[House Hearing, 107 Congress]
[From the U.S. Government Publishing Office]



 
   WELFARE REFORM: A REVIEW OF ABSTINENCE EDUCATION AND TRANSITIONAL 
                           MEDICAL ASSISTANCE
=======================================================================

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED SEVENTH CONGRESS

                             SECOND SESSION

                               __________

                             APRIL 23, 2002

                               __________

                           Serial No. 107-104

                               __________

       Printed for the use of the Committee on Energy and Commerce


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 house








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                               __________
                    COMMITTEE ON ENERGY AND COMMERCE

               W.J. ``BILLY'' TAUZIN, Louisiana, Chairman

MICHAEL BILIRAKIS, Florida           JOHN D. DINGELL, Michigan
JOE BARTON, Texas                    HENRY A. WAXMAN, California
FRED UPTON, Michigan                 EDWARD J. MARKEY, Massachusetts
CLIFF STEARNS, Florida               RALPH M. HALL, Texas
PAUL E. GILLMOR, Ohio                RICK BOUCHER, Virginia
JAMES C. GREENWOOD, Pennsylvania     EDOLPHUS TOWNS, New York
CHRISTOPHER COX, California          FRANK PALLONE, Jr., New Jersey
NATHAN DEAL, Georgia                 SHERROD BROWN, Ohio
RICHARD BURR, North Carolina         BART GORDON, Tennessee
ED WHITFIELD, Kentucky               PETER DEUTSCH, Florida
GREG GANSKE, Iowa                    BOBBY L. RUSH, Illinois
CHARLIE NORWOOD, Georgia             ANNA G. ESHOO, California
BARBARA CUBIN, Wyoming               BART STUPAK, Michigan
JOHN SHIMKUS, Illinois               ELIOT L. ENGEL, New York
HEATHER WILSON, New Mexico           TOM SAWYER, Ohio
JOHN B. SHADEGG, Arizona             ALBERT R. WYNN, Maryland
CHARLES ``CHIP'' PICKERING,          GENE GREEN, Texas
Mississippi                          KAREN McCARTHY, Missouri
VITO FOSSELLA, New York              TED STRICKLAND, Ohio
ROY BLUNT, Missouri                  DIANA DeGETTE, Colorado
TOM DAVIS, Virginia                  THOMAS M. BARRETT, Wisconsin
ED BRYANT, Tennessee                 BILL LUTHER, Minnesota
ROBERT L. EHRLICH, Jr., Maryland     LOIS CAPPS, California
STEVE BUYER, Indiana                 MICHAEL F. DOYLE, Pennsylvania
GEORGE RADANOVICH, California        CHRISTOPHER JOHN, Louisiana
CHARLES F. BASS, New Hampshire       JANE HARMAN, California
JOSEPH R. PITTS, Pennsylvania
MARY BONO, California
GREG WALDEN, Oregon
LEE TERRY, Nebraska
ERNIE FLETCHER, Kentucky

                  David V. Marventano, Staff Director

                   James D. Barnette, General Counsel

      Reid P.F. Stuntz, Minority Staff Director and Chief Counsel

                                 ______

                         Subcommittee on Health

                  MICHAEL BILIRAKIS, Florida, Chairman

JOE BARTON, Texas                    SHERROD BROWN, Ohio
FRED UPTON, Michigan                 HENRY A. WAXMAN, California
JAMES C. GREENWOOD, Pennsylvania     TED STRICKLAND, Ohio
NATHAN DEAL, Georgia                 THOMAS M. BARRETT, Wisconsin
RICHARD BURR, North Carolina         LOIS CAPPS, California
ED WHITFIELD, Kentucky               RALPH M. HALL, Texas
GREG GANSKE, Iowa                    EDOLPHUS TOWNS, New York
CHARLIE NORWOOD, Georgia             FRANK PALLONE, Jr., New Jersey
  Vice Chairman                      PETER DEUTSCH, Florida
BARBARA CUBIN, Wyoming               ANNA G. ESHOO, California
HEATHER WILSON, New Mexico           BART STUPAK, Michigan
JOHN B. SHADEGG, Arizona             ELIOT L. ENGEL, New York
CHARLES ``CHIP'' PICKERING,          ALBERT R. WYNN, Maryland
Mississippi                          GENE GREEN, Texas
ED BRYANT, Tennessee                 JOHN D. DINGELL, Michigan,
ROBERT L. EHRLICH, Jr., Maryland       (Ex Officio)
STEVE BUYER, Indiana
JOSEPH R. PITTS, Pennsylvania
W.J. ``BILLY'' TAUZIN, Louisiana
  (Ex Officio)

                                  (ii)








                            C O N T E N T S

                               __________
                                                                   Page

Testimony of:
    Del Rosario, Jacqueline Jones, Executive Director, 
      ReCapturing the Vision International.......................    41
    Kaplan, David W., Head of Adolescent Medicine, Professor of 
      Pediatrics, University of Colorado School of Medicine......    53
    Mann, Cindy, Senior Fellow, the Kaiser Commission on Medicaid 
      and the Uninsured..........................................    57
    McIlhaney, Joe S., Jr., the Medical Institute for Sexual 
      Health.....................................................    47
    Scanlon, William J., Director, Health Care Issues, U.S. 
      General Accounting Office..................................    64
Material submitted for the record by:
    American Civil Liberties Union, prepared statement of........   107
    American Hospital Association, prepared statement of.........   109
    Diggs, John R., prepared statement of........................   109
    Golden, Alma L., prepared statement of.......................   112
    Richards, Cory L., Alan Guttmacher Institute, letter dated 
      May 1, 2002................................................   114

                                 (iii)

  


   WELFARE REFORM: A REVIEW OF ABSTINENCE EDUCATION AND TRANSITIONAL 
                           MEDICAL ASSISTANCE

                              ----------                              


                        TUESDAY, APRIL 23, 2002

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 3 p.m., in 
room 2322, Rayburn House Office Building, Hon. Michael 
Bilirakis presiding.
    Members present: Representatives Bilirakis, Upton, 
Greenwood, Norwood, Buyer, Pitts, Tauzin (ex officio), Brown, 
Waxman, Strickland, Barrett, Hall, Stupak and Green.
    Also present: Representative Harman.
    Staff present: Erin Kuhls, majority counsel; Steven Tilton, 
health policy coordinator; Eugenie Edwards, legislative clerk; 
Amy Hall, minority professional staff member, John Ford, 
minority counsel; Bridgett Taylor, minority professional staff 
member; Karen Folk, minority professional staff member; and 
Jessica McNiece, staff assistant.
    Mr. Bilirakis. I now call to order this hearing of the 
Health Subcommittee and would like to thank our witnesses for 
taking the time to appear before us today and I feel sure that 
your testimony will prove valuable as we consider reauthorizing 
our Nation's welfare laws.
    The Personal Responsibility and Work Opportunity 
Reconciliation Act of 1996 reformed our Nation's welfare laws 
to put an emphasis on work and end the seemingly endless cycle 
of dependence that was present under the old Aid to Families 
with Dependent Children program.
    The Health Subcommittee has jurisdiction over two areas of 
this landmark legislation which will be the focus of today's 
hearing. The issues that we're considering today are accurately 
captured, I feel, by the title of the 1996 law. Personal 
responsibility is encompassed by the funding provided to Title 
V of the Social Security Act related to abstinence only 
education. Title V allocated $50 million for fiscal years 1998 
to 2002 for block grants to States for development of 
abstinence only education programs. To date, 49 of the 50 
States have elected to participate in this program and I think 
this suggests that States have a high interest in abstinence 
only education programs.
    I'm very pleased that my own Satte of Florida has elected 
to participate in this program. In fact, today we will hear 
from Jacqueline Del Rosario who will provide our subcommittee 
with valuable real world and I underline real world data on 
Florida's experience. So often up here in Washington we don't 
have the opportunity to hear from experts like Ms. Del Rosario 
who have real world exposure. Again, I welcome you particularly 
Ms. Del Rosario. I'm anxious to hear more about the near 100 
percent success that your program has achieved with respect to 
limiting teen pregnancy rates.
    Transitional medical assistance is the second component, 
God knows, a very significant one the 1996 law that is under 
this subcommittee's jurisdiction. As we all know, the costs of 
health insurance continue to rise. Many low income individuals 
who move from welfare to work often take low wage jobs that do 
not offer private health insurance coverage. Transitional 
medical assistance extends Medicaid coverage to these former 
welfare recipients for up to 1 year after they leave the rolls. 
Obviously, the potential loss of one's health insurance would 
be a significant disincentive to leaving welfare and entering 
the work force. Transitional medical assistance removes this 
barrier and ensures people do not have to sacrifice their 
health care in order to enter the work force.
    I would like to again thank our witnesses for appearing 
before us today and now I'm pleased to recognize the ranking 
member, Mr. Brown, for his opening statement.
    Mr. Brown. Thank you, Mr. Chairman, I want to welcome our 
witnesses, thank you for joining us today.
    Although there's no funding for the transitional medical 
assistance program in the Republican budget blueprint, 
reauthorization of this program isn't or shouldn't be a 
partisan issue. I appreciate your willingness, Mr. Chairman, 
and Chairman Tauzin's willingness to focus on TMA this 
afternoon.
    The President's budget includes funding for 1-year 
extension of TMA because to quote their budget document ``this 
coverage helps ensure the work pays for families by preventing 
them from losing their health coverage when they start jobs.'' 
Well put, but actually, the fundamental goal of welfare to work 
is not to increase the number of individuals who enter the 
workplace, it's to increase the number of individuals who stay 
in the workplace. Employers who have hired welfare recipients 
have stated that access to help insurance is one of the five 
most important factors that keep those workers on the job. The 
TMA program makes sense. There are steps we can take to 
strengthen and improve the program that also makes sense.
    TANF has a 5-year authorization. TMA should be a 5-year 
authorization too. TMA is weighed down by some counter-
productive regulatory requirements. I know how much my friends 
on the other side of the aisle hate government regulations. 
Here's a golden opportunity to eliminate some of them.
    Let me give one example. Even though TMA recipients are 
eligible for 6 months regardless of income, these recipients 
must periodically go to the welfare office to report their 
income so individuals who are newly employed must take several 
days off from work to report information irrelevant, really 
irrelevant to their TMA eligibility or they will lose their TMA 
eligibility. We need to do something about that and other 
needless hurdles that compromise the reach and the 
effectiveness of the program.
    There's another logical step that we can take. We can 
restore Medicaid eligibility to legal immigrants, banning legal 
immigrant families, families that work here, pay taxes here 
just like all of us in this room, banning legal immigrant 
families from the Medicaid program is unfair, it's arbitrary 
and it's foolish. Reducing the number of uninsured is a 
bipartisan goal. You can search high and low and not find a 
more effective way to contravene that goal than by excluding 
legal immigrants from Medicaid. Immigrants are more than twice 
as likely to be uninsured as non-immigrants. Our colleagues, 
Mr. Waxman and Mr. Diaz-Balart, have introduced legislation, 
H.R. 1143 which would remove that Medicaid ban. If we took no 
other action this year to expand insurance coverage, we should 
at least retrace our footsteps and incorporate H.R. 1143 into 
this year's TANF reauthorization.
    I want to turn to the other topic of this afternoon's 
agenda, abstinence only education. The key word is ``only.'' I 
doubt there is any parent or policymaker who opposes featuring 
abstinence as a critically important component of sex 
education. We know for a fact that very few parents favor 
abstinence only education. A recent poll shows that 90 percent 
of parents with adolescents at home want their child's sex 
education program to cover both abstinence and general 
information covering topics like birth control. Yet, if a State 
wants to use Federal tax dollars to provide sex education it 
must agree to use an abstinence only curriculum. There appears 
to be a major disconnect. And I have to say it's ironic that 
we're considering Medicaid and abstinence only education in the 
same hearing. The administration, the Republican majority are 
generally very supportive of State flexibility. That's nowhere 
more apparent than in Medicaid. Look for the fine print in the 
Medicaid flexibility waivers. There really isn't any. These 
waivers and the President's Rx drug waivers are a hair's breath 
away from the blank check. But when it comes to any issue like 
abstinence only education, it's somehow Okay for this 
administration, it's okay for the Federal Government to put a 
chokehold on the States. It's a Federal State matching program 
with a curriculum wholly dictated by the Federal Government. So 
sometimes we want States' rights, other times when it doesn't 
serve our purpose, we don't.
    To protect our kids and respect their parents' wishes, 
States should be able to use this funding to promote abstinence 
in the context of real world choices and implications.
    Thank you, Mr. Chairman.
    Mr. Bilirakis. I thank the gentleman. Mr. Upton, for an 
opening statement.
    Mr. Upton. Well, thank you, Mr. Chairman, for convening 
this hearing. As a lead sponsor of H.R. 4122, legislation 
reauthorizing these programs, I'm very pleased that we're 
moving in a very timely manner to reauthorize these vital 
components of the 1996 Welfare Reform Bill.
    Anyone who doesn't think abstinence education works has 
only to examine the Michigan record. Begun in 1993, Michigan's 
Abstinence Program, MAP, is an innovative approach implemented 
through the community empowerment model. Community coalitions 
plan, implement, evaluate, revise, and monitor the program. It 
works. For the last 3 years in a row, Michigan has received a 
bonus award from the Department of HHS given each year to up to 
five States which experience the largest decrease in their 
ratio of out-of-wedlock to total births, while also 
experiencing a reduction in their abortion rate.
    Too many of our children's dreams have been cut short by 
bad decisions that dramatically alter the course of their 
lives. Abstinence education programs give our young both the 
inspiration and education that they need to make good, 
healthful decision. Our young people look to us for clear 
messages and for help in setting high standards for themselves. 
Abstinence education programs will give them that help, that is 
for sure.
    It is also vital that we reauthorize the TMA, Transition 
Medical Assistance Program. One of the greatest disincentives 
to leaving the welfare rolls and entering the workforce is the 
loss of Medicaid coverage, particularly for children. It is 
important that we ensure that former welfare recipients and 
their families do not abruptly lose their coverage. This 
legislation, H.R. 4122, extends that vital program for another 
year. We look forward to today's hearing and we look forward to 
working with the chairman and I yield back the balance of my 
time.
    [The prepared statement of Hon. Fred Upton follows:]
  Prepared Statement of Hon. Fred Upton, a Representative in Congress 
                       from the State of Michigan
    Mr. Chairman, thank you for convening today's hearing to review the 
Abstinence Education and Transitional Medical Assistance programs. As 
the lead sponsor of H.R. 4122, legislation reauthorizing these 
programs, I am very pleased that we are moving in a timely manner to 
reauthorize these vital components of the 1996 welfare reform bill.
    Anyone who doesn't think abstinence education works has only to 
examine the Michigan record. Begun in 1993, Michigan's Abstinence 
Partnership (MAP) program is an innovative approach implemented through 
the community empowerment model. Community coalitions plan, implement, 
evaluate, revise and monitor the program. Parent education is provided 
to encourage effective communication with youth about the importance 
and benefits of choosing abstinence. For the last three years in a row, 
Michigan has received a bonus award from the Department of Health and 
Human Services given each year to up to five states which experience 
the largest decrease in their ratio of out-of-wedlock to total births, 
while also experiencing a reduction in their abortion rate.
    And Michigan is far from alone in embracing abstinence education as 
an effective means of reducing teen pregnancies and out-of-wedlock 
births and of protecting our young people from the scourge of sexually 
transmitted diseases. State participation in the Title V abstinence 
education program is voluntary, and for every four dollars in federal 
funding states receive, they must put in three dollars in non-federal 
funding. Yet interest in this program is high. Today, 49 out of the 50 
states are participating in the program, and over one-third of all 
school districts in the nation now choose to teach abstinence education 
in their classrooms. As part of their abstinence education programs, 
states and local grantees have launched media campaigns to influence 
attitudes and behavior, developed abstinence curricula, revamped sexual 
education classes, started mentoring programs, and implemented many 
other creative and effective approaches to encourage abstinence.
    It is important to note that reauthorizing the Title V Abstinence 
Education program will in no way affect federal support for other teen 
pregnancy prevention/sexual education programs. There are at least 25 
federal programs providing funding for contraceptive/sex education, 
while there are only 3 abstinence-focused programs. Contrary to claims 
that you may have heard about restrictions on what may be discussed in 
abstinence education programs, nothing in the federal law or guidelines 
to the states prohibits the discussion of any subject. And contrary to 
the claim that there is no scientific evidence that abstinence programs 
work, there are in fact ten scientific evaluations available showing 
that abstinence education is effective in reducing early sexual 
activity.
    Since the 1996 enactment of welfare reform including abstinence 
education, teen pregnancy and birthrates have been falling. That is 
good news, but we need to continue and build on this success. Out-of-
wedlock births are often disastrous for mothers, children, and society 
as a whole. Children born out of wedlock are far more likely to be 
poor, suffer ill health, drop out of school, and in the case of boys, 
are twice as likely to commit a crime leading to incarceration by the 
time they reach their early thirties.
    Sexually transmitted diseases (STDs) have reached epidemic 
proportions in our country, placing the health and lives of sexually 
active young people in serious peril. In the 1960s, one in 47 sexually 
active teenagers was infected with an STD. Today, one in four is 
infected. Young people need to know that having sexual relations puts 
them at risk not only for HIV/AIDS, but also herpes, which is incurable 
and may infect babies during birth resulting in severe damage or death. 
Teens need to know that they are at risk for Human Papillomavirus 
(HPV), which is the leading viral STD and which causes nearly all cases 
of cervical cancer. And they need to know that scientific research 
shows that condom use offers relatively little protection from herpes 
and no protection from HPV. Abstinence education programs provide this 
information.
    Too many of our children's dreams have been cut short by poor 
decisions that dramatically alter the course of their lives. Abstinence 
education programs give our young people both the inspiration and 
education they need to make good, healthful decisions. Our young people 
look to us for clear messages and for help in setting high standards 
for themselves. Abstinence education programs will give them that help.
    It is also vital that we reauthorize Transitional Medical 
Assistance. One of the greatest disincentives to leaving the welfare 
rolls and entering the workforce is the loss of Medicaid coverage, 
particularly for children. It is important we ensure that former 
welfare recipients and their families do not abruptly lose their 
coverage. H.R. 4122 extends this vital program for one year.
    I look forward to today's hearing and to moving to a full Committee 
markup on these two important parts of welfare reform.

    Mr. Bilirakis. The Chair thanks the gentleman. Mr. Waxman, 
for an opening statement.
    Mr. Waxman. I think Mr. Hall is here before me.
    Mr. Bilirakis. Were you here when the gavel went down?
    Mr. Waxman. No, I wasn't.
    Mr. Bilirakis. Mr. Hall for an opening statement.
    Mr. Hall. Mr. Waxman got up here before I did, by many 
years.
    Mr. Waxman. You're a fine, young man.
    Mr. Hall. And I'd be glad to follow Mr. Waxman any time.
    Mr. Chairman, I want to thank you for bringing this before 
the subcommittee, these bills, abstinence education and 
transitional Medicaid assistance, both of which, I think, are 
critically important to providing critical health care need for 
the most vulnerable of our country.
    I'm pleased to be the Democratic co-sponsor of both 
reauthorizations and I hope there will be bipartisan support 
for their passage. The abstinence education bill is simply 
reauthorization of Title V funding to promote adolescent 
health, prevent teen pregnancy and reduce sexually transmitted 
diseases by stressing abstinence. Teaching our children to 
abstain from sexual activity is one absolute way to prevent 
pregnancy. Of course, there are others. Unfortunately, some 
people feel that this legislation threatens family planning and 
contraceptive programs. Although I might be willing to threaten 
family planning and contraceptive programs, this bill doesn't 
do it.
    These Title V funds do not impact other family planning 
programs and are not mutually exclusive of other sex education 
methods. Funding abstinence education simply expands the 
options our communities will have at their disposal to help 
reduce teenage pregnancy. We're all in agreement that teenage 
out-of-wedlock pregnancies is a problem that we have to 
address. Why then do we want to prevent our communities from 
gaining access to this important tool?
    Mr. Chairman, a vote against providing a meager $50 million 
for abstinence education isn't bolstering family planing and 
contraceptive sex education methods. It's a vote against a 
complementary tool in protecting our teens.
    The other piece of legislation I've co-sponsored is the 
reauthorization of transitional Medicaid assistance. This 
program extends Medicaid benefits for 1 year to those people 
who are succeeding in removing themselves from the welfare 
roles. Many poor and near poor families cannot afford their own 
health insurance, even if they are working, yet they may not 
qualify for Medicaid in some States. By bridging this gap, this 
helps families to stay off of welfare. I hope both my 
Democratic and Republican colleagues will join me in supporting 
these two important critical reauthorizations. Both have proven 
effective in the past and I believe it could be a devastating 
shock to our community should these programs disappear.
    I yield back my time.
    Mr. Bilirakis. Thank you. Dr. Norwood, for an opening 
statement.
    Mr. Norwood. Thank you, Mr. Chairman. I'm anxious to hear 
from our witnesses and with that I would ask permission to put 
my statement in the record and thank you for having the 
hearing.
    Mr. Bilirakis. Without objection, the opening statement of 
all members of the subcommittee will be made a part of the 
record.
    Let's see, Mr. Waxman, for an opening statement.
    Mr. Waxman. Thank you very much, Mr. Chairman. 
Unfortunately, this committee has chosen to limit this hearing 
today to only some of the areas in this committee's 
jurisdiction which are part of welfare reform. We're looking at 
transitional Medicaid assistance for people leaving the welfare 
rolls for work and we're looking at the abstinence education 
program established in the Welfare Reform Law of 1996. But the 
Majority is studiously ignoring the ban on Medicaid coverage 
for legal immigrant children and pregnant women that resulted 
from the anti-immigrant provisions that were forced through 
this Congress in 1996, under the guise of reforming the welfare 
system. That policy was wrong then and it's wrong now. Banning 
coverage of legal, immigrant children and pregnant women for 5 
years after entering the country and continuing to attribute 
the sponsor's income to the near permanent barrier occurs is 
worse than simply short-sighted health policy. It is a perverse 
and insidious discrimination against legal immigrants who work 
and pay taxes. It risks long-term health effects on children 
born without prenatal care. It undermines efforts for broad 
participation of children in the Medicaid and the SCHIP 
programs. And we're not just ignoring the topic in today's 
hearing, the limited, narrowly drawn mark-up vehicle the 
committee will consider tomorrow is obviously designed to block 
members from having any opportunity to redress this wrong. Some 
might even conclude that this is clearly an effort to protect 
members from voting on this issue. Better to discriminate in 
the dark than vote directly on this mean-spirited policy.
    I conclude that this is an intentional action in response 
to the wishes of this administration. It leaves legal immigrant 
children and pregnant women without health care and it leaves 
States holding the bag. If they want to provide coverage, as 
many do, they have no Federal matching assistance. It is ironic 
indeed that this administration which seems willing to waive 
just about any requirement of Medicaid law has refused to use 
its waiver authority to allow States to cover legal immigrant 
women and children and now has also blocked consideration of 
legislation to remedy this.
    This decision denies our colleague representative, Lincoln 
Diaz-Balart, the lead sponsor of H.R. 1143, the Legal Immigrant 
Children's Improvement Act and the 118 bipartisan co-sponsors 
who have joined us on the bill the opportunity to vote on 
remedying this policy. This is the right time to end that 
discrimination and this is the right mark-up to take action on 
that legislation. It is doubly ironic that instead, we're 
focusing on continuing a program of abstinence education that 
has very little to do with good health policy, but a lot to do 
with the political agenda.
    Let's be clear. No one is against abstinence. No one is 
dismissing the advantages of abstinence, particularly to young 
people who are not yet mature enough to make important life 
choices. No one is against educating young people about the 
advantages of abstinence, but it is a ridiculous policy to 
pretend that people, including young people, will not be 
sexually active whatever we may tell them. They need to know 
how to protect themselves from unwanted pregnancies and from 
transmission of sexually transmitted diseases and HIV. This 
knowledge can literally be the difference between life and 
death.
    A program that purports to be about public health, but 
which does not allow open and complete communication on all the 
ways of avoiding unwanted pregnancies and transmission of 
sexually transmitted diseases and HIV is not just a poor 
program, but a harmful program. A gag rule on information is no 
way to solve a serious public health problem and I'm pleased 
that our colleague, Congresswoman Harman, will be offering some 
amendments on this subject. I hope we can get bipartisan 
support.
    In closing, let me note that the Transitional Medical 
Assistance Program which is also being considered today is a 
vital part of any successful effort to move people off welfare 
and into the work force. I believe this program has broad 
support on both sides of the aisle. In view of that, it is 
particularly regrettable that the legislation before the 
committee tomorrow is limited to a 1-year extension of 
Transitional Medical Assistance. Obviously, it takes much 
more--it would make much more sense to reauthorize this program 
for the full period of reauthorizatoin of TANF. I hope my 
colleagues on the committee would recognize the clear advantage 
of that and will----
    Mr. Bilirakis. The gentleman's time has expired.
    Mr. Waxman. Just to complete the sentence. That presents 
itself on the floor or in conference to achieve that result.
    Mr. Bilirakis. The Chair recognizes the chairman of the 
full committee, Mr. Tauzin, for an opening statement.
    Chairman Tauzin. Thank you, Mr. Chairman. I want to thank 
you for holding this very important hearing. Reauthorization of 
the landmark 1996 Welfare Reform Law is an important priority 
for Congress this year. In the next few weeks, in fact, we will 
be undertaking this very worthy task and the hearing and the 
testimony that this panel will provide today will help us in 
that effort. I want to thank you for coming and sharing with us 
today.
    We're focusing on two welfare reform issues within the 
committee's jurisdiction--abstinence only education and 
transitional medical assistance. I understand there are 
differences of opinion regarding one of these issues, which I 
expect will produce a healthy bit of debate today. Back in 
1996, Congress passed, and President Clinton signed into law, 
welfare reform legislation. This law included a permanent 
appropriation of $50 million over 5 years for abstinence only 
education. Almost every State has participated in this State 
block grant program voluntarily. To do so, they have to match 
every $4 Federal with $3 of their own, which suggests a very 
high State interest in using abstinence only education as one 
way to address teen pregnancy. We've seen an incredible 
reduction in the rates of teen pregnancy in this country and, 
more importantly, a huge reduction in the number of children 
living under poverty. Obviously, the program is working and we 
need to continue it.
    In fact, to address the States' high teen birthrates and 
sexually transmitted disease rates, my own State of Louisiana 
has applied for and received funding for abstinence only 
education under Title V. The goals of the Louisiana program are 
laudable, to reduce teen pregnancy and STD rates by delaying 
the onset of sexual activity, to decrease risk behaviors and to 
educate young people concerning the importance of obtaining 
self-sufficiency and marriage before engaging in sexual 
activity.
    Louisiana has a coordinated state-wide evaluation plan in 
place to measure the effect of the program in meeting these 
goals. This important program reaches kids through 10 community 
based projects that are designed to promote sexual abstinence 
among adolescents ages 13 through 19. The program also uses 
public and private schools to get the abstinence message to 
teens and pre-teens through clubs established in 30 high 
schools in various school districts across the State, and in 
seventh grade health classes in various junior high schools in 
our State.
    I look forward to the testimony of Ms. Del Rosario who will 
speak firsthand about her experience spreading the message of 
abstinence to at risk teens through her program entitled 
Recapturing the Vision. Her program strengthens students, 
providing them with accurate information to promote healthy 
sexual decisions and behaviors so that these students can build 
a much brighter future for themselves. I want to thank you for 
traveling from Florida to be with us today.
    We will also hear today testimony from Dr. Joe McIlhaney, 
who after nearly 30 years of practice as a gynecologist is 
dedicating himself to addressing two medical problems affecting 
our Nation's youth, out-of-wedlock pregnancy and sexually 
transmitted disease issue.
    I would also like to thank and welcome Dr. Kaplan, a 
professor from the University of Colorado, School of Medicine, 
who has a different perspective through his work as a 
pediatrician.
    This hearing will also focus on an important work support 
for former welfare recipients, Transitional Medical Assistance. 
This benefit ensures that former welfare recipients have health 
care coverage after entering the work force. It is due to 
expire this year. We all recognize that this assistance 
provides a valuable incentive for people to move off of 
welfare. In fact, the President said, if you want to value and 
measure compassion in the welfare area, it's not on how much we 
spend on welfare, how many people are on welfare, but how many 
people we rescue from that system and actually introduce to the 
world of self-respect and decency, to a world where they're not 
dependent upon someone else, but they have their own 
independent life. That is indeed the goal of this hearing 
today.
    Cindy Mann from the Kaiser Commission on Medicaid and the 
Uninsured and Bill Scanlon from the General Accounting Office 
are here today to highlight the benefits of Transitional 
Medical Assistance and we look forward to hearing from them.
    Ms. Bilirakis, let me thank you again for holding this 
important hearing and I yield back the balance of my time.
    Mr. Bilirakis. I thank the chairman. Mr. Stupak for an 
opening statement.
    Mr. Stupak. I'll pass, Mr. Chairman.
    Mr. Bilirakis. Dr. Norwood?
    Mr. Norwood. I've already passed.
    Mr. Bilirakis. You've already passed, haven't you. Mr. 
Pitts.
    Mr. Pitts Thank you, Mr. Chairman, for holding this 
important hearing today. In the 1996 Welfare Reform Law, 
Congress provided $50 million each year for fiscal year 1998 to 
2002 for abstinence only education to help our Nation's young 
people avoid unplanned pregnancies, sexually transmitted 
diseases and the emotional consequence of sex outside of 
marriage. I am pleased that the legislation before us today 
will reauthorize this program for the next 5 years at $50 
million a year.
    Mr. Chairman, as we address this issue, we must be aware of 
the consequences of early sexual activity, the undesirable 
contents of conventional safe sex educational programs and the 
findings concerning the effectiveness of genuine abstinence 
programs. Abstinence education is essential to reducing out-of-
wedlock childbearing, preventing sexually transmitted diseases 
and improving emotional and physical well-being among our 
Nation's youth. True abstinence education programs help young 
people to develop an understanding of commitment, fidelity and 
intimacy that will serve them well as the foundations of 
healthy marital life in the future. Abstinence education 
programs have repeatedly been shown to be effective in reducing 
sexual activity among their participants. In my State of 
Pennsylvania, abstinence education and related services is a 
$3.8 million initiative. The Pennsylvania program incorporates 
local communities in crafting and implementing the abstinence 
services. It emphasizes the role of parents and guardians in 
teaching the skills to empower youth to abstain from sexual 
activities as well as ask the role of health care providers in 
providing counseling and guidance to teens and their parents.
    Pennsylvania also has a strong media component to their 
abstinence education program in which a television, radio or 
movie theater campaign encourages parents to talk to their kids 
about sexual matters. I'm also pleased to report that the 
Pennsylvania Department of Health is able to use some TANF 
funds to create an abstinence curriculum targeting Latino 
youth. While preliminary reports sound promising, I'm looking 
forward to seeing the final evaluation of the entire project in 
Pennsylvania when the grant ends in September 2002.
    Mr. Chairman, as we review this issue, I think we need to 
realize that sexually transmitted diseases including incurable 
viral infections have reached epidemic proportions. Annually, 3 
million teenagers contract STDs. STDs afflict roughly 1 in 4 
teens who are sexually active. Second, early sexual activity 
has multiple negative consequences for young people. Research 
shows that young people who become sexually active are not only 
vulnerable to STDs, but also likely to experience emotional and 
psychological injuries, subsequent marital difficulties and 
involvement in other high risk behaviors. Third, conventional 
safe sex programs, sometimes erroneously called abstinence plus 
programs, place little or no emphasis on encourage young people 
to abstain from early sexual activity. Instead, such programs 
strongly promote condom use and implicitly condone sexual 
activity among teens. This is not true abstinence education. 
And finally, despite claims to the contrary, there are 
scientific evaluations showing that real abstinence programs 
can be highly effective in reducing early sexual activity and I 
would like to ask unanimous consent to submit for the record a 
summary of these evaluations.
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    Mr. Bilirakis. Without objection.
    Mr. Pitts Abstinence education has proven effective in 
reducing the rate of sexual activity among teens. As Members of 
the House, we have a duty to ensure that we are not sending 
mixed messages to our youth. I look forward to hearing from the 
witnesses today on abstinence only education and would 
encourage my colleagues to reaffirm our commitment to 
abstinence only education, support the reauthorization, Title 
V, abstinence block grants in the interest of protecting and 
preserving the health of our Nation's children. I yield back 
the balance of my time.
    Mr. Bilirakis. I thank you, Mr. Pitts. Ms. Harman, for an 
opening statement?
    Ms. Harman. Well, thank you, Mr. Chairman. I didn't expect 
to offer one, so I'll wait until the questioning period. Thank 
you very much.
    Mr. Bilirakis. Thank you very much. Mr. Greenwood, for an 
opening statement.
    Mr. Greenwood. Thank you, Mr. Chairman. I'll be very brief. 
I have two daughters, 15 and 16\1/2\. I am more interested in 
abstinence than I've ever been interested in it in my life 
right now.
    And I believe that any sex education that doesn't talk 
about abstinence is poor sex education indeed. If you don't 
talk about the fact that abstinence is the only way to be 
certain to avoid pregnancy and sexually transmitted diseases, 
you do a disservice to children. Certainly, if you implicitly 
or otherwise promote sexual activity among teenagers, I think 
you do a disservice to children.
    My concern is I think you do a disservice to children when 
that's all that you tell them. That's certainly not all that my 
wife and tell our daughters because we want our daughters to 
understand how their bodies work. We want them to understand 
how male bodies work. We want them to understand how they work 
together and then we want them to understand why it is in their 
interest to abstain from sex until they're in a committed and 
hopefully married relationship. But I am so interested in 
abstinence that I think we ought to spend Federal dollars to 
teach abstinence, but since we don't spend any Federal dollars 
to teach sex education in the schools at all, I think we need 
to teach both. And I think it's a no brainer. And I don't know 
what we're fighting about. But I look forward to fighting about 
it.
    Mr. Bilirakis. I believe that completes the opening 
statements of all the people who are present. That being the 
case, we'll go right into the Panel.
    First, I would ask unanimous consent that a letter which 
has been shared with the minority, dated April 23 from 
Secretary Thompson to Chairman Tauzin regarding this issue and 
the fact that the administration supports a 5-year 
reauthorization of the abstinence program and also is a strong 
supporter of the 1-year reauthorization of Transitional Medical 
Assistance, I ask unanimous consent that it be admitted into 
the record.
    There's a letter here from Mr. Rick Pollack, Executive Vice 
President of the American Hospital Association, dated April 
19th, advancing health in America, dated April 19th. I ask 
unanimous consent that be made part of the record.
    We'll go into our Panel then. Ms. Jacqueline Del Rosario 
resides in Miami, Florida. Dr. Joe S. McIlhaney, The Medical 
Institute for Sexual Health, Austin, Texas. Dr. David W. Kaplan 
is head of the Adolescent Medicine and Professor of Pediatrics, 
University of Colorado School of Medicine. Dr. Cindy Mann, a 
Senior Fellow with the Kaiser Commission on Medicaid and the 
Uninsured. And Dr. William J. Scanlon, Director of Health Care 
Issues with General Accounting Office. We've had the honor and 
pleasure of having Mr. Scanlon here many times. It's awfully 
nice to see you, sir and we will start off with Ms. Del 
Rosario. We set the clock at 5 minutes. If you haven't quite 
completed your statement, I certainly won't cut you off. Please 
proceed.

