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Providing Reproductive Health Services for Adolescents:

State Options

Introduction

Adolescents and Reproductive Health

Programs to Provide Adolescent Reproductive Health Services

TANF and Reproductive Health

Promising Models

Conclusion

Appendix A. Services Covered by SCHIP, State by State

Appendix B. Principles for Designing Effective Interventions

Notes

The subject of adolescent reproductive health is a sensitive one for many reasons. Most people have strong religious, moral, political and health arguments as grounds for their beliefs about teenagers and sex. Poverty, a decreased likelihood of graduating from high school, low birth-weight and inadequate health care are among the many negative effects pregnancy has on adolescents and their children. Although the most appropriate approach to this issue is still being debated, most people agree that it is important to deal with the negative effects that teen sex has had on teens and on society as a whole. Despite substantial declines in the teenage pregnancy rate in the past decade, the United States still leads the industrialized world in teen pregnancy rates.(1) In this country, the current teen pregnancy rate is higher than it was in the mid-1980s. In addition, new cases of sexually transmitted diseases (STDs), including the deadly HIV virus, occur every day, with about one in four sexually active teenagers acquiring an STD every year.(2)

States and the federal government have responded to the problem of teen pregnancy and HIV and other STDs among teens in a number of ways. The welfare reform act- the Personal Responsibility and Work Opportunity Act- enacted in 1996 has as one of its four central purposes the reduction of out-of-wedlock births, primarily teen births.(3) As a result, states have new incentives to decrease teen pregnancy, as well as new options for funding reproductive health services to teens. Conversely, some long-standing funding sources- such as Title XX-for reproductive health programs have had the same or significantly reduced funding level over the years. Through the State Children's Health Insurance Program (SCHIP), which offers a new funding source and vehicle to reach adolescents, states have substantial freedom in the design and execution of their programs.

All states currently operate programs that provide reproductive health services for adolescents, using the various sources of federal funds, alone or a combination of sources, to support their efforts. This report discusses some of the major federal sources of funding for reproductive health services for adolescents-SCHIP, Medicaid, the National Family Planning Program, the Maternal and Child Health Services Block Grant, the Social Services Block Grant and Temporary Assistance for Needy Families (TANF). Understanding all the available options is the first step toward maximizing the resources that are available to states. The second- and equally important step- is knowing what approaches have been effective in achieving state goals. Investing monetary and human resources in programs that have been evaluated and proven successful is the best way to guarantee a return on an investment. This report offers some concrete options for addressing this complex and, at times, controversial issue.

Adolescents, defined here as people between the ages of 10 and 19, represented approximately 16 percent-or 38.4 million- of the total U.S. population in 1998.(4) Throughout the high school years, approximately half of these youth, both boys and girls, are sexually active.(5) The issues that arise from teens having sex are numerous and often have profound effects. Two outcomes discussed in this report are pregnancy and HIV and other STDs. Both have tremendous personal, emotional, health and medical, economic and social implications. Before we explore these issues and state activities that deal with them, let's take a look at some facts about the adolescent population. In this report, the terms teen, adolescent and youth will be used interchangeably.

• Sexually active teens who do not use contraceptives have a 90 percent chance of a pregnancy within a year.(6) In the United States, a teenager becomes pregnant every 26 seconds.(7) Incorrect and inconsistent use of contraceptives also accounts for a significant number of teen pregnancies.
• Thirteen percent of all U.S. births are to teen moms, 78 percent of teenage pregnancies are unplanned, and 11 percent of all 15- to 19-year-old girls become pregnant each year.(8)
• From 1986 to 1991, teen birth rates went up 24 percent. The birth rate then went down 12 percent from 1991 to 1996. The teen pregnancy rate also fell by 17 percent from 1990 to 1996. The teen birth rate dropped in every state, but with substantial variations. Racial differences in teen birth rate declines were as follows: African-American teens experienced a 21 percent drop; white teens a 9 percent drop; and Hispanic teens a 5 percent drop. Hispanic teens currently have the highest teen birth rates.(9)
• Teen abortion rates dropped 22 percent between 1991 and 1996.(10)
• Teens are at an elevated risk for STDs. Young women in particular are more susceptible to STDs because they have fewer antibodies to fight pathogens and have a "biologically immature cervix."(11)
• One in four sexually active teenagers get a STD every year.(12)

