30 years of age, and 67% had family incomes at or below the federal poverty level (FPL);
   3. Title X providers serve a racially and ethnically diverse population. Thirty-one percent of users self-identified with at least one of nonwhite race categories (African American, Asian, Native Hawaiian or Pacific Islander, American Indian or Alaska Native, or more than one race) and 33% self-identified as Latino;
   4. Title X providers offer clients a range of safe, effective contraceptive methods. Among the 3.1 million female clients at risk of unintended pregnancy, 70% exited their last encounter with either a most effective (female sterilization, implant, or IUD) or moderately effective (injectable contraception, vaginal ring, contraceptive patch, pills, diaphragm, or cervical cap) contraceptive method;
   5. Title X-funded cervical and breast cancer screenings allow for early detection. Pap testing was conducted on 18% of female users, and 14% of those tests had an indeterminate or abnormal result requiring further evaluation. Providers performed clinical breast exams on 25% of female users and referred 5% of those examined for further evaluation based on abnormal findings;
   6. Title X-funded STD and HIV services provide testing necessary for preventing disease transmission and adverse health consequences. Providers tested 61% of female users under 25 for chlamydia. Providers also performed 2.4 million gonorrhea tests, 1.2 million HIV tests, and 709,161 syphilis tests; and,
   7. Title X projects rely on revenue from a variety of public and private sources. Grantees reported total project revenue of almost $1.3 billion to support their approved Title X services projects. Five sources accounted for 86% of total revenue: Medicaid (38% or $495.2 million), Title X (19% or $244.6 million), state and local governments (15% or $188.2 million), private third-party payers (11% or $140.1 million), and client service fees (4% or $52.4 million).
4. California Title X. Essential Access Health, the sponsor of this resolution, is the sole Title X grantee for California and received $20.5 million in federal fiscal year 2017. These funds were sub-granted to approximately 366 health center and 63 health care agencies. Thirty-eight of California’s 58 counties have Title X funded health care sites. Although California receives only about 8% of the nation’s Title X funding, approximately 25% of the program’s patients receive services in this state. Approximately 86% of California’s Title X patients have income below 150% of the federal poverty level, 50% are uninsured, and 66% are between the ages of 20 and 34.
5. HHS final rule. On March 4, 2019, HHS issued a final rule related to Title X to take effect on May 3, 2019. According to OPA, it issued this final rule to ensure compliance with, and enhance implementation of, the statutory requirement that none of the funds appropriated for Title X may be used in programs where abortion is a method of family planning. According to a March 2019 Kaiser Family Foundation Issue Brief, the final rule will make significant changes to the program and will:
   1. Block the availability of federal funds to family planning providers that also offer abortion services;
   2. Prohibit sites that participate in Title X from referring pregnant clients to abortion providers;
   3. Eliminate current requirements for Title X sites to provide non-directive pregnancy options counseling that includes information about prenatal care/delivery, adoption, and abortion;
   4. Prioritize providers that offer comprehensive primary health care services over those that specialize in reproductive health services; and,
   5. Encourage participation by “non-traditional” organizations such as those that only offer one method of family planning, such as fertility awareness-based methods.

If implemented, the changes to Title X will shrink the network of participating providers and could reduce the scope of services offered to low-income and uninsured people that rely on Title X-funded clinics for their family planning care. The attorneys general from 23 states (including California), family planning organizations (including the sponsor of this resolution), and the American Medical Association filed legal challenges in federal court to block the implementation of the regulations, claiming the new rules violate the Constitution and federal law, restricts access to critical preventive health care and access to birth control, prohibits doctors from providing accurate information for patients and referrals for abortion, and will cause harm to patients and providers through dramatic alterations to the Title X program. The courts will likely make a decision on whether to stay the implementation before May 3.

1. Support. Supporters of this resolution write that the Trump Administration’s recently released harmful and unlawful Title X regulations represent some of the most extreme policy changes proposed since Title X was established. The regulations would affect care delivered at all Title X-funded health centers in the state. If implemented, the regulations could delay access to comprehensive reproductive health care for low-income patients and devastate California's Title X network by: a) denying women information about their health options; b) disrupting the provider-patient relationship; c) deterring teens from accessing care; and, d) forcing qualified family planning providers to choose between a critical funding source and accepting onerous and unnecessary regulations. The regulations would also disproportionately affect communities of color and reverse the progress California has made in reducing unintended pregnancy rates.

SUPPORT AND OPPOSITION:

Support: Essential Access Health (sponsor)

California Pan-Ethnic Health Network

California Women’s Law Center

Clinica de La Raza

Coalition of Orange County Community Health Centers

CaliforniaHealth+ Advocates

Los Angeles LGBT Center

Los Angeles Trust for Children’s Health

National Health Law Program

TEACH

Women’s Foundation of California

Oppose: None received

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