STATEMENTS OF JACQUELINE JONES DEL ROSARIO, EXECUTIVE DIRECTOR, 
 RECAPTURING THE VISION INTERNATIONAL; JOE S. McILHANEY, JR., 
THE MEDICAL INSTITUTE FOR SEXUAL HEALTH; DAVID W. KAPLAN, HEAD 
OF ADOLESCENT MEDICINE, PROFESSOR OF PEDIATRICS, UNIVERSITY OF 
  COLORADO SCHOOL OF MEDICINE; CINDY MANN, SENIOR FELLOW, THE 
KAISER COMMISSION ON MEDICAID AND THE UNINSURED; AND WILLIAM J. 
SCANLON, DIRECTOR, HEALTH CARE ISSUES, U.S. GENERAL ACCOUNTING 
                             OFFICE

    Ms. Rosario. Thank you. Thank you for inviting me to share 
today. I believe that I will bring a very unique perspective on 
the issue of abstinence education. As I began to do my research 
for my presentation I was very surprised to find that there's 
just tons of documentation of studies and evaluations that have 
been conducted. There are many that say that abstinence only 
education is successful. There are others that say it is not. 
It just depends on what side of the field that you're standing 
on.
    I was much more of a skeptic when I entered the field. When 
I worked with teens at the middle and high school levels what I 
found was that they have very, very different views of sex. It 
was not because of a revolution, but they were very base in 
action. Wanting to have sex, my challenge was telling kids 
well, you want to postpone that, you don't want to get 
pregnant. You want to preserve your education? Why? Because 
it's going to give you a better life. Well, no, my mom had me 
at 17. My grandmother had her at 18. Or that they have a 
boyfriend that they want to give a baby to. I mean these are 
the issues that I don't think that condom distribution really 
is going to be able to impact.
    One day I was delivering a lesson with the students 
discussing various issues and I was asking what do some of 
these statements, what message do they send to you? One was sex 
outside of marriage, the other was condom distribution or 
contraceptions in schools. Unanimously, kids that had just 
earlier stated I'm not considering being abstinent, others 
saying that they were, unanimously all of them stated that I 
believe that this message tells them that adults are saying 
that they're not going to be able to abstain from sex, you're 
going to do it and it's okay as long as you protect yourself.
    I quickly became a very ardent believer in the abstinence 
message. This is because I find that kids do want a very clear 
and concise message and I was surprised to find that many want 
to take the high road. I think that as roads we have to 
encourage them to raise a standard, but more than that, I 
believe that the abstinence funding allows us to really build 
human character.
    For the first time, we're really able to use these dollars 
to build the individual that's going to continue to keep our 
Nation strong. And I think that we're talking about the 
subculture that's developing in the United States of America. 
Kids have mixed values. They're very confused. And I think that 
we have to begin to be surrogates to help to strengthen the 
families, to keep kids dreaming about their futures and 
believing in life as a possibility. And that's what I found to 
be the purpose of abstinence education.
    As I said before my research, I found that there were 
studies that proved that abstinence was successful, others that 
said that it was not. I have looked at several issues 
concerning this, however. In our state, sex education is taught 
in the schools. Currently, 9 out of 10 schools out of the 2 
million nationwide do teach a comprehensive sex education 
course. In addition to that Title X funding has not been 
decreased to make room for abstinence education. The funding in 
our State level is $15.2 million, $8 million of that is given 
at the State level for Title V abstinence education; 4 of that 
$8 million is a match from the State.
    Despite these things happening, I think that we're able to 
see that there has not been a significant change in the trends 
of sexual behaviors, nor has there been a decline really in 
pregnancy rates over the 30 years that Title X funding has been 
given. I think that we've seen a decrease over the past 10 
years and many will say, according to the argument that 
abstinence education profoundly has impacted that. Others might 
say that it has not.
    But I would ask you to consider today the plight of 
America's youth. As I look at some of the attitudes that I'm 
witnessing in the classrooms, I'm concerned. I'm concerned 
because it's not about Johnny loving Sally any more. It's about 
the subculture. It's about a lifestyle and we need programs 
that are going to enable us to teach to the whole person, not 
to the behavior, bandaid approach that we're going to apply a 
condom or use a contraceptive over the genitalia, but what's 
going to protect the dignity. I'm interested in building the 
fiber of our Nation one individual at a time and I think that 
abstinence education allows us to do that with the young people 
of this Nation. And I think to circumvent that would be to 
abate progress.
    Recapturing the Vision has been in existence for 8 years. 
We've enjoyed funding that was not under Title V, but we've 
also had funding under Title V education dollars and our 
program to date has a success rate of 99.9 percent. Let me give 
you a picture of the type of citizens that we work with. 
Basically, 65 percent of those that we serve are on public 
assistance. They are intergenerational kids outside of wedlock. 
In other words, they are the offspring of the offspring of the 
offspring of a teen parent.
    They are receiving sex education, but they have a mindset 
that does not even make them sometimes want to avoid pregnancy. 
What I found in my dealing with this population is that they're 
wanting us to believe in them and they're wanting us to furnish 
them with the skills to support the high road. I think that 
many kids are taking the high road. Of the 52 high school age 
students that are sexually active, remember that there's 48 
percent that are not. But even of those 52 percent that are, I 
think that we can still let them know that they need to take 
the high road. Abstinence education teaches to the 
psychological situations and circumstances to early sexual 
involvement outside of marriage.
    It gives them the skills that they need to be able to 
support this decision to remain abstinent. I'm talking about 
character development. I'm talking about conflict resolution 
skills, negotiation skills, refusal skills. I'm talking about 
the understanding and building of value for marriage and 
family. It's that simple.
    This is America today. Some of the subcultures that we're 
seeing now are transcending the 'hood. They're moving into 
suburbia and I think that they're getting so many messages 
about condoms and safe sex and all of those things, abstinence 
represents one voice in a crowd of many. Last week I was 
watching MTV. They were talking about safe sex and condoms. 
Abstinence represents a very small voice. It's one voice that 
cannot be snuffed out. It's a voice, I believe that's going to 
do more than just prevent teen pregnancies, but it's going to 
be able to build strong citizens for our Nation.
    Thank you.
    [The prepared statement of Jacqueline Jones Del Rosario 
follows:]
              Prepared Statement of Jacqueline Del Rosario
Introduction
    I am Jacqueline Jones Del Rosario, Executive Director of 
ReCapturing the Vision International, a non-profit organization working 
in the field of abstinence-only education since 1994. I would like to 
share my unique experience in the area of abstinence and Title V 
Funding.
    I initiated abstinence-only education purely as a skeptic. I 
believed that teens from strong families or those with strong religious 
convictions could perhaps be taught to delay sex until marriage because 
I believed that our message merely reinforced the same message these 
children received from strong home environments. I did not believe, 
however, that the masses of at-risk teens from impoverished backgrounds 
could adhere to the abstinence message. After all, many of them could 
not understand why they should avoid getting pregnant before 
graduating.
    In the beginning years of ReCapturing the Vision, I was teaching a 
group of thirty students at Madison Middle School. This school is 
located in a dilapidated area of Miami-Dade County. Over 80% of the 
students enrolled received free or reduced priced lunches each day. 
This school had been rated a ``D'' school under the criteria 
established by Governor Jeb Bush.
    In the lesson that I was delivering that day, we reviewed pages 
from the Capturing the Vision textbook. The students were asked to 
explain what messages do the following actions send: lying, sex outside 
of marriage and the distribution of birth control in school. I received 
an awakening when the students unanimously responded that the message 
they gathered from the distribution of condoms was that adults expected 
them to have sex, but only asked them to use protection. In the 
student's minds, this action represented consent, as long as protection 
was used.
    The answer from this population was riveting. I had heard it said 
that abstinence with contraceptives was a ``mixed message'' but I never 
believed it to be true. Kids need a concise and clear message. To hear 
it from the students caused me to believe that we must be the voice 
that tells them that we expect them to abstain and we believe they can 
do it.
Sex Education is Being Taught in 91% of Schools
    According to a recent Kaiser Family Foundation Study, nine out of 
ten (89%) of the nation's nearly 20 million public secondary schools 
teach sex education (Kaiser Family Foundation, Sex Education in 
America: A Series of National Surveys of Students, Parents, Teachers, 
and Principals. September 2000). This holds true in Miami-Dade and 
Broward counties where the students receive sex education involving 
information on contraceptives and STD's including HIV. However, at the 
onset of our program, less than 10% of those who received this 
education knew what abstinence meant.
    Through this, ReCapturing the Vision has realized that sex for 
today's generation is different from when our parents dealt with it 
during their adolescence. No longer is sex an expression of love; it 
has evolved as a social trend, and because of this, ReCapturing the 
Vision has become that one voice that encourages kids that they do not 
need to have sex, nor do they have to. ReCapturing the Vision teaches 
the consequences of sexual involvement and educates students on STD's, 
but most of all; we build personal value and foster the vested interest 
that kids need take into their futures.
    In 1999, a nationwide study of principals discovered that 58% 
describe their school's sex education curriculum as comprehensive, 
teaching that ``young people should wait to have sex but if they do 
not, they should use birth control and practice safer sex.'' On the 
contrary, only 34% say that they offer abstinence-only education 
teaching ``young people should only have sex when they are married'' 
(Kaiser Family Foundation, Sex Education in America: A Series of 
National Surveys of Students, Parents, Teachers, and Principals. 
September 2000).
    According to the 2000 Federal School Health Education Profiles 
study, the median percentage of schools offering required health 
education courses to students in grades 6 through 12 was 91%. Among 
these schools, a large percentage said that they tried to increase 
knowledge of HIV (96%) and teenage pregnancy prevention (84%) (Centers 
for Disease Control and Prevention, Guidelines for Effective School 
Health Education to Prevent the Spread of AIDS, MMWR 37 (S-2): 1-14, 
January 29, 1988).
    If the pregnancy rate for Dade County were calculated for 445 
students, RTV would expect 8.12 births to girls under the age of 19, 
despite the fact that children receive at least one sexual education 
course between grades 6 and 12. ReCapturing the Vision has served over 
5,500 at-risk teens over the past eight years and only one participant 
has become pregnant during that time period. It is clear that 
abstinence-only education can make in impact in our city.
    As a program currently being evaluated under Title V by Mathematica 
Policy Research and locally at the state level, we are certain that the 
findings of these evaluations will only support what we have found to 
be true through internal evaluation. We have found that abstinence 
education is effective, not only in the lives of mainstream youth, but 
for at-risk teens as well.
Title X Funding Has Not Produced Results
    The 1970's produced an increase in the birthrate of unmarried 
adolescents by 23.8%. The 1980s, increased to 52.3%. In the 1990's 
however, the birth rate to unmarried adolescents increased only by 
4.5%.
    The Title X funding expansion initiated the safe sex movement in 
the 1970s, and was followed by an increased growth rate in abortions, 
births to unmarried teens and premarital sex by teenagers. In the 80's 
Title X funding was decreased, and following that cut was a reduction 
in the growth rates of abortion and unwed births. Title X dollars 
proved that contraception distribution and the ``safe sex'' message was 
not effective, but was creating an environment to breed an increase in 
teen sexual activity.
    In the 1990s privately funded abstinence programs worked to change 
the tide, while Title X continued to teach the safe sex message. The 
1990s showed a dramatic decrease in the growth trend of birth rates to 
unwed teens, increasing only by 4.5%. It would be illogical to 
attribute such an improvement to the Title X initiative, when the 
previous 20 years have proven that Title X programs have consistently 
produced opposite results.
    The rise in abstinence programs in the 1990s has produced this 
change in trends. The growing abstinence-only message coincides with 
the improvement in the data reflecting adolescent sexual behavior. 
Abstinence programs are extremely effective. In 1982 through 1987, an 
abstinence program implemented in Denmark, SC reduced teen pregnancy by 
59%. In the 1990s, the implementation of an abstinence-only curriculum 
in Washington, D.C. reported a pregnancy rate of 1.1%. ReCapturing the 
Vision in Miami-Dade and Broward Counties in Florida show a 1.1% teen 
pregnancy rate in eight years of service provision to the public.
    It is likely that the increase in the abstinence message is 
directly responsible for the improvement in the positive trend in 
adolescent sexual behavior recorded in recent years. It is safe to 
assess that these improvements would have been much greater if the 
allocated Title X dollars during the 1990s had been devoted to 
abstinence only education.
Evaluating Strong, Not Weak, Abstinence Programs
    I have noted that there exists a definite conflict in most of the 
studies being conducted on abstinence-only education. Most do not 
measure up to the abstinence definition. That is to say, most of the 
programs being evaluated do not teach the eight points outlined in the 
Title V Social Security Act. This issue has been brought to the 
forefront of the current evaluation being conducted by Mathematica 
Policy Research. Those in the field have voiced their concerns that the 
programs being evaluated should be strong and solid programs, 
fulfilling congressional guidelines for abstinence education. There is 
a great variation among current programs being evaluated at the state 
levels. Some programs consist of five or more presentations. Their 
focus is to merely teach teens to say no to sex before marriage. These 
programs are not comprehensive and they do not contain the elements of 
most successful abstinence programs. According to A National Strategy 
to Prevent Teen Pregnancy, Annual Report 1998-99, U.S. Department of 
Health and Human Services, 1999, the following are five ``Key 
Principles'' that should be featured in successful abstinence programs:

1. Parental and Adult Involvement. Parents and other adult mentors must 
        play key roles in encouraging young adults to avoid early 
        pregnancy and stay in school.
2. Abstinence. Abstinence and personal responsibility must be the 
        primary message of prevention programs.
3. Clear Strategies for the Future. Young people must be given clear 
        connections and pathways to college or jobs that give them hope 
        and a reason to stay in school and avoid pregnancy.
4. Community Involvement. Public and private sector partners throughout 
        the surrounding areas--including parents, schools, business, 
        media, health and human service providers, and religious 
        organizations--must work together to develop comprehensive 
        strategies.
5. Sustained Commitment. Real success requires a sustained commitment 
        to the young person over a long period of time.
    If we are to examine the issue to arrive at the truth, again I must 
restate, strong and solid programming must be the basis of all 
evaluations.
ReCapturing the Vision, An Abstinence Program for Youth
    ReCapturing the Vision does not just teach teens to say no to sex, 
but we also build their values and cause them to embrace the future. 
RTV embodies all five of these elements. As a result, ``no'' becomes a 
natural response. Building peer groups and educating parents on how to 
communicate with their teens on sexual issues has also made a great 
impact. Many parents have initially stated that they don't tell their 
kids to abstain. Rather, they state in a greater frequency that 
protection is imperative. Improving teen/parent communication has 
strengthened the clear message that teens are receiving about sex and 
parental expectations.
    RTV is a holistic, multi-tier program providing abstinence 
strategies through a three-tier service delivery: school, home and the 
community. In the context of the school, RTV addresses the whole 
participant, building self-esteem, developing character, and providing 
information and skills to make positive choices. The program is 
delivered as an elective course during the regular school day. Students 
receive daily instruction throughout the entire school year. Our goal 
is to address the root issues of youth behaviors versus attempting to 
protect them from those risky behaviors.
    In the context of the home, RTV integrates the parent and family 
into the scope of service. Trained social workers make monthly home 
visits and conduct casework including counseling, referral services and 
parent training. Family mentoring spawns from this tier of service and 
involves families of the highest need in intensive three-day excursions 
that take place outside of their current environment. Families are 
immersed in bonding type activities and receive training to build the 
family structure and unity.
    The community brings the third and final level of intervention 
through after school programs delivered through partnerships with local 
churches and community based organizations that are in the feeder 
patterns of the schools that we serve; thereby offering students 
positive activities and opportunities for remediation during critical 
after school hours.
    Large-scale community events take the abstinence message community 
wide as significant community entities are educated on the importance 
of abstinence and the role they can play in the fight. These events 
include conferences, concerts, rallies and training workshops.
RTV Success Rates
    Through RTV's philosophy of addressing the whole child, versus 
merely teaching them to say no, consistent data clearly documents the 
inroads that we have made in changing teen attitudes and behaviors:

 100% of students enrolled demonstrate increased self-esteem as 
        assessed by an attitudinal survey.
 89% of students improved behavior as evidenced by a decrease 
        in outdoor suspensions and 80% in indoor suspensions.
 RTV has a 99.99% success rate in preventing teenage 
        pregnancies among students actively involved in the program for 
        one year.
 60% of students improved attendance
 75% improved academic performance as indicated by an increase 
        in grade point averages.
The Economic Implications Equal Mindsets
    Economics play a strong role in sexual behaviors and trends. The 
pregnancy rates for non-Hispanic black and Hispanic teenagers are about 
twice as high as non-Hispanic white teenagers. The lower pregnancy 
rates are due to differences between groups in economic opportunity and 
family stability (National Vital Statistics Reports, Vol. 47, No. 29, 
December 15, 1999).
    In 1995, 57% of non-Hispanic black teenagers and 52% of Hispanic 
teenagers compared to 46% non-Hispanic white teenagers are sexually 
active. About 1 in 3 sexually active black and Hispanic teenagers 
became pregnant in 1995, compared with about 1 out of 6 sexually active 
non-Hispanic white teenagers. The differences in sexually activity and 
pregnancy are associated in part with differences between groups in 
economic opportunities and family stability.
    Condoms cannot address the social ills that plague our nation, but 
abstinence can. Pregnancy rates are economically derived (Wilson, W.J. 
The Truly Disadvantaged: The Inner City, The Underclass, and Public 
Policy. University of Chicago Press. Chicago. 1987). Many children from 
impoverished backgrounds do not even have the desire to avoid teenage 
pregnancy. In fact, many desire to have a child and see the birth of a 
baby as a direct link to public assistance. In many inner city 
neighborhoods, early sexual activity and teenage pregnancies has become 
a lifestyle. I have seen first hand the influence that economics play 
in sexual attitudes. An alarming truth that was uncovered during my 
labor in the field is that nearly 45-50% of the participants we serve 
have no value for marriage or the family. They have never seen a 
wedding and live in a home with a single parent and that parent's live-
in companion. Many do not have negative ideas about teenage pregnancy 
and do not see it is a danger to their future, but rather, a way of 
life in their world. Abstinence-only education is the weapon that can 
fight in this war.
    As a nation, we need to be about addressing the behaviors versus 
applying the band-aid to the behavior. In this case, this is what 
contraceptives represent. Sadly enough, however, if a child does not 
deem avoiding teenage pregnancy a worthy cause, they will never use 
contraceptives as a means to prevent something that is not perceived as 
being a threat to their future. Abstinence is a necessary extension of 
welfare reform. It is a means to elevate the mindset of at-risk 
populations who are not engaging in sexual intercourse because Sally 
loves Johnny, but because it is a part of the behaviors that this 
subculture has adopted. This scenario has weakened the fiber of our 
nation as generational cycles of teen pregnancy and poverty threaten 
our stance as a national power.
    Contraceptives cannot protect a 15-year-old from the erosion of her 
dignity and self-worth. There must be another value that causes teens 
to raise their standards and protect their emotional and physical 
health. This message is embodied in the plan defining abstinence-only 
education. Title X Funding has not undergone the same scrutiny but has 
received funding for the past 30 years. Abstinence-only deserves an 
opportunity to demonstrate its impact in the field.
    RTV is developing teens that are abstaining from premarital sex, 
remaining in school, and even better, improving their grades and 
behavior as evidenced by improved GPA and reduced suspensions. They are 
learning to work for success and to protect their futures. We are 
fostering teens that may be the first in several generations to become 
self-reliant and support themselves versus a life on and off public 
assistance. They are the core of a better nation. Their offspring will 
receive a perception quite different from that of their parents and 
grandparents. They won't be the product of a single family nor will 
they be 50% more likely to be involved in criminal behavior. They will 
have a good start in life and will manifest a true turn of the tides of 
teenage pregnancy.

    Mr. Bilirakis. Thank you very much, Ms. Del Rosario.
    Dr. McIlhaney? Please, pull the mike closer. Obviously, 
your written statements are part of the record and we would 
hope that you would--Ms. Del Rosario did complement or 
supplement it, if you will. Please, Doctor, go ahead.

               STATEMENT OF JOE S. McILHANEY, JR.

    Mr. McIlhaney. Thank you, Mr. Chairman, and distinguished 
members. I'm a gynecologist who practiced medicine for 28 
years. I had a rewarding practice, caring for infertile women, 
doing in vitro fertilization, taking care of lots of 
adolescents. I left my practice to commit the remainder of my 
medical career to helping prevent two of the problems that I 
saw hurting my patients the most, the out-of-wedlock pregnancy 
and sexually transmitted disease problems. And today, I'm 
president of the Medical Institute for Sexual Health, a 
nonprofit medical educational organization which I founded in 
1992.
    In 1996, I testified on the proposed Welfare Reform Act. My 
message then was that sexually transmitted disease and 
nonmarital pregnancy are much, much more common than most 
Members of Congress and most Americans realize. To its credit, 
Congress provided funding that has helped more than 700 
abstinence programs around the country devoting serious and 
much needed attention to these problems.
    The good news today is that since 1990, the number of teens 
becoming sexually active and the number of teens becoming 
pregnant has been declining so that today more than half of 
teens in high school across, high schools across the country 
are still virgins and we have the lowest teen birth rate that 
we've had since the 1950's as this first chart shows.
    It's reasonable to conclude that one factor contributing to 
this improvement has been the concombinant rise in abstinence 
education programs, there's some specific programs, as a matter 
of fact, such as the one in Monroe County, New York and others 
that have actually found declining teen pregnancy rates as a 
result of their education programs. But the bad news is that 25 
percent of teens are infected with a sexually transmitted 
disease. There are 3 to 4 million teens that get a new sexually 
transmitted disease every year. In addition, the epidemic has 
evolved to a new and more dangerous epidemic, no longer 
gonorrhea and syphilis which are treatable with a shot of 
penicillin, but now we have an epidemic of viral diseases. HPV 
which is human papillomavirus, herpes, HIV, and we've never 
cured any human viral infection.
    One study shows that 50 percent, half of sexually active 15 
to 20 year olds are infected with human papillomavirus. 
Approximately 6 percent of teenagers are infected with genital 
herpes. Then there's chlamydia which is dangerous because it's 
so common in teens. It's rarely symptomatic and it causes 
infertility. Twelve percent of 17 year old female Army recruits 
were found to be infected with chlamydia on induction and they 
didn't know it.
    Today, 1 in 4 adolescents is infected with an STD. Today, 
there are more diseases, 25 sexually transmitted diseases as 
opposed to 2 when I started medical practice back in 1968. 
Today, the diseases that are most dominant are viral diseases 
and with no cure. And there is no evidence, for example, that 
condom reduces sexual transmission of the common sexually 
transmitted disease which is human papillomavirus because it's 
99 percent of all cervical cancer, killing more women than AIDS 
kills and causing almost all abnormal Pap smears and there's an 
epidemic of abnormal Pap smears among teenagers today, when I 
saw almost no adolescents with abnormal Paps when I started 
practicing in 1968.
    One reason STDs have become so common among teenagers is 
that the younger age of sexual initiation is happening. The 
more sexual partners, as a matter of fact, that teens tend to 
have is associated with or beginning sexual activity at a 
younger age as this next chart shows. The biggest risk for 
becoming STD-infected is how many sexual partners you or I have 
had in our lifetime. Even though the pregnancy rate among teens 
has declined, as I mentioned, a devastating trend has 
developed. Whereas in 1960, 15 percent of teen births were to 
unmarried teens. Today, 78 percent of teen births are out of 
wedlock. There seems to be a resurgence of insistence that so-
called abstinence plus or dual message programs, discussing 
abstinence while also teaching all about contraception, that 
these are the solution to these epidemics. But let me remind 
you that for many years these programs were the predominant 
approach for sexuality education in this country. These 
programs, as a matter of fact, were almost unchallenged during 
the 1980's and it was during those years that the problem I've 
just outlined grew the most. As a matter of fact, it was during 
those years when my attention was grabbed by what was happening 
to my patients and what I saw in research literature. In 
addition, these programs developed and were studied extensively 
by the most prestigious academic institutions in America.
    Let me remind you that what those studies show. Only a 
handful of these programs and there are multitudes of them have 
shown any significant impact on any behavioral or health 
outcome. Only two of the Centers for Disease Control's 
``Programs That Work'' have reported statistically significant 
delays in the initiation of sexual activity and only one of 
those has reported a truly substantial impact on this delay of 
sexual activity. Not one of those CDC programs has studied the 
incidents of sexually transmitted disease or of pregnancy rates 
in kids that were exposed to those education programs.
    Much has been made of reports that parents want their 
children to have dual message programs. None of these surveys 
included parents who have been given even as little information 
as I have provided you today about how often condoms and 
contraceptives fail and how prevalent diseases have become. I 
believe parents would want a vigorous effective abstinence 
education program for their children if they knew the facts, 
even that I've provided you today.
    There's abundant evidence that the safer sex paradigm has 
not solved the problem. As a matter of fact, Doug Kirby who is 
a well-known advocate of safer sex programs, if we would put up 
the next chart, after he did extensive research of the 
sexuality programs said it may actually be easier to delay the 
onset of intercourse than to increase contraceptive use.
    We recognize that we not yet have sufficient data to 
positively determine the degree of effectiveness of abstinence 
education, but results are promising.
    Mr. Bilirakis. Please summarize.
    Mr. McIlhaney. I have just about two more sentences. The 
National Evaluation of Abstinence Programs of Mathematica will 
be completed in the year 2005. If we don't continue with the 
current level of funding or if we change the focus of the 
programs funded, for example, by changing the A through H 
definitions, we'll lose an invaluable opportunity to learn how 
we can effectively help young people avoid sexual activity, at 
risk behavior at least as detrimental to their health as the 
use of alcohol drugs and tobacco.
    Thank you very much.
    [The prepared statement of Joe S. McIlhaney, Jr. follows:]
  Prepared Statement of Joe S. McIlhaney, Jr., President, The Medical 
                      Institute for Sexual Health
    Thank you, Chairman Bilirakis and distinguished members of the 
Subcommittee.
    I am a gynecologist who practiced medicine for twenty-eight years. 
I had a rewarding practice of in vitro fertilization and surgery, but I 
left my practice to commit the remainder of my medical career to 
helping prevent two of the most profound medical problems of our day, 
out-of-wedlock pregnancy and sexually transmitted disease. I have been 
doing this through an organization called The Medical Institute for 
Sexual Health, which I founded in 1992. The mission of the Medical 
Institute for Sexual Health is to identify, evaluate and communicate 
credible scientific data in practical, understandable and dynamic 
formats to promote healthy sexual decisions and behavior in order to 
dramatically improve the welfare of individuals and society.
                             the good news
    In 1996, I testified before the House Ways and Means Subcommittee 
on Human Resources on the proposed Welfare Reform Act. My message then 
was that sexually transmitted disease and non-marital pregnancy are 
hurting far more people in society than most members of Congress and 
other Americans realize. To its credit, in an effort to constructively 
and meaningfully deal with these pregnancy and disease problems, 
Congress funded abstinence education with $50 million a year for five 
years through the Title V provision of the Welfare Reform Act. This 
funding has helped more than 700 abstinence education programs around 
the country to devote serious and much needed attention to these 
problems.
    I come today with good news and bad news. The good news is that 
there is credible evidence showing that abstinence education is having 
an impact. More young people are living an abstinent lifestyle, and 
fewer teens are becoming pregnant. Today, more than half of all high 
school students are virgins.\1\ Also, beginning in 1990, the number of 
teens becoming pregnant began declining. Today we have the lowest teen 
birth rate that we have had since the 1950s, and teen pregnancy rates 
are lower than they have been any time since 1976.\2\,\3\
    A ray of light and hope is emerging. Trend data showing declining 
sexual activity among adolescents and declining teen pregnancy rates 
reveal a societal shift in a positive direction--it is reasonable to 
conclude that one contributing factor is the concomitant rise in 
abstinence education programs, though how large of a contributing 
factor we do not know. Some specific programs, such as the one in 
Monroe County, New York, and the Best Friends program that began in 
inner city Washington, DC, show a very marked decline in pregnancy 
rates.\4\,\5\
                              the bad news
    But the bad news is that we still have an enormous problem. 
Sexually transmitted infection is highly prevalent among adolescents. 
Three to four million STDs are contracted yearly by 15 to 19 year-olds, 
and another five to six million STDs are contracted annually by 20 to 
24 year-olds.\6\ Approximately six percent of adolescent females tested 
at family planning clinics and nine percent of female U.S. Army 
recruits (12.2% of 17 year-olds) are infected with Chlamydia 
trachomatis.\7\,\8\ 5.6% of 12 to 19 year-olds and 17% of 20 
to 29 year-olds are infected with herpes simplex virus type 2 (the 
virus that causes genital herpes).\9\ And whereas in the 1960s, only 
two STDs were of real concern, we are now aware of more than 25 
(Appendix A). It is clear that, if and when young people begin sexual 
activity prior to marriage, they are at very high risk of acquiring an 
STD.
    One reason STDs have become so prevalent among young people is 
that, in spite of the recent trend toward later sexual initiation, we 
had for years been experiencing a trend toward earlier sexual 
initiation, and the trend toward later marriage 
continues.\10\,\11\ The combination of these two factors 
means that people are likely to be single and sexually active for a 
significant period of time--5 to 10 years or longer--during which they 
will normally accumulate a number of sexual partners. In fact, age of 
sexual onset is a very strong predictor of lifetime number of sexual 
partners.\12\ And an individual's risk of ever having contracted a 
sexually transmitted disease is strongly linked to his or her lifetime 
number of sexual partners.\13\,\14\,\15\
    In addition, a major shift has occurred over the past three 
decades. The diseases primarily infecting young people are no longer 
syphilis and gonorrhea, which are frequently symptomatic and treatable 
with penicillin, but viral diseases such as human papillomavirus (HPV), 
herpes, and the unusual bacterium, chlamydia. The viral diseases cannot 
be cured--only managed. And chlamydia, a major cause of infertility in 
young women, is asymptomatic in up to 85% of infected women \16\ but 
can still cause significant problems even without the presence of 
noticeable symptoms.
    The sexually transmitted disease that has become the most common is 
a virus called human papillomavirus (HPV). The most recent major study 
about young women and HPV shows that 50% of sexually active women 
between the ages of 18 and 22 are infected with 
HPV.\17\,\18\ The National Institutes of Health Workshop On 
The Scientific Evidence On Condom Effectiveness For STD Prevention 
reported that there is no evidence that condoms reduce the sexual 
transmission of this infection.\19\ The NIH report also found no 
evidence for risk reduction for the transmission of herpes. A recent 
study has shown that condom use can produce a significant reduction 
(but not elimination) in the risk of herpes acquisition by women; 
however, the study did not find any impact for men.\20\ In addition, 
researchers at Johns Hopkins University, upon completing a study of STD 
prevalence at an adolescent clinic, found re-infection rates of 
chlamydia in adolescent girls to be so high that they recommended 
testing every sexually active adolescent girl in the United States 
every six months for chlamydia infection (regardless of reported condom 
use).\21\
    Even though the pregnancy rate among teens has declined, today, 78% 
of teen births are out-of-wedlock, compared to 15% in 1960.\22\ These 
out-of-wedlock births contribute to poverty, crime, and negative 
outcomes for children including physical and emotional health problems, 
and educational failure. For example:

1. Poverty--In 1995, 66% of families with children headed by a never-
        married single parent were living in poverty.\23\
2. Child health ``White infants born to unmarried mothers are 70% more 
        likely to die in infancy. Black infants born to unmarried 
        mothers are 40% more likely to die.\24\
3. Education--Living in a single-parent family approximately doubles 
        the likelihood that a child will become a high-school 
        dropout.\25\
4. Crime--Boys raised in single-parent homes are twice as likely to 
        commit a crime that leads to incarceration by their early 
        thirties.\26\
            ``abstinence plus'' education is not the answer
    Many have suggested that so-called ``abstinence plus''--dual 
message programs discussing abstinence while also teaching all about 
contraception--is the appropriate answer to the twin epidemics of 
sexually transmitted diseases and out-of-wedlock pregnancies. Yet, for 
many years, it is just such programs that have been the predominant 
approach of sexuality education. And what did we see during these 
years? A genuine epidemic of sexually transmitted diseases is 
devastating our young people.
    There have been many studies of dual message educational programs. 
Only a handful of these studies have found any significant impact on 
ANY behavioral or health outcome.\27\ And most of these have only made 
``statistically significant'' impacts on behavioral outcomes (many 
times of questionable practical significance--such as ``condom use at 
last intercourse'' and ``frequency of unprotected sex'' in the past few 
months). Only two of the CDC's ``Programs That Work'' have reported 
statistically significant delays in the initiation of sexual activity, 
and only one of these has reported a truly substantial impact on this 
outcome.\28\,\29\ Recently and to the acclaim of the media, 
a study reported a reduction in pregnancy rates among participants in a 
teen pregnancy prevention program. The intervention made no impact on 
rates of sexual activity and did not even measure STD rates. And the 
impact on teen pregnancy was almost entirely attributable to injectable 
contraception use, which provides NO risk reduction for HIV or any 
other STD.\30\ Additionally, this intervention was so expensive, per 
student, that it cannot be considered a reasonable option in most 
settings. Finally, not a single one of the CDC's so-called ``Programs 
That Work'' has even investigated its impact on STD or pregnancy 
rates!\31\
    Despite what you may sometimes hear, there is no abundance of 
evidence that ``dual message'' or ``comprehensive'' programs are 
effective at preventing teen pregnancies and STDs. In fact, there is 
precious little evidence that these programs are really successful at 
all. Proponents of dual message programs face the same problems today 
as they have for many years--an inability to document tangible success 
in protecting adolescent health. And to whatever extent these programs 
give young people the impression that ``sex is really not a big 
concern, as long as you `protect yourself','' such programs may even 
contribute to the problem.
    Additionally, ``safer sex'' programs do not even address the 
problem of out-of-wedlock pregnancy. At best, these programs may 
encourage young people to wait before having sex; but there is rarely 
if ever any mention of the importance of actually being abstinent UNTIL 
MARRIAGE. As I have already stated, in spite of the recent decline in 
teen pregnancy rates, there has been a steady increase in the 
proportion of teen births occurring to unmarried teens. Similarly, the 
proportion of all births occurring out of wedlock has risen 
dramatically in the past few decades, so that in 1999, 33% of all 
American births occurred to unmarried women (compared to just 18% in 
1980) \32\. Could this increase be related to the lack of an emphasis 
on marriage in our classrooms over that period? It has only been in the 
past few years that this trend has begun leveling off, but certainly 
there must be a much greater emphasis placed on abstinence until 
marriage, not just until some unspecified later date--an emphasis that 
is clearly required by the Section 510 definition of abstinence 
education.
    Much has been made of the fact that many parents and sexuality 
education teachers believe it is necessary, as an element of public 
sexuality education, to teach kids very directly how to use condoms and 
contraceptives. Clearly, parents care about their adolescent children 
and desperately want to protect them from harm. Unfortunately, far too 
many parents are inadequately informed about the problems of 
contraceptive and condom use. How many parents know, for example, that 
condoms do not appear to reduce the risk of infection with human 
papillomavirus, which is the cause of almost all cervical cancer and 
most abnormal Pap smears? Do most parents understand that even with 
100% consistent condom use, their sexually active adolescents are at 
risk of contracting one of the other prevalent STDs (gonorrhea, 
chlamydia, trichomoniasis, etc. . . .)? Do parents understand that, for 
many sexually transmitted diseases, if condoms are not used 100% of the 
time it is little or no better than not using a condom at all, ever? 
\33\ If America's parents knew the facts--and these are scientifically 
supported facts, not conjecture nor ideology--we know they would agree 
with us: Their children need to hear that the only reliable way to 
protect themselves from a sexually transmitted disease that can have 
lifelong, physically and emotionally painful ramifications, is to 
abstain from sexual activity.
                       marriage is a health issue
    Title V clearly articulates an abstinence-until-marriage message. 
Marriage involves both personal and public health issues. An 
individual's number of sexual partners is directly linked to his or her 
risk of contracting a sexually transmitted disease. The one environment 
where people are most likely to have one sexual partner for a long 
period of time is marriage. The largest study ever done examining sex 
in America was conducted by researchers at the University of Chicago 
and published in the aptly named book, Sex in America.\34\ These 
researchers reported that, in contrast to what most Americans believe, 
when a marriage is intact, married couples almost never have sex 
outside of that marital relationship. Young people should be encouraged 
to maximize their own personal health by reserving sexual activity for 
marriage.
                               conclusion
    With STD prevalence among young people continuing at high levels, 
condoms clearly not eliminating the risk of any STD, and a continued 
increase in the proportion of births occurring to unmarried mothers, 
there is abundant evidence that the ``safer sex'' paradigm, despite 
more than 20 years and a variety of education programs designed to 
promote condom use, has not solved the problem. Since new research is 
beginning to suggest that abstinence education can effectively address 
these problems, it is important that we continue the effort begun in 
1996 and allow these programs sufficient time to continue to prove 
their effectiveness. Title V, including the definitions A through H, 
must be maintained as is. Doing so will ensure that research and 
evaluation can continue so that we can learn how this option is best 
delivered, and how abstinence education can best protect young people.
    We recognize that we do not yet have sufficient data to positively 
determine the degree of effectiveness of abstinence education. But 
results are promising. The national evaluation of abstinence programs 
by Mathematica will be completed in 2005. If we do not continue with 
the current level of funding, or if we change the focus of the programs 
funded under Title V, we will lose an invaluable opportunity to learn 
how we can effectively help young people avoid sexual activity--a risk 
behavior at least as detrimental to their health as the use of alcohol, 
drugs, and tobacco. And there will be no going back. If we damage the 
integrity of Title V the opportunity to fully explore this public 
health option will be lost. This is not about politics or ideology. 
This is about medicine, science, and data. All of which tell us the old 
approaches aren't working, not when millions of adolescents are 
contracting sexually transmitted diseases. We owe it to our young 
people to fully explore and evaluate the abstinence education approach, 
and that means continuing the Title V program as it is currently 
designed and being implemented.

                              References:

    1. Centers for Disease Control and Prevention. Youth Risk Behavior 
Surveillance System: Sexual Behaviors. 1999. Available at: http://
apps.nccd.cdc.gov/YRBSS. Accessed on April 19, 2002.
    2. Ventura SJ, Mathews TJ, Hamilton BE. Births to teenagers in the 
United States, 1940- 2000. National Vital Statistics Reports; 49(10). 
Hyattsville, Maryland: National Center for Health Statistics. 2001.
    3. Ventura SJ, Mosher WD, Curtin SC, Abma JC, Henshaw S. Trends in 
pregnancy rates for the United States, 1976-97: An update. National 
Vital Statistics Reports; 49(4). Hyattsville, Maryland: National Center 
for Health Statistics. 2001.
    4. Doniger AS, Riley JS, Utter CA, Adams E. Impact evaluation of 
the ``Not Me, Not Now'' abstinence-oriented, adolescent pregnancy 
prevention communications program, Monroe County, NY. J Health 
Communications. 2001;6:45-60.
    5. Rowberry DR. An Evaluation of the Washington, DC Best Friends 
Program [thesis]. Boulder, CO: Graduate School of the University of 
Colorado; 1995.
    6. American Social Health Association. Sexually Transmitted 
Diseases in America: how Many Cases and at What Cost? Menlo Park, CA: 
Kaiser Family Foundation; 1998.
    7. Centers for Disease Control and Prevention. Sexually Transmitted 
Disease Surveillance, 2000. Atlanta, GA: U.S. Department of Health and 
Human Services, Centers for Disease Control and Prevention, September 
2001.
    8. Gaydos CA, Howell MR, Pare B, et al. Chlamydia trachomatis 
infections in female military recruits. N Engl J Med. 1998;339:739-744.
    9. Fleming DT, McQuillan GM, Johnson RE, et al. Herpes simplex 
virus type 2 in the United States, 1976 to 1994. N Engl J Med. 1997; 
337:1104-1111.
    10. Centers for Disease Control and Prevention. Current trends 
premarital sexual experience among adolescent women--United States, 
1970-1988. MMWR. 1991;39(51-52):929-932.
    11. U.S. Census Bureau. Estimated Median Age at First Marriage, by 
Sex: 1890 to the Present. 2001. Available at: http://www.census.gov/
population/www/socdemo/hh- fam.html. Accessed on April 19, 2002.
    12. Abma J, Chandra A, Mosher W, Peterson L, Piccinino L. 
Fertility, family planning, and women's health: New data from the 1995 
National Survey of Family Growth. National Center for Health 
Statistics. Vital Health Statistics; 23(19). 1997.
    13. Ho GYF, Bierman R, Beardsley L, Chang CJ, Burk RD. Natural 
history of cervicovaginal papillomavirus infections in young women. N 
Engl J Med. 1998;338:423-428.
    14. Ibid # 9.
    15. Eng TR, Butler WT, eds. The Hidden Epidemic-Confronting 
Sexually Transmitted Disease. Institute of Medicine. Washington, DC: 
National Academy Press; 1997.
    16. Ibid.
    17. Wheeler CM, Parmenter CA, Hunt WC. Determinants of genital 
human papillomavirus infection among cytologically normal women 
attending the University of New Mexico student health center. Sex 
Transm Dis. 1993;20:286-289.
    18. Peyton CL, Gravitt PE, Hunt WC, et al. Determinants of genital 
human papillomavirus in a U.S. population. J Infect Dis. 2001;183:1554-
1564.
    19. National Institutes of Health. Workshop Summary: Scientific 
Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) 
Prevention. 2001. Available at: http://www.niaid.nih.gov/dmid/stds/
condomreport.pdf. Accessed on April 19, 2002.
    20. Wald A, Langenberg AG, Link K, et al. Effect of condoms on 
reducing the transmission of herpes simplex virus type 2 from men to 
women. JAMA. 2001;285:3100-3106.
    21. Burstein GR, Gaydos CA, Diener-West, Howell MR, Zenilman JM, 
Quinn TC. Incident Chlamydia trachomatis infections among inner-city 
adolescent females. JAMA. 1998;280:521-526.
    22. Ventura SJ, Bachrach CA. Nonmarital childbearing in the United 
States, 1940-99. National Vital Statistics Reports; 48(16). 
Hyattsville, Maryland: National Center for Health Statistics. 2000.
    23. Fagan PF. How broken families rob children of their chances for 
future prosperity. Backgrounder. 1283. Washington, DC: Heritage 
Foundation. 1999. Available at: www.heritage.org/library/backgrounder/
bg1283.html. Accessed on April 19, 2002.
    24. Waite LJ, Gallagher M. The Case for Marriage: Why Married 
People are Happier, Healthier, and Better Off Financially. Broadway 
Books. New York. 2000.
    25. Ibid.
    26. Ibid.
    27. Kirby D. Emerging Answers: Research Findings on Programs to 
Reduce Teen Pregnancy. Washington, DC: National Campaign to Prevent 
Teen Pregnancy. 2001.
    28. Kirby D, Barth RP, Leland N, Fetro JV. Reducing the Risk: 
Impact of a new curriculum on sexual risk-taking. Fam Plan Persp. 
1991;23:253-263.
    29. St. Lawrence JS, Brasfield TL, Jefferson KW, Alleyne E, 
O'Bannon RE, Shirley A. Cognitive-behavioral intervention to reduce 
African American adolescents' risk for HIV infection. Journal 
Consulting Clinical Psychology. 1995;63:221-237.
    30. Philliber S, Kaye J, Herrling S. The National Evaluation of the 
Children's Aid Society Carrera-Model Program to Prevent Teen Pregnancy. 
Philliber Research Associates. 2001.
    31. Centers for Disease Control and Prevention. HIV Prevention Fact 
Sheets. Available at: www.cdc.gov/nccdphp/dash/rtc/hiv-curric.htm. 
Accessed on April 19, 2002.
    32. Ibid # 22.
    33. Ibid # 19.
    34. Michael RT, Gagnon JH, Laumann EO, Kolata G. Sex in America. 
Boston, MA: Little, Brown and Company; 1994.
           appendix a: list of sexually transmitted diseases
1. Gonorrhea; 2. Chlamydia; 3. Lymphogranuloma venereum (caused by 
certain strains of Chlamydia trachomatis); 4. Syphilis; 5. Chancroid; 
6. Donovanosis (Granuloma inguinale); 7. Ureaplasma urealyticum; 8. 
Human Immunodeficiency Virus (HIV) Types I and II; 9. Shigellosis*; 10. 
Salmonellosis*; 11. Herpes Simplex Virus Types I and II; 12. 
Cytomegalovirus*; 13. Human Papillomavirus (approximately 30 sexually 
transmitted strains); 14. Molluscum contagiosum; 15. Hepatitis A; 16. 
Hepatitis B; 17. Hepatitis C*; 18. Hepatitis D*; 19. Body or pubic 
lice; 20. Trichomoniasis; 21. Scabies*; 22. Giardiasis*; 23. 
Amoebiasis*; 24. Bacterial vaginosis*; and 25. Human Herpes Virus type 
VIII;

    * Sexual transmission occurs but is not the primary mode of 
transmission.

