Title X Family Planning Program Turns 50

Title X of the Public Health Service Act established the National Family Planning Program at HHS in 1970. For 50 years, Title X clinics have ensured access to a broad range of family planning methods and related health services for millions of women, men, and adolescents with priority given to persons from low-income families. These services are voluntary, confidential, and intended to assist in preventing or achieving pregnancy. Since the program’s inception, Title X clinics have provided more than 190 million client visits. 

Each decade has brought changes to the program but the dedication of Title X grantees to help clients meet their family planning goals has remained constant. Today, Title X grantees comprise a network of public and private nonprofit entities providing services to their communities in the U.S. and in eight U.S. territories and freely associated states.

Screening and Preventive Health Services. Title X-funded STD and HIV screening services prevent transimission and adverse health consequences. Title X Clinics Performed 1.9 HIV tests per 10 clients.

The program’s contribution to the prevention of sexually transmitted infections and related adverse health consequences is substantial. Our Family Planning Annual Report (FPAR) data show that from 1999 to 2019, Title X clinics performed 34.1 million chlamydia tests, 18.3 million HIV tests, and 76.5 million non-HIV STD tests. During this same period, Title X-funded cancer screenings provided 37 million Pap tests and 42 million clinical breast exams.

From 1970 to 2020, Title X grantees have served clients despite a variety of complex challenges. The U.S. Virgin Islands Department of Health Family Planning Program (VIFPP), which has received Title X funding since 1975, is an example of this resiliency. The devastating 2017 hurricanes Irma and Maria destroyed much of VIFPP’s materials and supplies. “We served patients in a flooded building on St. Thomas for weeks, and we had to evacuate our sites on both St. Thomas and St. Croix,” says the program director. “As soon as tents and tarps could be raised, we were seeing clients. We’re pretty tough.” Learn more about how Title X grantees tackle challenges.

Title X grantees are the key component of the program’s success. The grantees’ experience, dedication, resilience, and innovative flexibility are the foundation that will help them tackle future challenges. The onset of the COVID-19 pandemic in early 2020 created widespread and unprecedented hurdles for Title X grantees across the U.S. Many grantees implemented rapid response plans to provide high-quality healthcare while stay-at-home orders were in effect. Within days of the pandemic’s onset staff began planning for telehealth services. Soon thereafter clinics accessed clinical trainings and began providing services to clients by phone, video, curbside, and other innovative technologies.

Title X grantees are the key component of the program’s success. The grantees’ experience, dedication, resilience, and innovative flexibility are the foundation that will help them tackle future challenges. 

The most recent report from the CDC highlighted the grim reality that sexually transmitted infections reached an all-time high in 2018, marking the fifth consecutive year of increases for chlamydia, gonorrhea, and syphilis. Young women (ages 15-24) account for 44 percent of reported cases and face the most severe consequences of an undiagnosed infection. Optimal health for our clients requires that we adopt a patient-centered approach that sensitizes providers to identify and support each client’s care, recognizing that some methods very effective in preventing pregnancy, leave clients unprotected against sexually transmitted infections and make their ability to achieve pregnancy in the future more difficult.

Family planning was declared one of the top ten greatest public health achievements in the 20th century.  Access to these services has continued to assist many Americans achieve desired birth spacing and family size in the early years of this century. As we celebrate 50 years of Title X, we applaud the program’s accomplishments and embrace continued resiliency and innovative change.  We look with confidence and excitement towards a bright future of promoting health across the reproductive lifespan.

