Submitted via www.regulations.gov  

Andrew Reisig & Joel Savary
Office of Federal Financial Management
Office of Management and Budget
725 17th Street, NW
Washington, DC 20503 

RE: Docket No. OMB-2026-0034, Regulation for Federal Financial Assistance, 91   Fed. Reg. 32198 (May 29, 2026). 

Dear Mr. Reisig and Mr. Savary, 

The Reproductive Freedom Alliance (RFA) submits these comments to urge the Office of Management and Budget (OMB) and the Department of Health and Human Services (HHS) to jointly withdraw their proposed regulation for federal financial assistance.  As a nonpartisan coalition of 24 governors,1 the RFA is deeply concerned that this proposed rule could result in a reduction of critical federal support for reproductive health care across the country, including maternal health and contraceptive care in rural communities, and destabilize the functioning of essential reproductive health programs throughout the nation. 

As an alliance committed to expanding and protecting access to reproductive health care, RFA has focused its comment specifically on the harms this proposed rule would have on the ability of states to provide a stable, effective health care system responsive to the reproductive health needs of residents. If implemented, the proposed rule would destabilize successful grantee projects by changing termination rules, endanger the ability of providers to deliver care to different communities, and significantly reshape and politicize merit-based grantmaking processes while damaging the ability of researchers and health care providers to develop scientific and medical advances. RFA is also concerned about the speed with which a major rule of this nature is being rolled out and urges OMB to provide additional time for the public to provide meaningful comment to this rulemaking. 

1. The proposed rule would create new authority to arbitrarily terminate, pause, or modify already-awarded funding, threatening the stability of state budgets, health care providers, research initiatives, future planning efforts, and the pipeline of future health care provision and research. 

States often seek grants to support the reproductive health of their residents and subgrants those funds to direct service providers.2 The proposed rule jeopardizes states’ ability to maintain stable access to care and to support critical service providers in their states by removing guardrails on discretionary termination authority. Instead, the rule would permit agencies to unilaterally terminate discretionary grants based on political considerations, even where the award terms never reserved that right, and the grantee did not have advance notice. Grant funding stability is a critical component of effective grant-making—without confidence that grants will be fully funded, grantees will not have the ability to hire grant-funded positions and invest in talent development and longer-term grant funded research or projects.   

For example, many states maintain Perinatal Quality Initiatives, dedicated to improving maternal health, which are in part funded by the CDC.3 Those grants are further sub-granted to stakeholders, including health care providers, hospitals, localities and community-based organizations that have records of improving maternal and infant health.4 Indeed, experts have long found that “[c]ommunity-based organizations (CBOs) are uniquely positioned to excel in providing maternal health care. Not only do they tailor their services and outreach to meet the needs of the communities in which they are located, but their providers and staff are part of those communities themselves.”5 However, under the proposed rule, if any administration at any particular time decides that the state’s program or any of its partner organizations are politically disfavored, the entire program could be terminated with no cause and no notice. This would be devastating to the critical work of these entities, which work to improve the quality of care for mothers and babies, reduce complications and improve overall health.6  

Other programs funded by federal Maternal Health Innovation grants, Safe Motherhood and Infant grants, and Rural Maternal Health grants similarly pair critical health service providers with state and local governments to improve services and care over time. These programs rely on staffing, strategic plans, and clear implementation goals to succeed and demonstrate impact, but without stable, multi-year support in their funding, the many institutions that must commit to a course of action to make any of these programs successful may not be willing to participate in them. 

1. The proposed rule may make it more difficult to effectively address community-specific health challenges. 

For many years, health care providers and all levels of government have tried to determine which communities or populations are impacted most by different health concerns so that solutions can be tailored to address a particular community’s problem most effectively. HRSA, for example, states that “[p]regnancy-related problems are serious issues in the United States [and t]hese problems affect different groups of people in different ways.”7 This often requires collecting demographic information from program recipients and using that information to tailor program elements.8  More than two decades ago, HHS developed the Healthy People 2010 set of goals, which sought to address health disparities across demographic groups. 9 The goals of those interventions included ensuring the efficient and effective use of government resources, applying the right programs in the right places to get the best possible outcomes.  