    Mr. Bilirakis. Thank you very much, Doctor.
    Dr. Kaplan.

                  STATEMENT OF DAVID W. KAPLAN

    Mr. Kaplan. Mr. Chairman, thank you very much for inviting 
me to testify before the subcommittee today on the important 
topic of sex education for our Nation's youth as you consider 
reauthorizing the abstinence only provisions of the 1996 law 
and formally known as welfare reform.
    I am Chief of Adolescent Medicine and Professor of 
Pediatrics in the Department of Pediatrics at the University of 
Colorado School of Medicine and head of Adolescent Medicine at 
the Children's Hospital in Denver. As a physician who sees the 
realities of adolescent life on a daily basis, the struggles 
with emerging sexuality, the impact of peer pressure and the 
media, the effort to make responsible decisions and the 
consequences of poor choices, I wish to appeal to the 
subcommittee and indeed to the Congress as a whole to be 
realistic and responsible when it comes to sex education and to 
provide young people with all the information they need to 
protect their health and lives in the era of AIDS.
    Do not make this an either/or issue because it's not. Young 
people need information about abstinence and they need 
information about contraception. They need information about 
abstinence because, as the American Academy of Pediatrics 
policy statement on adolescent HIV prevention states, ``it is 
the surest way to prevent STDs including HIV infection and 
pregnancy.''
    The Academy policy statement goes on to say ``although 
abstinence is the safest method of avoiding sexual exposure to 
HIV, it is impossible to predict which adolescents will remain 
abstinent. Therefore, education about safer sexual practices 
including the use of condoms and other barrier methods needs to 
be provided to adolescents in order to protect them.''
    More than half of all the teens ages 15 to 19 in this 
country have had sex. That figure is nearly 70 percent for 18-
year-olds. Whether you are a pediatrician or a policymaker, a 
parent or a teacher, this reality confronts us. We must stop 
politicizing the issue and acknowledge the need for teens to 
learn how to protect themselves from unintended pregnancy and 
STDs. Parents themselves are far more pragmatic and realistic 
than conventional wisdom would have us believe. The Kaiser 
Family Foundation released a major survey of parents, their 
teens, sex education teachers and principals and in that survey 
85 percent of parents said how to use condoms and other forms 
of birth control should be covered as well as how to talk about 
their use with partners.
    Young people themselves share similar views and say that 
there should be more, not less, information provided in sex 
education classes. Young people say there should be more 
information on how to use and where to get birth control. They 
also say they need more information on how to talk with the 
partner about birth control and sexually transmitted diseases.
    I'm a physician. My testimony is based both on my 
experience in providing health care to teenagers over the last 
30 years and scientific evidence. Neither the evidence 
justifies nor my experience supports further funding of 
abstinence only programs. In 2001, the National Campaign to 
Prevent Teenage Pregnancy found no credible studies of 
abstinence only education showing any significant impact on 
participants' initiation of or frequency of sex and contrary to 
the governing myth underpinning abstinence only education 
comprehensive sex education actually delays the onset of sex 
and reduces its frequency and increases contraceptive use. 
That's why comprehensive sex education, not abstinence only is 
worth funding.
    Again, the American Academy of Pediatrics reached a similar 
conclusion on censoring information and denying access to 
contraception and I quote, ``there is no evidence that refusal 
to provide contraception to adolescents results in abstinence 
or postponement of sexual activity. In fact, if adolescents 
perceive obstacles to obtaining contraception and condoms, they 
are more likely to have negative outcomes to sexual activity. 
In addition, no evidence exists that the provision of 
information to adolescents about contraception results in 
increased rates of sexual activity, earlier age of first 
intercourse or greater number of partners.
    ``Two school-based controlled studies have demonstrated a 
delay on the onset of sexual intercourse in the intervention 
group that used a comprehensive approach that included a 
discussion of contraception. Availability of contraception is 
not causally related to sexual experimentation.''
    Simply put, informing young people about contraception does 
not cause them to have sex. The basic foundation of sound 
public health policy is education.
    There is a clear consensus among experts that abstinence 
only education that censors information about contraception 
does not constitute sound public health policy. Indeed, I 
cannot think of any other issue which is so strongly endorsed 
by the leading health and medical organizations, yet remains 
held hostage to politics.
    In 2001, the Surgeon General recommended giving information 
on both abstinence and contraception. The National Academy of 
Sciences Institute of Medicine criticizes abstinence only 
education and supports comprehensive sex and HIV education 
programs which it says can reduce high risk sexual behaviors 
among adolescents.
    The National Institute of Health concluded ``abstinence 
only programs cannot be justified in face of the effective 
programs given effect that we face an international emergency 
on HIV.''
    Mr. Bilirakis. Please summarize, Doctor.
    Mr. Kaplan. In summary, I would suggest a few key 
principles. First of all, do no harm. Provide medically 
accurate information about abstinence and contraception. 
Second, teachers should not be censored from answering young 
people's questions about their health. Third, we need to follow 
research, what really works, and last, we need to be realistic 
and provide young people with all the information they need to 
protect their lives and health in an era of AIDs.
    Thanks very much.
    [The prepared statement of David W. Kaplan follows:]
   Prepared Statement of David Kaplan, Chief of Adolescent Medicine, 
  Department of Pediatrics, University of Colorado School of Medicine
    Thank you very much for inviting me to testify before the 
subcommittee today on the important topic of sex education for our 
nation's youth, as you consider reauthorizing the abstinence-only 
provisions of the 1996 law informally known as ``welfare reform.'' I am 
Chief of Adolescent Medicine and Professor of Pediatrics in the 
Department of Pediatrics, at the University of Colorado School of 
Medicine, and head of adolescent medicine at the Children's Hospital in 
Denver. I am also the Chairman of the Committee on Adolescence at the 
American Academy of Pediatrics.
    As a physician who sees the realities of adolescent life on a daily 
basis--the struggle with emerging sexuality, the impact of peer 
pressure and the media, the effort to make responsible decisions and 
the consequences of poor choices' I wish to appeal to the 
subcommittee--and, indeed to the congress as a whole--to be realistic 
and responsible when it comes to sex education and to provide young 
people with all the information they need to protect their health and 
lives in the era of AIDS.
    Do not make this an either/or issue--because it is not. Young 
people need information about abstinence and contraception. They need 
information about abstinence because, as the american academy of 
pediatrics policy statement on adolescent HIV prevention states, ``it 
is the surest way to prevent stds, including HIV infection, and 
pregnancy.'' 1
---------------------------------------------------------------------------
    \1\ Committee on Adolescence, American Academy of Pediatrics (AAP), 
Condom Use By Adolescents, 107(6) Pediatrics 1463, 1467 (June 2001).
---------------------------------------------------------------------------
    The academy policy statements go on to say: ``although abstinence . 
. . is the safest method of avoiding sexual exposure to HIV, it is 
impossible to predict which adolescents will remain abstinent. 
Therefore, education about safer sexual practices, including latex 
condom use, and other barrier methods should be provided so adolescents 
might opt to stop or alter their sexual behavior.'' 2
---------------------------------------------------------------------------
    \2\ Committees on Pediatric AIDS and Adolescence, AAP, Adolescents 
and Human Immunodeficiency Virus Infection: The Role of the 
Pediatrician in Prevention and Intervention, 107(1) Pediatrics 188-190 
(Jan. 2001).
---------------------------------------------------------------------------
    More than half of all teens aged 15-19 in this country have had 
sex. That figure is nearly 70% for 18 year-olds.3 Whether 
you are a pediatrician or a policymaker, a parent or a teacher, this 
reality confronts us. We must stop politicizing the issue and 
acknowledge the need for teens to learn how to protect themselves from 
unintended pregnancy and STDs.
---------------------------------------------------------------------------
    \3\ The Alan Guttmacher Institute (AGI), Teen Sex and Pregnancy, 
Facts in Brief (1999).
---------------------------------------------------------------------------
    Parents themselves are far more pragmatic and realistic than 
conventional wisdom would have us believe. The Kaiser Family Foundation 
released a major survey of parents, their teens, sex education 
teachers, and principals. In that survey, 85% of parents said how to 
use condoms and other forms of birth control should be covered, as well 
as how to talk about their use with partners (88%).4
---------------------------------------------------------------------------
    \4\ News Release, Kaiser Family Foundation (KFF), National Study on 
Sex Education Reveals Gaps Between What Parents Want and Schools Teach 
(Sept. 22, 2000).
---------------------------------------------------------------------------
    Young people themselves share similar views, and say there should 
be more, not less, information provided in sex education classes. Young 
people say there should be more information on how to use and where to 
get birth control; they also say they need more information on how to 
talk with a partner about birth control and STDs.5
---------------------------------------------------------------------------
    \5\ Id.
---------------------------------------------------------------------------
    I am a physician. My testimony is based both on my experience 
providing health care to teenagers over the last 30 years and the 
scientific evidence. Neither the evidence justifies nor my experience 
supports further funding of abstinence-only programs. In 2001, the 
national campaign to prevent teen pregnancy found no credible studies 
of abstinence-only education showing any significant impact on 
participants' initiation of or frequency of sex. And contrary to the 
governing myth underpinning abstinence-only education, comprehensive 
sex education actually delays the onset of sex, reduces its frequency 
and increases contraceptive use.6 That's why comprehensive 
sex education--not abstinence-only--is worth funding.
---------------------------------------------------------------------------
    \6\ Douglas Kirby, The National Campaign to Prevent Teen Pregnancy, 
Emerging Answers: Research Findings on Programs to Reduce Teen 
Pregnancy (2001), at 88, 95.
---------------------------------------------------------------------------
    Again, the american academy of pediatrics reached a similar 
conclusion on censoring information and denying access to 
contraception:
    ``There is no evidence that refusal to provide contraception to an 
adolescent results in abstinence or postponement of sexual activity. In 
fact, if adolescents perceive obstacles to obtaining contraception and 
condoms, they are more likely to have negative outcomes to sexual 
activity. In addition, no evidence exists that provision of information 
to adolescents about contraception results in increased rates of sexual 
activity, earlier age of first intercourse, or a greater number of 
partners. Two school-based controlled studies that demonstrated a delay 
of onset of sexual intercourse in the intervention group used a 
comprehensive approach that included a discussion of contraception. 
Availability of contraception is not causally related to sexual 
experimentation.'' 7
---------------------------------------------------------------------------
    \7\ Committee on Adolescence, AAP, Contraception and Adolescents, 
104(5) Pediatrics 1161 (Nov. 1999).
---------------------------------------------------------------------------
    Simply put, informing young people about contraception does not 
cause them to have sex. The basic foundation of sound public health 
policy is education.
    There is a clear consensus among the experts that abstinence-only 
education that censors information about contraception does not 
constitute sound public health policy. Indeed, I cannot think of any 
other issue which is so strongly endorsed by the leading health and 
medical organizations, yet remains hostage to politics.

 In 2001, the surgeon general recommended giving information on 
        both abstinence and contraception.8
---------------------------------------------------------------------------
    \8\ The Surgeon General's Call to Action to Promote Sexual Health 
and Responsible Sexual Behavior (July 9, 2001), at http://
www.surgeongeneral.gov/library/sexualhealth/call.htm.
---------------------------------------------------------------------------
 The National Academy of Sciences' Institute of Medicine 
        criticizes abstinence-only education and supports comprehensive 
        sex and hiv/aids education programs, which, it says, can reduce 
        high-risk sexual behaviors among adolescents.9
---------------------------------------------------------------------------
    \9\ Committee on HIV Prevention Strategies in the United States, 
Institute of Medicine, No Time to Lose: Getting More from HIV 
Prevention 118-20 (National Academy Press 2001).
---------------------------------------------------------------------------
 The National Institutes of Health concluded: ``abstinence-only 
        programs cannot be justified in the face of effective programs 
        and given the fact that we face an international emergency in 
        the AIDS epidemic.'' 10
---------------------------------------------------------------------------
    \10\ National Institutes of Health, Interventions to Prevent HIV 
Risk Behaviors, NIH Consensus Statement (Feb. 11-13, 1997), at 16.
---------------------------------------------------------------------------
 The American Academy of Pediatrics recommended last year that 
        ``all adolescents should be counseled about the correct and 
        consistent use of latex condoms to reduce risk of infection.'' 
        11
---------------------------------------------------------------------------
    \11\ AAP, supra note 2.
---------------------------------------------------------------------------
 The American Medical Association urges schools to implement 
        comprehensive sex education programs that include information 
        about contraceptives.12
---------------------------------------------------------------------------
    \12\ Council on Scientific Affairs, American Medical Association, 
Report 7 of the Council on Scientific Affairs (1-99): Sexuality 
Education, Abstinence, and Distribution of Condoms in Schools, at 
http://www.ama-assn.org/ama/pub/article/2036-2376.html (last visited 
Mar. 4, 2002).
---------------------------------------------------------------------------
 The American College of Obstetricians and Gynecologists 
        supports sex education programs that include information about 
        contraception.13
---------------------------------------------------------------------------
    \13\ American College of Obstetricians & Gynecologists (ACOG) 
Statement of Policy, Statement on Sexuality Education (July 1996); ACOG 
Statement of Policy, The Limitations of Abstinence-Only Sexuality 
Education (May 1998).
---------------------------------------------------------------------------
 And the American Public Health Association urges that 
        comprehensive sex education be included as an integral part of 
        all school systems' curricula.14
---------------------------------------------------------------------------
    \14\ American Public Health Association, Policy Statement 9309: 
Sexuality Education (Jan. 1, 1993).
---------------------------------------------------------------------------
    The Office of the Surgeon General. The Institute of Medicine. The 
NIH. The American Academy of Pediatrics. The AMA. ACOG. APHA. Those are 
the professionals, the most respected leadership in our country. 
Unanimously, they take the same, evidence-based approach I urge 
congress to adopt. Yet, in programs funded with abstinence-only 
dollars, teachers can't even answer students' questions about 
prohibited topics--despite experts' recommendations.
    Information is a tool, not an opponent, of responsible, healthy 
decision-making. Our young people are not all the hormone-driven 
stereotypes we see portrayed so often in our culture. They are capable 
of making good choices. Depriving them of medically accurate 
information will not protect them. It will only make them more 
vulnerable.
    Mr. Chairman, our nation's youth face a reproductive health crisis: 
despite some encouraging signs that adolescent pregnancy rates are 
declining 15, teens still confront the twin epidemics of 
teen pregnancy (numbering almost 900,000 a year 16) and HIV, 
as well as other sexually transmitted diseases. Every day in America 
10,000 young people contract a sexually transmitted disease, 2400 
become pregnant, and tragically, 55 contract HIV.17 I know 
in my heart that we can do a better job for our youth.
---------------------------------------------------------------------------
    \15\ Ventura et al., Declines in Teenage Birth Rates, 1991-98: 
Update of National and State Trends, National Vital Statistics Report 
(Centers for Disease Control & Prevention) (Oct. 25, 1999), at 2.
    \16\ AGI, Teenage Pregnancy: Overall Trends and State-by-State 
Information (Apr. 1999), table 3.
    \17\ Pregnancy and STD statistics are for teens aged 15-19; HIV 
statistics are for young people aged 13-24. Id.; KFF & American Social 
Health Association, Sexually Transmitted Diseases in America: How Many 
Cases and at What Cost? 4, 8 (1998); Office of National AIDS Policy, 
The White House, Youth and HIV/AIDS: A New American Agenda (Sept. 
2000), at v.
---------------------------------------------------------------------------
    In closing, I would suggest that we follow a few key principles:

 Do no harm. Provide medically accurate information about 
        abstinence and contraception.
 Teachers must not be censored from answering young people's 
        questions about their health.
 Follow the research on what really works.
 Be realistic. Provide young people with all the information 
        they need to protect their health and lives in the era of aids.
    Thank you very much.

    Mr. Bilirakis. Thank you very much, sir.
    Ms. Mann.

                     STATEMENT OF CINDY MANN

    Ms. Mann. Thank you, Mr. Chairman, and members of the 
committee for the opportunity to testify about health care 
coverage for families leaving welfare and specifically the 
Transitional Medical Assistance program.
    Let me start with what I think is a sobering fact and that 
is if you are a parent, caring for a child, and you are poor, 
that is your income is below poverty, you are more likely to be 
uninsured if you have a job, than if you don't have a job. Poor 
parents who work are--43 percent of poor parents who work don't 
have health insurance coverage. This anomaly occurs because 
poor and near poor parents are caught between two systems of 
coverage. The first system, I think which most of us are most 
familiar with is the employer-based health care system. Most of 
us get our health insurance coverage from our employers, but 
that's not true with low wage workers. If you have low wages, 
you're much less likely to get coverage through your job. A 
study in 1988 looking at people with earnings of about $7 an 
hour or less showed that only 50 percent of them had employer-
based coverage either through their own employer or through 
their spouse's employer. Forty percent weren't offered coverage 
at all, and 10 percent declined that coverage largely because 
of their costs.
    The second system that poor parents are caught between is 
publicly funded coverage. Medicaid and the States Children's 
Health Insurance Program now offered coverage to most of the 
children in low income working households, however, the parents 
in those households are largely left out of publicly financed 
coverage. Medicaid eligibility for parents is no longer tied to 
welfare. Delinking Medicaid and welfare eligibility was part of 
the welfare law that was enacted in 1996. However, most States 
set their eligibility levels for parents in Medicaid at income 
levels that are about the same levels as welfare. If you earn 
about the average wage that people earn when they leave welfare 
for work, about $1300 a month, which is about the poverty line 
for a family of three, you are ineligible for Medicaid in 39 
States. That's where TMA comes in and the Chairman aptly 
described the purpose of TMA. It provides time-limited Medicaid 
coverage to those parents who already have Medicaid coverage 
and who then get a job and would lose their on-going regular 
Medicaid coverage because of their earnings. They don't get 
employer-based coverage. They're no longer eligible for regular 
Medicaid. TMA provides them an extension of coverage. It 
doesn't last forever. It's limited to 12 months and some people 
get it for less than 12 months, but it does assure that a 
parent can take the job and not immediately at least lost their 
Medicaid coverage when they join the workforce.
    It's a program that's enjoyed broad bipartisan support for 
almost 20 years. It was first created actually in 1984, amended 
and expanded in 1998 and revisited and extended again in 1996 
at the Welfare Law and extended again in the year 2000.
    While there seems to be very broad consensus in this 
committee and beyond that TMA ought to be continued, there has 
been some concern about low participation rates in the TMA 
program. In the past several years there's been a considerable 
amount of attention paid as to why Medicaid rolls have declined 
at the same welfare rolls have declined, even though the two 
programs have become delinked. There were many reasons for some 
of the problems that were experienced, particularly having to 
do with State and local implementation of the delinking 
provisions and some slowness at the State and local level to 
change computer systems to ensure that when people left the 
welfare system, they were properly continued on Medicaid, 
generally, and on TMA if that was the category of Medicaid that 
they qualified for. Other problems arose because families 
didn't always know they were eligible for TMA.
    Some of these problems have been addressed and Medicaid 
enrollment is beginning to rebound in a number of States. 
However, other problems have come to surface that have 
interfered with TMA participation. Let me mention a few steps 
that can be remedied only with legislative changes.
    First, TMA is limited to those people who have been on 
Medicaid for at least 3 out of 6 months prior to getting a job. 
That seems to conflict with State efforts to encourage quick 
attachment to the labor market. Let me give you an example. If 
you are a family, you're on welfare in January and Medicaid is 
starting in January, you get a job in February that doesn't 
offer health insurance coverage and you're no longer eligible 
for Medicaid because of your wages, you would not be able to 
qualify for TMA under Federal rules because you will not have 
met that 3 out of 6 months requirement.
    Second, TMA is limited to 12 months, as we've noted. Some 
States would like to extent TMA beyond that period of time, but 
they don't have the statutory discretion to do that.
    And third, I'd like to mention some very prescriptive 
reporting requirements that are built into the Federal law. 
States must send families forms and families must fill out 
forms in the 4th, 7th and 10th month of this limited 12-month 
period of coverage. It's really the only area in the Medicaid 
statute that I can think of where the reporting requirements 
are laid out in this kind of way. Generally, States have the 
responsibility to make sure that people who are in the Medicaid 
program are eligible, but in the area of TMA, the statute is 
very prescriptive and tells States exactly how they need to 
proceed. These reporting requirements have been administrative 
barriers for States and they have caused eligible families to 
lose coverage.
    Let me close by noting how important health care coverage 
is to the population that's targeted by TMA. Low-income parents 
tend to have greater health care problems than other people and 
those health care problems, as members have noted, will 
interfere with their ability to care for their children and to 
support their families through employment. Health coverage 
doesn't guarantee good health, but it certainly provides access 
to care that can bring a measurable difference in the lives of 
poor families.
    When the welfare reform was debated in 1996, there was 
nearly universal agreement that health care coverage was a 
critical part of the support system to help struggling families 
stay afloat with limited wages. TMA is not the solution to the 
coverage problems faced by poor families, but it is certainly a 
very critical component of our far from perfect system.
    Mr. Bilirakis. Please summarize, Ms. Mann.
    Ms. Mann. Without TMA, there can be little doubt that more 
poor working parents will, in fact, join the ranks of the 
uninsured. I'll close there.
    [The prepared statement of Cindy Mann follows:]
 Prepared Statement of Cindy Mann, Senior Fellow, Kaiser Commission on 
                       Medicaid and the Uninsured
    Thank you for the opportunity to offer testimony on Transitional 
Medical Assistance.
    I am Cindy Mann, Senior Fellow with the Kaiser Commission on 
Medicaid and the Uninsured. The national nonpartisan Commission 
services as a policy institute and forum for analyzing health care 
coverage and access for low-income populations and assessing options 
for reform. Before joining the Commission, I served as the Director of 
the Family and Children's Health Program Group at the Health Care 
Financing Administration (now the Centers for Medicare and Medicaid 
Services) overseeing the administration of Medicaid for families and 
children, including Transitional Medical Assistance.
    Low-income people (those with incomes below 200% of the federal 
poverty line, or $30,040 for a family of three), including parents who 
have left welfare and are now employed, have a much higher risk than 
others of being uninsured. A third of low-income parents, including 40 
percent of parents with incomes below poverty, lack health insurance 
coverage. (The poverty level is $15,020 for a family of three.) Figure 
1. Ironically, poor parents are more likely to be uninsured if they are 
employed than if they are not employed (43% uninsured v. 31% uninsured) 
because low-wage workers often do not have access to employer-based 
coverage and, in most states, Medicaid eligibility standards for 
parents are so low that even parents with very low wages are ``over 
income'' and cannot qualify for ongoing Medicaid coverage.
    Transitional Medical Assistance (TMA) is one policy that helps 
address this troubling dynamic. TMA offers critical support to many of 
the most vulnerable families in this nation. It provides temporary 
health care coverage to families with low wages, primarily those who 
have left welfare to take a job. TMA covers children and their parents, 
but it is particularly important for low-income working parents for 
whom TMA is often their only source of coverage. If TMA lapses at the 
end of this fiscal year, poor and near-poor parents will become 
uninsured, with adverse effects for their health, their ability to care 
for their children, and their capacity to retain employment and support 
their families. On the other hand, if TMA is extended and improved, 
even more low-income working parents will have a guarantee of coverage 
at least for a limited period of time.
TMA has been supported and expanded over the years
    TMA is a common-sense ``welfare-to-work'' initiative that was 
created with strong bipartisan support years before the current era of 
welfare reform. It was first established in 1984 and was revised and 
expanded in 1988 as part of the Family Support Act of 1988. During this 
time, Medicaid eligibility for families with children was linked to 
welfare. In general, this meant that families that received welfare 
(Aid to Families with Dependent Children, or AFDC) were automatically 
enrolled in Medicaid and that when a family left welfare its Medicaid 
coverage would end. Congress recognized that parents leaving welfare 
for work are often not offered coverage at their workplace and was 
concerned that the loss of Medicaid coverage could discourage families 
from seeking jobs and make it difficult for them to retain employment. 
The 1987 Report of the House Energy and Commerce Committee accompanying 
the measure that broadened TMA noted that ``(F)ormer AFDC families that 
work their way off welfare have the greatest need for health care 
coverage, because they are least able to pay for services out of pocket 
and because their health is more likely to be poor. Yet these are 
precisely the families that are among those most likely to be 
uninsured.'' 1 TMA assured that parents receiving welfare 
could take a job without losing Medicaid at least for a limited period 
of time.2
    In 1996, when Congress drafted the Personal Responsibility and Work 
Opportunity Reconciliation Act of 1996 (PRWORA) to replace AFDC with 
the Temporary Assistance to Needy Families (TANF) block grant, it 
revisited Medicaid coverage rules, including TMA. Welfare reform 
underscored the important role Medicaid plays for low-income families, 
including those who may not be receiving welfare. PRWORA broke the 
historic link between Medicaid and welfare and created in its place a 
new Medicaid eligibility category for families with children. Under 
these new rules, families qualify for Medicaid based on their income, 
not based on their status as welfare recipients. PRWORA also extended 
TMA to 2001, demonstrating Congress' continued commitment to assuring 
that families would not immediately lose health care coverage if they 
left welfare because a parent in the family found employment. The TMA 
sunset date was extended for one more year in legislation enacted in 
2000.3
    Under current law, states must provide TMA to families who 
otherwise would become ineligible for ongoing Medicaid coverage under 
the new family coverage category (``section 1931'') created by 
PRWORA.4 TMA is available if the family was receiving 
Medicaid for three out of the prior six months and is losing regular 
Medicaid because of earnings or child support payments. If the receipt 
of child support triggers TMA coverage, the family is eligible for four 
months of coverage. If TMA is based on earnings, the family is eligible 
for six months of coverage, plus an additional six months if family 
income, less child care expenses, stays below 185 percent of the 
poverty level ($27,787 for a family of three) and the family complies 
with federal reporting requirements. Families with access to employer-
based coverage can combine this coverage with Medicaid. TMA would cover 
some medical services not covered by the employer plan, and help pay 
premiums and cost sharing imposed by the employer plan. Employer-based 
coverage is often not available to parents leaving welfare
    While most Americans receive their health care coverage through 
employer-subsidized plans, low-wage workers are substantially less 
likely to have job-based coverage. In 1998, only half of the workers 
earnings less than $7 an hour (which is close to the average wage 
earned by those leaving welfare who are employed) were covered by plans 
offered either by their employers or their spouses' employer. Forty 
percent were not offered health insurance and an additional 10 percent 
declined an offer of coverage, largely as a result of costs. Figure 2. 
Even without considering deductibles and co-payments, the average cost 
of maintaining coverage offered through the work place is often well 
beyond the reach of parents leaving welfare. The average employee 
contribution for family coverage in 2001 would consume 11 percent of 
the average gross earnings reported by families leaving welfare for 
employment ($1,360 a month).5 Individual coverage is less 
costly but still difficult for many families living below or close to 
the poverty level to afford, and premium costs are rising rapidly.
    Other factors that typify the circumstances of many of the families 
leaving welfare also contribute to low rates of employer-based coverage 
among TANF leavers. Parents leaving welfare are often new employees 
both because they may be entering the labor market for the first time 
and because they change jobs often due to the dynamics of the low-wage 
labor market and the challenges of maintaining child care and reliable 
transportation. New employees are often not offered employer-based 
coverage even in firms that offer longer-term employees coverage. In 
addition, women leaving welfare frequently find work at retail or 
service firms where employer-based coverage is less prevalent.
    For all these reasons, only a small portion of families leaving 
welfare have employer-based coverage. The Urban Institute found that, 
in 1999, on average, only one out of five parents had employer-based 
coverage in the first year after leaving welfare. Employer-based 
coverage picked up substantially after one year, but still, even at a 
time when the economy was particularly strong, only a minority (44%) of 
parents had employer-based coverage more than one year after leaving 
welfare.6
For parents, regular Medicaid often does not fill the gap left by 
        employer-based coverage
    Medicaid and now the State Children's Health Insurance Program 
(SCHIP) fill in much of the gap in coverage for children left by 
relatively low rates of job-based coverage among low-income workers and 
their dependents. Under federal minimum eligibility standards, all 
states must provide Medicaid coverage to children under age six if 
their incomes are below 133 percent of the federal poverty line 
($19,977 for a family of three). Older children must be covered if 
their income is below the poverty level. Options available to states to 
receiving federal matching funds to cover children at higher levels 
have prompted most states to expand coverage through Medicaid and SCHIP 
beyond these minimum levels. As of January 2002, every state covered 
children with incomes up to at least 140 percent of the poverty line, 
and all but 11 states covered children with incomes up to 200 percent 
of FPL. As a result, most (83%) low-income children are now eligible 
for Medicaid or SCHIP.7 Many immigrant children are still 
left out of coverage, but for most other children the primary challenge 
is to improve participation rates in Medicaid and SCHIP.
    The story is far different for the parents of these children. There 
is no uniform national minimum eligibility standard applicable to 
parents under Medicaid; the federal minimum standard varies by state 
pegged to the state's 1996 AFDC income standard. States have options to 
broaden their family coverage to reach more low-income working parents, 
but to date, only 18 states cover parents with incomes at 100 percent 
of the poverty level through regular Medicaid (or through a waiver). In 
seven states the income eligibility standard for a parent with earnings 
is below 33 percent of the poverty line ($4,957 for a family of three). 
Figure 3.
    As a result of these low eligibility standards, in most states low-
income working parents, including many of those leaving welfare, have 
too much income to qualify for regular Medicaid. The earnings of those 
who leave welfare and find jobs average $1,360 a month.8 
This is below the poverty level for a family of three, yet in 39 states 
a parent with two children earning this amount will be ``over income'' 
for regular Medicaid.9 In the absence of TMA, most parents 
at these wage levels would not have any route to Medicaid coverage 
unless they are pregnant or disabled. Given limited access to employer-
based coverage, parents moving into the labor market earning these 
wages would be at great risk of being uninsured if TMA were not 
available.
TMA implementation issues
    While TMA has been a valuable source of coverage for millions of 
people in low-income working families, TMA has not always operated 
smoothly for either families or for states. Some problems have arisen 
as a result of implementation problems at the state and local level. In 
addition, some families do not take advantage of TMA because they are 
unaware of the coverage it offers. Families often close their Medicaid 
case when someone in the household finds employment, unaware that they 
may continue to be eligible for Medicaid. Many families wrongly assume 
that they have to be receiving welfare in order to qualify for 
Medicaid.10
    Implementation problems were identified following the enactment of 
the federal welfare law in 1996. The welfare rolls plummeted, and, in 
many states, Medicaid enrollment dropped sharply as well even though 
most families leaving welfare should have been eligible for Medicaid at 
least for a temporary period of time.11 Some of the decline 
occurred because state and local procedures and computer systems did 
not ensure that families who were leaving welfare were being properly 
evaluated for continuing Medicaid eligibility, including TMA. Studies 
have found that only one third to one half of the adults leaving 
welfare had Medicaid coverage following their TANF exit. According to 
an analysis by the Urban Institute relying on 1999 data, half of the 
women leaving welfare had Medicaid coverage during the year after 
leaving TANF. More than one-third (37%) percent were 
uninsured.12 Figure 4. TANF ``leavers'' studies funded by 
the Department of Health and Human Services had similar 
findings.13
    As a result of the unanticipated drop in Medicaid enrollment 
following welfare reform, many states began to focus in on the problem 
and make corrections, sometimes as a result of litigation or the threat 
of litigation.14 In 1999 through 2000, the Centers for 
Medicare and Medicaid Services (formerly HCFA) visited each of the 50 
states and issued reports on state and local policies and procedures, 
and in April of 2000, CMS instructed all states to take steps to 
address any problems that might continue to exist and to restore 
coverage to children and parents who had been terminated from coverage 
improperly.15
    Partly as a result of these state and federal efforts, Medicaid 
enrollment began to rebound in 1998, although enrollment trends varied 
significantly across states. Indiana's experience is instructive. The 
state identified implementation problems and outreach needs and took a 
number of steps to improve policies and procedures so that families 
moving in and out of the welfare system as well as those who did not 
apply for welfare did not lose out on Medicaid coverage. After three 
years of enrollment declines, Indiana saw its family caseload in 
Medicaid rise by 40 percent between May 1998 and April 2000. TMA 
enrollment quadrupled during this period.16 Indiana's 
experience shows that proper implementation coupled with aggressive 
outreach can make a substantial difference in the extent to which 
Medicaid generally and TMA specifically live up to their potential for 
covering low-income working families.
TMA design issues
    There appears to be broad consensus that TMA is an important 
component of the Medicaid program and state and federal welfare-to-work 
initiatives. Some changes in the federal design of TMA could, however, 
boost participation. Some of these changes have been proposed in 
pending legislation. 17

 Currently, TMA is available only to families that have been 
        enrolled in regular Medicaid for at least three out of the last 
        six months. Some states have noted that this requirement is not 
        consistent with their welfare program's ``work first'' 
        approach, which stresses a quick attachment to the labor 
        market. If a family begins receiving welfare and Medicaid in 
        January and the parent finds a job in February with wages that 
        would make the family ineligible for regular Medicaid, that 
        family would not be eligible for TMA because it would not have 
        satisfied the ``three out of six months'' requirement.
 The federal law includes prescriptive TMA reporting 
        requirements. In order to retain eligibility throughout the 
        full 12-month period, families must submit written reports of 
        their earnings and child care expenses in the 4th, 7th, and 
        10th months. These reporting requirements create administrative 
        burdens for states and can cause coverage problems for 
        families. The GAO has recommended that Congress consider 
        allowing states flexibility to change or eliminate these 
        reporting requirements.18
 Some states have been interested in extending TMA beyond the 
        12 months allowed under the law. A few states have waivers 
        extending TMA, but these waivers are generally no longer 
        available due to budget neutrality rules.19 A 
        legislative change would be necessary to allow states the 
        option to provide TMA for longer periods of time.
Health Coverage Makes a Difference
    With or without improvements in the way TMA operates, there is 
nearly universal agreement that TMA plays an important role promoting 
welfare-to-work efforts and providing health care coverage to some of 
the most vulnerable families. Health care coverage alone does not 
guarantee quality health care, but coverage makes it much more likely 
that people will get the health care they need. A recent study showed 
that low-income adults are almost three times more likely to have an 
unmet medical need if they are uninsured.20 Those with 
Medicaid coverage do not report these same levels of unmet needs. For 
example, a study found that low-income women are 2.5 times more likely 
to report unmet or delayed health care needs than are low-income women 
with either Medicaid or private coverage.21 Figure 5.
    As the Congress recognized when it expanded TMA in the Family 
Support Act of 1988, parents relying on welfare and those leaving 
welfare for work are often in poor health. Poor health status is 
generally correlated with low incomes. 22 Health-related 
problems take their toll on poor women's ability to care for their 
families and to work and retain employment. The National Governors 
Association has identified health-related problems as a key barrier to 
work and a challenge to state welfare-to-work initiatives.23 
Recent reports have highlighted the importance of quality coverage as a 
means of decreasing absenteeism and increasing productivity at 
work.24 While coverage does not assure good health, it 
affords individuals access to health care, which can help them manage 
and address health problems and better care for their children and 
participate in the work force.
    TMA is a critical component of the labyrinth of mechanisms by which 
some of the people who do not have access to employer-based coverage 
can obtain health care coverage. It has a limited reach both because it 
is a targeted program and because it provides time-limited coverage. 
Even with TMA, four out of ten poor parents are uninsured, and with a 
souring economy, rising health costs, and state budget cutbacks, the 
number of low-income people who lack health insurance coverage is 
expecting to rise. By extending TMA and perhaps improving how it works, 
Congress will be assuring that some of America's hardest working 
families do not join the ranks of the uninsured.