Poor and low-income teens are at a particular risk for teen pregnancy and HIV and other STDs infection. According to a report by Planned Parenthood, teens living below 200 percent of the federal poverty guideline level (FPL) account for 73 percent of teen pregnancies in teens aged 15 to 19, although they constitute only 38 percent of teens in this age group.(13) Latino teens are at a particularly high risk for pregnancy. Latinos are the fastest growing minority in the United States, and it is estimated that they will be the largest minority by the year 2010.(14) Latina teens have the highest birth rate among all teens, although African American teens have the highest pregnancy rate.(15) Overall, Latino teens are more sexually active, have a lower contraceptive use than other teens, and have experienced the smallest decline in teen birth rate.(16) It is important to note, however, the wide variation of birth rates among Latino sub-groups and among states.(17)

Reproductive health includes a wide scope of services from pregnancy and prenatal care to cancer screening, education, contraception and post-partum care. This report focuses on reproductive health services that serve to prevent pregnancy and/or screen, diagnose, treat and prevent HIV and other STDs. Several public programs provide reproductive health services to teens.

Title X was established in 1970 under President Nixon to improve maternal and infant health; lower the incidence of unintended pregnancy; reduce the incidence of abortion; and decrease the rates of STDs.(18) Title X was the first national, federally-funded program devoted exclusively to providing family planning services. Title X is a categorical grant program that serves predominantly low-income people, many of them uninsured and not eligible for Medicaid.(19) Clinics that receive Title X finding also often serve Medicaid enrollees when other providers do not accept Medicaid.(20) There are no eligibility requirements for Title X; people living at and below the poverty level receive fully subsidized services. Those between 100 percent and 250 percent of the federal poverty level pay on a sliding scale basis, while those above 250 percent of the federal poverty level are required to pay the full fee. It is estimated that about 60 percent of clients seen at Title X-funded centers are eligible for services free of cost due to their income level.(21) Teens are charged a fee based on their own income, not their parents'. Title X offers comprehensive reproductive health services, including contraceptive services and supplies, gynecological services, cancer and other medical screening, education and counseling, referral and infertility services through community-based providers. In addition, the program maintains a clearinghouse for reproductive health materials and information and supports training of health providers and research on family planning delivery issues.(22)

Title X funds go to private and public agencies, such as community health centers, university medical centers and state health departments, among others. Approximately 80 percent of state health departments receive Title X funding-about 60 percent of Title X service funds.(23) (24)

Of the people served at clinics that receive Title X funds, approximately 30 percent are age 20 years or younger.(25) Often, family planning clinics are a key point of entry for youths, most of them female, into the health care system.(26) Title X requires, as part of its regulations, that confidential service be given to anyone regardless of age or marital status, thus providing adolescents with the confidentiality they seek in such services.(27) Furthermore, approximately 90 percent of agencies that receive Title X funds encourage their staff to spend extra time with teenagers in counseling about pregnancy and HIV and other STDs prevention.(28) Although men make up only 2 percent of the clients seen at agencies receiving Title X-funding, most agencies provide specific services and programs for men, as well as targeted programs for teenagers. More than half of these agencies also report having educational components that encourage abstinence and delaying the onset of sexual activity as preferable options.(29) The Alan Guttmacher Institute estimates that publicly funded reproductive health services prevent 386,000 teen pregnancies each year, of which 155,000 would have been live births.(30)

Funding and support for Title X was strong and growing in the 1970s but has since decreased dramatically. Between 1980 and 1998, the funding level for Title X dropped 61 percent when inflation is taken into account.(31) Until the mid-80's, Title X represented the largest public contributor to family planning,(32) but currently accounts for about 21 percent of the total public funds spent on contraceptive services and supplies- a big change since its inception.(33) Funding increased substantially from $203 million in FY 1998 to $215 million in FY 1999, the largest increase in a number of years.(34) Since 1985, Congress has continued to appropriate funds to Title X, but has not reauthorized it.(35)

Despite its decreased funding, Title X remains a vital part of the nation's reproductive health network. It is the only national program that provides family planning services exclusively and comprehensively. The fact that it serves a disproportionate number of low-income, poor and young women makes it a key instrument in reaching youth who are at higher risk for pregnancy and HIV and other STDs and providing them with needed services that are confidential, low-cost or free at a variety of accessible locations.