• 200.218 of the proposed rule, however, appears to restrict the use of federal funds to “conduct[] statistical or demographic analysis for internal program evaluation, research or other purposes,” even if that analysis is critical to ensuring the efficacy of a program.10 This provision apparently runs counter to longstanding health goals by creating confusion about the ability of agencies to collect data that would inform states’ understanding of a particular community’s health challenges and whether the programs put in place are effective. Such a restriction could also run counter to statutory requirements associated with particular federal programs, which in many cases require the collection and analysis of such data. RFA is concerned that such a restriction, which does not address the many possible statutory conflicts, will cause confusion and result in worse health outcomes. At a minimum, OMB should clarify the language of this section of the proposed rule.

1. The proposed rule appears to impose an expansive duty upon grantees to refrain from public education activities in ways that may chill or entirely prevent effective health care providers from participating in federally funded programs.  

Many health care providers, particularly those that serve low-income or otherwise underserved populations, often include a community education element in their service, to reach those who may otherwise not seek care or not know that they can seek care.11 Under the National Voter Registration Act of 1993, state agencies that offer public assistance, including Medicaid and Medicare services, must offer voter registration, and many other health care providers choose to offer voter registration cards, including hospitals and health centers that serve low-income communities. 12 

Current OMB guidance already prohibits grantees from including costs for advocacy on legislation or efforts to “improperly” influence federal rules or grants. §200.450 of the proposed rule not only bars costs for any type of public education “not necessary” for the grant objectives, it requires agencies “to avoid even the appearance of supporting such prohibited activity,” potentially chilling health care providers from providing public education about a range of reproductive and public health issues and from engaging in legally permissible or even mandated voter registration activities.  

1. The proposed rule threatens to politicize all covered federal grant awards and could seriously limit access to reproductive health care. 

Federal funding for health care services and research has become critical both to the existing safety net and to future health care developments.13  Federal funding supports research on new models and funds necessary points of care.14 Rural health care in particular requires effective investment from federal and state government along with private sector partnerships to address longstanding access challenges.15  While some federal funding comes through separately funded programs like Medicaid and Medicare, many federal grant programs exist to spark innovation, like those through the Health Resources and Services Administration (HRSA), which funds efforts to “build health care capacity, strengthen rural health networks, support rural hospitals, and address workforce shortages.”16  

Health innovations build upon themselves with the support of long-term investments and expertise both within and outside government funding decisions therefore should not be subject solely to the political priorities of a particular administration.  Grant programs created by Congress should be administered in service of those program’s goals, not in service of a particular administration’s political objectives.  However, we are concerned that this proposed rule would require political appointee review of any grant application and potential rejection of grant applications not because they are unlikely to achieve the purposes of the grant or based on the merit of their proposal, but because the current administration does not approve of their policy positions, political activities, or even affiliations and associations.17  

Moreover, RFA is also concerned that the proposed rule appears to encourage civil society groups that opposed previously issued grants or grantees to partner with the federal government in litigation against those grantees—even though the federal government itself was the source of the grant.18  This raises serious concerns about the federal government’s role as both grantor and adversary of its grantees.19 The role of the federal government has been and must continue to be to fund effective research and services through appropriately reviewed grant applications that are intended to affect the purposes approved by Congress and the President. It should not be to use political beliefs and the courts to target disfavored potential and current grantees.  

Reproductive health care services are fundamental to overall women’s health and, by extension, the health of their children and families.20 However, reproductive health care is often politicized, with politicians and political appointees taking personal positions on health care that are at odds with clear medical evidence and best practices.21  If political appointees may follow political priorities rather than statutory program purposes, access to basic and well-established reproductive health care could be threatened as longstanding providers of care may be targeted and lose funding for political rather than evidence-based reasons.   