                               References

    1 H.R. Rep. No. 159, 100th Congress, 1st Sess., Part 3, 
at 12.
    2 TMA was also extended to families who might otherwise 
lose Medicaid due to child support income so that successful efforts to 
increase child support payments from absent parents did not result in 
the immediate loss of health care coverage.
    3 Congress extended the sunset date to September 30, 
2002 in P.L. 106-554, section 707(a).
    4 Technically this means that a family does not have to 
be receiving welfare in order to qualify for TMA, since welfare receipt 
is no longer an eligibility requirement for Medicaid. However, as 
explained below, in most states the income standards for the family 
coverage category are so low that in those states TMA still largely 
functions as a welfare-to-work initiative.
    5 Data on average premium costs for employees are from 
Kaiser Family Foundation and Health Research and Educational Trust, 
Employer Health Benefits, 2001 Annual Survey, 2001; data on average 
wages of parents leaving welfare are from P. Loprest, How are Families 
That Left Welfare Doing? A Comparison of Early and Recent Welfare 
Leavers, New Federalism Policy Brief, Urban Institute, April 2001.
    6 Urban Institute analysis of 1999 National Survey of 
America's Families.
    7 L.Dubay, J.Haley, G.Kenney, Children's Eligibility for 
Medicaid and SCHIP: A View from 2000, Urban Institute, January 2002. 
These figures take into account restrictions in Medicaid and CHIP based 
on immigration status. About eight percent of low-income children are 
not eligible for coverage based on federal Medicaid immigration-related 
eligibility restrictions.
    8 P. Loprest, How are Families That Left Welfare Doing? 
A Comparison of Early and Recent Welfare Leavers, New Federalism Policy 
Brief, Urban Institute, April 2001.
    9 KCMU analysis of K. Maloy et al, Can Medicaid Work for 
Working Families, George Washington University, and M.Broaddus et al, 
Expanding Family Coverage: States' Medicaid Eligibility Policies for 
Working Families in the Year 2000, Center on Budget and Policy 
Priorities. In some states, a parent receiving Medicaid who finds a job 
may be able to receive Medicaid at somewhat higher income levels for a 
limited period of time due to earning disregards that are available to 
persons already receiving Medicaid.
    10 M. Perry, Kannel, S., Valdez, R.B., Chang, C. 
Medicaid and Children: Overcoming Barriers to Enrollment, Kaiser 
Commission on Medicaid and the Uninsured, January 2000.
    11 GAO, Medicaid Enrollment: Amid Declines, State 
Efforts to Ensure Coverage After Welfare Reform Vary, GAO HEHS-99-163, 
September 1999.
    12 Urban Institute analysis of 1999 National Survey of 
America's Families, April 2002. These figures do not add up to 100 
percent because some people have both private coverage and Medicaid.
    13 G. Acs, P. Loprest, T. Roberts, Final Synthesis 
Report of Findings from ASPE ``Leavers'' Grants, Urban Institute, 
December 2001, Chapter IV, http://aspe.hhs.gov/hsp/leavers99/
synthesis02/index.htm.
    14 Efforts taken by Washington state and Pennsylvania 
and Maryland are described at http://www.hcfa.gov/medicaid/
wrmdpawa.htm. See also, Adjusting Computer Systems for the TANF De-
link, prepared by C. Gerhardt, State of Maryland, Department of Health 
and Mental Hygiene, hcfa.gov/med/mmis/927mann.pdf.
    15 CMS, Letter to State Medicaid Directors, April 7, 
2000; http://www.hcfa.gov/medicaid/letters/smd40700.htm.
    16 Statement of Kathleen Gifford, Assistant Secretary, 
Office of Medicaid Policy and Planning, Indiana Family and Social 
Services Administration, House Ways and Means Committee, Subcommittee 
on Human Resources on Health Coverage for Families Leaving Welfare, May 
16, 2000.
    17 HR 2630, HR 2775, and S.1269.
    18 GAO, Medicaid Enrollment: Amid Declines, State 
Efforts to Ensure Coverage After Welfare Reform Vary, GAO HEHS-99-163, 
September 1999.
    19 According to CMS, 11 states had waivers to extend TMA 
beyond 12 months, but only 6 of these waivers are currently in effect 
and 3 will expire in 2002. In the past, states were able to show that 
these waivers would not add to federal costs because they would lower 
AFDC costs by preventing some families from having to fall back on 
welfare because they lacked health coverage while they were working. 
Now that AFDC has been replaced by the TANF block grant, a decline in 
the welfare caseload due to extended TMA would not reduce federal 
expenditures.
    20 B. Strunk, P. Cunningham, Treading Water: American's 
Access to Needed Medical Care, 1997-2001, Health Systems Change 
Tracking Report, Results from the Community Tracking Study, No. 1, 
March 2002.
    21 R. Almeida, L. Dubay, G.Ko, ``Access to Care and Use 
of Health Services by Low-income Women'', Health Care Financing Review, 
2001; 22:27-47.
    22 See, for example, H. Mead, K. Witkowski, B.Gault, H. 
Hartmann, ``The Influence of Income, Education and Work Status on 
Women's Well-being'', Womens Health Issues, 2001; 11:160-172, comparing 
the health status of poor women with that of women with incomes above 
200 percent of the poverty level. The study found that poor women were 
more than three times as likely as nonpoor women to report fair or poor 
health (34% v. 9%). The GAO has found that a significant portion of 
TANF recipients are disabled have poor mental and physical health, 
suffer from substance abuse and have experienced domestic violence. 
GAO, Welfare Reform: Moving Hard-to-Employ Recipients Into the 
Workforce 2001, GAO-01-368. Other studies have found that many current 
and former TANF recipients have mental health problems, including 
depression. Lennon, Blome, English, Depression and Low-Income Women: 
Challenges for TANF and Welfare-to-Work Policies and Programs, Research 
Forum on Children, Families and the New Federalism, National Centers 
for Children in Poverty, 200l.
    23 S. Callahan, Understanding Health-Status Barriers 
that Hinder Transition from Welfare to Work, National Governors 
Association, 1999.
    24 TC Buchmueller, The Business Case for Employer-
Provided Health Benefits: A Review of the Relevant Literature, 
California Health Care Foundation, 2000.

    Mr. Bilirakis. Thank you very much.
    Dr. Scanlon.

                 STATEMENT OF WILLIAM J. SCANLON

    Mr. Scanlon. Thank you very much, Mr. Chairman and members 
of the subcommittee. I'm pleased to be here today to talk about 
our work on the uninsured and the traditional Medicaid program 
as it relates to Transitional Medical Assistance that you're 
considering reauthorizing.
    This additional year of Medicaid coverage can play a 
critical role in supporting individuals as they transition from 
welfare to work. As everyone agrees and as Ms. Mann indicated, 
having health insurance is important for all persons. Health 
insurance and the access to the services it affords may be 
particularly important for those who are coming off of welfare 
who may have more health problems than average. Access to 
health insurance and health care on a timely basis helps avoid 
the development of some problems and the exacerbation of others 
which may result in longer term impairments and costs. For 
example, the uninsured are much more likely to be hospitalized 
for avoidable conditions such as asthma and diabetes. The 
uninsured are much more likely to be diagnosed with cancer at a 
later stage where there's less of a positive prognosis for 
improvement.
    While securing a job to leave welfare is a very positive 
first step, however, our work and the work of others on the 
uninsured and on the insurance markets makes it clear that 
these newly employed individuals may have significant 
difficulty obtaining adequate health insurance. As you know, 
and as Ms. Mann indicated, we rely heavily on the employer-
based health insurance system. Over two-thirds of non-elderly 
Americans get their health insurance through their employers, 
but at the same time it's true that 75 percent of the uninsured 
adults are employed. This is because not all employers offer 
insurance and not all workers that are offered insurance choose 
to purchase it. Especially vulnerable are individuals who work 
part-time, are employed in low wage jobs or who work in certain 
industries such as retail services. These are exactly the types 
of jobs that many former welfare recipients have.
    Even when employers offer coverage, a significant number of 
individuals leaving welfare may not accept it. The cost may be 
simply too high as employees of some firms are asked to pay a 
significant share of premiums. Transitioning workers commonly 
have jobs that pay $7 or $8 per hour. Getting coverage on their 
own through the individual insurance market may be even more 
expensive or even potentially impossible. It will depend upon 
State laws whether these individuals are guaranteed access to 
insurance coverage or whether there is any limitation on 
premiums. We have found repeatedly in our work on the 
individual insurance market that persons with health problems 
can be denied coverage completely or charged considerably more 
than the standard premium, unless prohibited by State law.
    In this context, Transitional Medical Assistance provides 
an important protection to families in their efforts to move 
from welfare to work. In our prior work on transitional 
Medicaid, we found wide differences across the States in the 
shares of persons eligible for the program that actually 
enrolled, and large shares of persons who, when enrolled, did 
not receive the full year of coverage authorized.
    Several States have worked to facilitate beneficiaries' 
access through outreach, education and other efforts and have 
achieved participation rates of over 70 percent among families 
transitioning to the workforce. Interestingly, some of the 
outreach and education is directed at State and county 
eligibility workers, to ensure that they properly assist 
potential eligibles to enroll. Other efforts target eligible 
individuals and employers to increase awareness of the benefit.
    A key factor though in why many families did not receive 
their full program benefits was that they did not report their 
incomes as required, that is, at the 4th, 7th and 10th months 
of their enrollment, the requirements that Ms. Mann had 
indicated. In fact, State officials told us that families 
typically receive coverage for only 6 months and that was 
generally the result of the required income reports not being 
submitted, not because the families' incomes had become too 
high to be eligible for the program. The reporting requirements 
are aimed at assuring the program benefits go to persons who 
are genuinely eligible. This is an important objective. 
Nevertheless, that goal needs to be weighed against the cost of 
achieving it.
    Administrative costs submitting and reviewing required 
documentation for beneficiaries and State workers are one 
element to consider. Also, very important is whether the 
primary objective of the program providing coverage to eligible 
beneficiaries is being compromised. Some States have secured 
waivers of the reporting requirements so that their eligibles 
can get their full year of coverage. This committee has 
previously endorsed giving all States that flexibility to alter 
the reporting requirements and providing this flexibility for 
States to provide a full year of transitional Medicaid coverage 
would likely improve access to the benefits considerably. And 
it would put transitional Medicaid on a par with some other 
coverage options in the Medicaid program.
    Thank you very much, Mr. Chairman. This concludes my 
statement and I will be happy to answer any questions.
    [The prepared statement of William J. Scanlon follows:]
Prepared Statement of William J. Scanlon, Director, Health Care Issues, 
                United States General Accounting Office
    Mr. Chairman and Members of the Subcommittee: I am pleased to be 
here today as you consider the role of Medicaid in helping families' 
transition from welfare to the workforce. Since 1988, the Medicaid 
program has offered transitional Medicaid assistance, which provides 
certain families who are losing Medicaid as a result of employment or 
increased income up to one year of additional Medicaid health insurance 
coverage. Transitional Medicaid assistance was originally enacted for a 
10-year period, and has twice been extended to help provide continued 
health insurance coverage to families moving into 
employment.1
---------------------------------------------------------------------------
    \1\ The Family Support Act of 1988 created the transitional 
Medicaid assistance program as Sec. 1925 of the Social Security Act, 
and was scheduled to expire on September 30, 1998. See Pub. L. No. 100-
485, Sec. 303(a), 102 Stat. 2343, 2385, and 2391. The Personal 
Responsibility and Work Opportunity Reconciliation Act of 1996 extended 
states' obligation to provide transitional Medicaid assistance through 
2001. See Pub. L. No. 104-193, Sec. 114(c), 110 Stat. 2105, 2180. The 
Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act 
of 2000, extended the sunset provision to September 30, 2002. See Pub. 
L. No. 106-554, Appendix F, Sec. 707, 114-2763A-463, 114-2763A-577.
---------------------------------------------------------------------------
    The enactment of federal welfare reform in August 1996 
significantly changed federal welfare policy for low-income families 
with children in several ways, including establishing a 5-year lifetime 
limit on cash assistance.2 The welfare reform law also 
extended transitional Medicaid assistance through 2001, thus continuing 
an important link to health insurance coverage for individuals as their 
economic circumstances changed. States have implemented a variety of 
initiatives intended to help families move from cash assistance to the 
workforce, including some enhancements to transitional Medicaid. These 
initiatives have likely contributed to a drop in cash assistance 
caseloads of more than 50 percent from 1996 through mid-
2001.3
---------------------------------------------------------------------------
    \2\ See The Personal Responsibility and Work Opportunity 
Reconciliation Act of 1996, Pub. L. No. 104-193, Sec. 103, 110 Stat. 
2105, 2137.
    \3\ See U.S. General Accounting Office, Welfare Reform: States 
Provide TANF-Funded Work Support Services to Many Low-Income Families 
Who Do Not Receive Cash Assistance, GAO-02-615T (Washington, D.C.: 
April 10, 2002).
---------------------------------------------------------------------------
    Because the transitional Medicaid provision is due to expire in 
September 2002 and you are considering its extension, you asked us to 
provide information on the role this program plays in supporting 
transitions from welfare to work. Accordingly, my remarks today will 
focus on how

 transitional Medicaid assistance provides low-income working 
        families an option to maintain health insurance coverage, and
 states have used transitional Medicaid to provide health 
        insurance coverage to families.
    My comments are based largely on our previously issued reports and 
testimony on Medicaid and welfare reform.4
---------------------------------------------------------------------------
    \4\ See GAO related products at the end of this statement.
---------------------------------------------------------------------------
    In summary, transitional Medicaid assistance is a key protection 
offered to families at a critical juncture in their efforts to move 
from welfare to work. Employment in low-wage or part-time positions--
which is common for these newly working individuals--frequently does 
not provide adequate access to affordable health insurance, whether 
through employer-sponsored or individually purchased health insurance, 
thus making transitional Medicaid coverage an important option. Our 
earlier work showed that, for 21 states we reviewed, the implementation 
of transitional Medicaid assistance varied across the states and that 
certain state practices had enhanced beneficiaries' ability to retain 
Medicaid coverage. For example, some states reported increasing 
training for state eligibility determination workers to better inform 
beneficiaries of this entitlement and how to access it. We also found, 
however, that many families did not receive their full transitional 
Medicaid assistance benefits because they failed to report their income 
three times, as required, throughout the 12-month period of coverage. 
Amending the Medicaid statute to provide states with additional 
flexibility to ease income-reporting requirements for the coverage 
period of transitional Medicaid assistance, as has been done for other 
aspects of the Medicaid program, could further facilitate uninterrupted 
health insurance coverage for families moving from cash assistance to 
the workforce.5
---------------------------------------------------------------------------
    \5\ See U.S. General Accounting Office, Medicaid Enrollment: Amid 
Declines, State Efforts to Ensure Coverage After Welfare Reform Vary, 
GAO/HEHS-99-163 (Washington, D.C.: Sept. 10, 1999). In this report, we 
recommended that the Congress consider allowing states to lessen or 
eliminate requirements for beneficiary income reporting in transitional 
Medicaid assistance. We also recommended that the Administrator of the 
Health Care Financing Administration (HCFA) (1) determine the extent to 
which transitional Medicaid is reaching the eligible population and (2) 
provide states with guidance regarding best approaches for implementing 
this benefit. Since that time, HCFA, now the Centers for Medicare and 
Medicaid Services has acted on the second recommendation, but not the 
first.
---------------------------------------------------------------------------
                               background
    Transitional Medicaid assistance offers families moving from cash 
assistance to employment the opportunity to maintain health insurance 
coverage under Medicaid, a joint federal-state health insurance 
program. Medicaid spent about $216 billion in fiscal year 2001 on 
coverage for certain low-income individuals.6 Transitional 
Medicaid assistance provides certain families losing Medicaid as a 
result of employment or increased income with up to one year of 
Medicaid coverage.7 Families moving from cash assistance to 
work are entitled to an initial 6 months of Medicaid coverage without 
regard to the amount of their earned income, and 6 additional months of 
coverage if family earnings, minus child care costs, do not exceed 185 
percent of the federal poverty level.8 To qualify for either 
6-month period, a family must have received Medicaid in 3 of the 6 
months immediately before becoming ineligible as a result of increased 
income.9
---------------------------------------------------------------------------
    \6\ States administer Medicaid within broad federal guidelines that 
specify the categories of low-income individuals that states must cover 
and the categories that are optional. However, not all low-income 
individuals are eligible for Medicaid; for example, most childless 
adults are not eligible. In fiscal year 1999 (the most recent 
enrollment data available), Medicaid financed coverage for nearly 41 
million individuals.
    \7\ Prior to welfare reform, some states received waiver authority 
under Sec. 1115 of the Social Security Act to extend Medicaid benefits 
beyond the 12 months allotted in Sec. 1925 of the Social Security Act. 
After August 22, 1996, this waiver became subject to a budget 
neutrality test, which meant that the cost of extending coverage had to 
be offset by transitional coverage.
    \8\ In 2002, the federal poverty level for a family of three was 
$15,020, or about $1,252 per month.
    \9\ GAO/HEHS-99-163, September 10, 1999.
---------------------------------------------------------------------------
    When federal welfare reform was enacted in 1996, states implemented 
a variety of initiatives intended to help families move from welfare to 
the workforce. Welfare reform provided states additional flexibility in 
helping cash assistance recipients to both find work and achieve family 
independence. As a result, states have expanded and intensified their 
provision of work support services such as those for job search, job 
placement, and job readiness.10 Many individuals in this 
population had low skills and faced a number of barriers to maintaining 
work and independence. For example, our work has shown that factors 
such as limited English proficiency, poor health, and the presence of a 
disability were some of the factors that affected the extent to which 
former cash assistance recipients were able to find and keep 
employment.11
---------------------------------------------------------------------------
    \10\ GAO-02-615T, April 10, 2002.
    \11\ See U.S. General Accounting Office, Welfare Reform: Moving 
Hard-to-Employ Recipients Into the Workforce, GAO-01-368, (Washington, 
D.C.: March 15, 2001).
---------------------------------------------------------------------------
    Maintaining health insurance coverage is important to persons 
entering the workforce because there are important adverse health and 
financial consequences to living without health insurance. The 
availability of health insurance enhances access to preventive, 
diagnostic, and treatment services as well as provides financial 
security against potential catastrophic costs associated with medical 
care. Research has demonstrated that uninsured individuals are less 
likely than individuals with insurance to have a usual source of care, 
are more likely to have difficulty in accessing health care, and 
generally have lower utilization rates for all major health care 
services. Uninsured individuals are more likely than those insured to 
forgo services such as periodic check-ups and preventive services, 
well-child visits, prescription drugs, dental care, and eyeglasses. As 
a result, individuals not covered by health insurance can require 
acute, costly medical attention for conditions that may be preventable 
or minimized with early detection and treatment.
  transitional medicaid assistance can fill gaps in accessibility of 
            private health insurance for low-income workers
    Limitations in private sources of coverage underscore the 
importance of transitional Medicaid assistance as an option for those 
moving from cash assistance to employment. Private health insurance is 
not accessible to or affordable for everyone. Although most working 
Americans and their families obtain health insurance through employers, 
many workers do not have coverage because their employers do not offer 
it or the coverage offered is limited or unaffordable. Lack of 
insurance is more common among certain types of workers, employers, and 
industries and may disproportionately represent individuals 
transitioning from cash assistance to work. For example, individuals 
who work part-time or are employed in low-wage jobs are less likely to 
have access to affordable employer-sponsored coverage. Furthermore, 
those who do not have employer-sponsored coverage may find alternative 
sources of coverage, such as the individual insurance market, expensive 
or altogether unavailable. Without continued access to Medicaid, some 
of these individuals, who are often in low-wage jobs, will have limited 
or no access to alternative coverage and could end up uninsured.
Private Sources of Health Insurance Are Not Universally Available And 
        May Have Coverage Limitations
    Employment-based coverage is the primary means for nonelderly 
Americans to obtain health insurance, and over two-thirds of nonelderly 
adults obtained their coverage through an employer in 2000. However, a 
significant number of workers do not have health insurance because 
either their employers do not offer it or they choose not to purchase 
it. In 2000, 30 million nonelderly adults were uninsured, even though 
75 percent worked for some period during the year. (See fig. 1.)
    Lack of insurance coverage is more common among certain types of 
workers, employers, and industries. Part-time employees and employees 
of small firms (fewer than 10 employees) are more likely to be 
uninsured than employees who work full-time or for a large company. 
Individuals working in certain industries are less likely to be offered 
health insurance. For example, in 1999, more than 30 percent of workers 
in the construction, agriculture, and natural resources (for example, 
mining, forestry, and fisheries) industries were uninsured, as were 
about 25 percent of workers in wholesale or retail trade. In contrast, 
10 percent or less of workers in the finance, insurance, real estate, 
and public employment sectors were uninsured. These patterns may 
disproportionately affect individuals leaving cash assistance because 
they often work in low-wage jobs, part-time, or in industries such as 
retail that often do not provide health coverage.
    Young adults, aged 18 to 24, are more likely than any other age 
group to be uninsured, largely because certain characteristics of their 
transition to the workforce--working part-time or for low wages, 
changing jobs frequently, and working for small employers--make them 
less likely to be eligible for employer-based coverage. Among those 
aged 18 to 24, 27 percent were uninsured and among those aged 25 to 34, 
21 percent were uninsured in 2000. (See fig. 2.)
    Even when employer-sponsored coverage is available, its costs may 
be prohibitive or its benefits very limited. Employer-sponsored health 
plans may not subsidize coverage for dependents, may restrict or 
exclude certain benefits, or may subject participants to out-of-pocket 
costs either through premium contributions or cost-sharing provisions 
that low-wage workers may find unaffordable. For example, a 2001 survey 
by Mercer/Foster Higgins found that, on average, large employers (500 
or more employees) require employees enrolled in preferred provider 
organizations (PPO) to contribute $56 each month for employee-only 
coverage, or $191 each month for family coverage.12 For 
lower-wage workers, such as individuals leaving cash assistance and 
entering the workforce, even coverage that is affordable for a worker 
may be too expensive for covering the rest of the family members.
---------------------------------------------------------------------------
    \12\ Mercer/Foster Higgins, National Survey of Employer-sponsored 
Health Plans 2001: Report on Survey Findings (New York: William H. 
Mercer, 2001), p. 13. The Mercer/Foster Higgins survey is 
representative of all employers in the United States with at least 10 
employees.
---------------------------------------------------------------------------
    Those without access to employer-sponsored coverage may look to the 
individual insurance market to obtain coverage, and in 2000, 5 percent 
of nonelderly Americans (or 12.6 million individuals) relied on 
individual health insurance as their only source of coverage. However, 
restrictions on who may qualify for coverage and the premium prices 
charged can have direct implications for consumers. For example, 
depending on their health status and demographic characteristics such 
as age, gender, and geographic location, individuals in the majority of 
states may be denied coverage in the private insurance market or have 
only limited benefit coverage available to them. In addition, while all 
members of an employer-sponsored group health plan typically pay the 
same premium for employment-based insurance regardless of age or health 
status, in most states individual insurance premiums are higher for 
older or sicker individuals than for younger or healthier individuals, 
potentially making this option unaffordable.13 For example, 
a recent study examined individual insurers' treatment of applicants 
with certain pre-existing health conditions, such as hay fever. The 
study of insurers in eight localities found that for applicants with 
hay fever, 8 percent would decline coverage, 87 percent would offer 
coverage with a premium increase, benefit limit, or both, and 5 percent 
would offer full coverage at the standard rate.14 Cost 
differences are often exacerbated by the fact that individuals must 
absorb the entire cost of their health coverage, whereas employers 
usually pay for a substantial portion of their employees' coverage.
---------------------------------------------------------------------------
    \13\ The Health Insurance Portability and Accountability Act of 
1996 (HIPAA) guarantees some individuals leaving employer-sponsored 
group health plans access to continued coverage or to a product in the 
individual market. See 29 USC Sec. 1181 (2000), 42 USC Sec. 300gg 
(Supp. II 1996). Although individuals leaving public insurance 
programs, such as Medicaid, are not eligible for this HIPAA protection, 
they may obtain coverage in most states from high risk pools that 
provide coverage for applicants denied individual coverage due to 
health status. These policies tend to cost 25 to 100 percent more than 
rates charged to healthy individuals.
    \14\ Georgetown University Institute for Health Care Research and 
Policy and K.A. Thomas and Associates, How Accessible is Individual 
Health Insurance for Consumers in Less-Than-Perfect Health? (Washington 
D.C.: The Kaiser Family Foundation, 2001), http://www.kff.org 
(downloaded on August 14, 2001). The authors examined underwriting 
treatment of hypothetical applicants by 19 insurers in eight markets 
around the country.
---------------------------------------------------------------------------
Transitional Medicaid Assistance Can Provide Continued Insurance 
        Coverage
    Because of limitations in the availability of private insurance--
especially for low-paid, part-time workers and those in certain 
industry sectors that often characterize jobs available to individuals 
moving from cash assistance to work--transitional Medicaid assistance 
is an important option for health insurance coverage. Individuals with 
lower incomes have a much higher than average probability of being 
uninsured. (See fig. 3.) Typically, former welfare recipients entering 
the workforce work part-time or in low-wage jobs that are less likely 
to provide health coverage or only provide coverage at a prohibitive 
cost. For example, we noted in our 1999 report on states' experiences 
in implementing transitional Medicaid assistance that one state found 
that out of nearly l,600 former welfare recipients surveyed, 43 percent 
of the heads of households worked fewer than 32 hours per week and did 
not have health insurance, and 32 percent held low-wage jobs, such as 
in retail stores, hotels, restaurants, and health care establishments.
    In addition, although some employers of former cash assistance 
recipients may not offer health insurance, numerous studies have shown 
that a significant number of these individuals have access to employer 
coverage but choose not to accept it. For example, a recent study 
showed that although about 50 percent of individuals transitioning from 
cash assistance to employment had access to employer coverage, only 
about one-third opted to participate in the employer-sponsored 
plan.15 The relatively low ``take-up'' rate is due largely 
to the high costs of many employer health plans. Transitioning workers, 
who commonly earn between $7 and $8 an hour, may simply be unable to 
afford their share of the premium, since their annual earnings range 
from 73 percent to 111 percent of the federal poverty level. (See Table 
1.)
---------------------------------------------------------------------------
    \15\ Gregory Acs, Pamela Loprest, and Tracy Roberts, Final 
Synthesis Report of Findings from ASPE ``Leavers'' Grant (Washington, 
D.C.: The Urban Institute, 2001). To conduct studies of families that 
had left welfare, the Office of the Assistant Secretary for Planning 
and Evaluation of the Department of Health and Human Services awarded 
competitive grants to select states and large counties in September 
1998. This report synthesizes the findings from 15 of these studies.

Table 1: Hourly Wages as a Percentage of the Federal Poverty Level for a
                          Family of Three, 2002
------------------------------------------------------------------------
                                                             Salary as a
                                                             percentage
                                  Hours per      Annual        of the
                                    week        earnings       federal
                                                               poverty
                                                                level
------------------------------------------------------------------------
$5.15 \1\.....................           30        $8,034            53
                                         40       $10,712            71
$7.00.........................           30       $10,920            73
                                         40       $14,560            97
$8.00.........................           30       $12,480            83
                                         40       $16,640           111
------------------------------------------------------------------------
\1\ Represents the minimum wage, which was last increased on September
  1, 1997.
Source: GAO analysis of salaries in relation to the 2002 federal poverty
  level of $15,020 for a family of 3.

 states' efforts encouraged use of transitional medicaid, but not all 
                 eligible families received assistance
    While the Medicaid statute provides families moving from welfare to 
work with up to 12 months of transitional Medicaid coverage, we have 
reported that certain states had obtained waivers from HCFA to extend 
the length of coverage provided, and that the share of eligible 
families that actually received this entitlement varied significantly 
by state. States offered from 1 to 3 years of transitional Medicaid 
assistance in 1999. In the several states that were able to provide 
data on participation in transitional Medicaid assistance, we found 
that participation rates among newly working Medicaid beneficiaries 
ranged from 4 to 94 percent. Several states had made efforts to 
facilitate beneficiaries' participation in transitional Medicaid. For 
example, nine states reported developing outreach and education 
materials to inform families and eligibility determination workers 
about transitional Medicaid assistance. While such approaches helped 
make transitional Medicaid more available, beneficiaries' failure to 
report income as required often resulted in their losing eligibility 
after the first 6 months.
Length of Coverage and Program Participation Was Mixed Among States
    States' implementation of transitional Medicaid coverage varied, 
resulting in differing lengths of time for which coverage was provided 
and differing rates of family participation. As of 1999, the most 
currently national data reported, 10 states--Arizona, Connecticut, 
Delaware, Nebraska, New Jersey, Rhode Island, South Carolina, 
Tennessee, Utah, and Vermont--provided over 1 year of coverage, while 
the remaining states provided 1 year of coverage. (See fig. 4.) In the 
several states that were able to provide such data, transitional 
Medicaid participation rates ranged from about 4 percent of the 
families moving from cash assistance in one state to 94 percent of such 
cases in another. However, low participation rates in transitional 
Medicaid assistance did not always indicate that families had lost 
Medicaid coverage altogether. For example, officials in the state with 
a 4 percent participation rate said that most families losing cash 
assistance were still enrolled in Medicaid through other eligibility 
categories for low-income families.
States' Initiatives Facilitated Beneficiary Use of Transitional 
        Medicaid Assistance, But Not All Families Maintained Coverage
    We found that several states had initiatives in place to facilitate 
beneficiaries' access to transitional Medicaid assistance. The 
following are examples of such initiatives.

 Nine states reported developing specific materials regarding 
        transitional Medicaid assistance in easy-to-understand language 
        for eligibility determination workers and beneficiaries.
 One state revised its computer systems so that eligible 
        families leaving cash assistance due to employment were 
        automatically transferred to transitional Medicaid assistance 
        coverage. In addition, this state's eligibility workers 
        randomly contacted families who were leaving cash assistance to 
        determine their health insurance status and to ensure that they 
        obtained the additional months of Medicaid coverage for which 
        they were eligible. As a result of this state's efforts, about 
        70 percent of the families leaving cash assistance or Medicaid 
        received transitional Medicaid coverage.
 Officials in three other states encouraged increased 
        participation in transitional Medicaid assistance by contacting 
        families with closed cash assistance cases to determine whether 
        these families had obtained the additional months of Medicaid 
        coverage if so entitled. One of these states, which also 
        provided 24 months of transitional Medicaid assistance, 
        reported that 77 percent of eligible families were receiving 
        this benefit.
    However, even with such successful enrollment efforts, many 
families did not receive the full transitional Medicaid assistance 
benefits because they failed to periodically report their income as 
required. The Medicaid statute requires that beneficiaries report their 
income three times during the 12 months of transitional Medicaid 
assistance: once in the first 6-month period and twice in the second 6-
month period. Failure to report income status in either of these 6-
month periods results in termination of transitional Medicaid benefits.
    In 1999, we reported that families' failure to periodically submit 
required income reports often resulted in their not receiving 
transitional Medicaid coverage for the full period of eligibility. For 
example, officials in three states we reviewed told us that families 
typically received only 6 months of transitional Medicaid, generally 
because they failed to submit the required income reports--and not 
because of a change in income that made them ineligible for 
transitional Medicaid. In contrast, the state that had a 94 percent 
participation rate for transitional Medicaid offered coverage for 24 
months and had received HCFA approval to waive the periodic income 
reporting requirements. Overall, we found that states that waived 
income-reporting requirements reported higher participation rates than 
states that did not.
    In implementing public programs such as Medicaid, difficult trade-
offs often exist between ease of enrollment for eligible individuals 
and program integrity efforts to ensure that benefits are provided only 
to those who are eligible. The experience of some states in easing 
statutory periodic income reporting requirements proved successful in 
increasing participation for eligible beneficiaries. In view of 
concerns that beneficiary reporting requirements were limiting the use 
of the transitional Medicaid benefit, HCFA proposed legislation to 
eliminate beneficiary reporting requirements for the full period of 
eligibility (up to 1 year). To date, no action has been taken on this 
proposal. In our earlier report we recommended that the Congress may 
wish to consider allowing states to lessen or eliminate periodic 
income-reporting requirements for families receiving transitional 
Medicaid assistance, provided that states offer adequate assurances 
that the benefits are extended to those who are eligible. Precedent for 
a full year of coverage in Medicaid has been provided in other aspects 
of the Medicaid program. For example, the Balanced Budget Act of 1997 
allowed states to guarantee a longer period of Medicaid coverage for 
children, such as 12 months, regardless of changes in a family's 
financial status.\16\ As of July 2000, 14 states had implemented this 
option.\17\ A similar approach could facilitate uninterrupted health 
insurance coverage for families that are moving from cash assistance to 
the workforce.
---------------------------------------------------------------------------
    \16\ See Pub. L. No. 105-33, Sec. 4731, 11 Stat. 251, 519 (1997). 
According to an official from the Centers for Medicare and Medicaid 
Services (CMS), the transitional Medicaid assistance reporting 
requirements override other Medicaid provisions, such as continuous 
eligibility. Thus, according to CMS' interpretation, a state's use of 
continuous eligibility does not eliminate the periodic income reporting 
requirements for transitional Medicaid assistance.
    \17\ Donna Cohen Ross and Laura Cox, Making It Simple: Medicaid for 
Children and CHIP Income Eligibility Guidelines and Enrollment 
Procedures, Individual State Profiles (Washington, D.C.: The Kaiser 
Commission on Medicaid and the Uninsured, October 2000).
---------------------------------------------------------------------------
                        concluding observations
    Transitional Medicaid assistance can play an important role in 
helping individuals move successfully from cash assistance to 
employment, thus further advancing the goals of welfare reform. Without 
access to Medicaid coverage, these individuals, who are often in low-
wage jobs, might have limited or no alternative health coverage and 
join the ranks of the uninsured. While our earlier work demonstrated 
that states varied in the extent to which families were participating 
in transitional Medicaid assistance, states that worked to minimize 
obstacles--particularly by reducing or eliminating income reporting 
requirements--had higher participation rates. Removing periodic 
reporting requirements would help further increase the use of 
transitional Medicaid assistance, provided that sufficient safeguards 
remained in place to ensure that only qualified individuals receive the 
benefits.
    Mr. Chairman, this concludes my prepared statement. I will be happy 
to answer any questions that you or Members of the Subcommittee may 
have. 
[GRAPHIC] [TIFF OMITTED] T9467.030