Medicaid is a federal-state program that provides health care for low-income people and requires states to cover certain basic services. Family planning services are mandatory, and the federal government pays for 90 percent of the cost, a higher rate than other health services.(36) The scope of supplies and services offered is left to the states' discretion, as long as they " are sufficient in amount, duration and scope to reasonably achieve their purpose." (37) Federal Medicaid dollars also can be used for pregnancy tests and STD screening. Abortions may be covered only when necessary to save the life of the mother, or in cases of rape or incest. There is no cost-sharing for family planning services, and confidentiality is mandated under the Medicaid statute(38) for all recipients, regardless of age. Eligibility levels for adolescents-and older children in general- are comparatively low in many states.(39) Some children have lost Medicaid coverage as a result of welfare reform and the de-linking of welfare and Medicaid. However, efforts to identify Medicaid-eligible children are being aided by SCHIP outreach activities (see Title XXI section.)

Under the early and periodic screening, diagnosis and treatment (EPSDT), a comprehensive benefits package available to children enrolled in Medicaid, people under

age 21 must receive any services a health care provider deems necessary.(40) These services include all mandatory and optional services allowed under Medicaid, regardless

of whether they are included in the state Medicaid program. Such services include reproductive health services, such as contraceptives; screening and treatment or STDs; counseling; and health education for teens.(41) States also can require certain services, such as reproductive health, to be included in EPSDT assessments. In 1996, only 37 percent of eligible children received a medical check-up through EPSDT.(42) In addition, infants and young children are much more likely to be seen through EPSDT than adolescents are.(43)

Medicaid has become the largest source of funds for contraceptives, contributing 46 percent of the total public expenditures for contraceptives for teens and poor women.(44) According to a study by the Alan Guttmacher Institute, for every Medicaid dollar (state and federal combined) spent on contraceptives, $3 is saved on potential Medicaid costs for pregnancy and newborn-related care.(45)

Twelve states have obtained special permission from the Health Care Financing Administration (HCFA) to expand family planning services to women who currently are not covered by Medicaid (see figure 4).(46) States can offer coverage on the basis of income or by extending coverage post-pregnancy through 1115 research-and-demonstration waivers.(47) Thus, states have another option for expanding coverage of Medicaid family planning services to adolescents and adults above the Medicaid eligibility level. Furthermore, family planning services can be defined broadly to cover many reproductive health services. Federal law requires that states cover pregnant women and children up to age six to 133 percent of the federal poverty level. For children up to age 19, coverage is being phased in and by 2002 all children up to age 19 will be covered up to 100 percent of the federal poverty level.(48)

Title V was established in 1935 with the mission to reduce infant mortality, improve maternal health and outcomes, reduce adolescent pregnancy and to achieve other maternal and child health objectives. Title V, which became a block grant in the 1980s, is administered by the Maternal and Child Health Services Bureau and has three components:

• block grants to all states and territories;
• Special Projects of Regional and National Significance (SPRANS); and
• Community Integrated Service Systems grants (CISS).

States are required to contribute $3 for every $4 received from the federal government under this program. States have considerable leeway in the programs they can fund with Title V money. The programs are as diverse as immunizations, prenatal care, services for children with special health care needs, school health and family planning.(49) Family planning has long been an integral part of the mission of the Maternal and Child Health Services (MCH) Block Grant. In 1997, 42 states, the District of Columbia and Puerto Rico used Title V funds for reproductive health services.(50) In fact, a 1995 survey conducted by the Alan Guttmacher Institute, showed that 35 percent of agencies providing family planning services used Title V funds and among those agencies also receiving Title X funds, 44 percent used Title V funds.(51) Although most states use Title V funds for a broad scope of reproductive health services, a few states, such as Rhode Island, use the funds for pilot projects that focus on specific services.(52)

Funding for the MCH Block Grant has grown steadily during the past decade, from about $500 million in 1981 to about $700 million in 1999,(53) and remains strong today. Political support for Title V has been solid, so the funding level has not decreased or stagnated like funding for other programs that support reproductive health services. Although Title V does not represent a significant portion of the contraceptive services and supplies public funds (only about 5 percent in 1994), it is a thriving source of funding upon which many states rely. In addition, the flexibility granted to states and the unwavering political support make Title V a key component of states reproductive health efforts.