One of RFA’s many concerns with the proposed rule is that it jeopardizes the continued availability of contraception, despite its well-recognized benefits: 

Access to contraception is positively tied to other health outcomes, including lower maternal and infant mortality rates, reduced preterm births, and lower rates of reproductive cancers. Research suggests that contraceptive access improves economic and educational outcomes for women — including 20 percent higher college enrollment, higher wages, and lower rates of poverty. In 2024, eight in 10 women of reproductive age, or ages 18 to 49, reported using some form of contraception in the previous 12 months, and four in five Americans supported legislation to protect access. As well as being politically popular, contraceptives are cost effective: every dollar spent on contraceptive services saves nearly six dollars in public spending. 22  

Contraception has been funded by federal and state governments for over fifty years on a bipartisan basis through Title X and a number of other programs.23 Nonetheless, the current administration has already begun to apply political standards to federal contraceptive programs. For example, a recent Notice of Funding Opportunity for Title X—the most significant source of federal funding for contraception aside from Medicaid—stated that political appointees would have to sign off on each grant and that the grant priorities would change, despite what litigants are arguing are inconsistencies with the statute and other regulations.24  Under the similar politicized standards articulated both in this proposed rule and in the new Title X Notice of Funding Opportunity, we are concerned that any grant that is intended to increase access to reproductive health care that includes contraception may be unable to achieve its grant goals if the political appointee tasked with evaluating the program has a political or even personal objection to contraception or otherwise disagrees with the aims of the program.25   

Furthermore, federal funding is a critical component of medical and scientific advancements in the United States. Investments through the National Institutes for Health (NIH), CDC and other health agencies have resulted in medical breakthroughs, scientific discoveries, and improvements in overall population health.26 However, there has been an insufficient investment in women’s health and reproductive health in particular. In recognition of this, the NIH directed an assessment of women’s health research, which concluded that “research on women’s health conditions, including those that are female specific . . . is severely lacking [and that] [m]edical advances for women have lagged.”  The assessment recommended that priorities for women’s health research should be “data driven and include input from the scientific and practitioner communities and the public,” including by using “data-driven methods, such as epidemiologic studies and disability or quality-adjusted life years, to assess the public health effect of conditions that are female specific, disproportionately affect women, or affect women differently.”27   

• 200.205(c) of the proposed rule would require that political appointees “not ministerially ratify or routinely defer to the recommendations of others,” and “must instead use their independent judgment when evaluating Federal award proposals.”  91 Fed. Reg. 32,249. As a result, political appointees may consider but not defer to expert judgment – even though they may not be experts themselves or may not be experts in the particular scientific or medical area at issue.

As a result, this proposed rule has the potential to reduce research on women’s health and stifle scientific discoveries by making all research funding governed by this rule subject to the discretion of political appointees and making clear that the political appointee’s judgement is determinative.28 This could impact reproductive health care, including contraception, fertility care, or research having to do with pregnancy, including miscarriages. While currently this may include political appointees calling into question, without any basis, medications like mifepristone or different forms of hormonal contraception, future administrations may target other types of reproductive health care that for whatever reason are politically disfavored at that time. This type of political decision making should have no place in the determination of how best to use scarce public dollars to improve health care outcomes.   

Finally, §200.477 of the proposed rule appears to attempt to expand the reach of the Hyde Amendment, a budget appropriation rider that is typically attached to Medicaid in the federal budget. While Hyde and other federal statutes already prohibit federal funding in many programs from being used to pay for abortion services, this proposed rule goes further and is far more vague than existing regulations or statutes. The proposed rule includes a new cost principle providing that “[c]osts associated with elective abortions are unallowable, except as expressly authorized by Federal law.” This language appears to expand abortion funding bans beyond federal statutes and may more generally impact access to grant funding for health care providers, because “costs associated with” is undefined, discouraging the provision of comprehensive reproductive health care due to fear of non-compliance.  

1. Conclusion. 

RFA is committed to ensuring that federal and state health programs remain grounded in scientific expertise and objective evaluation and provide administrative stability. The proposed rule would introduce significant uncertainty into federal grantmaking, diminish the role of evidence-based decision-making, and politicize critical grant streams that provide access to essential health care for communities. For these reasons, RFA urges OMB, HHS and the other 41 co-signing agencies to withdraw the proposed revisions to the Uniform Guidance.  Further, RFA reiterates that the time frame for this major role is insufficient, and we urge OMB to provide additional time for the public to provide meaningful comment to this rulemaking.   

Respectfully submitted,  

Christina Chang  

Executive Director  

Reproductive Freedom Alliance