[GRAPHIC] [TIFF OMITTED] T9467.031

    Mr. Bilirakis. Thank you very much, Dr. Scanlon. Of course, 
my gratitude to all of you. The Chair would yield to Chairman 
Tauzin to inquire.
    Chairman Tauzin. Thank you, Mr. Chairman. Dr. Kaplan, in 
the time we have, let me ask you a couple of questions. In your 
written testimony you indicated that teachers cannot answer 
students' questions about prohibited topics in programs funded 
with abstinence only dollars. I assume you're talking about 
prohibited topics you mean contraceptives and sexually 
transmitted diseases, don't you?
    Mr. Kaplan. That's correct, yes.
    Chairman Tauzin. Now we have the Project Reality Game Plan 
curriculum before us. Chapter 4 deals specifically with 
sexually transmitted diseases and HIV and talks about condoms. 
It's my understanding that 30 plus programs receiving Title V 
funds use this curriculum. How do you reconcile that? This is 
the plan in front of me here. If it allows you to talk about 
sexually transmitted diseases, HIV and condoms and 30 programs 
use the curriculum, isn't it clear that any program funded 
under Title V can indeed provide information about 
contraceptives? It just can't promote or endorse contraceptive 
use. Isn't that correct?
    Mr. Kaplan. Yes. It's my understanding that the Title V 
prohibits programs from discussing how to use contraception or 
how to use condoms to actually prevent sexually transmitted 
disease.
    Chairman Tauzin. It can't promote or endorse the use, but 
it can discuss condoms. It can discuss HIV and sexually 
transmitted diseases, can't it?
    Mr. Kaplan. Well----
    Chairman Tauzin. That's what the game plan says.
    Mr. Kaplan. Right.
    Chairman Tauzin. In Chapter 4.
    Mr. Kaplan. Describing a sexually transmitted disease is 
one thing and getting an understanding of how you get it and 
how to prevent it is something else.
    Chairman Tauzin. I just find it a little inconsistent to 
say they can't answer questions in that program. I think they 
can, clearly, under the 30 plus programs that use this 
curriculum.
    Let me also ask you, isn't it true that any school that has 
an abstinence only program can also provide sex education 
programs in other settings such as health, physical education 
classes which is often done?
    Mr. Kaplan. My understanding is if they do not use Title V 
funds, then they could have a comprehensive sex education----
    Chairman Tauzin. But even if they use Title V funds, they 
can have a separate one in health and p.e. courses, can't they?
    Mr. Kaplan. They probably could, yes.
    Chairman Tauzin. Yes, they can. Even more of a concern to 
me is Dr. McIlhaney's testimony. Amazing information. And I 
want to get your comments on this, Dr. Kaplan. He brought to 
our attention a fact that I had not heard before. I knew that 
there were more sexually transmitted diseases now than there 
were when we were growing up, at least to be concerned about. 
According to testimony today, there were basically two then. 
There are 25 today. Most of these are viruses that are not 
curable. But he also indicates in his testimony that the 
National Institutes of Health Workshop on Scientific Evidence 
and Condom Effectiveness for Sexually Transmitted Disease 
Prevention reported that there is no evidence that condoms 
reduce the sexual transmissions of HPV, which is now found in 
50 percent of sexually active women between the ages of 18 and 
22. If that is true and I assume, Dr. McIlhaney, your facts are 
correct here, how do you not--how could you not recommend an 
abstinence only program being effective, when in 20 years these 
other programs have literally produced these kind of statistics 
today?
    Mr. Kaplan. Can I respond?
    Chairman Tauzin. Yes, please.
    Mr. Kaplan. You know, I think the thing that unifies all of 
us is that we're all very concerned about our youth.
    Chairman Tauzin. Well, yes.
    Mr. Kaplan. We're very concerned about the epidemic of STDs 
in this country which is higher than any other industrialized 
country. We're excited to see the pregnancy rates are coming 
down, but our pregnancy rates among teens are still the highest 
in industrialized countries. This is a very complex problem and 
one that is very difficult to resolve.
    Chairman Tauzin. Why wouldn't you want----
    Mr. Kaplan. Youth development programs are very important 
to engage our youth, not only because of STDs, but also because 
of substance abuse.
    Chairman Tauzin. Of course, of course.
    Mr. Kaplan. So anything that we can do to engage our youth 
and help them through this difficult period is very, very 
important.
    Chairman Tauzin. J.C. Watts puts it this way. He said if 
you knew that you had a program that was reducing accidents in 
a plant and you added a new program in that helped reduce it 
even further, why wouldn't you want to continue the second 
program, even if it reduced it 1 percent, 10 percent, 15 
percent, if you knew this was helping, why wouldn't you want it 
reauthorized?
    Mr. Kaplan. In my practice I spend a tremendous amount of 
time talking with kids about abstinence and encouraging those 
kids that are not sexually active, not to become sexually 
active and yet at the same time I want to be sure that those 
kids understand how to prevent getting a sexually transmitted 
disease once they start having sex. It's that 100 percent----
    Chairman Tauzin. If they learn that condoms won't even 
prevent them, why wouldn't you want a program that emphasizes 
abstinence when that's the only program that's going to prevent 
some of these viral diseases.
    Mr. Kaplan. Condoms are not 100 percent. They're just not, 
but they're better than nothing.
    Chairman Tauzin. According to Dr. McIlhaney's testimony, 
there's no evidence at all that they reduce the sexual 
transmission of HPV virus. If there's no evidence they help at 
all, and abstinence clearly helps, why wouldn't you want that 
program as part of the Federal mix?
    Mr. Kaplan. According to the CDC and you probably need to 
talk to the CDC about this in their recommendations about the 
prevention of HPV they say in addition, the use of latex 
condoms has been associated with a reduction in the risk of HPV 
associated diseases such as cervical cancer. Are they 100 
percent? No, they're probably not. Does more research have to 
be done? Absolutely so.
    Chairman Tauzin. My time is up. But I want to finish with 
one thought.
    Ms. Del Rosario, I just the read the article by this young 
man Clifford Mack and your words were so beautiful today when 
you talked about this program helping to build the character of 
these kids. It was this young man who basically makes my point. 
He ends by responding to the question why not wait? ``It's why 
I wait because I am worthy of it.'' I am worthy of it.
    Ms. Rosario. Yes.
    Chairman Tauzin. That statement really makes the case 
you've made today that you're building character while you may 
be protecting kids from all the statistics that Dr. McIlhaney 
and Dr. Kaplan have both cited to us. Thank you very much.
    Mr. Bilirakis. Mr. Brown to inquire.
    Mr. Brown. Thank you, Mr. Chairman. We've talked today 
about families' eligibility for up to 12 months of coverage for 
Transitional Medical Assistance once they leave welfare and go 
back to work.
    Ms. Mann, the problem that people have illustrated is that 
there are various reporting requirements making it difficult 
sometimes during this 12 months to the point that some people 
lose their coverage. Some have suggested Congress should allow 
the States the option to make these families automatically 
eligible for up to 12 months. Tell me what's good about that or 
not good about that, how that would change the system?
    Ms. Mann. There are two different ways to go and they're 
not mutually exclusive. One would be to give States the option 
to eliminate the reporting requirements or to eliminate them 
all together. And an additional option may be to allow States 
to do what's called continuous eligibility, meaning once you're 
on TMA you're guaranteed the 12 months of coverage regardless 
of any fluctuations in income or changes in income. And 
Congress actually took exactly that step in the Medicaid 
program for children in 1997 in the Balanced Budget Act when it 
enacted the CHIP program, found that a lot of children would 
get into coverage, but would lose that coverage and the 
benefits of continuous eligibility and continuous access to 
care and allowed States the option to do continuous coverage. 
And so it's another direction you might want to go with respect 
to TMA.
    Mr. Brown. How many States have done that?
    Ms. Mann. I believe at last count about 12 States have 
adopted that option.
    Mr. Brown. To shift to Dr. McIlhaney, to shift to the 
abstinence only, we debate the merits of abstinence only 
programs whether we should continue to fund them. I want to 
note that in his fiscal year 2003 budget, the President argues 
for the elimination of Federal programs that he says have not 
undergone rigorous evaluation. He feels so strongly about this 
he proposes to eliminate 35 programs entirely, simply because 
legitimately perhaps because there's no evidence that they are 
effective. He mentions--the elimination of programs such as 
dropout prevention, $10 million; alcohol abuse, reduction 
grants, $25 million; student mentoring programs, $17.5 million; 
foreign language assistance, $14 million; and on and on and on 
and on. Interestingly, by contrast, the President's budget 
continues funding abstinence only education despite the fact 
that it seems from evidence that such an approach has not 
proven effective. The budget states the President is committed 
``to stop the cycle of funding decisions based on wishes, 
rather than performance information.''
    My question is you were advisor to the Kirby Study, 
correct? And the study said currently there does not exist any 
research with reasonably strong evidence demonstrating that any 
particular abstinence only program actually delayed the onset 
of sexual intercourse or reduced any other measure or sexual 
activity. I'm told your job was to ensure the Kirby Study was 
accurate and reliable.
    I also remember the technical work group for the evaluation 
of Title V abstinence education programs, the interim report 
which was delivered to this office here only an hour before the 
hearing, said empirical evidence on the effectiveness of 
abstinence education is limited. Moreover, most studies of 
abstinence education programs have methodological flaws that 
prevent them from generating reliable estimates of pregnancy 
impacts. That being two statements from organizations you've 
supported, been involved in, advised, now your testimony today 
says there's credible evidence showing that abstinence 
education is having an impact. Reconcile that, what those two 
studies and organizations said and what you are saying today in 
terms of impact.
    Mr. McIlhaney. First, I believe that there are reams of 
evidence, as I mentioned before. We've got 20 years of the dual 
message program studied by the very best academic institutions 
that show very, very little evidence of any kind of success at 
all. They almost never even measure pregnancy rates or STD 
rates. That's the first part of my answer to your question.
    Second is, as far as my being a member of Doug Kirby's 
research task force for the National Campaign, there was no way 
to do a minority report on that and I dissented with him and he 
and I are friends. We've talked about this extensively. As a 
matter of fact, when the Monroe County program was reported and 
I mentioned it in my testimony I went to him and I said now 
Doug, are you going to advertise that study as broadly as you 
did Emerging Answers and he said well, no.
    Let me remind you of two or three things. In all the 
programs that Doug Kirby reported in Emerging Answers, sort of 
implying that they were going to be successful, two thirds of 
those programs did not impact a student's sexual activity. Two 
thirds did not lower sexual activity. Half of them didn't even 
increase contraceptive use. So the title Emerging Answers is 
relatively appropriate. Now there are a number of emerging 
answers about abstinence education. The problem is unlike the 
dual message programs which have been around for a long time, 
have had lots of money for having studies done, these programs 
have been relatively unfunded until 1996. It takes 2 or 3 
years. I think we can probably perhaps hear this from the 
fellow panelists that it takes 2 or 3 years to get a program 
even up and really going well. And that's why it's so 
important, in my opinion, to continue this funding. The other 
programs have not worked. It's been during their dominance that 
the STD and unmarried pregnancy rates have grown the most. It's 
time for us to turn a corner and try something truly different 
and the best direction we have for this is to continue 
abstinence education, study it well, see what the results are. 
There are studies that are giving this good direction. I 
mention Monroe County. The Ad Health study, the biggest study 
ever done one adolescents in America show that kids who were 
taking pledges of abstinence and about 10 percent of boys and 
15 percent of girls who had taken those pledges, above every 
other thing in their lives, that was the thing that was 
impacting their delaying the onset of sexual activity. That in 
itself is tremendous evidence about their success.
    Mr. Bilirakis. I thank the gentleman. Ms. Del Rosario, how 
much of your life have you dedicated to working with at risk 
youth?
    Ms. Rosario. Well, I've been in the system of education for 
the past 15 years and I've been dedicating 8 years to 
abstinence only education through Recapturing the Vision.
    Mr. Bilirakis. Did you found that organization?
    Ms. Rosario. I did.
    Mr. Bilirakis. You're the Executive Director.
    Ms. Rosario. I am.
    Mr. Bilirakis. And you've been at it for 8 years. What's 
the average age of your target audience?
    Ms. Rosario. Our program targets middle school to high 
schoolers and we have smaller populations of teen parents which 
range in age from 17 to about 20.
    Mr. Bilirakis. Middle schoolers?
    Ms. Rosario. That would be age about 11 to about 16.
    Mr. Bilirakis. What's your percentage, roughly, of your 
entire targeted audience that falls in that category, middle 
school category?
    Ms. Rosario. I'd say that 80 percent of those that we serve 
fall in the middle school age.
    Mr. Bilirakis. Eighty percent?
    Ms. Rosario. Yes, and then about 20 percent would fall in 
the other two groups.
    Mr. Bilirakis. Well, our world is grateful to people like 
you to devote your life to these types of problems.
    Ms. Del Rosario, we've heard testimony today and I 
certainly don't question Dr. Kaplan's dedication to the subject 
and his intent, but his testimony calls for a more balanced 
approach to educate the Nation's teens, that abstinence only 
education is not enough. You've been listening, I'm sure, to 
the others' testimony. It does an injustice to our youth by 
inadequately preparing them for real life, leaving them 
unprotected against sexually transmitted diseases and out of 
wedlock pregnancies. How would you refute those statements, if, 
in fact, you would refute those statements and how does your 
program prove those statements wrong?
    Ms. Rosario. Well, firstly, I would begin by stating that I 
don't think that at all abstinence only education leaves them 
unprotected. As I mentioned before, every one in our State does 
receive at least one comprehensive sex education course before 
they graduate. So that's the first thing. No. 2, we do have 
$15.2 at the State level that are given for Title X and $8 
million given for abstinence only education. So it's kind of 
very obvious to weigh the difference. There's half nearly of 
those dollars are given for abstinence whereas the other 
portion is given----
    Mr. Bilirakis. Your organization receives Title X dollars?
    Ms. Rosario. We do not.
    Mr. Bilirakis. You do not.
    Ms. Rosario. We do not.
    Mr. Bilirakis. Just Title V?
    Ms. Rosario. Correct. I don't really foresee that there's 
anything about Title V abstinence only education that leaves 
kids uncovered or unprotected. As a matter of fact, it is the 
program that teachers toward the antecedence of teenage 
pregnancy which is a more holistic philosophy and concept.
    Some of the outcomes of our program, for example, would be 
that 89 percent of those kids, these are the antecedents that 
I've speaking of, show a decrease in outdoor suspension; 80 
percent a decrease in indoor suspension; 75 percent improve in 
their grade point average; 60 percent in attendance and 100 
percent improve in self-esteem and this is demonstrated by an 
assessment instrument, an attitudinal survey that's 
administered pre and post-program intervention.
    Mr. Bilirakis. Well, some information has been distributed 
to Members of Congress give the impression and the chairman got 
into this that those who receive funding under Title V cannot 
also receive family planning funding, so you've already told us 
that's not correct.
    Ms. Rosario. That is absolutely not correct. Additionally, 
I am able to answer questions, if a student asks a question 
about--first of all, we teach on STDs and condom effectivity. 
However, we are able to answer questions. We're also directed 
to make direct referrals so that they're able to actually get 
the contraceptive help.
    Mr. Bilirakis. In practice, that's what you do?
    Ms. Rosario. That is correct.
    Mr. Bilirakis. If you were able to receive Title X, could 
you receive Title X funding?
    Ms. Rosario. I could via the stipulations. It must be a 
totally separate program.
    Mr. Bilirakis. Yes, that was going to be my next question. 
How would you then treat that? How would you handle that?
    Ms. Rosario. Oh, I think that first of all, you have to 
have a staff that's going to believe in what they're doing and 
even as we're electing teachers to teach the Recapturing the 
Vision program in the different States that we're in, one of 
the things that we look for, people that believe that they can 
bring change and that kids can perform and so I think that if 
you're going to do both types of programs, I would suggest that 
you have different staff and that is one of the dictates that 
our State officials do kind of ask that, they strongly 
encourage, let me say that, that you have separate staff for 
the Title X versus the Title V.
    Mr. Bilirakis. Separate staff, separate locations, that 
sort of thing?
    Ms. Rosario. Well, they don't stress the location, but just 
separate staff and separate programs so that you're doing, 
you're not mixing the message within one.
    Mr. Bilirakis. You've already said that you're not 
prohibited from answering questions under Title V about 
critical topics such as sexually transmitted diseases, is that 
correct?
    Ms. Rosario. That's true. This is correct.
    Mr. Bilirakis. Oh yes, before I yield, the report, the NIH 
report that was referred to by the chairman in his questioning, 
entitled Scientific Evidence on Condom Effectiveness for 
Sexually Transmitted Disease Prevention dated June 12-13, I 
would ask unanimous consent it be made a part of the record. 
And I yield to Mr. Waxman.
    Mr. Waxman. I thought Mr. Hall was very reluctant.
    Mr. Bilirakis. And I trust he won't be chairing this 
committee any time soon, but when he does he can then chair it 
as he pleases.
    In the meantime, I yield to Mr. Waxman.
    Mr. Waxman. I will abide by your rules, Mr. Chairman.
    Mr. McIlhaney, I just want to get some things straight 
about your views. Let's take as a given that total abstinence 
is always the best protection against pregnancy, transmission 
of sexually transmitted diseases including HPV and HIV. We all 
agree with that.
    Do you agree though that despite our best efforts, people 
will engage in sexual activity including young people, even 
adolescents?
    Mr. McIlhaney. I think some will, but I think it's fewer 
than we have assumed.
    Mr. Waxman. Some will.
    Mr. McIlhaney. Some will, but I'm not fatalistic about the 
number that most people would say.
    Mr. Waxman. If you agree with the idea that some are going 
to be sexually active, even if condoms are not 100 percent 
effective, aren't people better off using a condom than going 
without if they want to avoid pregnancy and transmission of 
sexually transmitted diseases and HIV?
    Mr. McIlhaney. I think people need to be aware of the fact 
of what the NIH report said and I was--I was actually on that--
in that group that made those findings. The research is very 
clear. If we looked at the world's research that condoms will 
fail for HIV transmission about 15 percent. There's a relative 
risk for people that, if they hadn't used condoms would have 
gotten infected; 15 percent of those would get infected even if 
they used condoms 100 percent of the time.
    Mr. Waxman. Well, my question is, aren't they better off 
using a condom than not using a condom?
    Mr. McIlhaney. They're less likely to get infected with 
HIV.
    Mr. Waxman. And less likely to get pregnant too, right?
    Mr. McIlhaney. They're less likely to get pregnant. The 
failures are much higher and as a physician, what I would do if 
my patients and what I would advocate programs do is advocate 
and teach and encourage what is the safest. As a matter of 
fact, the only reasonable way to avoid these problems.
    Mr. Waxman. We all agree that that is the safest way, but 
we're talking about the millions of people who are going to 
engage in sexual activity notwithstanding your advice and my 
advice to them to the contrary, but even if we disagree, we 
know that condoms prevent transmission of STDs and HIV and can 
prevent pregnancy, the question of HPV is still up in the air, 
but wouldn't you still prefer that a condom be used if sexual 
activity is occurring?
    Mr. McIlhaney. I think that there are different types of 
messages at different places. Okay----
    Mr. Waxman. I'm not talking about the message. I'm talking 
about the reality. Wouldn't you prefer, if after the messages 
fail to stay abstinent, if there's going to be sexual activity 
that in order to prevent transmission of sexual diseases and 
pregnancy and HIV that you would prefer someone from a medical 
point of view use a condom?
    Mr. McIlhaney. I would prefer they protect themselves if 
they are insistent on having sexual intercourse and are not 
married individuals. The problem I have with what we're talking 
about here, at least what I understand we're talking about here 
at this hearing with these sexuality education programs though 
is that we have clear evidence that they have not been 
successful. As I said, two thirds of the programs that Doug 
Kirby talked about in Emerging Answers were ineffective in 
lowering sexual activity rates. Half of them were ineffective 
in getting people to use----
    Mr. Waxman. The question also is do we have clear evidence 
that these abstinence only programs do work?
    Mr. McIlhaney. We have what we would call emerging answers 
on that, the fact that in Monroe County the actual pregnancy 
rates declined. With the pledge programs, we actually have one 
that now has reported declining pregnancy rates which is 
something the dual message programs almost never even talked 
about or even measured.
    Mr. Waxman. Let me ask Dr. Kaplan, because I see my light 
is on yellow, so I'm going to get the gavel on me any minute 
now. What do you think about this?
    Mr. Kaplan. Well, the evidence on condoms, even more recent 
evidence since the NIH report really does document that condoms 
will prevent gonorrhea, will prevent chlamydia. There's a new 
study out that it will prevent the most common STDs, herpes, 
not HPV. The most common STDs, condoms can have an impact. HPV 
is still a major issue and any teenager who's going to have 
sexual intercourse has got to be aware that they are putting 
themselves at risk. There's no doubt about that. It's not 100 
percent.
    Mr. Waxman. Thank you. My time has expired. Thank you, Mr. 
Chairman.
    Mr. Bilirakis. Thank you, Mr. Waxman. Mr. Upton to inquire.
    Mr. Upton. Thank you, Mr. Chairman. Continuing the entire 
welfare reform bill is very critical to all of us here and some 
of us on both the Education and Workforce Committee as well as 
obviously this one, Energy and Commerce. I can remember well 
when Chairman Boehner presented the administration's bill 
that's been introduced and there were a number of us there that 
said where is the extension of Medicaid benefits? That was one 
of the most important things we were able to do and of course, 
we have jurisdiction of it here in this committee instead of 
the Education and Workforce Committee, so we're pleased to tell 
them we had jurisdiction and in fact, that was going to be 
continued. And I appreciated your testimony on that issue and 
as I met with a number of folks from my Family Independence 
Agency which is in essence the welfare office in Michigan just 
yesterday, we talked extensively about making sure that that 
program continue, as well as the job training money which is so 
important to get people the skills needed to get into the 
workforce. And Dr. Scanlon and Ms. Mann, we appreciated your 
testimony for sure on that issue in its full detail and I would 
only ask Dr. Scanlon, I noted as a frequent visitor to our 
subcommittee on a whole number of topics, you talked only about 
extending Medicaid benefits. Does that mean that the GAO has 
not been brought into this sex education debate at all?
    Mr. Scanlon. That's correct. We have not been asked.
    Mr. Upton. So with a letter, we can get you involved and 
indeed double versed. Is that correct?
    Mr. Scanlon. We always try to respond to the requests.
    Mr. Upton. We'll look forward to that in the future. I 
think we might be able to work on a letter.
    As my friend, Mr. Greenwood, indicated, he's the father of 
two teenage girls. I'm the father of one teenage daughter and 
soon to be a teenage son as well. And I visit a school every 
week across my District. One of the toughest meetings that I've 
had is to visit what I call the kids with kids, single moms, 
15, 16 years old. They have a very rough life ahead of them. 
It's all we can do to encourage them to stay in school, to get 
that high school diploma and GED later, if they have to, 
because of all the pressures that are on them. As I have sat 
down with these kids on a number of occasions, even though I 
feel like maybe I'm still a kid and I turned 49 years old today 
and only last week was carded----
    Ms. Harman. Will the gentleman yield?
    Mr. Upton. Yes.
    Ms. Harman. On a bipartisan basis, we'd like to wish him a 
happy birthday.
    Mr. Upton. Well, I was carded only again last week twice.
    I even made Paul Harvey in my hometown. But as much as I'd 
like to identify with these kids, with kids particularly, I 
know that peer pressure, I think, as I've said, to get them 
talking about all the problems that they have as new moms is 
awfully tough and it's that message I think works best, trying 
to dissuade kids to be sexually inactive and I think that it's 
important that we do look at these abstinence only programs and 
I know that when I talk to my Michigan folks and with my staff, 
Michigan, as I indicated in my opening statement, has done a 
remarkable job of decreasing not only abortion rates, but also 
pregnancy rates among teens and it's only been since the mid-
1990's, I think it was 1996, that the abstinence programs have 
started in Michigan schools. And therefore, we're just 
beginning now to see the results of it which is finally, we're 
seeing a real decline. I guess the point that I would make as 
we listen to the testimony and read it as well some of the 
questions here that this important element of the legislation 
that we're going to consider and mark-up this week doesn't take 
a single dime away from the sex education, the programs that 
talk about condoms and the use of that, the parental 
involvement and all those different things, but this is a 
program that if the States decide to use it as Michigan has, 
where we match if $4 for every--$4 Federal dollars for every $3 
State, it is a program that can be used to help supplement and 
get that message not only to young men, but obviously as well 
to young women. My sense is that it works. Did you turn that 
thing on at the right time?
    Mr. Bilirakis. This is green and this is red.
    Mr. Upton. I was going to say this must be DC and they got 
the red light cameras in the wrong spot. Okay, good.
    Mr. Bilirakis. Anyhow your time is expired?
    Mr. Upton. It did?
    Mr. Bilirakis. It's 26 seconds over. Did you have something 
you wanted to finish up, please feel free?
    Mr. Upton. I just wanted to make the point that it doesn't 
take a dime away. That in fact, it does work and we've seen 
real results in Michigan and that's why it's important that the 
rest of the country experience it as well if they choose.
    Thank you.
    Mr. Bilirakis. I thank the gentleman. Mr. Hall to inquire.
    Mr. Hall. Mr. Chairman, thank you. I'll be fairly brief. 
You know, we talked about children. I had three sons and then a 
grandson until he was 20 years old before a little girl every 
showed up and now we have two little girls and I'm a lot more 
interested in abstinence now than I have been, but let me tell 
you this, abstinence, condoms, day-after pill and all that 
needs some additional thrust and I certainly plan, as long as 
I'm around, to stand at the corner of the high school drive and 
my grandchildren's home with a two by four and every damn 
little kid that comes by there on a bicycle that's a boy is 
going to be going a lot faster than he got headed there.
    So what I'm saying and saying it probably poorly is it 
takes family and backup and love and care and kindness and 
understanding. I was County Judge in a rural county for 12 
years when I had many young girls come to me. I was 24 then and 
looked about 19, but a lot of young girls come before me that 
their fathers had disowned because they were pregnant at a time 
when they were most needed were least understood. I think all 
everything we're talking about here gets back to family, gets 
back to educating the family and through them the children, but 
I thank you all for your testimony.
    I don't think any of us have any problem with the 
abstinence thrust, that you think it's that and Ms. Del Rosario 
thinks it does maybe a little more than some of you do. She 
agrees that it can use help, it can use assistance and I think 
all of you have that same feeling, so--and by the way I think 
your State takes $4 million out in the abstinence program and I 
don't want to be bragging, but I think Texas takes the biggest 
amount which means they match, they have the greatest matching 
fund and it's around $5 million and that's very close where our 
two States are. But I think it's a good program. It's about $50 
million a year and doesn't touch any other titles, Title XX 
money so far as I know, so I don't think we have any problem on 
supporting it and it's what goes with it and what we're going 
to put with it.
    Now on the Transitional Medical Assistance part, and these 
are both reauthorizations and there's a battle for bucks and 
I'd like to add things to the Transitional Medical Assistance, 
but I'm not sure that we can and can survive the Senate or 
survive the Conference Committee. I think you have to get what 
you can get when you can get it and that's what we're trying to 
do in these two bills.
    I'd like to--this bill has a 6-month waiting period and I 
don't like that any more than anyone else, but if you give up 
on the 6-month waiting bill and also include the legal 
immigrants that were cut out in 1996 it doubles the cost and I 
think any conference committee that's going to be looking at 
this is going to be looking at the cost and I'd like to get 
what we can get and maybe come back at another year or another 
conference or in another bill to go further.
    Do you, any of you have any problem with that thrust?
    Ms. Mann. If I----
    Mr. Hall. Other than the two by four part.
    A two by four is a stick about this big around and yeah 
long.
    Ms. Mann. I won't speak to the two by four. I'll just 
mention that one of the implementation issues around 
Transitional Medical Assistance, as both Dr. Scanlon and I 
mentioned, had to do with State implementation, change in their 
computer systems, making sure it worked, that when people left 
welfare, they were properly evaluated for Medicaid. Part of the 
problem of not having a longer extension of TMA is it leaves 
States wondering is it going to expire, is it going to continue 
and their willingness and ability to invest their time and 
their funds to improving the systems and boost participation 
may be dampened. That may be something to consider, certainly 
the fiscal constraints are clear.
    Mr. Hall. Do you have any facts or figures on what the 
effect of it would be?
    Ms. Mann. The effect of extending Transitional Medical 
Assistance?
    Mr. Hall. Of curing the problem that you've set forth.
    Ms. Mann. In terms of improving participation rates, we 
have and in my testimony I cite some information provided by 
the State of Indiana that did a number of improvements when it 
found it was losing a lot of people who were eligible and with 
those improvements no change in eligibility rules, just 
improvements in reaching people that they quadrupled the number 
of people who actually got TMA.
    So the improvements can really make a large difference if 
the States invest the time and energy and to some extent the 
resources to make it work.
    Mr. Hall. The cost effectiveness that you talk about is in 
results and not particularly in money?
    Ms. Mann. Well, and then there's some cost effectiveness 
that Dr. Scanlon mentioned in terms of avoiding unnecessary 
hospitalizations and other care that could be more expensive 
down the line, if parents don't get their primary care 
initially.
    Mr. Hall. I yield back my time, Mr. Chairman.
    Mr. Bilirakis. Mr. Greenwood.
    Mr. Greenwood. Thank you, Mr. Chairman. I'd like to have a 
chat with you, Ms. Del Rosario. First of all, I want to tell 
you that I thought your statement was beautiful, elegant and I 
find very little, if anything, to disagree with. I liked what 
you had to say. And as I said, I'm the father of teenaged girls 
and I think you mentioned MTV. I cut MTV off from coming into 
our house when they were 5 and 6 and they're still mad at me 
because I still won't let it come because I think it's part of 
the poisonous environment that our children are exposed to. I 
think the media is entirely irresponsible when you're talking 
about television, music, movies. It is a difficult, difficult 
thing to try to bring up a teenager to be safe in this society.
    And I truly believe in abstinence as a value. I truly 
believe that these kids who are 14 and 15 and 16 and 17 need to 
be abstinent. They're far better off if they're abstinent. 
They're safer and they're healthier and their lives will 
probably be better if that's--if they are.
    Here's my problem. I think that education, as I said in my 
opening statement, that education about abstinence is necessary 
for kids. I don't think it's sufficient. I think education 
about biology, including about how contraceptives work and 
don't work is necessary. I don't think it's sufficient. And I 
worry about what happens when you separate the two. I think 
society is reacting to the fact that many of our sex education 
courses have just been about the cold, hard facts without any 
discussion about emotional impact and no discussion of 
abstinence and values and what all of this means in the context 
of your lives and I understand why that was insufficient. And I 
understand the concern about dual message. I understand that, 
how do you say I think you're better off if you're abstinent, 
but in case you're not, here's how to use these methods of 
contraception. I understand that, but I also think I can 
remember enough about my own teenage years and I think I've 
been around. I've been a social worker. I've been around kids 
long enough to know that if they don't think that they're 
getting the full story from you, they're not going to believe 
that what they're getting is really wisdom. And I worry why it 
is that we can't integrate these messages with kids. Why it is 
that we don't trust the truth, why can't we tell kids the 
truth, the whole truth and nothing but the truth and if we 
believe in our hearts that--we believe the truth. We believe 
that kids are better off abstaining. We believe that 
contraceptives are not fullproof. We believe that kids can get 
hurt emotionally by premature sexual activity. Why can't we 
tell kids the whole truth and then they'll know, they'll trust 
us because when I look at this abstinence program, there's a 
lot of good stuff in here. I wouldn't mind having my daughters 
read this, but it also has the flavor of I'm only going to tell 
you so much, I'm going to give you one side of the story and 
I'm afraid kids go, we know what this is, this is propaganda. 
This is one side of the story. So my question is you seem to 
indicate that you think because you can answer any questions 
that are posed to you that you are providing a balanced 
education, but this whole notion of having to separate 
faculties and programs gives me the sense that the abstinence 
programs, abstinence only programs aren't giving kids the whole 
story, about trusting kids with the whole story and therefore 
are going to be suspect because they feel that they're not 
really getting the scoop.
    Ms. Rosario. First of all, in response to your question, in 
my 8 years I've never heard, first of all, I've never had a 
student to ask me to give them a large amount of information 
about contraceptives, never. No. 2, I've never heard it stated 
that they felt that anything was being withheld from them. I 
think what I want to address is this fact or fiction? If 9 out 
of 10 schools out of the 2 million our U.S.A. are offering 
comprehensive sex education, why would we think that they're 
not getting this information?
    Mr. Greenwood. Let me interrupt you and I'll implore the 
chairman to give you enough time to get everything you want to 
say, but why would we want to have them divided at all? This 
notion that over here we have this insufficient----
    Ms. Rosario. I was about to address that. I think it's 
because we are dealing with a mixed message. I think that's 
what I came into the ballgame not really validating. I didn't 
believe that was an issue. I'd heard it, but I did not believe 
until I heard it from the children. So now I am and I will have 
to disagree. I think there is no other way. If you're going to 
keep a mixed message out of the picture, I can't tell you on 
one side to do this and then tell you something else on the 
other side. However, if I withheld information from you or did 
not give you access, then I think that you have validity with 
your case. But the statement that you made, first of all, I 
believe that it's false. It's not correct. It's not what's 
happening.
    Mr. Greenwood. Which statement is that?
    Ms. Rosario. Meaning that kids are not getting both sides. 
I think that they're getting both sides not only in their 
school setting, from television. It's good that you did turn 
off MTV, but there are millions of other kids that don't have a 
good father like yourself at home, that are not able to turn 
off the television and they are getting those messages.
    Mr. Greenwood. My question is we don't like dual messages 
to the extent that one message undermines the other. I 
understand that. But when we're saying 9 out of 10 kids are 
going to get this sort of sterile sex education that doesn't 
talk about their values and their emotions over here and then 
we would like to make sure they get this over here, they're 
getting two messages and it seems to me that that's a less 
effective way----
    Ms. Rosario. If I could just state----
    Mr. Greenwood. Than combining them.
    Ms. Rosario. Let me give you an idea. If you have in one 
particular school, like our average high school has about 4,000 
students, every one of those 4,000 students is going to get sex 
education. The amount that's going to get an abstinence only 
education might be less than 5 percent of that population. So I 
think that that changes your perspective on it. We're talking 
about 4,000 kids that are going to absolutely get that message 
at least once, sometimes twice, before they graduate.
    Mr. Greenwood. And that's why I would support Federal 
funds----
    Ms. Rosario. Abstinence only education is to make sure----
    Mr. Greenwood. To make sure that no kid got sex education 
that didn't have an abstinence component.
    Ms. Rosario. But then how do you address the issue of a 
mixed message? And then how do you also address----
    Mr. Greenwood. By telling the truth, the whole truth and 
nothing but the truth and trusting the truth.
    Ms. Rosario. This is the problem though. You can say that 
from here, but when it gets carried out down here, a lot of 
different things are going to transpire.
    Mr. Greenwood. My time has expired.
    Mr. Bilirakis. Mr. Green to inquire.
    Mr. Green. Thank you, Mr. Chairman, and I want to follow up 
my colleague because of the mixed messages. I have a lot of 
follow-up and concerns. One is that as far as I know, the 
Federal Government outside of Title X has no comprehensive sex 
education requirement or funding for public schools. Is that 
correct? The 4,000 students you talked about, is that those 
4,000 students, they're not receiving that because of something 
that Congress passed?
    Ms. Rosario. I'm not aware.
    Mr. Green. As far as I know, there's not.
    Ms. Rosario. What I was discussing was in my written 
statement which are the Title V dollars which are 2 to 1 in 
most States.
    Mr. Green. Okay.
    Mr. McIlhaney. And the Federal Government certainly funds 
CDC and to the Division of Adolescent School Health. There are 
programs that work. We say fund it extensively.
    Mr. Green. But there's no requirement that we do that. CDC 
sets that out, but my local school district makes that 
decision.
    Mr. McIlhaney. Yes, but your local school decision might 
make a decision about whether to bring in a Title V program or 
not too.
    Mr. Green. I know that's true. Let me go back to my 
colleague on the mixed message.
    Ms. Del Rosario, in your testimony that abstinence plus 
programs are ineffective because they send children a mixed 
message, and I guess you have a lot of anecdotal information 
today, whether it's my colleague from Texas, Ralph Hall or 
myself, to have a son and a daughter who are now adults, but at 
what age do you think a child develops analytical skills 
necessary to comprehend all the information?
    Ms. Rosario. I think that that can be gathered by looking 
at statistics. We're seeing that the onset of sexual 
intercourse is beginning earlier. That's why we targeted middle 
school because first of all they can understand the 
information, but also it's a time when the peer pressure is 
going to be mounting. It's going to be of the greatest impact 
to their future.
    Mr. Green. So middle school, you think these children are 
having to make these decisions now. do you think they 
comprehend a mixed message? If all you say is just say no, I 
think you'll be laughed out of most of 6th and 7th grade 
schools.
    Ms. Rosario. That's not what we do and that's not what I 
support at all. As a matter of fact, it's the opposite. I 
support a comprehensive program that teaches to the antecedence 
of out of wedlock births, teenage pregnancy.
    Mr. Green. And I don't think most of us disagree. I want 
abstinence to be taught, but I also know I want to make sure 
that if they don't have the fortitude or the wherewithal or the 
ability to have the abstinence, we need to have them educated 
on how they can do and that's, I think, the concern from some 
of us on the committee.
    Let me, when you talk about the need for background in the 
studies, both Dr. Kaplan and Ms. Del Rosario, references in 
your testimony, both of you all, leading organizations, there 
are no references, whether it's the Institute of Medicine, 
Surgeon General, National Institutes of Health or American 
Academy of Pediatrics, they all support comprehensive sex 
education. Is that correct?
    Ms. Rosario. Well, let me go back and correct my last 
statement, because if you're using that term to refer to the 
type of sex education, I was saying comprehensive in terms of 
holistic education. I just want to make that clear.
    Mr. Green. Well, again, maybe we're semantics, but I don't 
mind holistic as long as it includes everything.
    Ms. Rosario. To make it clear that's called abstinence plus 
or comprehensive sex education. And I think we need to clarify 
our terms.
    Mr. Green. Which again gives the child the information as 
children are making these decisions much earlier, as you 
testified, so they have all the information to make that 
decision.
    Ms. Rosario. And they have gotten it already outside of the 
abstinence only course.
    Mr. Green. And I'll mention this, I've been proud of using 
in speeches and I think some of my colleagues on both sides 
have used them. We've seen a decline in unwed pregnancies over 
the last number of years and I can't recall whether it's 4 or 5 
years. Now I know and what you're saying maybe they are getting 
that mixed message now, but obviously something is working and 
I'd just like to continue it and I don't know if ``Just Say 
No'' will work with the typical child.
    Ms. Rosario. Can I respond to that?
    Mr. Green. Sure.
    Ms. Rosario. One of the issues that I really think is very 
important is my recommendation as we even examine the 
reauthorization of abstinence funding, but also those programs 
that are awarded funding. I think that you can't just--you're 
trying to change a lifestyle by a 5-minute presentation telling 
kids to say no. I don't support that. What I'm saying is that 
holistic approaches such as those that are outlined in the 
congressional guidelines are what's necessary, approaches that 
are going to address the entire child, build self-esteem, 
character, deal with the value of marriage and family.
    Mr. Green. Again, I don't think there's any doubt that we 
agree with that.
    Ms. Rosario. But what I'm saying is that there are programs 
that are out there now that will give say five, 1-hour 
presentations on abstinence only and they might say say no and 
let me teach you one or two refusal skills. I say that my 
suggestion would be that we choose programs that are going to 
be a little bit more holistic.
    Mr. Green. Mr. Chairman, could I get Dr. Kaplan to respond 
because----
    Mr. Bilirakis. Very briefly now. It's really unfair to Ms. 
Harman and Mr. Pitts who have been sitting through the entire 
hearing and--very briefly, Dr. Kaplan.
    Mr. Kaplan. Sure, I just wanted to make it clear why we've 
seen a decrease in teenage births. Since the 1990's, the 
Centers for Disease Control has studied this and 75 percent of 
the decrease is due to more effective means of contraception, 
especially longer forms of contraception, Depo Provera and 
Norplant, really has resulted in the huge decrease that we've 
seen.
    There's been some decrease in sexual activity and we've 
seen a delay of onset of kids becoming sexual active in that 
other remaining 25 percent, but the big change really has been 
more effective and better use of contraceptions and also an 
increased use of condoms during that period of time.
    Mr. Bilirakis. Mr. Pitts, to inquire.
    Mr. Pitts Thank you, Mr. Chairman. Ms. Del Rosario, thank 
you for your testimony. These handouts are marvelous. You 
mentioned an astounding statistic, a success rate I believe you 
said of 99.9 percent. Why is your program so effective? Tell us 
how you such a success rate?
    Ms. Rosario. I think that first of all our program does 
address in the congressional guidelines, it's a very 
comprehensive program. It doesn't just want to give a message 
that kids parrot back, saying no, no. But first of all we begin 
to build the skills. We begin to build their value of 
themselves and we get them vested in their future.
    I think that kids postpone sex and they also decide to 
value their future opportunities in not getting pregnant, if 
they feel that they have future opportunities. So that is a 
very vital component of the program. We don't just work also 
with the students that are in the program,but we also begin to 
work with their siblings and their parents. The whole purpose 
is to build stability in the family and to build the family, so 
that we're not just reaching one generation, but we're reaching 
three in the process.
    And I think that when we're not trying to put the bandaid, 
but we're trying to find out why kids behave the way that they 
do and address that at the root source, versus let them 
continue to behave in a way that's unproductive for them and 
then just try to cover it the best way that we can, that's when 
we see true success.
    There's another case that I cited in my written testimony. 
There's a program in Denmark, South Carolina that has similar 
outcomes. Their prevention rate was 59 percent in teen 
pregnancy during the 2\1/2\ years that they ran their program. 
At our local level, in the city of Miami, it is estimated that 
14.2 births would occur in a population of 1,000 teens within a 
year's period. That would mean that by this time if you 
multiplied that by the 5,500 youth that we served that we 
should have a substantial amount of pregnancies beyond that, 
which we do. How do you explain it, particularly seeing that 
we're working with truly high risk populations who do not have 
proper role models, who have never seen--one of my biggest 
challenges was to build the value for marriage which is one of 
the reasons why I remember my mom told me, you know, you're 
going to don that beautiful white dress. We're going to go all 
out. I would say that to these kids and they would look at me 
like, hm, because they've never seen anyone married. Everybody 
cohabitates, you know, and these are the greater issues and 
that's what I believe that this legislation has allowed us to 
really address. School systems are under funded and over 
burdened. They cannot be the surrogates. But this funding 
allows us to teach those behaviors that make for successful 
living. It allows us to kind of bridge the gap. I'm not saying 
that there's any one program that's going to do everything. You 
don't understand what I'm saying. Don't misunderstand. But I'm 
saying this is a vital program. It has proven itself successful 
and like I said before, there are so many for it and so many 
against it, I think that we can all sit here all day long and 
come up with different studies that will document one stance or 
the other. But our program has been in effect for 8 years. Our 
research, we're research-driven, and it's sound. This is what 
has happened. So of course, I believe strongly in it and will 
continue to serve our communities with this approach.
    Mr. Pitts Thank you. I just hope we find a lot of other 
States using your or similar programs.
    Dr. McIlhaney, it's evident that you're well-qualified to 
speak about STDs. Would you speak about the long-term effects 
for adolescents who contract an STD? You mentioned you were on 
the NIH panel to determine the effectiveness of condoms and you 
spoke of HPVs. Can you just elaborate a little bit more about 
do condoms protect against the transmission of HPV and what are 
the effects of getting this virus?
    Mr. McIlhaney. I appreciate your asking that because I 
think the impact is much worse than most people realize. First, 
HPV is the most common sexually transmitted disease. As I said, 
it infects about 50 percent of sexually active adolescent 
females, even up to the age of 22. Most of those young people's 
bodies will clear it, but those of about 5 percent will 
probably develop abnormal Pap smears and a certain number of 
those will proceed to cancer. Human papillomavirus is a cause 
of 99 percent of cervical cancer in women, and as I said 
earlier it's a cause of almost all truly abnormal precancerous 
Pap smears of which we have an epidemic going on with kids 
today.
    When any woman gets an abnormal Pap smear, if it persists 
and indicates pre-cancer, they may have to have a proceed done 
called a LEEP procedure where a portion of the cervix is cut 
out. If there's no immunity, they can get infected again with 
human papillomavirus and have to have that done again. That can 
ultimately, rarely, but occasionally, lead to prematurity or 
even infertility.
    It's very clear there is no evidence at all that condoms 
prevent the sexual transmission of that.
    Herpes is infected in about 1 in 5 Americans. There's been 
a 500 percent increase in Herpes among white adolescents over 
the past few years. And there are two problems with it. If 
people are Herpes infected, they are more susceptible and if a 
subsequent sexual partner has HIV to becoming HIV-infected. And 
if a woman has a Herpes outbreak at the time of delivery, it's 
possible that her baby can become infected. Half of those 
babies will die, half of them will become severely brain 
damaged. So although it doesn't happen very much, it's an 
extremely emotional issue for a woman who has Herpes and then 
might be delivering a baby 5 or 10 years later and still be 
having outbreaks.
    Mr. Pitts I didn't mean to cut you off, sir.
    Mr. McIlhaney. We could just go on and on----
    Mr. Bilirakis. I don't want you to go on and on.
    Mr. McIlhaney. I feel strongly about these problems and I 
saw them in my practice.
    Mr. Bilirakis. I know that Mr. Pitts does too.
    Mr. McIlhaney. May I mention just one other?
    Mr. Bilirakis. Please, sure.
    Mr. McIlhaney. Chlamydia. Chlamydia is infecting--
adolescents have a special predilection to it. They seem to be 
especially susceptible to it. And it occurs, it reinfects girls 
so often that Johns Hopkins in their adolescent clinics who are 
studying chlamydia infection in young women found reinfection 
rates so often that they recommend that every adolescent in 
America who is sexually active, adolescent girl who is sexually 
active be tested for chlamydia every 6 months regardless of 
condom use. And although Dr. Kaplan mentioned some recent 
studies which I'm very familiar with about reduction of risk, 
he used the word ``prevent'' which I would object to because 
they reduce the risk. But the problem is the condoms leave the 
risk of Herpes, for example, even with these new studies of at 
least 35 to 50 percent. They leave the risk of chlamydia 
infection and so often it's asymptomatic. Girls don't know they 
have it. It leaves the risk of infection with HIV, even as I've 
mentioned. So I think that those things people need to know 
about.
    Mr. Pitts Thank you very much.
    Mr. Bilirakis. Ms. Harman.
    Ms. Harman. Thank you, Mr. Chairman. Thank you for 
including me in this hearing and I really feel privileged to 
have listened to what I think is a very constructive and quite 
long conversation among us about this subject.
    I voted for welfare reform in 1996. I'm a mother of four 
children, two of whom are female, and the subject of teen 
pregnancy and reducing teen pregnancy is on my mind a great 
deal personally, as I know it is on the minds of many members 
of this Panel. Two of my kids are still teenagers and this is a 
conversation we have often in my family.
    I agree with Ms. Del Rosario that parents have to set 
limits and that parents have to provide clear lines, but I will 
tell you this is very hard to do, even if one is well-informed, 
one loves one's kids dearly, one believes in active parenting, 
one has read everything there is to read, and one went through 
all these issues oneself and hopefully came to reasonably wise 
conclusions.
    Having said that, tomorrow, I plan to offer one or two 
amendments to this section of the bill because I want to give 
more flexibility to States. I come from California which has 
turned down the Federal funds under this title--turned down $30 
million because my State believes that abstinence-only 
education doesn't work. It tried abstinence-only education from 
1992 to 1994--under a Republican Governor--and concluded that 
it didn't work. I understand the data is emerging that these 
programs can work. That's terrific. But the present data in 
every piece of information I can find, including the bible here 
which Dr. McIlhaney worked on, shows that the programs that do 
work involve something more. And I feel, consistent with the 
President's view of the 2003 budget, that we should only fund 
things that we know work. He's canceled a number of programs in 
the budget, including dropout prevention, alcohol abuse 
reduction grants, student mentoring programs and so forth 
because he can't find evidence that they work. So let's fund 
things that we know work. That's where I'm coming from. If we 
can prove in the future that abstinence-only works, that would 
be fine with me, let's fund it. In fact, if we can prove now, 
prove scientifically now that it works, let's fund it.
    Having said all that I have a couple of questions to you, 
Ms. Del Rosario because you've obviously run a fabulously 
successful program over 8 years, well before these funds were 
available.
    Are your participants self-selected or are they a general 
population pool in the area that you serve?
    Ms. Rosario. Well, basically, they are referred or even 
kids come and volunteer and say that they want to take the 
course. That's basically how we get those students enrolled.
    Ms. Harman. But they don't have to take it.
    Ms. Rosario. Oh no.
    Ms. Harman. So the pool that's there is there more or less, 
is this fair, because it wants to be there?
    Ms. Rosario. Right.
    Ms. Harman. There may be a different group than your 
general average public school group.
    Ms. Rosario. It could be that their parents want them to be 
there, that they want to be there.
    Ms. Harman. But there's some motivation, probably, personal 
motivation in each participant----
    Ms. Rosario. Well, it's consequence-driven, so they 
understand that there's a lot of things that they have to 
follow the rules of. So if they're willing to do that, then 
they're in the program.
    Ms. Harman. So you're not teaching the general population, 
you're teaching a self-selected population?
    Ms. Rosario. The funds are so limited, you have to be self-
selected.
    Ms. Harman. And when you measure your results, you're 
measuring the results of the kids who stay in the program?
    Ms. Rosario. Uh-huh.
    Ms. Harman. So if some kids leave your program, you don't 
measure their results?
    Ms. Rosario. Well, we're a part of the national evaluation.
    Ms. Harman. What does that mean?
    Ms. Rosario. Congress commissioned a study, Mathematic 
Policy Research has begun that study. I believe we're in year 
3. And we're one of the top six programs in the Nation that was 
chosen for Title V funding to be evaluated. So in that study, 
they are using cohort groups and program students and they're 
tracking them for a period of about 4 to 5 years.
    Ms. Harman. Four to 5. That was my next question. So they 
do track kids who have left your prgram?
    Ms. Rosario. Yes.
    Ms. Harman. But I'm still correct that the kids in your 
program are a self-selected group, not a random group?
    Ms. Rosario. See, I'm just not clear on what you mean by 
self-selected.
    Ms. Harman. I mean that they want to be there.
    Ms. Rosario. Yes. So do the control group.
    Ms. Harman. Okay. Time is short. I just have one other 
question to you. You said several times that 9 out of 10 
schools offer comprehensive sex information. What is the basis 
for that statement?
    Ms. Rosario. It's in my written statement. It was data that 
I researched. I think there's three States that allow parents 
to absolutely protest and remove students from that sex 
education course, but basically all of the States do.
    Ms. Harman. Who funds that comprehensive----
    Ms. Rosario. I know that some of the funding is done under 
Title X, but it's not done at the school level. I'm not really 
certain on what constitutes----
    Ms. Harman. Right. My understanding is that Federal funding 
under Title X is not for school-based education. Title X does 
provide for family planning and health care and does provide 
for some teen services, but they're at medical centers, not in 
schools.
    Ms. Rosario. There is some because I work at some of the 
centers where we do have programs that they're offering onsite, 
condoms and any type of contraceptive use that the kids might 
need. And those are those types of schools that are called 
Schools of Choice.
    Ms. Harman. Okay, but I would appreciate it if you could 
provide us with--Mr. Chairman, I'd like to request this, the 
justification for that statement that 9 out of 10 schools offer 
this education and where the funding comes from because my 
understanding is that most of it does not come from Federal 
funds. Some States have these funds, some States don't have 
these funds. We're talking here about extending a Federal 
program--welfare reform--and trying to reduce teen pregnancy, 
to provide some funds for that. And so it is my view, Mr. 
Chairman, that the funds we provide in this Federal program to 
reduce teen pregnancy should go to programs that work. I don't 
think anyone is really disagreeing with this idea, and funds 
should be available in schools for programs that work.
    Ms. Rosario. I'll also try to include additional 
information such as Title V funding that is done through wages 
or TANF dollars. We received initially those dollars to provide 
comprehensive sex education and we elected to do abstinence 
only and had to really fight to be able to do that, so I know 
those are another set of funds that are under TANF that we're 
able to do sex education with.
    Ms. Harman. Well, I appreciate that. I'd appreciate maybe 
staff can clarify that for me too before tomorrow. I want to be 
sure that what I talk about is based on fact. Does any, I 
think, even though the light is green, I have a feeling it's 
red.
    Mr. Bilirakis. Very brief. We've got to finish up.
    Mr. Kaplan. Yes, I think you're correct, that there are not 
Federal dollars for family planning in the schools and 
actually, in Colorado, my state, you know, it's pretty sketchy 
as to how much comprehensive sex education is actually offered 
and there was a study in family planning perspectives in 2000 
and the thing that I'm concerned about is that we've seen a 
real deterioration in comprehensive sex education. In this 
study they found in 1999 that 25 percent of secondary teachers 
were teaching abstinence only as the only way to prevent 
pregnancy and STDs, so we've sort of lost the general education 
that kids need to have about these problems.
    Ms. Harman. Well, thank you again, Mr. Chairman for 
allowing me to participate.
    Mr. Bilirakis. Dr. McIlhaney, I know you're anxious to say 
something, are you?
    Mr. McIlhaney. Sure, sure.
    Mr. Bilirakis. You look like you're chomping at the bit.
    Mr. McIlhaney. May I, sir?
    Mr. Bilirakis. Very briefly. Okay, first, I'll help with 
providing the data about the Federal funds for sexuality 
education because we've recently added that up to well more 
than $135 million, almost up to $400 million that will help 
provide some information for that through all sorts of 
agencies, Agriculture, Interior and surprisingly, other places.
    I'd just like to mention one thing and that is that there's 
sort of this--it almost feels like sort of this dreamy thing 
about the comprehensive sex ed., that they truly are 
comprehensive. They are far from comprehensive. The abstinence 
element, as a matter of fact, in many of these programs that 
even are sometimes referred to as abstinence plus programs have 
either no abstinence information at all or very little.
    Another problem with them----
    Mr. Bilirakis. You're referring to Title V programs?
    Mr. McIlhaney. No sir. I'm referring to the abstinence plus 
or comprehensive sex education or these programs that we've 
been talking about as well, providing full information. They 
don't do that. As a matter of fact, abstinence part of those 
programs is very minimal.
    Doug Kirby himself also showed that unless a teacher feels 
strongly that the young person can access this information, 
understand it and use it, that it's not going to be effective. 
We understand that even for Algebra teachers, they've got to 
believe kids can understand Algebra. And there are essentially 
none of these programs I know of that those who really 
understand abstinence programs would say that the abstinence 
part of these dual-message programs would even be considered an 
abstinence education program.
    As a matter of fact, in most of these programs, we've seen 
some recent stuff that would say that the information in these 
dual-message programs is really alarming and is something if 
parents and many of you knew, were there, you'd probably be 
almost shocked about. So these are not comprehensive programs 
in providing either kind of message for kids. We have to--I 
totally agree with Ms. Del Rosario that young people who are 
taught about abstinence have to be taught by somebody who truly 
believes that those young people can understand this and will 
do it.
    Mr. Bilirakis. Ms. Del Rosario, let me ask you, do you all, 
those of you who work in the Title V programs around the 
country, the 49 States, do you share, the way you present the 
programs and the results and the success rate, etcetera?
    Ms. Rosario. We do.
    Mr. Bilirakis. You do.
    Ms. Rosario. Under SPRANS and under Title V abstinence only 
dollars. It's even contractually stated that you have to gather 
at least once a year and that's what we do to really strengthen 
the programs and to perfect them.
    Mr. Bilirakis. Are you confident that the other Title V 
programs use the same concept that yours does?
    Ms. Rosario. Some of them do. I've traveled and I've been 
speaking around the country and I've seen some that are and 
some that are not. And that's why I made that suggestion about 
the types of programs that we're looking at. Because I mean we 
can have a good intention, but if we fund poor programs or weak 
programs, I don't care what their message is, it's not going to 
work.
    Mr. Bilirakis. Well, I'd really like to thank you all. 
You're a very respected panel of witnesses. Obviously, you all 
care about this issue. We didn't hear too much from Ms. Mann 
and Dr. Scanlon, I guess, because we sort of got caught up in 
this other more controversial issue.
    Mr. Brown. Mr. Chairman?
    Mr. Bilirakis. I'll recognize you in a moment, sir, but 
there's in the national newspaper, Today, there's an article 
that highlighted the issue of abstinence only education and one 
of the teens interviewed in the piece mentioned and I quote, 
``the abstinence messages are getting through'' according to 
this teen. So I guess she sort of agrees with Ms. Del Rosario.
    Well, tomorrow we have our hearing and--I mean our mark-up. 
And not much time in between and it's unfortunate, but if you 
all have--and I'll yield to Mr. Brown in a moment--but if you 
have any suggestions, all of you in terms of issues, that we 
should be discussing or maybe the legislation, please feel free 
to pass that on to us.
    Mr. Brown?
    Mr. Brown. Thank you, Mr. Chairman. I'd like to thank the 
panel, too.
    Two years ago, this subcommittee passed a 1-year extension 
of the transitional Medicaid program. We also passed under the 
leadership of Chairman Bilirakis two improvements to TMA, one 
was a State option to waive the reporting requirements which 
Dr. Scanlon, Ms. Mann mentioned. The other is an exemption from 
the TMA requirements for States that already broadly covered 
the population, this population up to 285 percent of poverty. 
These improvements, as you know, Mr. Chairman, never made it 
into law last year, but I hope--2 years ago--but I hope that we 
can work together. I know tomorrow we won't make that change, 
but through this process we can work together to do that, if we 
could.
    Mr. Bilirakis. Well, and you made the point in your opening 
statement, Mr. Brown, that there are no new additional Medicaid 
dollars in the budgets, so in order to have these transitional 
funds, we're going to have to find some sort of an offset and 
hopefully we can all work together, because I know we all want 
that to take place.
    Mr. Brown. And I also would ask unanimous consent to enter 
this into the record. This is the endorsement by members of the 
clergy and lay religious leaders of the Planned Parenthood 
Federation, America's Statement on Comprehensive Sexuality 
Education.
    Mr. Bilirakis. Without objection, that will be the case.
    [The material follows:]
     Prepared Statement of Planned Parenthood Federation of America
                         clergy advisory board
    We, the undersigned, are clergy and lay religious leaders who 
represent diverse religious traditions and come from all walks of life. 
We believe that an individual's sexuality must be affirmed as an 
essential dimension of being human. Concerned about the sexual health 
of our country, we strongly support the bold and courageous 
recommendations of the ``Surgeon General's Call to Action to Promote 
Sexual Health and Responsible Sexual Behavior'' for more knowledge, 
more services, and more open discussion.
    Accordingly, we call on our elected leaders to ensure that our 
young people receive medically accurate and balanced sexuality 
education.
Speak the Truth
    As clergy, we have a responsibility to remind our congregations, 
our communities, and our elected leaders that both the Hebrew Bible and 
the New Testament, as well as the teachings of other religious faiths, 
view the body and the physical world as a sacred arena in which God 
acts. Did not God bless human beings with the opportunity to bear 
children as a singular sign not only of the sacredness of life but also 
as a sign of their capacity for sexual intimacy?
    Yet we treat human sexuality as inherently dangerous and off-limits 
for discussion. Discomfort with their own sexuality inhibits many 
parents from talking with their children about this most natural part 
of life. A lack of information and understanding about sexuality also 
contributes to painful discrimination against sexual minorities.
    Our sexuality is God given, and so, too, is the command that we 
instruct our children so that they will gain understanding and the 
ability to make wise choices.
Fund Programs That Work
    The current debate over sexuality education in the nation's public 
schools is one more example of how theological abstraction and moral 
absolutes have been permitted to substitute for common sense and 
compassion, not to mention the lessons that medicine and science can 
teach us.
    For the sake of our young people, we urge our elected leaders not 
to ignore the expert findings that there is no reliable, scientific 
evidence to demonstrate that abstinence-only sexuality education works, 
while there is substantial evidence to show that comprehensive 
sexuality education has been successful in preventing teen 
pregnancy.\1\
---------------------------------------------------------------------------
    \1\ See Douglas Kirby, Emerging Answers (Washington: The National 
Campaign to Prevent Teen Pregnancy, 2001).
---------------------------------------------------------------------------
    Substituting dicta for instruction stifles the kind of open 
discussion that fosters the development of healthy and responsible 
attitudes toward our God-given gift of sexuality.
    As community leaders who care about the well being of young people, 
we, like a substantial majority of Americans, encourage teens to 
abstain from sexual intercourse. But, like a substantial majority of 
Americans, we also recognize that many will not.\2\
---------------------------------------------------------------------------
    \2\ Jacqueline Darroch, et. al., ``Changing Emphasis on Sexuality 
Education in U.S. Public Secondary Schools.'' Family Planning 
Perspectives 32(5): 204, 205 (2000).
---------------------------------------------------------------------------
    Giving young people complete information does not influence them to 
engage in sexual activity any earlier--that's what the research 
shows.\3\ How can we, in all good conscience, deny young people 
knowledge that would protect them from becoming parents before they are 
ready to have children and would also protect them from either 
contracting or spreading sexually transmitted infections?
---------------------------------------------------------------------------
    \3\ See Kirby, op. cit.
---------------------------------------------------------------------------
Don't Discriminate
    Finally, we believe that public funding that supports only 
abstinence-only education discriminates against the religious 
denominations that support comprehensive sexuality education. Twelve 
denominations favor curriculums that discuss abstinence as one option 
and include information about all aspects of human sexuality, with the 
objective of developing sexually healthy adults who can make 
responsible choices about their reproductive lives.\4\
---------------------------------------------------------------------------
    \4\ Debra Haffner, A Time to Speak: Faith Communities and Sexuality 
Education (N.Y.: SIECUS, 1998).
---------------------------------------------------------------------------
    Many faith traditions teach that children must be treated, with due 
allowance for their ages, as responsible persons who can make critical 
decisions about their lives. Each child has a conscience. Each can be 
taught to become a reasoning and reasonable person. Each must be taught 
about human sexuality, so that each can make informed and responsible 
choices about his or her sexual life, including the choice to remain 
abstinent. As an integral part of this process, our young people have a 
right to the best information possible. We pledge to dedicate ourselves 
to ensuring that they receive nothing less.