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    Presented is GAO's Performance and Accountability Report for fiscal year 2020. In the spirit of the Government Performance and Results Act, this annual report informs the Congress and the American people about what we have achieved on their behalf. The financial information and the data measuring GAO's performance contained in this report are complete and reliable. This report describes GAO's performance measures, results, and accountability processes for fiscal year 2020. In assessing our performance, we compared actual results against targets and goals that were set in our annual performance plan and performance budget and were developed to help carry out our strategic plan. An overview of our annual measures and targets for 2020 is available here, along with links to a complete set of our strategic planning and performance and accountability reports. This report includes A Fiscal Year 2020 Performance and Financial Snapshot for the American Taxpayer, an introduction, four parts, and supplementary appendixes as follows: A Fiscal Year 2020 Performance and Financial Snapshot for the American Taxpayer This section provides an overview of GAO's performance and financial information for fiscal year 2020 and outlines GAO's near-term and future work priorities. Introduction This section includes the letter from the Comptroller General and a statement attesting to the completeness and reliability of the performance and financial data in this report and the effectiveness of our internal control over financial reporting. This section also includes a summary discussion of our mission, strategic planning process, and organizational structure, strategies we use to achieve our goals, and process for assessing our performance. Management's Discussion and Analysis This section discusses our agency-wide performance results and use of resources in fiscal year 2020. It also includes, among other things, information on our internal controls and the management challenges and external factors that affect our performance. Performance Information This section includes details on our performance results by strategic goal in fiscal year 2020 and the targets we are aiming for in fiscal year 2021. Financial Information This section includes details on our finances in fiscal year 2020, including a letter from our Chief Financial Officer, audited financial statements and notes, and the reports from our external auditor and Audit Advisory Committee. This section also includes an explanation of the information each of our financial statements conveys. Inspector General's View of GAO's Management Challenges This section includes our Inspector General's perspective on our agency's management challenges. Appendixes This section provides the report's abbreviations and describes how we ensure the completeness and reliability of the data for each of our performance measures. For more information, contact Timothy Bowling (202) 512-6100 or bowlingt@gao.gov.
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    In U.S GAO News
    The Department of Defense (DOD) has reviewed the financial assistance it provides for off-base child care services and taken steps to standardize this assistance across the military services. Specifically, in August 2018, representatives of each service agreed to work toward a goal of standardizing the only element of the fee assistance calculation that varies among the services—the maximum provider rate. DOD officials said that they assess progress toward this goal each year, but have not set a definite deadline for full standardization. With respect to assistance for off-base child care at high-cost duty stations, DOD's 2020 report on its child care programs states that the Air Force, Marines, and Navy review high-cost locations annually, and the services may approve increased provider rate caps for specific high-cost locations. In addition, it states that the services may grant waivers allowing increased fee assistance for individual families experiencing hardship. DOD has also assessed factors that contribute to wait lists for on-base child care. According to DOD’s report, DOD found that wait lists are the result of a myriad of factors, including staff shortages and facility conditions that vary across service locations. Officials said DOD has worked for several years to analyze and address wait lists. In 2017, DOD launched a web portal that consolidates child care data across the services and in August 2019, DOD officials began monthly monitoring of wait list data from this portal. These data allowed DOD to identify four geographic regions and six additional locations that account for the majority of wait lists, and focus their efforts on addressing the issues affecting these regions and locations, according to the report. DOD officials said that any requests for additional resources to help address wait lists must be handled through the individual services’ budgeting processes. DOD offers child care in a variety of on- and off-base settings for children of military families. In fiscal year 2020 these child care programs received nearly $1.2 billion in federal funds; in addition, parents pay a portion of the costs. The National Defense Authorization Act for Fiscal Year 2020 required DOD to report on elements of its financial assistance to off-base child care providers and wait lists for on-base child care, and included a provision for GAO to review DOD's report. This report describes DOD's assessment of (1) financial assistance provided to off-base child care providers, and (2) its efforts to reduce wait lists for child care at military bases. GAO reviewed DOD's report on this assessment, interviewed DOD officials, and reviewed relevant federal law. For more information, contact Kathryn A. Larin at (202) 512-7215 or larink@gao.gov.
