[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.
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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
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\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).
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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
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\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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