--------------------------------------------------------------------------------------------------------------------------------------------------------
                                       I60First and Middle
                                              Name
--------------------------------------------------------------------------------------------------------------------------------------------------------
Chaplain...........................  Lesley................  Adams................  St. John's Chapel.....  Geneva...............  NY
Ms.................................  Janis.................  Adams................  Presbytery of           Cincinnati...........  OH
                                                                                     Cincinnati.
Dr.................................  Michael J.............  Adee.................  First Presbyterian      Sante Fe.............  NM
                                                                                     Church.
Rev................................  Julia J...............  Aegerter.............  Unitarian Universalist  Evansville...........  IN
                                                                                     Church of Evansville.
Rev................................  Clifford L............  Aerie................  United Church of        Cleveland............  OH
                                                                                     Christ.
Rabbi..............................  Heather...............  Altman...............  Bet Torah.............  Mt. Kisco............  NY
Rev................................  David A...............  Ames.................  Episcopal Chaplain,     Providence...........  RI
                                                                                     Brown University.
Rev................................  Wayne R...............  Anderson.............  United Methodist        Louisville...........  KY
                                                                                     Church.
Rev................................  Nancy L...............  Anderson.............  Minnehaha UCC.........  Minneapolis..........  MN
Rev................................  Alice V...............  Anderson.............  The New York Ave.       Washington...........  DC
                                                                                     Presbyterian Church.
Rev. Dr............................  Susan R...............  Andrews..............  Bradley Hills           Bethesda.............  MD
                                                                                     Presbyterian Church.
Rev................................  Susan C...............  Armer................  St. Matthew's           Auburn...............  WA
                                                                                     Episcopal Church.
Rabbi..............................  Benjamin..............  Arnold...............  ......................  Amherst..............  NY
Rev................................  Mark E................  Asman................  Trinity Episcopal       Santa Barbara........  CA
                                                                                     Church.
Rev................................  Theodore A............  Atkinson.............  Oxford Presbyterian     Oxford...............  PA
                                                                                     Church.
Rev................................  A.E...................  Aurand...............  Incarnation Lutheran    Cedarhurst...........  NY
                                                                                     Church.
Rev................................  Louisa M..............  Baer.................  Blue Ash Presbyterian   Cincinnati...........  OH
                                                                                     Church.
Rev................................  Brian.................  Bagley-Bonner........  Newbury United          Newbury..............  OH
                                                                                     Community Church.
Rev................................  David.................  Bahr.................  Archwood United Church  Cleveland............  OH
                                                                                     of Christ.
Rev. Dr............................  Warner M..............  Bailey...............  Ridglea Presbyterian    Fort Worth...........  TX
                                                                                     Church.
Rev................................  Melvin L..............  Bailey...............  Shiloh Baptist Church.  Tulsa................  OK
Rev................................  Darline D.............  Balm-Demmel..........  UMC...................  Des Moines...........  IA
General............................  Philip W..............  Barrett..............  General Presbyter-      Des Moines...........  IA
Presbyter..........................                                                  Presbytery of Des
                                                                                     Moines.
Rev................................  S. John...............  Bartley..............  ......................  Atlanta..............  GA
Rabbi..............................  Pamela Frydman........  Baugh................  Or Shalom Jewish        San Francisco........  CA
                                                                                     Commuity.
Rev................................  Eugene C..............  Bay..................  Byrn Mawr Presbyterian  Bryn Mawr............  PA
                                                                                     Church.
Rev................................  Paul..................  Beckel...............  First Universalist      Wausau...............  WI
                                                                                     Unitarian Church.
Rev................................  Silvia R..............  Behrend..............  First Unitarian Church  Salt Lake City.......  UT
                                                                                     of Salt Lake City.
Rabbi..............................  Martin P..............  Beifield, Jr.........  Congregation Beth       Richmond.............  VA
                                                                                     Ahabah.
Rev................................  Emmy Lou..............  Belcher..............  Unitarian Universalist  Travers City.........  MI
                                                                                     Congregation of Grand
                                                                                     Traverse.
Rev. Dr............................  Mark..................  Belletini............  First Unitarian         Columbus.............  OH
                                                                                     Universalist Church
                                                                                     93 W. Weisheimer.
Rev................................  Russell L.............  Bennett..............  Fellowship              Tulsa................  OK
                                                                                     Congregational Church
                                                                                     UCC.
Rev................................  Eric..................  Bentrott.............  Pilgrim Congregational  Cleveland............  OH
                                                                                     Church.
Rev................................  J.C...................  Berbiglia............  Presbyterian Church     Helotes..............  TX
                                                                                     (USA).
Rabbi..............................  Peter S...............  Berg.................  Temple Emanu-El.......  Dallas...............  TX
Rev................................  Julie.................  Bergdahl.............  Redeemer Lutheran       Plattsburgh..........  NY
                                                                                     Church.
Brother............................  Clark.................  Berge................  Society of St. Francis  Mount Sinai..........  NY
Rabbi..............................  Jonathan..............  Biatch...............  Beth El Hebrew          Alexandria...........  VA
                                                                                     Congregations.
Rev................................  Mark..................  Bigelow..............  Congregational Church   Huntington...........  NY
                                                                                     of Huntington, UCC.
Rev................................  Wes...................  Bixby................  Smith Memorial Cong     Hillsboro............  NH
                                                                                     Church, UCC.
Rev................................  Kathleen A............  Bishop...............  Unity Church..........  Fort Lauderdale......  FL
Rev. Dr............................  Nadean................  Bishop...............  MN Religious Coalition  Minneapolis..........  MN
                                                                                     for Reproductive
                                                                                     Choice.
Rev................................  Cynthia L.............  Black................  Parish Church of        Kalamazoo............  MI
                                                                                     Christ the King at
                                                                                     the Cathedral.
Rev................................  James C...............  Blackburn............  Diocese of Maryland...  Baltimore............  MD
Chaplain...........................  Lee...................  Blackburn............  ......................  Kansas City..........  KS
Vicar..............................  Martha................  Blacklock............  St. Mary the Virgin     Keyport..............  NJ
                                                                                     Episcopal Church.
Rev................................  Rebecca M.............  Blackwell............  ......................  Philadelphia.........  PA
Rev................................  Rosalee...............  Blake................  UMC...................  Chicago..............  IL
Rev................................  Dallas A..............  Blanchard............  ......................  Pensacola............  FL
Rev................................  David M...............  Blanchard............  Unitarian Universalist  Andover..............  MA
                                                                                     Association.
Rabbi..............................  Barry H...............  Block................  Temple Beth-El........  San Antonio..........  TX
Rev................................  Eddie.................  Blue.................  Church of the Holy      Baltimore............  MD
                                                                                     Trinity (Episcopal).
Cantor.............................  Sheri.................  Blum.................  Congregation B'nai      Bridgeport...........  CT
                                                                                     Israel.
Mr.................................  Theodore A............  Blunk................  Old Stone Presbyterian  Cleveland............  OH
                                                                                     Church.
Rev................................  Melinda...............  Bobo.................  St. Martin's by the     Minnetonka Beach.....  MN
                                                                                     Lake Episcopal Church.
Rabbi..............................  David.................  Bockman..............  Beth Meyer Synagogue..  Raleigh..............  NC
Rev................................  Steve.................  Bohlert..............  CPCUCC................  Comstock Park........  MI
Rabbi..............................  Elizabeth.............  Bolton...............  Congregation Beit       Balitmore............  MD
                                                                                     Tikvak.
Rev................................  Edward K..............  Brandt...............  Red Clay Creek Pres.    Wilmington...........  DE
                                                                                     Church.
Rev................................  Robert L..............  Brashear.............  West-Park Presbyterian  New York.............  NY
                                                                                     Church.
Rabbi..............................  Balfour...............  Brickner.............  Stephen Wise Free       New York.............  NY
                                                                                     Synagogue.
Rev................................  Harlan................  Breininger...........  United Church of        Jim Thorpe...........  PA
                                                                                     Christ.
Rev................................  J. Wesley.............  Brown................  United Methodist        Santa Barbara........  CA
                                                                                     Church.
Rev................................  Robert O..............  Browne...............  Presbytery of Santa Fe  Albuquerque..........  NM
Rev................................  Ellen A...............  Brubaker.............  United Methodist        Grand Rapids.........  MI
                                                                                     Church.
Reverend...........................  Daniel E. H...........  Bryant...............  Christian Church        Eugene...............  OR
                                                                                     (Disciples of Christ).
Rev................................  Roger.................  Buchanan.............  Carversville Christian  Perkionmenville......  PA
                                                                                     Church.
Rabbi Emeritus.....................  Gustav................  Buchdahl.............  Temple Emanuel........  Baltimore............  MD
Rev................................  Kathleen..............  Buckley..............  Chaplain, St. Lawrence  Canton...............  NY
                                                                                     University.
Rev................................  Daniel................  Budd.................  First Unitarian Church  Shaker Heights.......  OH
                                                                                     of Cleveland.
Rev................................  Cynthia S.............  Bumb.................  United Church of        St. Louis............  MO
                                                                                     Christ.
Rev................................  Larry V. R............  Bunnell..............  Presbyterian Church     Klamath Falls........  OR
                                                                                     (USA).
Ms.................................  Angela................  Buxton...............  UMC, Brunswick........  Brunswick............  ME
Cantor.............................  Norma Bruce...........  Byers................  American Conference of  Manchester...........  NJ
                                                                                     Cantors.
Dean...............................  John A................  Cairns...............  Fourth Presbyterian     Chicago..............  IL
                                                                                     Church.
Rev. Dr............................  Kristina..............  Campbell.............  SW Conference, United   Scottsdale...........  AZ
                                                                                     Church of Christ.
Rev................................  Steven................  Carlson..............  Emmaus Lutheran Church  Eugene...............  OR
Rev................................  Walter................  Carlson..............  UMC...................  Pana.................  IL
Cantor.............................  Susan.................  Caro.................  Temple Judea..........  Tarzana..............  CA
Rev................................  Katherine L...........  Carpenter............  PCUSA.................  Lynchburg............  VA
Rev. Dr............................  Wayne.................  Carter...............  Trinity Episcopal       Pharr................  TX
                                                                                     Church.
Rev................................  Ashli.................  Cartwrigt-Peak.......  Little Eagle Christian  Westfield............  IN
                                                                                     Church.
Rev. Dr............................  Ignacio...............  Castuera.............  St. John's United       Los Angeles..........  CA
                                                                                     Methodist Church.
Rev. Dr............................  Kenneth...............  Cauthen..............  Professor of Theology.  Rochester............  NY
Rev................................  Barbara...............  Chaapel..............  First Presbyterian      Philadelphia.........  PA
                                                                                     Church.
Rev................................  Shirely M.............  Chan.................  Riverside Salem UCC...  Eden.................  NY
Rev. Dr............................  Gary W................  Charles..............  Old Presbyterian        Alexandria...........  VA
                                                                                     Meeting House.
Rabbi..............................  Joshua................  Chasan...............  Ohavi Zedek Synagogue.  Burlington...........  VT
Rev................................   Pamela C.............  Cheney...............  United Church of        Cleveland............  OH
                                                                                     Christ.
Rev................................  Barbara...............  Child................  St. John's Unitarian    Cincinnati...........  OH
                                                                                     Church.
Rev. Dr............................  Bruce.................  Chilton..............  Church of St. John the  Barrytown............  NY
                                                                                     Evangelist.
Rev................................  Richard...............  Chrisman.............  Central Congregational  Jamaica Plain........  MA
                                                                                     Church.
Rev................................  Micahel O.............  Christensen..........  Warwick United Church   Newport News.........  VA
                                                                                     of Christ.
Rev. Dr............................  Diane.................  Christopherson.......  United Church of        Ann Arbor............  MI
                                                                                     Christ.
Rev................................  Robert................  Clark................  ......................  Denver...............  CO
Rev................................  Peggy C...............  Clason...............  Unitarian Universalist  Cleveland Hts........  OH
                                                                                     Society of Cleveland.
Rev................................  Maryell...............  Cleary...............  Unitarian Universalist  East Lansing.........  MI
                                                                                     Church of Greater
                                                                                     Lansing.
Rev. Prof..........................  Howard................  Clinebell............  ......................  Santa Barbara........  CA
Rev................................  Charles...............  Cloughen, Jr.........  ......................  Sparks...............  MD
Rev................................  Edward A..............  Clydesdale...........  ......................  Newark...............  NJ
Pastor.............................  Robert C..............  Cochran..............  Lutheran Campus         Kalamazoo............  MI
                                                                                     Ministry, ELCA.
Rev................................   Matthew..............  Cockrum..............  First Unitarian         Milwaukee............  WI
                                                                                     Society of Milwaukee.
Rev................................  Anne G................  Cohen................  United Church of        Los Angeles..........  CA
                                                                                     Christ.
Rev................................  Helen Lutton..........  Cohen................  First Parish of         Lexington............  MA
                                                                                     Lexington.
Rev................................  Ernestine B...........  Cole.................  Columbia Theological    Decatur..............  GA
                                                                                     Seminary.
Rev................................  Ann Marie.............  Coleman..............  University Church.....  Chicago..............  IL
Rev................................  John..................  Collins..............  NY Conference, United   New York.............  NY
                                                                                     Methodist Church.
Dr.................................  Shelia................  Collins..............  NY Conference, United   New York.............  NY
                                                                                     Methodist Church.
Rev................................  Cyril C...............  Colonius.............  ......................  Kalamazoo............  MI
Rev................................  Lucretia..............  Cooksy...............  Jubilee United          Duncanville..........  TX
                                                                                     Methodist Church.
Rabbi..............................  Sigma.................  Coran................  Williams College......  Williamstown.........  MA
The Rev............................  Sandra Lee............  Cordingley...........  Christ Episcopal        West River...........  MD
                                                                                     Church.
Rev................................  Mary Jane.............  Cornell..............  ......................  Atlanta..............  GA
Rev................................   Monica...............  Corsaro..............  Chaplain, Planned       Seattle..............  WA
                                                                                     Parenthood Affiliates
                                                                                     of Washington State.
Rev................................  Pamela................  Cranston.............  St. Cuthbert's          Oakland..............  CA
                                                                                     Episcopal Church.
Rabbi..............................  Meryl.................  Crean................  ......................  Elkins Park..........  PA
Rev................................  James.................  Crowder..............  Episcopal Church......  Cockeysville.........  MD
Rev................................  Thomas L..............  Culbertson...........  Emmanuel Episcopal      Baltimore............  MD
                                                                                     Church.
Rev................................  Richard A.............  Cullen...............  Auburn United           Auburn...............  ME
                                                                                     Methodist Church.
Rev................................  Arthur E..............  Curtis...............  Unitarian Universalist  Anchorage............  AK
                                                                                     (ret.).
Rev................................  Ben...................  Dake.................  ......................  Cottage Grove........  OR
Rev................................  Beverly...............  Dale.................  Christian Association   Philadelphia.........  PA
                                                                                     University of
                                                                                     Pennsylvania.
Rev................................  Nancy C...............  Danson...............  United Methodist        San Jose.............  CA
                                                                                     Church.
Rev................................  Wayne.................  Darnell..............  Inter Faith Ministry..  Ft. Lauderdale.......  FL
Rabbi..............................  Andrew................  Davids...............  Union of American       New York.............  NY
                                                                                     Hebrew Congregations.
Rabbi..............................  Josef A...............  Davidson.............  B'nai Zion              Chattanooga..........  TN
                                                                                     Congregation.
Rev................................  Tom...................  Davis................  Chair, PPFA Clergy      Saratoga Springs.....  NY
                                                                                     Advisory Board.
Rabbi..............................  David.................  Davis................  Vanderbilt University.  Nashville............  TN
Dr.................................  Holly Haile...........  Davis................  Padoquohan Medicine     Southampton..........  NY
                                                                                     Lodge; and Member of
                                                                                     the Long Island
                                                                                     Presbytery, PCUSA.
Rev................................  Virgie J..............  Davis................  Zion United Church of   Dale.................  WI
                                                                                     Christ.
Ms.................................  Peggy.................  Davis-Herod..........  South Haven UCC.......  Bedford..............  OH
Rev................................  Lisa W................  Davison..............  Christian Church        Lexington............  KY
                                                                                     (Disciples of Christ)
                                                                                     & Lexington
                                                                                     Theological Seminary.
Rev................................  Michael...............  Davison..............  Christian Church In     Lexington............  KY
                                                                                     Kentucky.
Rev................................  Lorraine..............  De Armitt............  Southold United         Southold.............  NY
                                                                                     Methodist Church.
Ms.................................  Adele.................  de Ryk...............  Parish Nurse, All       Loveland.............  CO
                                                                                     Saints Episcopal
                                                                                     Church.
Rev................................  Michael R.............  De Vaughn............  Carter Chapel CME       Amarillo.............  TX
                                                                                     Church.
Rev................................  Robert C..............  Dean.................  Episcopal Church......  StaffordVA...........
Rev................................  Gregory...............  Dell.................  Broadway United         Chicago..............  IL
                                                                                     Methodist Church.
Rev................................  Robert................  Dell.................  UCC...................  Sandwich.............  IL
Ms.................................  Jean..................  DeVoll-Donaldson.....  Lutheran School of      Chicago..............  IL
                                                                                     Theology at Chicago.
Rev................................  William A.............  DeWolfe..............  Unitarian Universalist  Damariscotta.........  ME
                                                                                     Church.
Rabbi..............................  Barry.................  Diamond..............  Temple Emanu-El.......  Dallas...............  TX
Mr.................................  Richard...............  Dickens..............  West End Collegiate     New York.............  NY
                                                                                     Church.
Rabbi..............................  Lucy..................  Dinner...............  ......................  Raleigh..............  NC
Rabbi..............................  Fred S................  Dobb.................  Adat Shalom             Bethesda.............  MD
                                                                                     Reconstructionist
                                                                                     Congregation.
Mr.................................  Donald F..............  Doering..............  ......................  Amherst..............  NY
Rev................................  Roy...................  Donkin...............  Emmanuel Baptist        Albany...............  NY
                                                                                     Church.
Rev................................  Cheryl D..............  Donkin...............  Emmanuel Baptist        Albany...............  NY
                                                                                     Church.
Rev................................  Jack..................  Donovan..............  Unitarian Universalist  Gainesville..........  FL
                                                                                     Fellowship.
Rev................................  Randall...............  Doubet-King..........  United Church of        Chicago..............  IL
                                                                                     Christ.
Rev................................  Nancy.................  Doughty..............  ......................  Traverse City........  MI
Rev................................  Elizabeth Morris......  Downie...............  St. Jude's Episcopal    Fenton...............  MI
                                                                                     Church.
Rabbi..............................  William...............  Dreskin..............  Woodlands Community     White Plains.........  NY
                                                                                     Temple.
Ms.................................  Barbara...............  Drew.................  ......................  Newton...............  PA
Rev................................  Sarah B...............  Drummond.............  University Christian    Milwaukee............  WI
                                                                                     Ministries.
Rev................................  Karen N...............  Dungan...............  First United Methodist  Osage................  IA
                                                                                     Church.
Rev. Dr............................  Eileen................  Dunn.................  Director of Women's     Auburn...............  WA
                                                                                     Programs, Green River
                                                                                     Community College.
Rev. Dr............................  Lyle J................  Dykstra..............  Limestone Presbyterian  Wilmington...........  DE
                                                                                     Church.
Ms.................................  Karen.................  Dyste................  Central Presbyterian    Eugene...............  OR
                                                                                     Church.
Rev................................  Rose..................  Edington.............  Unitarian Fellowship    Athens...............  OH
                                                                                     of Athens.
Rev................................  Jan...................  Edmiston.............  Fairlington             Alexandria...........  VA
                                                                                     Presbyterian Church.
Rev................................  Carol.................  Edwards..............  Unitarian Universalist  Santa Barbara........  CA
                                                                                     at Live Oak.
Rev................................  Janet E...............  Eggleston............  UMC...................  Springfield..........  PA
Rabbi..............................  Dan...................  Ehrenkrantz..........  B'nai Keshet..........  Montclair............  NJ
Rev................................  Lauren D..............  Ekdahl...............  Trinity United          Lincoln..............  NE
                                                                                     Methodist.
Rev................................  Jim...................  Eller................  All Souls UU Church...  Kansas City..........  MO
Rev................................  Steve.................  Ellis................  Episcopal Church of     Capitola.............  CA
                                                                                     St. John the Baptist.
Rev. Dr............................  Marvin M..............  Ellison..............  Bangor Theological      Portland.............  ME
                                                                                     Seminary.
Rev................................  Nancy Nelson..........  Elsenheimer..........  United Church of        Cleveland............  OH
                                                                                     Christ.
Rabbi..............................  Sue...................  Elwell...............  Union of American       Philadelphia.........  PA
                                                                                     Hebrew Congregations.
Ms.................................  Marjorie..............  Enseki...............  FCC...................  Eugene...............  OR
Rabbi..............................  Rachel................  Esserman.............  ......................  Endwell..............  NY
Rev................................  Jon M.................  Fancher..............  Rocky River             Rocky River..........  OH
                                                                                     Presbyterian Church.
Rev................................  Douglas E.............  Fauth................  The Christian           Philadelphia.........  PA
                                                                                     Association at the
                                                                                     University of
                                                                                     Pennsylvania.
Rabbi..............................  Morley T..............  Feinstein............  Temple Beth-El........  South Bend...........  IN
Rabbi..............................  Steven M..............  Fink.................  Temple Oheb Shalom....  Baltimore............  MD
Rev................................  Wendy.................  Fish.................  First Unitarian         Columbus.............  OH
                                                                                     Universalist Church.
Rev................................  John W................  Fisher...............  Sunnyside United        Kalamazoo............  MI
                                                                                     Methodist Church.
Pastor.............................  Eric..................  Fjeldal..............  Yalesville United       Wallingford..........  CT
                                                                                     Methodist Church.
Rev................................  Ray...................  Flachmeier...........  Evangelical Lutheran    Richardson...........  TX
                                                                                     Church of America.
Rev................................   Madonna..............  Flanders.............  Alton UMC.............  Bangor...............  ME
Rev................................  Ann...................  Fontaine.............  Episcopal Church......  Jackson..............  WY
Ms.................................  Rita..................  Fossell..............  Presbysterian Women-    Lake Bluff...........  IL
                                                                                     Churchwide.
Rev. Dr............................  Garnett E.............  Foster...............  Louisville              Louisville...........  KY
                                                                                     Presbyterian
                                                                                     Theological Seminary.
Rev................................  C.H...................  Fotch................  St. John's Episcopal    Ross.................  CA
                                                                                     Church.
Rev................................  Kimberly Buechner.....  Fouse................  Presbyterian Church     Cold Spring..........  KY
                                                                                     (USA).
Rev. Dr............................  Richard E.............  Fouse................  Doylestown              Doylestown...........  PA
                                                                                     Presbyterian Church.
Rev................................   Anne C...............  Fowler...............  St. John's Episcopal    Jamaica Plain........  MA
                                                                                     Church.
Rev................................  Amy A.................  Freedman.............  Channing Memorial       Newport..............  RI
                                                                                     Church.
Rabbi..............................  Allen I...............  Freehling............  University Synagogue..  Los Angeles..........  CA
Rabbi..............................  Gordon M..............  Freeman..............  Congregation B'nai      Walnut Creek.........  CA
                                                                                     Shalom.
Rabbi..............................  Jonathan B............  Freirich.............  Cleveland Hillel......  Cleveland............  OH
Rabbi..............................  Ronne.................  Friedman.............  Temple Israel.........  Boston...............  MA
Rabbi..............................  Alan D................  Fuchs................  ......................  White River Junction.  VT
Rev................................  Holly Spencer.........  Fuqua................  ......................  Lexington............  KY
Rev. Dr............................  George T..............  Gardner..............  College Hill United     Wichita..............  KS
                                                                                     Methodist Church.
Rabbi..............................  David J...............  Gelfand..............  The Jewish Center of    East Hampton.........  NY
                                                                                     the Hamptons.
Rev................................  Gretchen Seidler......  Gibbs................  ......................  Mill Creek...........  IN
Rev................................  Gordon D..............  Gibson...............  Unitarian Universalist  Elkhart..............  IN
                                                                                     Fellowship of Elkhart.
Rev................................  Lance A.B.............  Gifford..............  St. John's Mt.          Baltimore............  MD
                                                                                     Washington.
Rev................................  Martha E..............  Gilbert..............  The United Methodist    Ellenburg............  NY
                                                                                     Church.
Rev................................  Richard S.............  Gilbert..............  First Unitarian Church  Rochester............  NY
Rev................................  Christopher A.........  Gilmore..............  Winnetka                Winnetka.............  IL
                                                                                     Congregational Church.
Rabbi..............................  Gail..................  Glicksman............  ......................  Haverford............  PA
Rabbi..............................  Brian.................  Glusman..............  ......................  Birmingham...........  AL
Rev................................  Jerry.................  Goddard..............  Unitarian Universalist  Newmarket............  NH
Rabbi..............................  Irwin.................  Goldenberg...........  Temple Beth Israel....  York.................  PA
Rabbi..............................  Jeffrey W.............  Goldwasser...........  Congregation Beth       North Adams..........  MA
                                                                                     Israel.
Rev................................  Thomas W..............  Goodhue..............  United Methodist        Bayshore.............  NY
                                                                                     Church of Bayshore.
Rev................................  Charlotte.............  Gosselink............  PA Southeast            Collegeville.........  PA
                                                                                     Conference UCC.
Rev................................  Beth..................  Graham...............  Unitarian Universalist  Huntington...........  NY
                                                                                     Fellowship.
Rev................................  Peter.................  Grandy...............  Asylum Hill             Hartford.............  CT
                                                                                     Congregational Church.
Rev................................  Robert J..............  Granger..............  Overlook United         Woodstock............  NY
                                                                                     Methodist Church.
Cantor.............................  Oma T.................  Green................  American Conference of  Teaneck..............  NJ
                                                                                     Cantors.
Rev. Dr............................  W. Bradford...........  Greeley..............  Main Line Unitarian     New Castle...........  NH
                                                                                     Church.
Rabbi..............................  Frederick.............  Greene...............  Congregation B'nai      Bridgeport...........  CT
                                                                                     Israel.
Rev. Dr............................  Larry.................  Greenfield...........  Religious Institute     Chicago..............  IL
                                                                                     for Sexual Morality,
                                                                                     Justice and Healing.
Rev................................   John M...............  Gregory-Davis........  Meriden Congregational  Meriden..............  NH
                                                                                     Church, UCC.
Rev................................   Susan................  Gregory-Davis........  Meriden Congregational  Meriden..............  NH
                                                                                     Church, UCC.
Rev................................  Daphne................  Grimes...............  Episcopal Church......  Cody.................  WY
Rev. Dr............................  Larry A...............  Grimm................  St. Paul Presbyterian   Lakewood.............  CO
                                                                                     Church.
Rev. Dr............................  J. Bennett............  Guess................  Justice and Witness     Cleveland............  OH
                                                                                     Ministries, UCC.
Ms.................................  Debra W...............  Haffner..............  Religious Institute on  Norwalk..............  CT
                                                                                     Sexual Morality,
                                                                                     Justice, and Healing.
Rev................................  Bill..................  Hamilton-Holway......  Unitarian Universalist  Berkeley.............  CA
                                                                                     Church of Berkeley.
Rev................................   Barbara..............  Hamilton-Holway......  Unitarian Universalist  Berkeley.............  CA
                                                                                     Church of Berkeley.
Rev................................  Barbra M..............  Hansson..............  Unitarian Universalist  Plattsburgh..........  NY
Rev................................  Charles E.............  Harlow...............  UCC...................  Talent...............  OR
Rev................................  Cedric A..............  Harmon...............  ......................  Washington...........  DC
Rev. Dr............................  Marni.................  Harmony..............  First Unitarian Church  Orlando..............  FL
Rev................................  Allen V...............  Harris...............  Franklin Circle         Cleveland............  OH
                                                                                     Christian Church
                                                                                     (Disciples of Christ).
Ms.................................  Sandra................  Harwood..............  First Presbyterian      Buffalo..............  NY
                                                                                     Church-Buffalo.
Rev................................  Danna Drum............  Hastings.............  ......................  .....................  .....................
Rev................................  Kathryn...............  Hawbaker.............  ......................  Camden...............  OH
Rev................................  Ann L.................  Hayman...............  Mary Magdalene Project  Reseda...............  CA
Rev................................  Barbara A.............  Heck.................  Rutgers Protestant      New Brunswick........  NJ
                                                                                     Campus Ministries.
Rev................................  Jane..................  Heckles..............  So. Cal. Nev.           Altadena.............  CA
                                                                                     Conference, United
                                                                                     Church of Christ.
Rev. Dr............................  Joel J................  Heim.................  Disciples Peace         Waukesha.............  WI
                                                                                     Fellowship.
Rev................................  Ken...................  Henry................  Central Presbyterian    Eugene...............  OR
                                                                                     Church.
Rev................................  Kathleen..............  Hepler...............  Unitarian Universalist  Lincroft.............  NJ
                                                                                     Congregation of
                                                                                     Monmouth County.
Rabbi..............................  Rachel................  Hertzman.............  Hillel of Greater       Baltimore............  MD
                                                                                     Baltimore.
Rev................................  Jean Ellen............  Herzegh..............  PC (USA)..............  Burns................  OR
Rev................................  Anita C...............  Hill.................  St. Paul Reformation    St. Paul.............  MN
                                                                                     Lutheran Church.
Ms.................................  Bani..................  Hines-Hudson.........  Director of Education-  Louisville...........  KY
                                                                                     PP of Greater
                                                                                     Louisville.
Rev................................  Allen.................  Hinman...............  St. John's Episcopal..  Passaic..............  NJ
Rev................................  Elaine................  Hinnant..............  First Plymouth          Englewood............  CO
                                                                                     Congregational, UCC.
Rev................................  Virginia C............  Hoch.................  Goshen United           Goshen...............  NY
                                                                                     Methodist Church.
Rev................................  Linda.................  Hoddy................  Unitarian Universalist  Saratoga Springs.....  NY
                                                                                     Congregation.
Rev................................   Judith M.............  Hoffhine.............  Broad St. Presbyterian  Columbus.............  OH
                                                                                     Church.
Rev................................  David J...............  Holden...............  United Church of        Cleveland............  OH
                                                                                     Christ.
Rev................................  Mark R................  Holland..............  Trinity UMC...........  Kansas City..........  KS
Rev................................   George E.............  Hollingshead.........  ......................  Villanova............  PA
Rev................................   Charles F............  Holm.................  First Presbyterian      Easton...............  PA
                                                                                     Church.
Rev................................  Jean A.F..............  Holmes...............  Nauraushaun             Pearl River..........  NY
                                                                                     Presbyterian Church.
Mr.................................  Joseph C..............  Hough, Jr............  Union Theological       New York.............  NY
                                                                                     Seminary.
Rev................................  D. Scott..............  Howell...............  United Church of        Cleveland............  OH
                                                                                     Christ.
Rev................................  Magaret E.............  Howland..............  White Plains            White Plains.........  NY
                                                                                     Presbyterian Church.
Dr.................................  Mary E................  Hunt.................  Women's Alliance for    Silver Spring........  MA
                                                                                     Theology, Ethics and
                                                                                     Ritual (WATER).
Rev. Dr............................  Robert D..............  Hurlbut..............  ......................  St. Paul.............  MN
Deacon.............................  Nancy W...............  Huston...............  Episcopal Church......  Omaha................  NE
Ms.................................  Betty.................  Huthcheson...........  ......................  Buffalo..............  NY
Rev................................   Randy................  Hyvonen..............  Washington, North       Spokane..............  WA
                                                                                     Idaho Conference, UCC.
Rev................................  Michael B.............  Ide..................  Evangelical Lutheran    St. Louis............  MO
                                                                                     Church in America.
Rev................................  William...............  Ingraham.............  Church of the Good      Anne Arbor...........  MI
                                                                                     Shepard.
Rabbi..............................  Lisa..................  Izes.................  Temple Sinai..........  Rochester............  NY
Rabbi..............................  Andrew................  Jacobs...............  Bet Am Shalom           White Plains.........  NY
                                                                                     Synagogue.
Rabbi..............................  Cheryl................  Jacobs...............  Planned Parenthood      Hawthorne............  NY
                                                                                     Hudson Peconic.
Pastor.............................  Alexander M...........  Jacobs...............  Lutheran Campus         Milwaukee............  WI
                                                                                     Ministry.
Rev................................  B. Leslie.............  James................  Macedonia African       Seaford..............  DE
                                                                                     Methodist Episcopal
                                                                                     Church.
Rev. Dr............................  Mark..................  Jennings.............  First Presbyterian      Richland.............  MI
                                                                                     Church.
Rev................................  Madeline..............  Jervis...............  Clarendon Presbyterian  Arlington............  VA
                                                                                     Church.
Rev................................   Bryan T..............  Jessup...............  The Unitarian           Fresno...............  CA
                                                                                     Universalist Church
                                                                                     of Fresno.
Rabbi..............................  Daniel................  Jezer................  Congregation Beth       De Witt..............  NY
                                                                                     Sholom-Chevra Shas.
Board Chair........................  Ann Hale..............  Johnson..............  Union Theological       Potomac..............  MD
                                                                                     Seminary, NYC.
Rev................................  Bruce.................  Johnson..............  Unitarian Universalist  Indianapolis.........  IN
                                                                                     Church of
                                                                                     Indianapolis.
Rev. Dr............................  William R.............  Johnson..............  Wider Church            Cleveland............  OH
                                                                                     Ministries, United
                                                                                     Church of Christ.
Ms.................................  Janet.................  Johnson..............  ......................  Concord..............  CA
Rev................................  Kathryn...............  Johnson..............  ......................  Seattle..............  WA
Rev. Dr............................  Peggy.................  Johnson..............  United Church of        Santa Barbara........  CA
                                                                                     Christ.
Rev................................  Anthony P.............  Johnson..............  First Unitarian         Orange...............  NJ
                                                                                     Universalist Church
                                                                                     of Essex County.
Rev................................  Rebecca...............  Johnston.............  Our Savior's United     Ripon................  WI
                                                                                     Church of Christ.
Rev................................  Charles H.............  Jorday...............  Pleasant Run UCC......  Indianapolis.........  IN
Ms.................................  Kathleen..............  Kahl.................  ......................  Chilton..............  WI
Rabbi..............................  Mark..................  Kaiserman............  Temple Emanu-El.......  Dalllas..............  TX
Rabbi..............................  Jeremy................  Kalmanofsky..........  Congregation Ansche     New York.............  NY
                                                                                     Chesed.
Rabbi..............................  Lewis.................  Kamrass..............  ......................  Cincinnati...........  OH
Rabbi..............................  Gerald M..............  Kane.................  Temple Beth El........  Las Cruces...........  NM
Rev................................  Charles G.............  Kast.................  Community Church of     Chapel Hill..........  NC
                                                                                     Chapel Hill.
Rabbi..............................  Nancy.................  Kasten...............  ......................  Dallas...............  TX
Rabbi..............................  Alan J................  Katz.................  Temple Sinai..........  Rochester............  NY
Rev................................  Fred..................  Keip.................  Unitarian Universalist  Grants Pass..........  OR
Rabbi..............................  Jonathan..............  Kendall..............  Temple Beit Hayam.....  Stuart...............  FL
Rev. Dr............................  Andrew C..............  Kennedy..............  First Unitarian         Milwaukee............  WI
                                                                                     Society of Milwaukee.
Rev................................  Diane.................  Kenney...............  United Ministry at USC  Los Angeles..........  CA
Rev................................  Thomas A..............  Kerr, Jr.............  Immanuel Church,        Wilmington...........  DE
                                                                                     Highlands (Episcopal).
Mr.................................  Amos..................  Kharma...............  Metropolitan Community  Harrisburg...........  PA
                                                                                     Church of the Spirit.
Ms.................................  Katharine.............  Kilpatric............  Presbytery of Giddings  St. Louis............  MO
                                                                                     Lovejoy.
Mr.................................  Steven F..............  Kindle...............  Clergy United, Inc....  Santa Barbara........  CA
Rev................................  Ruth L................  Kirk.................  St. Peter's Church,     Glenside.............  PA
                                                                                     Glenside.
Rev. Dr............................  Ron D.................  Kitterman............  UMC...................  Fort Dodge...........  IA]
Dr.................................  Joel T................  Klein................  ......................  Manchester...........  NH
Rabbi..............................  Elliott...............  Kleinman.............  ......................  Cleveland............  OH
Rev................................  David.................  Knox.................  ......................  Plainfield...........  IN
Rev................................  Tricia Dykers.........  Koenig...............  ......................  Cleveland Heights....  OH
Rabbi..............................  Neil..................  Kominsky.............  Temple Emanuel of the   Lowell...............  MA
                                                                                     Merrimack Valley.
Rabbi..............................  Sandford..............  Kopnick..............  The Valley Temple.....  Cincinnati...........  OH
Rabbi..............................  Elisa.................  Koppel...............  The Community           Port Washington......  NY
                                                                                     Synagogue.
Rabbi..............................  Douglas E.............  Krantz...............  Congregation B'nai      Armonk...............  NY
                                                                                     Yisrael.
Rev................................  Daniel H..............  Kuhn, Jr.............  Vine Street Christian   Nashville............  TN
                                                                                     Church.
Rev. Dr............................  Mary..................  Kuhns................  ......................  Louisville...........  KY
Rev................................  Wallace Ryan..........  Kuroiwa..............  United Church of        Cleveland............  OH
                                                                                     Christ.
Rabbi..............................  Steven................  Kushner..............  Temple Ner Tamid......  Bloomfield...........  NJ
Rev................................  Peter.................  Laarman..............  Judson Memorial Church  New York.............  NY
Rabbi..............................  Howard................  Laibson..............  Temple Israel.........  Long Beach...........  CA
Rev................................  Jeffrey...............  Lamb.................  Unitarian Universalist  Midland..............  TX
                                                                                     Church.
Rev................................  Werner................  Lange................  Auburn Community        Chagrin Falls........  OH
                                                                                     Church.
Dr.................................  Edwin.................  Lasbury..............  UMC...................  Hockessin............  DE
Rev................................  Debra.................  Latture..............  Presbyterian Church     Snow Hill............  MD
                                                                                     (U.S.A.).
Rabbi..............................  Michael A.............  Latz.................  Temple B'nai Torah....  Bellevue.............  WA
Rev................................  R. Vincent............  Lavieri..............  American Apostolic      Greenville...........  MI
                                                                                     Catholic Church.
Rev................................   Clifford M...........  Lawrence Jr..........  United Church of        Clearwater...........  FL
                                                                                     Christ.
Rev................................  Katherine M...........  Lehman...............  St. Bede's Episcopal    Menlo Park...........  CA
                                                                                     Church.
Rev................................  Lois Robinson.........  Lehman...............  Pitts Creek and Beaver  Pocomoke City........  MD
                                                                                     Dam Presbyterian
                                                                                     Churches.
Rev................................   Susan................  Leo..................  Bridgeport United       Portland.............  OR
                                                                                     Church of Christ.
Rev................................  William...............  Levering.............  Summit Presbyterian     Philadelphia.........  PA
                                                                                     Church.
Rabbi..............................  Amy...................  Levin................  Congregation B'nai      Gainesville..........  FL
                                                                                     Israel.
Mr.................................  Harry H...............  Levy.................  Temple Beth-El........  San Antonio..........  TX
Rabbi..............................  Eugene H..............  Levy.................  Congregational B'nai    Little Rock..........  AK
                                                                                     Israel.
Rabbi..............................  Janet.................  Liss.................  ......................  Glen Cove............  NY
Rabbi..............................  Mark G................  Loeb.................  Beth El Congregation..  Baltimore............  MD
Rabbi..............................  Robert H..............  Loewy................  ......................  Metaire..............  LA
Rabbi..............................  Alan David............  Londy................  Temple Beth Shalom....  Smithtown............  NY
Rev................................   Daniel M.............  Long.................  Lutheran Church.......  Lancaster............  PA
Rev................................  David.................  Lorenzen.............  First United Church of  Tipton...............  IA
                                                                                     Christ.
Rabbi..............................  Steven Stark..........  Lowenstein...........  Temple Sholom of        Chicago..............  IL
                                                                                     Chicago.
Rev. Dr............................  Doyle A...............  Luckenbaugh..........  UCC...................  Massillon............  OH
Rev................................  Douglas...............  Maben................  Green Mountain          Lakewood.............  CO
                                                                                     Presbyterian Church.
Rev................................   W. Stewart...........  MacColl..............  Northwoods              Houston..............  TX
                                                                                     Presbyterian Church.
Rev................................  Gene..................  Mace.................  United Methodist......  West Peoria..........  IL
Rev................................  Vilma M...............  Machin-Vazquez.......  United Church of        Cleveland............  OH
                                                                                     Christ.
Rabbi..............................  Dana..................  Magat................  Temple Emanu-El.......  San Jose.............  CA
Rev................................  Robert J..............  Magliula.............  Christ the King Church  Stone Ridge..........  NY
Dr.................................  Daniel................  Maguire..............  Prof. Of Moral          Milwaukee............  WI
                                                                                     Theology, Marquette
                                                                                     University.
Rev................................  Lea A.................  Mahan................  United Methodist        Peninsula............  OH
                                                                                     Church.
Rabbi..............................  Jonathan..............  Malamy...............  B'nai Vail              Vail.................  CO
                                                                                     Congregation.
Cantor.............................  Bruce.................  Malin................  American Conference of  Marstons Mills.......  MA
                                                                                     Cantors.
Rev................................  Ron...................  Manclaw..............  HIV/AIDS Pastoral Care  Fort Lauderdale......  FL
                                                                                     Network.
Rabbi..............................  Rosalin...............  Mandelberg...........  Baltimore Hebrew        Baltimore............  MD
                                                                                     Congregation.
Rev................................  Francis...............  Manly................  Unitarian Universalist  Buffalo..............  NY
Rabbi..............................  Jeffrey M.............  Marker...............  ......................  Brooklyn.............  NY
Ms.................................  Doriene D.............  Marshall.............  Director of Christian   Salt Lake City.......  UT
                                                                                     Education, Cottonwood
                                                                                     Presbyterian Church.
Rev................................   Christopher S........  Martin...............  St. Mary's Episcopal    Green Cove Springs...  FL
                                                                                     Church.
Dr.................................  Allen.................  Maruyama.............  Heritage Presbyterian   Olathe...............  KS
                                                                                     Church.
Rev................................  James S...............  Massie, Jr...........  The Episcopal Church..  Olcott...............  NY
Rev................................  Stephen J.............  Mather...............  Member, PPFA Board of   Anaheim..............  CA
                                                                                     Directors.
Mr.................................  Neal..................  Matson...............  Church of Christ......  Fairbanks............  AK
Rev................................  Nancy H...............  McCarthy.............  Episcopal Church......  Delray Beach.........  FL
Rev. Dr............................  James.................  McDonald.............  ......................  Washington...........  DC
Rev. Dr............................  Elizabeth.............  McDonald.............  ......................  Washington...........  DC
Rev................................  Timothy...............  McDonald.............  First Iconium Baptist   Atlanta..............  GA
                                                                                     Church.
Rev................................  David.................  McFarlane............  The Presbyterian        Sewickley............  PA
                                                                                     Church, Sewickley.
Rev................................   Deborah A............  McKinley.............  Third, Scots and        Philadelphia.........  PA
                                                                                     Mariners Presbyterian
                                                                                     Church.
Rev................................  Bethany...............  McLemore.............  Pastoral Counseling     Roanoke..............  VA
                                                                                     Center.
Rev................................  Laurie A..............  McNeill..............  Glenwood Landing......  NY...................
Ms.................................  Carolyn...............  Meagher..............  First Congregational    Indianapolis.........  IN
                                                                                     Church.
Rabbi..............................  Batsheva..............  Meiri................  Temple Emanuel........  Reisterstown.........  MD
Rev................................  Sarah J...............  Melcher..............  Presbytery of           Cincinnati...........  OH
                                                                                     Cincinnati.
Rev. Dr............................  Robert H..............  Meneilly.............  ......................  Prairie View.........  KS
Rev................................   David W..............  Meredith.............  Broad St. United        Columbus.............  OH
                                                                                     Methodist Church.
Rabbi..............................  Andrea................  Merow................  Temple Sholom.........  Philadelphia.........  PA
Rabbi..............................  Barbara...............  Metzinger............  ......................  Beaumont.............  TX
Rabbi..............................  James R...............  Michaels.............  Congregation Beth       Flint................  MI
                                                                                     Israel.
Rabbi..............................  Mathew D..............  Michaels.............  Congregation Jewish     Spring...............  TX
                                                                                     Community North.
Rev................................  Gary L................  Miller...............  ......................  Hartford.............  CT
Rev................................  William P.............  Miller...............  United Methodist        Whittier.............  CA
                                                                                     Church.
Rabbi..............................  Rachel L..............  Miller...............  Congregation B'nai      Walnut Creek.........  CA
                                                                                     Shalom.
Rev................................  Pamela M..............  Miller...............  Episcopal Church......  Big Rapids...........  MI
Rabbi..............................  Jonathan..............  Miller...............  Temple Emanu-El.......  Birmingham...........  AL
Rev................................  Melanie...............  Miller...............  First Congregational    Chappaqua............  NY
                                                                                     Church.
Rev................................  Joel..................  Miller...............  Unitarian Universalist  Buffalo..............  NY
                                                                                     Church.
Rev................................  Charles S.............  Milligan.............  Prof. Emeritus, Iliff   Denver...............  CO
                                                                                     School of Theology.
Rev................................   Linda Penrod.........  Million..............  United Methodist        Louisville...........  KY
                                                                                     Church.
Rev................................   Margaret.............  Mills................  West Reserve Assoc.,    Cleveland............  OH
                                                                                     UCC.
Rev................................  Susan A...............  Minasian.............  Disciples United        Lancaster............  PA
                                                                                     Community Church.
Rev................................  Irene K...............  Mitchell.............  ......................  Spokane..............  WA
Cantor.............................  Alberto...............  Mizrahi..............  Anshe Emet Synagogue..  Chicago..............  IL
Rabbi..............................  Jack..................  Moline...............  Agudas Achim            Alexandria...........  VA
                                                                                     Congregation.
Rabbi..............................  Diana.................  Monheit..............  The Temple............  Atlanta..............  GA
Rev................................  Karen A...............  Monk.................  United Methodist        Kingston.............  NY
                                                                                     Church.
Rev................................   Kenneth..............  Moore................  Christian Church in     Lincoln..............  NE
                                                                                     Nebraska.
Rev................................  Rob...................  Moore................  Evangelical Lutheran    Houston..............  TX
                                                                                     Church of America.
Rev................................  Mary Katherine........  Morn.................  First Unitarian         Nashville............  TN
                                                                                     Universalist Church.
Ms.................................  SarahLee..............  Morris...............  Covenant Presbyterian   Lubbock..............  TX
                                                                                     Church.
Rabbi..............................  Joel..................  Mosbacher............  Beth Haverim            MahwahN..............  J
                                                                                     Congregation.
Pastor.............................  R.W.W.................  Mueckenheim..........  United Methodist        Hempstead............  NY
                                                                                     Church of Hempstead.
Rev................................  Martha L..............  Munson...............  Unitarian Universalist  Elba.................  NY
                                                                                     Church of East Aurora.
Rev................................  John A................  Nelson...............  The Dover Church......  Dover................  MA
Rev................................  Culver H..............  Nelson...............  Church of the           Phoenix..............  AZ
                                                                                     Beatitudes (UCC).
Rev................................   Gustav...............  Nelson...............  Presbytery of Des       Des Moines...........  IA
                                                                                     Moines.
Rev................................   Stacey...............  Nicholas.............  Immanuel UMC..........  Canton...............  MO
Rev................................  Johanna...............  Nichols..............  Champlain Valley        Middlebury...........  VT
                                                                                     Unitarian
                                                                                     Universalist Society.
Rev................................  Sala..................  Nolan................  United Church of        Cleveland............  OH
                                                                                     Christ.
Rev................................  Eileen................  Norrington...........  United Church of        Cleveland............  OH
                                                                                     Christ.
Mr.................................  Robert................  Ohl..................  Old York Road Temple-   Abington.............  PA
                                                                                     Beth Am.
Rev................................  C. Bunny..............  Oliver...............  First Presbyterian      Ashland..............  OR
                                                                                     Church.
Rev................................  Erick.................  Olsen................  First Church            Fairfield............  CT
                                                                                     Congregational.
Rev................................  Melanie...............  Oommen...............  First Congregational    Eugene...............  OR
                                                                                     UCC.
Rabbi..............................  Michael...............  Oppenheimer..........  Suburban Temple-Kol     Beachwood............  OH
                                                                                     Ami.
Rev................................   Charles Blustein.....  Ortman...............  Unitarian Church......  Montclair............  NJ
Rev................................  Marilyn...............  Pagan................  ......................  Chicago..............  IL
Rev................................  Archie M..............  Palmer Jr............  Episcopal Diocese of    Glen Ridge...........  NJ
                                                                                     Newark.
Rev................................   Ann..................  Palmerton............  Broad Street            Columbus.............  OH
                                                                                     Presbyterian Church.
Rev................................  Sandra................  Paran................  Hospice of MI.........  Detroit..............  MI
Rev................................  Richard S.............  Parker...............  United Methodist        Babylon..............  NY
                                                                                     Church.
Rev................................  R. Wayne..............  Parrish..............  Loveland Presbyterian   Loveland.............  OH
                                                                                     Church.
Rev................................   Stephen J............  Patterson............  Theological Seminary..  St. Louis............  MO
Rev. Dr............................  Sheron................  Patterson............  St. Paul United         Dallas...............  TX
                                                                                     Methodist Church.
Rev................................  Mark R................  Pawlowski............  Planned Parenthood of   Kalamazoo............  MI
                                                                                     South Central
                                                                                     Michigan.
Rev................................  Ron R.................  Payson...............  Unitarian Universalist  Worcester............  MA
Rev................................  Edgar.................  Peara................  Unitarian Universalist  Eugene...............  OR
Rev................................  Frederic..............  Pease................  UCC...................  Dresden..............  ME
Rev................................  Guy R.................  Peek.................  RCRC, Western New York  Niagara Falls........  NY
Rev. Dr............................  John C................  Peiper...............  St. Christopher         Linthicum Heights....  MD
                                                                                     Episcopal Church.
Rev................................   Barbara..............  Pekich...............  ......................  Grand Rapids.........  MI
Rev................................   Clare L..............  Petersberger.........  Towson Unitarian        Lutherville..........  MD
                                                                                     Universalist Church.
Rev................................  Kerri.................  Peterson-Davis.......  Presbyterian Church     Duluth...............  GA
                                                                                     (USA).
Rev................................  Thomas................  Philipp..............  Long Island United      Merrick..............  NY
                                                                                     Campus Ministries.
Rev................................  Jeffrey...............  Phillips.............  Community United        Champaign............  IL
                                                                                     Church of Christ.
Rev................................  John B................  Pierce...............  Westminster             Eugene...............  OR
                                                                                     Presbyterian Church.
Rev................................  Deborah...............  Pitney...............  First UMC.............  Eugene...............  OR
Rev................................  Gayland...............  Pool.................  ......................  Fort Worth...........  TX
Rev................................  Lois M................  Powell...............  United Church of        Cleveland............  OH
                                                                                     Christ.
Bishop.............................  Neff..................  Powell...............  Episcopal Diocese of    Roanoke..............  VA
                                                                                     Southwestern Virginia.
Rabbi..............................  Sally J...............  Priesand.............  Monmouth Reform Temple  Tinton Falls.........  NJ
Rabbi..............................  James.................  Prosnit..............  Congregation B'nai      Bridgeport...........  CT
                                                                                     Israel.
Rev................................  Stephen D.............  Quill................  New Hope Lutheran       Missouri City........  TX
                                                                                     Church.
Ms.................................  Marlene...............  Quinn................  Limestone Presbyterian  Wilmington...........  DE
                                                                                     Church.
Rev................................  Jennifer L............  Rake-Marona..........  Group Health            Tacoma...............  WA
                                                                                     Cooperative.
Rev................................  James C...............  Ransom...............  Trinity Episcopal       Towson...............  MD
                                                                                     Church.
Rev................................  Anita.................  Rayburn..............  Tod Ave UMC...........  Warren...............  OH
Ms.................................  Anita.................  Redding..............  UCC...................  Cleveland............  OH
Rev................................   Willard T............  Reece................  Kansas Religious        Wichita..............  KS
                                                                                     Leaders for Choice.
Rev................................   George F.............  Regas................  The Regas Institute...  Pasadena.............  CA
Rev................................  Nelson R..............  Reppert..............  University United       Syracuse.............  NY
                                                                                     Methodist Church.
Rev................................  Ernesto...............  Reyes................  UCC...................  Los Angeles..........  CA
Ms.................................  Marlene...............  Richardson...........  ......................  Greenville...........  PA
Rabbi..............................  Leah..................  Richman..............  Oheb Zedeck Synagogue   Pottsville...........  PA
                                                                                     Center.
Rev................................  Tim...................  Riss.................  United Methodist        Smithtown............  NY
                                                                                     Church.
Rev................................  Paul B................  Robinson.............  Medford Congregational  Medford..............  OR
                                                                                     UCC.
Rev................................  T. Michael............  Rock.................  Central, United Church  Providence...........  RI
                                                                                     of Christ.
Mr.................................  Dave..................  Rockafellow..........  Unitarian Universal     Bozeman..............  MT
                                                                                     Fellowship of Bozeman.
Mrs................................  Rachel................  Rockafellow..........  Unitarian Universal     Bozeman..............  MT
                                                                                     Fellowship of Bozeman.
Ms.................................  Judith E..............  Rogers...............  Unitarian Universalist  Titusville...........  NJ
                                                                                     Church at Washington
                                                                                     Crossing.
Rev................................   Cally................  Rogers-Witte.........  Southwest Conference,   Phoenix..............  AZ
                                                                                     United Church of
                                                                                     Christ.
Rabbi..............................  Liz...................  Rolle................  Temple Sinai..........  Stamford.............  CT
Rev................................  Brooke................  Rolston..............  Campus Christian        Seattle..............  WA
                                                                                     Ministry.
Mr.................................  Gary..................  Rooney...............  Presbyterian Women      Minneola.............  KS
                                                                                     Churchwide
                                                                                     Coordinating Team.
Rev. Dr............................  Dan...................  Rosemergy............  Brookmeade              Nashville............  TN
                                                                                     Congregational
                                                                                     Church, UCC.
Rabbi..............................  Tracee L..............  Rosen................  Valley Beth Shalom....  Encino...............  CA
Ms.................................  Ellen Y...............  Rosenberg............  Women of Reform         New York.............  NY
                                                                                     Judaism, The
                                                                                     Federation of Temple
                                                                                     Sisterhoods.
Rabbi..............................  David.................  Rosenn...............  The Jewish Service      New York.............  NY
                                                                                     Corps.
Bishop.............................  Catherine S...........  Roskam...............  ......................  Dobbs Ferry..........  NY
Rev................................   Eugene...............  Ross.................  Central Pacific         Portland.............  OR
                                                                                     Conference--UMC.
Ms.................................  Gloria................  Rothhaas.............  Lakewood                Lakewood.............  OH
                                                                                     Congregational Church.
Rev................................   Richard F............  Rouquie, Jr..........  Hillwood Presbyterian   Nashville............  TN
                                                                                     Church.
Cantor.............................  Lori..................  Salzman..............  Temple Beth Shalom....  Needham..............  MA
Rev................................  David.................  Sammons..............  Mt. Diablo Unitarian    Walnut Creek.........  CA
                                                                                     Universalist Church.
Rev................................  Jason W...............  Samuel...............  Transfiguration         Lake St. Louis.......  MO
                                                                                     Episcopal Church.
Rabbi..............................  Marna.................  Sapowitz.............  Temple Beth Hatfiloh..  Olympia..............  WA
Rev................................  Jill Job..............  Saxby................  Maine Interfaith        Cape Elizabeth.......  ME
                                                                                     Council for
                                                                                     Reproductive Choices
                                                                                     and Unitarian
                                                                                     Universalist
                                                                                     Association.
Rev................................   Anna Clock...........  Saxon................  Westminster             Peoria...............  IL
                                                                                     Presbyterian Church.
Ms.................................  Marilyn...............  Scarpa...............  ......................  Newton...............  PA
Cantor.............................  Hollis Suzanne........  Schachner............  Temple Shir Tikva.....  Wayland..............  MA
Rev................................  James W...............  Schaefer.............  UCC...................  Decorah..............  IA
Rev................................  Donna.................  Schaper..............  Coral Gables Cong.      Coral Gables.........  FL
                                                                                     Church.
Cantor.............................  Jodi M................  Schechtman...........  Temple Beth Am........  Framingham...........  MA
Rabbi..............................  Amy R.................  Scheinerman..........  Beth Shalom             Taylorsville.........  MA
                                                                                     Congregation of
                                                                                     Carroll County.
Cantor.............................  Robert S..............  Scherr...............  Temple Israel.........  Natick...............  MA
Rev. Dr............................  Robert................  Schiesler............  St. Luke's Episcopal    Montclair............  NJ
                                                                                     Church.
Mr.................................  Brian.................  Schofield-Bodt.......  Golden Hill United      Bridgeport...........  CT
                                                                                     Methodist Church.
Rev................................  Christopher...........  Schooley.............  Christians              Newark...............  DE
                                                                                     Presbyterian Church.
Rev................................  William C.............  Schram...............  Presbyterian Church...  Fort Myers...........  FL
Rev................................  Gilbert...............  Schroerlucke.........  UM Clergy.............  Louisville...........  KY
Rev................................  Mike..................  Schuenemeyer.........  Diamond Bar             Diamond Bar..........  CA
                                                                                     Congregational UCC.
Ms.................................  Helen.................  Sears................  Churchwide              Owensboro............  KY
                                                                                     Coordinating Team
                                                                                     Presby. Women.
Rev................................  David.................  Selzer...............  Episcopal Church of     Buffalo..............  NY
                                                                                     the Good Sheperd.
Rev. Dr............................  Robert................  Senghas..............  Unitarian Universalist  Burlington...........  VT
Cantor.............................  Judith................  Seplowin.............  Temple Beth-El........  Providence...........  RI
Rev................................  John S................  Setterlund...........  Lutheran Church.......  Champaign............  IL
Rev................................  Arthur G..............  Severance............  First Unitarian         San Antonio..........  TX
                                                                                     Universalist Church
                                                                                     of San Antonio.
Rev. Dr............................  David M...............  Seymour..............  United Church of        Tulsa................  OK
                                                                                     Christ/Presbyterian
                                                                                     Church USA.
Rev................................   Robert E.............  Seymour..............  American Baptist......  Chapel Hill..........  CA
Rabbi..............................  Richard...............  Shapiro..............  Congregation B'nai      Santa Barbara........  CA
                                                                                     B'rith.
Rabbi..............................  Alan..................  Shavit-Lonstein......  Tri-City Jewish Center  Rock Island..........  IL
Rabbi..............................  Randy.................  Sheinberg............  Congregation Rodeph     New York.............  NY
                                                                                     Sholom.
Ms.................................  Patricia..............  Shepherd.............  ......................  Des Moines...........  IA
Rabbi..............................  Alan..................  Sherman..............  ......................  West Palm Beach......  FL
Rev................................   Mary E...............  Shields..............  Trinity Lutheran        Columbus.............  OH
                                                                                     Seminary.
Rev................................  Martha M..............  Shiverick............  Presbytery of the       Cleveland............  OH
                                                                                     Western Reserve.
Cantor.............................  Linda.................  Shivers..............  Congregation Neveh      Portland.............  OR
                                                                                     Shalom.
Rabbi..............................  Marion................  Shulevitz............  Rabbinical Assembly...  New York.............  NY
Rabbi..............................  Robert A..............  Silvers..............  Congregation B'nai      Boca Raton...........  FL
                                                                                     Israel.
Rev................................  Lib Mcgregor..........  Simmons..............  University              San Antonio..........  TX
                                                                                     Presbyterian Church.
Rev................................  Elisabeth K...........  Simpson..............  First Presbyterian      Glen Cove............  NY
                                                                                     Church.
Rev................................  William G.............  Sinkford.............  President, Unitarian    Boston...............  MA
                                                                                     Universalist
                                                                                     Association.
Rabbi..............................  Steven................  Sirbu................  North Shore Synagogue.  Syosset..............  NY
Rev. Dr............................  Joanne................  Sizoo................  Presbyterian Church     Cincinnati...........  OH
                                                                                     USA.
Rev................................  Jeremy................  Skaggs...............  Fellowship              Tulsa................  OK
                                                                                     Congregational Church.
Rev................................  Angela Maddalone......  Skinner..............  First Presbyterian      Yorktown Heights.....  NY
                                                                                     Church of Yorktown.
Chaplain...........................  Donald................  Skinner..............  Living Enrichment       Wilsonville..........  OR
                                                                                     Center.
Rev................................  Stanely E.............  Skinner..............  Emmanuel/Friedens       Schenectady..........  NY
                                                                                     Church.
Rev................................  Joseph Andrew.........  Slane................  Southminster            Birmingham...........  AL
                                                                                     Presbyterian Church.
Rev. Dr............................  Michael D.............  Smith................  First Presbyterian      Grinnell.............  IA
                                                                                     Church.
Ms.................................  Mary Elva.............  Smith................  Presbyterian Church     Louisville...........  KY
                                                                                     (USA).
Rabbi..............................  Ronald B..............  Sobel................  Congregation Emanu-El   New York.............  NY
                                                                                     of the City of New
                                                                                     York.
Rev................................  Richard...............  Sparrow..............  United Church of        Cleveland............  OH
                                                                                     Christ.
Ms.................................  Kerith................  Spencer-Shapiro......  Hebrew Union College-   New York.............  NY
                                                                                     Jewish Institute of
                                                                                     Religion.
Rev................................  David W...............  Spollett.............  First Church, UCC.....  Fairfield............  CT
Rev................................   E. Kyle..............  St. Claire...........  St. Philip's Episcopal  New Hope.............  PA
                                                                                     Church.
Rev................................   Lynn.................  Stanton-Hoyle........  Clifton Presbyterian    Clifton..............  VA
                                                                                     Church.
Rabbi..............................  Sonya.................  Starr................  Columbia Jewish         Columbia.............  MD
                                                                                     Congregation.
Rev. Dr............................  William R.............  Stayton..............  Widener University....  Chester..............  PA
Cantor.............................  Debra.................  Stein................  The Jewish Center of    East Hampton.........  NY
                                                                                     the Hamptons.
Rev. Dr............................  Elizabeth.............  Stein................  ELCA; New Hope          Missouri City........  TX
                                                                                     Lutheran Church.
Rabbi..............................  Margot................  Stein................  Jewish                  Elkins Park..........  PA
                                                                                     Reconstructionist
                                                                                     Federation.
Rabbi..............................  Jonathan A............  Stein................  ......................  New York.............  NY
Rabbi..............................  David E...............  Stern................  Temple Emanu-El.......  Dallas...............  TX
Cantor.............................  Ellen.................  Stettner.............  Stephen Wise Free       New York.............  NY
                                                                                     Synagogue.
Rev................................  Jerald M..............  Stinson..............  First Congregational    Long Beach...........  CA
                                                                                     Church.
Rev................................  Nathan L..............  Stone................  Unitarian Universalist  Waco.................  TX
                                                                                     Fellowship of Waco.
Rabbi..............................  Susan B...............  Stone................  Temple Beth Shalom....  Hudson...............  OH
Rev................................  Robert J..............  Stout................  UMC...................  Horse Cave...........  KY
Rabbi..............................  David.................  Straus...............  Main Line Reform        Wynnewood............  PA
                                                                                     Temple Beth Elohim.
Rev. Dr............................  Charles H.............  Straut, Jr...........  UMC...................  Brooklyn.............  NY
Rev................................   Victoria I...........  Streiff-Fraser.......  Unitarian Universalist  Columbus.............  IN
                                                                                     Congregation of
                                                                                     Columbus, In.
Rev................................  Elwood................  Sturtevant...........  Thomas Jefferson        Louisville...........  KY
                                                                                     Unitarian Church.
Cantor.............................  Jodi L.Sufrin.........  Temple Beth Elohim...  Wellesley.............  MA...................
Rabbi..............................  Brooks R..............  Susman...............  Temple Shaari Emeth/    Manalapan............  NJ
                                                                                     PPCNJ.
Rev................................  Helen.................  Svoboda-Barber.......  Episcopal.............  Topeka...............  KS
Rev................................  M. Thomas.............  Swantner.............  ......................  Pana.................  IL
Rev................................  Gail..................  Tapscott.............  Unitarian Universalist  Ft. Launderdale......  FL
                                                                                     Church of Ft.
                                                                                     Lauderdale.
Rev................................  Arch B................  Taylor...............  Presbyterian Church...  Louisville...........  KY
Rabbi..............................  David H...............  Teitelbaum...........  Board of Rabbis of      San Francisco........  CA
                                                                                     Northern California.
Mr.................................  Jeffery L.............  Termini..............  ......................  Tonawanda............  NY
Rev................................   Eugene...............  TeSelle..............  Vanderbilt Divinity     Nashville............  TN
                                                                                     School.
Rev................................  Bob...................  Thaden...............  United Congregational   Butte................  MT
                                                                                     Church UCC.
Rev................................   Jane.................  Thickstun............  UU Fellowship of        Midland..............  MI
                                                                                     Midland, MI.
Rev................................  Tim...................  Tiffany..............  First Christian Church  Medford..............  OR
Rev................................   George Ayer..........  Tigh.................  UMC...................  Lansdale.............  PA
Rev................................  Edward................  Tourangeau...........  St. John's Episcopal    Lafayette............  IN
                                                                                     Church.
Rev................................   Larry E..............  Treece...............  Evansville United       Evansville...........  WI
                                                                                     Church of Christ.
Cantor.............................  Louise................  Treitman.............  Temple Beth David.....  Westwood.............  MA
Rev................................  Thomas R..............  Uphaus...............  United Church of        Clinton..............  MI
                                                                                     Christ.
Rev................................  David L...............  Van Arsdale..........  First Presbyterian      Kalamazoo............  MI
                                                                                     Church.
Rev................................  Doug..................  Van Doren............  Plymouth                Grand Rapids.........  MI
                                                                                     Congregational UCC.
Rev................................  Jane W................  Van Zandt............  Episcopal Diocese of    Baltimore............  MD
                                                                                     Maryland.
Rev................................  Ernest F..............  VanderKruik..........  United Methodist        Warwick..............  NY
                                                                                     Church.
Rev................................  Karen.................  Vannoy...............  United Methodist        San Antonio..........  TX
                                                                                     Church.
Rev................................  Heidi.................  Vardeman.............  Macalester Plymouth     St. Paul.............  MN
                                                                                     United Church.
Rev................................  Jessica...............  Vazquez..............  Christian Church        Indianapolis.........  IN
                                                                                     (Disciples of Christ).
Rev................................  Ross..................  Walters..............  Eureka Christian        Eureka...............  IL
                                                                                     Church.
Rev................................  Paul Reynolds.........  Warren...............  St. Paul's UCC........  Schulenburg..........  TX
Rev................................  Penelope M............  Warren...............  Episcopal Church......  San Francisco........  CA
Rev................................  Mary Ellen............  Waychoff.............  Macon County Larger     New Cambria..........  MO
                                                                                     Parish-Presbyterian.
Rev................................   Theodore A...........  Webb.................  Unitarian Universalist  Sacramento...........  CA
Rev................................  Gloria................  Weber................  Evangelical Lutheran    St. Louis............  MO
                                                                                     Church of America.
Rabbi..............................  Elyse.................  Wechterman...........  Congregation Agudas     Attleboro............  MA
                                                                                     Achim.
Rev................................  Cynthia D.............  Weems................  United Methodist        Kansas City..........  KA
                                                                                     Church.
Rev................................  Victoria..............  Weinstein............  Channing Memorial       Columbia.............  MD
                                                                                     Church, Unitarian
                                                                                     Universalist.
Rev................................   Lauren M.............  Welch................  Episcopal Diocese of    Baltimore............  MD
                                                                                     Maryland.
Rev................................  Jonathan N............  Weldon...............  Episcopal Church of     Eugene...............  OR
                                                                                     the Resurrection.
Rev................................  Clarence E. Ken.......  Whitwer..............  United Church of        Grand Rapids.........  MI
                                                                                     Christ.
Rabbi..............................  David S...............  Widzer...............  Temple Shalom of        Newton...............  MA
                                                                                     Newton.
Rev................................  Bets..................  Wienecke.............  Live Oak Unitarian      Goleta...............  CA
                                                                                     Universalist
                                                                                     Congregation.
Rev................................  Susan Anslow..........  Williams.............  RCRC..................  Jamestown............  NY
Rev................................  Clark.................  Wills................  Episcopal Church......  Seattle..............  WA
Rev................................  Dennis................  Winkelback...........  New York Conference--   Newburgh.............  NY
                                                                                     United Methodist
                                                                                     Church.
Rev................................  Karyn L...............  Wiseman..............  Grandview UMC.........  Kansas City..........  KS
Rev. Dr............................  J. Philip.............  Wogaman..............  Foundry United          Washington...........  DC
                                                                                     Methodist Church.
Rev................................  William James.........  Wood.................  St. John's Episcopal    Wichita..............  KS
                                                                                     Church.
Rev................................  Hillary...............  Wright...............  ......................  Kansas City..........  MO
Rev................................  Michael G.............  Young................  First Unitarian Church  Honolulu.............  HI
                                                                                     of Honolulu.
Rev. Dr............................  Robert D..............  Young................  Presbyterian USA......  West Chester.........  PA
Ms.................................  Judith D..............  Zelson...............  Temple Beth-El........  Northbrook...........  IL
Rev................................   Craig D..............  Zimmerman............  St. Paul's United       Ringtown.............  PA
                                                                                     Church of Christ.
--------------------------------------------------------------------------------------------------------------------------------------------------------
The 1,700-member Central Conference of American Rabbis and the Justice and Witness Ministries of the United Church of Christ have also endorsed this
  statement.