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    What GAO Found Individuals who receive assistance from the federal Supplemental Security Income (SSI) program may also become eligible for Medicaid. SSI provides cash assistance to eligible individuals who are over age 65, blind, or disabled; and who have limited resources (i.e., assets) and income. Medicaid programs in 42 states and the District of Columbia use the SSI asset limit of $2,000 for an individual or $3,000 for a married couple. Medicaid programs in the remaining eight states may set an asset limit that differs from the current SSI asset limit. The Social Security Administration (SSA), which administers the SSI program, and state Medicaid programs electronically verify the assets of these individuals when determining financial eligibility: In the 42 states and the District of Columbia that use the SSI asset limit, SSA is the entity that verifies applicants' assets. SSA has two data sources to detect assets among SSI beneficiaries. The first data source is the Access to Financial Institutions initiative. This initiative verifies reported bank accounts and can detect potential undisclosed accounts from financial institutions within geographic proximity of an SSI recipient's residence. The second data source is Non-home Real Property, which uses a commercial data source to help investigate potential ownership of real property other than a primary residence. In the eight states that may set their own asset limits, the state's Medicaid program must verify Medicaid eligibility for SSI recipients using an electronic asset verification system (AVS). An AVS provides a portal between state eligibility systems and banks or other third-party systems with electronic access to financial information. Once a state has an AVS in place, state eligibility workers can submit a request through the portal to perform an asset check for a Medicaid applicant. The request is sent to different financial institutions. A vendor gathers the information from the financial institutions and returns it to the state, and eligibility workers use the information to make an eligibility determination. Some states also use their AVS to check on applicants' property information, which may come from commercial data sources. Why GAO Did This Study GAO was asked to review the use of electronic asset verification to determine eligibility for selected Medicaid beneficiaries. This report provides an overview of what is known about how state Medicaid programs verify assets of applicants who are eligible because they receive SSI, and how SSA verifies assets of SSI applicants, among other issues. To describe what is known about how state Medicaid programs and SSA verify applicants' assets, GAO reviewed its prior work, as well as related research by other organizations. GAO also obtained input from officials from the Centers for Medicare & Medicaid Services and SSA; and reviewed relevant federal laws, regulations, and guidance. The Department of Health and Human Services and SSA reviewed a draft of this report and provided technical comments, which GAO incorporated as appropriate. For more information, contact Carolyn L. Yocom at (202) 512-7114 or yocomc@gao.gov.
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    What GAO Found In 2019, the Department of Energy's (DOE)'s National Nuclear Security Administration (NNSA) provided a report to Congress on its findings from its survey of the seven contractors that manage and operate its nuclear security enterprise sites to identify requirements the contractors viewed as burdensome. This survey was congressionally mandated after reports by external groups found that the environment in which NNSA carried out its oversight of such management and operating (M&O) contractors was strained. GAO reviewed information on the following three areas related to NNSA's report: Comparison of NNSA's findings with related reports. GAO found that during the past 10 years, three external groups carried out studies and assessments of the nuclear security enterprise and issued reports citing ways NNSA's oversight has contributed to burden for M&O contractors. These groups were all directed by Congress to complete their studies, which were published between 2014 and 2020. Their reports also cite ways in which NNSA's oversight may have contributed to increased costs or reduced mission capabilities. NNSA's Burdensome Regulatory Requirements report explicitly identifies 91 requirements that M&O contractors found burdensome; these include requirements found in sources such as DOE and NNSA directives, federal regulations, and statutes. NNSA's approach to collecting and reporting information on requirements that M&O contractors identified as burdensome. NNSA first collected information on the requirements the contractors viewed as burdensome, and second, asked the contractors to rate these requirements based on the likelihood that the requirement could be changed and the effects such a change would have on cost savings, morale, recruitment and retention, and mission capability. While NNSA did not provide a definition to its contractors of what constituted a "burdensome" requirement, some contractors created their own definitions, while others told us the definition was understood based on the previously published related reports. GAO interviewed M&O contractor representatives and found that their definitions of what constituted a "burdensome requirement" varied. Also, the seven M&O contractors used different approaches to identify and rate requirements they considered burdensome. However, multiple M&O contractors identified the same requirements, or sources of those requirements, as burdensome. For example, one contractor identified the entire DOE Order for Program and Project Management of the Acquisition of Capital Assets (DOE Order 413.3B) as burdensome, while another contractor identified specific requirements within the same order as burdensome. NNSA actions to address matters that M&O contractors identified as burdensome. In its report, NNSA included a list of 16 matters that it committed to