    Mr. Bilirakis. Ladies and gentlemen, thank you so very 
much. It was a great hearing and you made it such and we have 
learned an awful lot. I trust we can all do the right thing 
tomorrow.
    Thank you. God bless you.
    [Whereupon, at 5:22 p.m., the hearing was adjourned.]
    [Additional material submitted for the record follows:]
        Prepared Statement of the American Civil Liberties Union
                            i. introduction
    The American Civil Liberties Union, a nationwide, non-partisan 
organization with nearly 300,000 members dedicated to protecting the 
individual liberties and freedoms guaranteed by the Constitution and 
laws of the United States, respectfully submits this testimony to the 
House of Representatives Committee on Energy and Commerce regarding 
abstinence-only-until-marriage education programs. As the Committee 
considers H.R. 4122, which would reauthorize the abstinence-only-until-
marriage education program contained in Section 510 of the Social 
Security Act through the year 2007, the ACLU urges the Committee to 
weigh the serious civil liberties and public health concerns posed by 
these programs.
    While the ACLU believes that discussion of abstinence is an 
important component of any educational program about human sexuality, 
we oppose programs, such as the one outlined in Section 510, that focus 
exclusively on abstinence and censor other valuable information that 
can help young people to make responsible and safe decisions about 
sexual activity and reproduction. Moreover, in addition to their 
restrictions on free speech, abstinence-only-until-marriage programs 
endanger the health of young people, create a hostile environment for 
lesbian and gay youth, and dangerously entangle the government with 
religion.
     ii. abstinence-only programs constitute government-sponsored 
                              censorship.
    The current Section 510 language permits federal funds to be used 
only for programs that have as their ``exclusive purpose,'' teaching 
the benefits of abstinence. See 42 U.S.C. Sec. 710. In addition, 
recipients of these funds may not provide a participating adolescent 
with any other information regarding sexual conduct in the same setting 
as the abstinence program. Thus, recipients of federal abstinence-only 
funds operate under a federally imposed gag order that prohibits them 
from providing information in a funded program on preventing sexually 
transmitted diseases or pregnancy through the use of recognized methods 
of contraception, even when they are asked directly for this 
information by a young person participating in the program. As the 
Supreme Court said in Board of Education v. Pico, 457 U.S. 853, 867 
(1982), when addressing censorship in a school context, ``We have 
recognized that the State may not, consistently with the spirit of the 
First Amendment, contract the spectrum of available knowledge. In 
keeping with this principle, we have held that in a variety of contexts 
the Constitution protects the right to receive information and ideas.'' 
(citations omitted).
    Because more comprehensive sexuality information cannot be provided 
in a federally funded abstinence-only program, the result of these 
programs is that teachers are censored and students are denied critical 
information. Material on contraception, sexually transmitted diseases, 
and sexual orientation has literally been ripped out of textbooks used 
in such programs. Some teachers have been disciplined or threatened 
with lawsuits for speaking frankly in the classroom about matters of 
sexuality or for answering direct questions from students. The fear of 
such recrimination chills important speech in our schools. ``[T]he 
First Amendment . . . does not tolerate laws that cast a pall of 
orthodoxy over the classroom.'' Keyishian v. Board of Regents, 385 
U.S.589, 603 (1967).
    The Section 510 abstinence-only program thus infringes on 
constitutional rights of free expression by censoring the transmission 
of vitally needed information about human sexuality and reproduction. 
Section 510 not only suppresses a particular viewpoint on sexuality, 
which is the most egregious form of speech regulation, cf. Rosenberger 
v. Rectors & Vistors of the Univ. of Virginia, 515 U.S. 819, 829 
(1995), it suppresses the very information about sexuality that is most 
critical to teens. Section 510 leaves grantees no choice but to omit 
any mention of topics such as contraception, abortion, homosexuality, 
and AIDS or to present these subjects in a nonscientific, inaccurate or 
incomplete fashion.
    ii. abstinence-only programs are ineffective and endanger young 
                            people's health.
    There is no compelling data that demonstrate that abstinence-only 
programs funded under Section 510 are effective in helping to delay 
sexual initiation or in reducing risk-taking behaviors among young 
people. In fact, the overwhelming weight of evidence suggests that 
programs that include messages about both abstinence and contraception 
are most effective in delaying the onset of sex among young people, 
reducing the number of sexual partners they have, and in making them 
better users of contraception when they do become sexually active.
    Far from being concerned about ``mixed messages,'' parents support 
comprehensive sexuality education that includes information about 
abstinence and about contraception. Studies show that parents want 
other trained adults to provide accurate and forthright information 
about sex to their children. See Tina Hoff et al., Sex Education in the 
Classroom 30-33 (2000).
    Evidence also suggests that the availability of federal abstinence-
only dollars is steering schools away from teaching comprehensive 
sexuality education altogether, even in their non-restricted (i.e. non-
federally funded) programs. There are several causes of this 
phenomenon. First, schools have limited curricular time to devote to 
sexuality instruction. If they are paid by the federal government to 
devote that instructional time to abstinence, they are unlikely to set 
aside additional time for comprehensive sex education. Second, because 
federal abstinence dollars are matching dollars, state funds for sex 
education are being diverted into these programs and there is little 
state funding left for more comprehensive programs. According to one 
study, as of 1999, one-third of the nation's high schools were 
promoting abstinence-only education, while excluding information about 
contraception and safer sex. See Adam Sonfield and Rachael Benson Gold, 
States' Implementation of the Section 510 Abstinence Education Program, 
FY 1999, 33(4) Family Planning Perspectives 166 (2001). Thus, 
abstinence-only money is reducing the availability of information that 
young people--many of whom are already sexually active--need to protect 
their health and to prevent unintended pregnancies.
    Abstinence-only programs also undermine efforts to stop the spread 
of HIV and other sexually transmitted diseases. These programs often 
provide inaccurate information about the effectiveness of condoms in 
preventing the transmission of HIV and exaggerate the data on condom 
failure rates. Such misleading information poses grave risks to young 
people's health.
 iv. abstinence-only programs create a hostile environment for lesbian 
 and gay teens and pose particular risks to the health of these teens.
    Abstinence-only programs are particularly harmful to lesbian and 
gay youth. By excluding information about safer sex practices and 
teaching about sex only in the context of marriage, abstinence-only 
programs stigmatize gay and lesbian teens and undermine efforts to 
educate those teens about HIV and STD prevention.
    Abstinence-only programs also create a hostile environment for 
lesbian and gay youth. These programs rely on fear and shame and 
address same-sex sexuality only as a context for HIV transmission. At 
least two widely used abstinence-only curricula--``Clue 2000'' and 
``Facing Reality''--are overtly hostile to lesbians and gay men. 
Moreover, section 510 requires that all federally funded programs teach 
that ``a mutually faithful monogamous relationship in the context of 
marriage is the expected standard of human sexual activity'' and that 
``sexual activity outside the context of marriage is likely to have 
harmful psychological and physical effects.'' See 42 U.S.C. Sec. 710. 
In a society that generally denies gays and lesbians the right to 
marry, these programs thus essentially reject the idea of sexual 
intimacy for lesbian and gay youth and even deny their very humanity. 
Such clear hostility violates the rights of lesbian and gay youth to 
attend school free of discrimination.
 v. abstinence-only programs dangerously entangle the government with 
                               religion.
    Many abstinence-only curricula contain religious prescriptions for 
proper behavior and values, in violation of the First Amendment's 
guarantee of the separation of church and state. A popular abstinence-
only curriculum called ``Sex Respect,'' for example, was originally 
designed for parochial school use. While it now uses the term 
``nature'' in place of ``God,'' it still has strong religious 
undertones and cites religious publications as its reference sources.
    Although federal guidelines do not permit abstinence-only grant 
recipients to convey religious messages and to impose religious 
viewpoints on participants, in practice, many of these programs do 
precisely that. In one example, a program that received federal 
abstinence-only funds submitted as part of its grant proposal a request 
for $750 to buy Bibles for each participant in the program and to 
engrave the participants' names on the Bibles. Another program that 
received federal abstinence-only funds submitted a sample skit as part 
of its funding request in which Jesus was a main character and in which 
the narrator explained that ``Christ can forgive any sins in our 
lives.'' This is an inappropriate and unnecessary entanglement of 
government with religion. The rigidity of the federal abstinence-only 
requirements make it more likely that such entanglement will occur 
because it skews funding toward more ideological perspectives and away 
from more medical and scientific perspectives.
                             vi. conclusion
    The ACLU urges the Committee to weigh these serious civil liberties 
concerns when considering H.R. 4122.
                                 ______
                                 
                              American Hospital Association
                                                     April 19, 2002

    Dear Energy and Commerce Committee Member:
    On behalf of the American Hospital Association (AHA) and our nearly 
5,000 member hospitals, health systems, and networks of care, I am 
writing to express support for two pressing legislative matters that 
should be included in your mark up of legislation reauthorizing the 
Temporary Assistance to Needy Families (TANF) program: Medicaid and 
SCHIP eligibility for legal immigrants and a longer extension of the 
Transitional Medical Assistance (TMA) program.
    AHA supports legislation that would allow states to cover legal 
immigrants under Medicaid and SCHIP, such as the Immigrant Children's 
Health Improvement Act (H.R. 1143). It is important that lawfully 
present pregnant women and children receive health care at the 
appropriate time, otherwise, they risk developing health complications 
that could have been prevented. Hospital emergency room services should 
not be the sole source of health care for poor immigrants. From an 
economic and health perspective, the benefits of investing in 
preventive services for these lawfully present persons are well 
established.
    AHA also supports a full extension of Medicaid services for 
families making their way from welfare to work. There already is wide 
bipartisan agreement that continued access to health care is a key 
factor in helping families stay in the workforce. TMA should be 
extended permanently or for the full period of this reauthorization 
bill and measures to simplify enrollment and retention of such families 
should be included.
    Thank you for your consideration of these important matters.
            Sincerely,
                                               Rick Pollack
                                           Executive Vice President
                                 ______
                                 
                Prepared Statement of John R. Diggs, Jr.
    Ladies and gentlemen of the Committee: With great pleasure we 
advocate for the reauthorization of Title V for a full five-year 
period.
    I am a board certified Internal Medicine specialist well versed in 
the literature and clinical aspects of sexually transmitted diseases 
and unmarried teenage pregnancy.
    We have learned that the ability to freely choose is a 
characteristic that Americans highly value. Until the advent of Title V 
through the Welfare Reform Act of 1996, Americans had very little 
choice in the method in which their children were instructed in schools 
on the issue of sex education.
    Finally, the paradigm shifted from sexual know-how to the new 
emphasis on character development and the renewal of the emphasis on 
marriage. Finally it was recognized that Title X, devoted to family 
planning, was unable to bring about a reduction in unmarried teenage 
pregnancy or STD rates.
    While there was never a provision for actually testing the 
effectiveness of Title X, its budget continued to grow without 
significant oversight or evidence of efficacy. Not only that but it 
turns out that most of the indicators of sexual chaos worsened during 
the unopposed reign of the ``comprehensive sex education'' school of 
thought and teaching.
    The most reliable STD statistic is that from NHANES regarding the 
frequency of genital herpes. The findings are remarkable. The series of 
studies show that the herpes rate climbed at the same time that condom 
promotion was at full tilt. The sexual revolution had already been 
established. AIDS had transformed from a phrase meaning ``help'' to a 
deadly, big disease with a little name. During the ten-year period 
between 1980 and 1990, herpes positivity rose by a third. The most 
recent NHANES study says that fully 20 percent of Americans over the 
age of 12 are permanently infected with Herpes 2, the causative agent 
of genital herpes.
    Clearly something comprehensive sex education and condom 
utilization failed to slow the epidemic--au contraire, herpes rates 
increased.
    True understanding of the problem was achieved with the release of 
a document from the National Institutes of Health entitled ``Scientific 
Evidence of Condom Effectiveness in Preventing Transmission of Sexually 
transmitted Diseases. The conclusions of the panel after extensive 
literature review were that scientific proof of condom effectiveness in 
preventing herpes transmission was lacking. However, this ten-month 
year old report has not had the expected effect of correcting the 
erroneous information about so-called `safe sex' that has dominated the 
educational platform of the last twenty years. The call for consistent 
condom use rings out in quarters from Planned Parenthood to a variety 
of other organizations interested in condom promotion. Unfortunately, 
it is still considered optional to tell the public the simple truth. 
Despite the dramatic increase in condom usage, the herpes epidemic 
continues unabated due to the startlingly obvious factor that condoms 
don't stop herpes transmission.
    The case of herpes and lack of condom effectiveness is only one 
example of the legerdemain that dominates the philosophy of 
``comprehensive sex education.'' Even the name itself is a misnomer. 
The most comprehensive aspect of the education is the complete denial 
that the cornerstone of the approach--condoms--has been found to be 
inefficacious, not by abstinence-until-marriage ideologues seeking 
supporting data from obscure journals, but by distinguished panel of 
experts who reviewed copious data to reach their conclusions.
    Of eight diseases, the panel could only find scientific evidence of 
condom effectiveness for one and a half. These results should compel 
wholesale changes in any program that touts itself as comprehensive. 
Parents, teachers and doctors should be scrambling to apologize to the 
offspring, students and patients for relying on outdated 
misinformation. This misinformation leads adolescents across the 
country to into a false sense of security not seen since the embarking 
of the Titanic. For decades, youth have been told to protect themselves 
with condoms. It turns out that such protection is no more effective 
than a newspaper protecting a fancy hairdo in a monsoon.
    For an educational philosophy that calls itself ``comprehensive'' 
to leave out this key piece of information is so ironic that one would 
think it intentionally sarcastic.
    Another example is a series of programs that the Centers for 
Disease Control and Prevention have labeled ``Programs That Work.'' If 
there ever was a misnomer, this is it. If a program can be firmly 
classified as working by a scientific organization, then it should 
decrease teen pregnancy and STD rates significantly and repeatedly. 
However, that is not the criteria by which these programs were 
christened. Instead, all they showed was an increase in condom usage 
and a delay in first sexual experience measured in mere weeks. Having 
established that condoms have severely limited proof effectiveness, 
programs that increase condom use actually increase the utilization of 
a defective methodology. More of something that doesn't work is more 
failure. The programs should be properly titled, ``Programs that wished 
they worked.'' Multiply numbers less than one leads to smaller and 
smaller numbers, not better outcomes.
    The CDC admits that 65 million Americans have an incurable sexually 
transmitted disease. This information, combined with the NIH findings 
on scientific evidence of condom effectiveness, is an irrefutable 
indictment of the comprehensive sex methodology. It has not worked and 
it cannot work. Furthermore, there is no theoretical foundation to 
expect success of the condom-based protection in the future.
    The result has been that we daily expose our youth to incurable 
disease. Most notable among these is human papilloma virus, HPV. The 
American Cancer society agrees that HPV is the causative agent of 
cervical cancer, a malady that kills more women in the USA than AIDS.
    The good news is that Health and Human Services, under the guidance 
of the Welfare Reform Act, invested in a new approach that has several 
important characteristics that distinguish it from the failed and 
simplistic ``Just Say Condom'' campaigns of the last two decades. Not 
only are the characteristics distinct but also the tone is distinct.
    Abstinence-until-marriage education is directive. It does not 
abandon teens to a panoply of complex choices where the most 
troublesome choices are also the most attractive. It does what any good 
teaching does--spotlights the best choice and presents it as the 
expected selection. Students respond to high expectations better than 
low common denominators.
    Abstinence-until-marriage education is modest. It does not violate 
the natural modesty of children by having an authority figure direct 
them to mimic handling mockups of male organs to demonstrate efficiency 
in handling prophylactics. There are two major problems. First, 
efficient handling of an inefficient product results in more STD 
exposure, not less. Second, it is degrading, especially for girls to 
publicly, in the name of academic education, practice private adult 
behavior. Condom games in the classroom game trivialize the marital 
act. While such trivialization is the staple of pornographers and other 
media exploiters, it degrades the classroom. The classroom should train 
our youth to compete academically in a hostile world. What can be more 
embarrassing than to discover that American kids can handle condoms but 
not the Pythagorean theorem? Such misplaced priorities are a recipe for 
disaster in terms of national security, national economic status, the 
ongoing development of superior educational systems and students. The 
most tragic victim is the national moral standard.
    Alex de Tocqueville said two centuries ago that, ``America is great 
because America is good.'' He did not say, ``America is great because 
their young 'uns can whip on condoms like no one in Europe!''
    Abstinence-until-marriage builds character and self-control. Unlike 
slapping on a condom, self-control must be cultivated over time. It is 
not a momentary act to master. When properly developed, it will help 
teens become adults that are effective, resistant to corruption, long-
range planners, and considerate of others. On the other hand, condom-
focused mentality thinks only of pleasing self. It demands immediate 
and compulsive satisfaction. Just as self-control bleeds into areas of 
life other than the sexual, likewise does the practice of immediate 
gratification.
    If society seeks an answer to the upward spiral of sexual assault 
of children and by children, look no further than the mantra of low 
expectations pedaled to youth, ``Kids are going to have sex anyway.'' 
If that notion, confirmed by adults, is accepted by the teens, having 
sex ``anyway'' can include even if the other person says ``no.''
    The character building associated with abstinence-until-marriage 
will benefit other areas of life. Several high-profile financial 
scandals, cheating at prestigious universities and public officials 
lying under oath point to the need to reinstate good character as a 
virtue rather than a stigma.
    Slowly but surely, it is becoming common knowledge that it is true: 
Abstinence-until-marriage and faithfulness within marriage are the only 
100 percent effective ways to avoid unmarried parenthood and STDs. 
Begrudgingly, even abstinence opponents admit this. They were, of 
course, encouraged to do so because there was a money stream attached 
to accepting such statements. Indeed, a number of parties affiliated 
with Planned Parenthood applied for Title V grants despite publicly 
denigrating the concepts.
    Their reluctantly offered endorsement is accepted.
    But there is something more important that comes with the Title V 
authorization. It is something that is usually prized by the most vocal 
opponents to Title V. That is ``choice.''
    Parents should have a choice of how to educate their children. 
Ideally, education on these issues should be issues for home and not 
for school. There has not been much choice in the last two decades. 
Coarse and graphic treatment of sex has been imposed by those who felt 
that the crisis was so urgent that we should bypass the usual 
precautions. Those precautions protect minors from sexual and age-
inappropriate images, inappropriate classroom discussion, and degrading 
and embarrassing classroom demonstrations.
    This was done in the name of eliminating a crisis but appears, 
instead, to have perpetuated a crisis.
    Much was made of a decision by the American Medical Association to 
endorse condom distribution in schools instead of abstinence. The AMA, 
in that same statement admitted that the decision was not based on the 
weight of the evidence. They wrote, ``condom distribution shows 
promise.'' About abstinence they wrote, ``needs more study.'' Each of 
these phrases mean the same thing--data is lacking to come to a 
scientific conclusion. Rather than plainly stating that, a small body 
of a few more than a dozen persons leveraged the entire organization of 
350,000 physicians to supposedly support this position. I applaud the 
honesty of the drafters in not overstating their findings. Indeed, data 
does not exist to make a scientific conclusion. Therefore, the AMA was 
reduced to endorsing a position despite a lack data to do so.
    An intelligent reading of the AMA's resolution reveals that we 
still have ``choice.'' Yes, parents and educators can legitimately 
challenge and even reject the failed comprehensive sex paradigm.
    Indeed, they have done so in droves. Hundreds of people and 
organizations have applied for funding provided by Title V. The 
government seed money has served to bring hope, modesty and respect to 
a position that ALL parties admit is the only one with 100 percent 
success in stopping the STD epidemic and unmarried teenage pregnancy. 
It only fails when people choose not to use it.
    Title V funding has brought about the development of new curricula 
and programs that bring hope, smiles, dignity and future orientation to 
a generation that has been hijacked into the existential wasteland of 
immediate gratification. The new programs serve to offer all teens a 
better way, a path with clear direction, solid principles and respect 
for the dignity of the individual. Most of all, important truths are 
revealed, finally magnifying the fine print of on condom efficiency. 
The fine print reads ``All you have heard about condoms as protection 
has been greatly exaggerated. More condom usage has only resulted in 
more STD transmission.''
    The reauthorization should be for the full five years. I have 
studied the questionnaire that is expected to offer ``the final word'' 
on abstinence-until-marriage. The questionnaire could not possibly 
answer the question, ``Does abstinence-until-marriage work?'' It reads 
more like a sex survey. The most astute parents will not permit their 
children to answer such invasive questions. The programs that 
understand the importance that modesty plays in a person maintaining 
integrity will also reject invasive questions. Therefore, the only 
persons who will consent are those who have an impaired sense of 
modesty. This produces selection bias that decreases the validity of 
such a questionnaire.
    The other major problems with this questionnaire are beyond the 
scope of this testimony but can be obtained by writing the Committee 
for Sound Evaluation at PO Box 45, South Hadley, MA 01075.
    With this tightly woven logical compendium of facts, it is a basic 
call to ``choice'' to allow parents and programs to continue the 
maturing of abstinence-until-marriage as the alternative to disastrous 
legacy of ``comprehensive sex education'' and its misnamed clone, 
``Abstinence Plus.''
    I offer this testimony with honesty and simplicity, as a physician 
that diagnoses and treats people who have grown up knowing nothing but 
``safe sex.'' If it were truly safe, I would not have to treat them.
    Please permit American families to continue to have a choice in 
this matter. If they don't want it, they can reject it at the state 
level by not matching the federal funds. Thus far, 49 of 50 states have 
seen fit to match the federal funds. That speaks volumes.
    Authorize Title V Abstinence-until-marriage for another five years. 
Choice is not dependent upon the results of a seriously flawed 
evaluation.
                                 ______
                                 
  Prepared Statement of Alma L. Golden, Medical Director and Carol J. 
                    Rand, SAGE Advice Council, Inc.
    The casualties of war are many and are strewn all around us. They 
are not the wounded, maimed and dead of terrorist attacks. They are the 
cancer-stricken, infertile and mortally wounded of sexually transmitted 
diseases. Most of their wounds were initially inflicted during 
adolescence. Deceived into believing that they were fully armed and 
protected, these youth launched into the fray of the ongoing sexual 
revolution. However, as P. J. O'Roarke has said, ``The germs won.'''
    Each year, three million of the STDs contracted occur among 
adolescents. Consequences of these infections range from quickly 
curable to lethal. Bacterial infections such as chlamydia and gonorrhea 
can be cured but, if left untreated in the female adolescent, they lead 
to pelvic inflammatory disease which scars reproductive organs and 
greatly increases the probability of infertility. Viral infections such 
as herpes simplex, human papilloma virus (HPV), and HIV have lifelong 
and potentially fatal consequences. Eruptions of herpes simplex can be 
randomly reactivated throughout life, causing not only pain and 
discomfort to the individual but also the possibility of transmission 
to the sexual partner. HPV infects about 30% of the sexually active 
teens, though rates between 45% and 51% have been found among female 
army recruits. Since HPV is associated with 93% or more of the cases of 
cervical cancer, and approximately 10% of those infected will progress 
to dysplasia, health ramifications for the next generation are 
enormous. Finally, though HIV is the least infectious of these STDs, 
its transmissibility is increased two to five times by the presence of 
other STDs. Currently, in developed countries, HIV has almost reached a 
``chronic illness'' status. However, when treatment fails, it is fatal.
    Additional casualties of this war come from unintended pregnancies. 
Lives of adolescents and their offspring are forever changed. Young 
women who choose to terminate these pregnancies often struggle 
emotionally with the results of that choice for the rest of their 
lives. Young women who carry these pregnancies full term encounter a 
host of difficulties--many ensuing from aborted schooling. (Only 64% of 
teen mothers complete high school or get a GED as compared to 94% of 
their female peers who did not give birth.) Lower maternal educational 
level segues into 80% of teen mothers eventually going onto welfare. 
Subsequently, the single teen mother's incomplete education and limited 
job opportunities make her children ten times more likely to be poor 
than those of a married high school graduate who was at least 20 years 
old at the birth of her first child.
    Surrounded by these walking wounded from the most recent campaigns 
of the sexual revolution, the commanding officers must analyze the 
current strategy, evaluate its effectiveness and plan a new assault. 
For the past thirty years, the strategy has been to advocate condom and 
contraceptive use as the best protection for naturally risk-taking 
teens.
    Just how well has this plan worked? Have millions of American 
adolescents marched into the heat of battle (pun intended), believing 
themselves to be more than adequately defended, only to find themselves 
shot down by ``friendly fire''? Young people across the nation are 
taught that proper use of condoms will protect them against pregnancies 
and all STDs. The truth is not so benevolent.
    In fact, condoms, even when correctly and consistently used, have a 
14% failure rate against pregnancies. When the joint report from NIAID 
and NIH was released in July 2001, the results of a review of 138 
studies were not reassuring. No conclusive evidence could be found for 
condom effectiveness against any STDs except for up to 85% protection 
against HIV and for female to male transmission of gonorrhea. 
Additionally, in January, 1998, this statement appeared in Family 
Planning Perspectives, ``After years of increased condom usage, reports 
show that STD rates are higher than ever.''
    Even if condoms had been documented to be completely protective, as 
many teenagers believe, the reality of adolescent condom use was 
revealed by the American Academy of Pediatrics Committee on Adolescence 
in June 2001: ``Only 45% of adolescent males report condom use for 
every act of intercourse,'' and ``condom use actually decreases with 
age when comparing males age 15-17 with males 18-19.'' Not only are 
these young warriors equipped with defective defense weapons, but they 
don't even use them. (That could be related to the sixteen steps of 
correct condom use which pediatricians are encouraged to review with 
their adolescent patients.)
    If the previous defense weaponry hasn't worked, what can? Recent 
legislation, the Welfare Reform Act of 1996, has funded abstinence-only 
education for adolescents. Though these are relatively recent programs, 
ten scientific evaluations have been done. All conclude that 
statistically significant decreases in rates of sexual activity and of 
teen pregnancy occurred in the communities where these programs were 
implemented.
    Rather than emphasizing the mechanics of sexual intercourse and of 
proper condom use, these programs stress the importance of strong 
character and family communication. Through the successful curricula, 
young people are taught to value fidelity and to resist negative peer 
pressure. Parents are the essential support personnel which this 
education brings into the war. Their powerful influence in guiding 
adolescents toward the healthiest choice (abstinence until marriage) is 
deliberately sought, rather than excluded. Once adolescents have the 
necessary skills in building loving, enduring relationships and have 
the support of their families, they can successfully avoid risk 
behaviors, such as sexual activity, which can sabotage their mission to 
become confident, capable and committed adults.
    The growing field of abstinence education affords great promise for 
America's young people--a future of optimal physical health (free of 
pregnancies and STDs), of optimal emotional health (free of guilt and 
regret) and of optimal spiritual health (full of a strong character and 
positive choices). Continued expansion of abstinence-until-marriage 
programs will also provide sufficient evaluation data to document its 
effectiveness in protecting adolescents.
    There is no need to send more ill-equipped American teenagers into 
the fierce battles of the sexual revolution. It is time for the 
commanding officers to assume proper responsibility, choose the most 
effective strategy and lead their troops to the healthiest possible 
future.
                                 ______
                                 
                                                        May 1, 2002
Committee on Energy and Commerce
Subcommittee on Health
2125 Rayburn House Office Building
Washington, DC 20515-6115
    Dear Mr. Chairman: On behalf of The Alan Guttmacher Institute 
(AGI), a not-for-profit corporation specializing in research, policy 
analysis, and public education on issues related to sexual and 
reproductive health, I appreciate the opportunity to submit written 
testimony for the official record of the hearing held on April 23, 
2002, before the Subcommittee on Health of the Energy and Commerce 
Committee, entitled ``Welfare Reform: A Review of Abstinence Education 
and Transitional Medical Assistance.''
    In recent years, AGI has conducted extensive research on matters 
that have a direct bearing on current policy discussions around 
abstinence promotion and sexuality education. This research includes 
nationally representative surveys of local public school district 
superintendents as well as public school teachers in grades 5-6 and 7-
12; an analysis of the factors responsible for recent declines in 
teenage pregnancy; and a cross-country comparison of teenage sexual and 
reproductive behavior. Much of this research appeared in the peer 
reviewed journal, Family Planning Perspectives, between 1999 and 2001.
    More recently, AGI summarized many of the Institute's research 
findings along with key research findings of other experts in the field 
in three articles published in The Guttmacher Report on Public Policy. 
These articles, which are attached for inclusion in the record, 
include: ``Sex Education: Politicians, Parents, Teachers and Teens'' 
(February 2001); ``Teen Pregnancy: Trends and Lessons Learned,'' 
(February 2002); and ``Abstinence Promotion and Teen Family Planning: 
The Misguided Drive for Equal Funding'' (February 2002). Several of the 
research findings summarized in these articles include:

 Abstinence education is already widely taught in schools 
    across the nation: Fully half (51%) of school districts with a 
    policy to teach sexuality education require that abstinence be 
    promoted to students as the preferred option but also permit 
    discussion of contraception; another third (35%) require that 
    abstinence be taught as the only option for unmarried people, while 
    either prohibiting the discussion of contraception altogether or 
    limiting discussion to contraceptive failure rates. Only 14% teach 
    about both abstinence and contraception as part of a broader 
    program designed to prepare adolescents to become sexually healthy 
    adults.
 Teachers are increasingly providing abstinence-only education 
    in the classroom, but many believe they are not meeting their 
    students' need for information. The proportion of public school 
    teachers who report that they teach abstinence as the only way of 
    preventing pregnancies and sexually transmitted diseases rose 
    dramatically between 1988 and 1999--from 2% to 23%. Despite the 
    fact that more than nine in 10 teachers believe that students 
    should be taught about contraception, one in four say they are 
    instructed not to teach the subject. One in four teachers also say 
    that they believe they are not meeting their students' need for 
    information.
 The vast majority of American parents favor broader sex 
    education programs over those that teach abstinence exclusively. 
    Almost two-thirds of parents (65%) believe that sex education 
    should encourage young people to delay sexual activity and also 
    prepare them to use birth control when they do become sexually 
    active. Moreover, among the one-third who say that adolescents 
    should be told ``only to have sex when they are married,'' an 
    overwhelming majority also say that schools should teach 
    adolescents how to use condoms and where to get and how to use 
    other birth control methods.
 Research shows that more comprehensive sexuality education can 
    be effective in reducing teenage pregnancy and promoting healthy 
    behaviors. Meta-evaluations of teenage pregnancy prevention 
    programs, including those that teach sexuality education, indicate 
    that programs that discuss both abstinence and contraception can 
    help young people to postpone sexual intercourse, and to reduce the 
    frequency of sex and increase contraceptive use among sexually 
    active teens. In contrast, these meta-evaluations conclude that 
    there is no reliable evidence to date supporting the effectiveness 
    of abstinence-only education.
 New research is also beginning to show that abstinence-only 
    education and strategies may have harmful health consequences for 
    teens by deterring contraceptive use among those who are sexually 
    active. The one national study available shows that programs that 
    encourage students to take a virginity pledge promising to abstain 
    from sex until marriage helped delay the initiation of intercourse 
    in some teens, but teens who broke their pledge were one-third less 
    likely than non-pledgers to use contraceptives once they became 
    sexually active. Similarly, sexually active teens who received 
    abstinence-only messages were found to be less likely to use 
    condoms than those who received safer-sex information designed to 
    reduce the risk for HIV infection.
 Recent declines in teen pregnancy can be attributed to both 
    abstinence and contraception--but in different proportions. 
    Approximately one-quarter of the decline in teenage pregnancy in 
    this country between 1988 and 1995 was due to increased abstinence, 
    while approximately three-quarters of the drop resulted from 
    improved contraceptive use among sexually active teens. (AGI's 
    methodology follows the consensus of a group that was convened by 
    the National Institute of Child Health and Human Development to 
    examine measurement issues regarding teen sexual activity and 
    contraceptive use, which included researchers from AGI, the 
    National Center for Health Statistics, The Urban Institute, Child 
    Trends and the National Campaign to Prevent Teenage Pregnancy.)
 Clearer messages about the importance of contraceptive use in 
    other Western industrialized nations contribute to their lower 
    rates of teenage pregnancy. Teenagers in the United States continue 
    to experience substantially higher pregnancy rates and birthrates 
    than do teens in other Western industrialized countries. This is 
    not because they have higher rates of sexual activity but because 
    they are less likely to use any contraceptive method and especially 
    less likely to use high effective hormonal methods. Moreover, 
    sexuality education and other communication efforts in these other 
    countries clearly and unambiguously stress the importance of 
    contraceptive use for sexually active people who are not actively 
    seeking pregnancy and that childbearing belongs in adulthood.
    Based on this information, AGI strongly believes that the 
restrictive definition of abstinence education contained in PRWORA and 
reauthorized by H.R. 4122--which requires the exclusive promotion of 
abstinence and which prohibits any discussion of the value of 
contraception--ignores what is largely responsible for recent declines 
in teenage pregnancy, is out of step with the desires of teachers and 
parents, prevents states from using federal dollars to implement 
sexuality education programs that have been proven to be effective, and 
may in fact place young people at risk by denying them the information 
they need to protect themselves against unintended pregnancy and 
sexually transmitted diseases. We therefore urge you instead to 
consider funding proven programs that encourage young people to delay 
sexual activity while teaching them about the importance and value of 
contraceptive use for people who are sexually active.
    We hope that this research and analysis will prove useful as the 
House of Representatives considers the reauthorization of section 510. 
Thank you for the opportunity to present this information and to 
express our views.
            Sincerely,
                                           Cory L. Richards
           Senior Vice President, Vice President for Public Policy 
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