reviewing based on the rating data it collected from M&O contractors and input from members of the Operations and Efficiencies Board, an internal body established to improve coordination and collaboration across NNSA's sites. According to NNSA officials, 10 matters are under revision or have been changed; two matters were reviewed, but no changes were made; and four matters were reviewed, and M&O contractor input will be considered should the regulation undergo a revision in the future. NNSA's list of matters included DOE directives, federal requirements, and an M&O contract change. According to agency officials, NNSA chose to prioritize its review of certain matters because the agency did not have the resources to review all 91 requirements that M&O contractors identified as burdensome. NNSA provided technical comments on a draft of this report, which were incorporated as appropriate. Why GAO Did This Study NNSA is responsible for maintaining a safe, secure, and reliable nuclear stockpile and relies on and oversees contractors who manage and operate its laboratory and production sites. NNSA's M&O contracts include requirements for contractors to adhere to laws, regulations, and DOE and NNSA directives. NNSA also has processes to hold contractors accountable for meeting these requirements. Senate Report 115-262, accompanying the John S. McCain National Defense Authorization Act for Fiscal Year 2019, directed NNSA to collect information from its M&O contractors on specific requirements they deemed particularly burdensome and to publish this information in a report. Senate Report 115-262 also included a provision for GAO to review NNSA's report. GAO's report provides information on (1) a comparison of NNSA's findings with findings reported by external groups, (2) NNSA's approach to collecting and reporting information on requirements the M&O contractors identified as burdensome, and (3) NNSA's actions to address the requirements that the M&O contractors identified. GAO reviewed NNSA's 2019 report and supplemental documents and interviewed NNSA officials and M&O contractor representatives. For more information, contact Allison Bawden at (202) 512-3841 or bawdena@gao.gov.
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    In U.S GAO News
    Data collected through the Point-in-Time (PIT) count—a count of people experiencing homelessness on a single night—have limitations for measuring homelessness. The PIT count is conducted each January by Continuums of Care (CoC)—local homelessness planning bodies that apply for grants from the Department of Housing and Urban Development (HUD) and coordinate homelessness services. The 2019 PIT count estimated that nearly 568,000 people (0.2 percent of the U.S. population) were homeless, a decline from the 2012 count of about 621,500 but a slight increase over the period's low of about 550,000 in 2016. While HUD has taken steps to improve data quality, the data likely underestimate the size of the homeless population because identifying people experiencing homelessness is inherently difficult. Some CoCs' total and unsheltered PIT counts have large year-over-year fluctuations, which raise questions about data accuracy. GAO found that HUD does not closely examine CoCs' methodologies for collecting data to ensure they meet HUD's standards. HUD's instructions to CoCs on probability sampling techniques to estimate homelessness were incomplete. Some CoC representatives also said that the assistance HUD provides on data collection does not always meet their needs. By strengthening its oversight and guidance in these areas, HUD could further improve the quality of homelessness data. To understand factors associated with homelessness in recent years, GAO used PIT count data to conduct an econometric analysis, which found that rental prices were associated with homelessness. To mitigate data limitations, GAO used data from years with improved data quality and took other analytical steps to increase confidence in the results. CoC representatives GAO interviewed also identified rental prices and other factors such as job loss as contributing to homelessness. Estimated Homelessness Rates and Household Median Rent in the 20 Largest Continuums of Care (CoC), 2018 Note: This map shows the 20 largest Point-in-Time counts by CoC in 2018. GAO estimated 2018 homelessness rates because the U.S. Census Bureau data used to calculate these rates were available up to 2018 at the time of analysis. GAO used 2017 median rents (in 2018 dollars) across all unit sizes and types. Policymakers have raised concerns about the extent to which recent increases in homelessness are associated with the availability of affordable housing. Moreover, counting the homeless population is a longstanding challenge. GAO was asked to review the current state of homelessness in the United States. This report examines (1) efforts to measure homelessness and HUD's oversight of these efforts and (2) factors associated with recent changes in homelessness. GAO analyzed three HUD data sources on homelessness and developed an econometric model of the factors influencing changes in homelessness. GAO also conducted structured interviews with 12 researchers and representatives of 21 CoCs and four focus groups with a total of 34 CoC representatives responsible for collecting and maintaining homelessness data. CoCs were selected for interviews and focus groups to achieve diversity in size and geography. GAO also visited three major cities that experienced recent increases in homelessness. GAO recommends that HUD (1) conduct quality checks on CoCs' data-collection methodologies, (2) improve its instructions for using probability sampling techniques to estimate homelessness, and (3) assess and enhance the assistance it provides to CoCs on data collection. HUD concurred with the recommendations. For more information, contact Alicia Puente Cackley at (202) 512-8678 or cackleya@gao.gov.
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