A final component of Title V, added in 1996, is the Abstinence Education Program. This program, included under Title V in the welfare reform legislation, is the first time the federal government has actively supported state and local efforts to teach youth the benefits of abstinence from sexual activity.(54) Annual appropriations of $50 million for five years are available to assist states in creating and maintaining abstinence-only education programs for teens and adults. All states except for California and New Hampshire are using these funds for abstinence-only education.(55) Abstinence-only education entails teaching children and unmarried adults that sex should be postponed until marriage. It does not promote information about contraceptive use and other reproductive health issues. Shepherd Smith, president of the Institute for Youth Development (IYD) and a strong proponent of abstinence-only programs, believes there should be rigorous evaluations of both abstinence-only and abstinence-plus programs to find out what works best.(56) Currently, there is no peer-reviewed evidence that shows that abstinence-only education has any effect on teens who already are sexually active,(57) and most studies have shown that abstinence-only education has no effect on sexually active teens and does not delay the onset of sexual intercourse.(58) (59) However, few rigorous evaluations have been conducted on this, or other, types of programs. Smith feels better data and well-defined criteria for "success" are needed. He believes that abstinence-only education has great value because it delays entry into a risky behavior (sexual activity) and it is the only way to guarantee that teens will not become pregnant or become infected with HIV or another STD.(60) More research and evaluations are needed to know if the money being invested in abstinence-only programs is achieving states' objectives. To that end, Congress allocated $6 million for a five-year evaluation of abstinence-only education programs. Conducted by Mathematica Policy Research, Incorporated, the evaluation will be completed in 2001.(61)

The Social Services Block Grant was enacted as part of the 1975 Social Security Act. This program was founded on the principles that, "State and local governments and communities are best able to determine the needs of the individuals to help them achieve self-sufficiency; and that social and economic needs are interrelated and must be met simultaneously." (62) Money is given to all states and territories based on their population and no matching of funds are required. Title XX gives states extreme flexibility in what services to fund, who is eligible, fund distribution and provision and delivery of services. As long as one of the five goals is being addressed, states can fund a broad scope of services. Among the services allowed by federal law is family planning, which is the only medical service allowed under Title XX.(63) In addition to using funds for social services, states can decide the level of funds they use for training, administration, planning, evaluation and technical assistance for the social services they provide.(64)

Currently, 15 states use Title XX funds for reproductive health services;

12 of these use money to directly provide contraceptive services and supplies.(65) According to the American Psychological Association, about 50,000 at-risk youth were served by Title XX in 1999, in addition to the thousands of children served by case management, prevention, intervention and counseling services.(66)

Funding for Title XX has declined greatly in the last two decades. Between 1977 and 1996, Title XX funding was cut by 59 percent.(67) In 1996 dollars, this means a drop from $6.8 billion in 1977 to $2.8 billion in 1996.(68) As a result of welfare reform, Title XX underwent a steep 15 percent cut and has continued to decline to an all-time low since its inception to $1.9 billion for fiscal year (FY) 1999 and $1.7 billion authorized for 2001.(69) To help states balance their loss of Title XX funds in the 1996 welfare law, the federal government allowed states to transfer up to 10 percent of their TANF funds to Title XX. After fiscal year 2001, states will be allowed to transfer only up to 4.25 percent of TANF funds to Title XX.(70) Some state family planning programs that have relied on Title XX funds for their existence are experiencing difficulties and are cutting back on services. They have decreased the number of people they serve, their hours of operation, the contraceptive choices they offer and some have closed.(71) (72) More repercussions of the Title XX cuts may be felt because most families that leave welfare still need a number of social services, including free or low-cost reproductive health services.

The Social Services Block Grant provides unequaled flexibility for states that want to provide reproductive health services for adolescents and others who need them. Despite the steep funding cuts, because of its minimal eligibility requirements, its wide scope, broad mission and specific authorization of family planning services, the Social Services Block Grant is an important resource and tool for states to use their creativity in fulfilling the reproductive health needs of adolescents.

SCHIP, enacted in August 1997 as part of the 1997 Balanced Budget Act, is intended to help states provide health insurance for children in families with incomes that are too high for Medicaid, and too low to make private coverage affordable. Almost three million of the nation's 11 million children who are without health insurance are ages 13 to 18, representing 12 percent of the total adolescent population in this country.(73)

SCHIP is a substantial federal investment in health care coverage, with $24 billion appropriated for the first five years and an additional $40 billion over the following 10 years. States also are given a more generous matching rate for SCHIP than for Medicaid. In addition to the higher matching rate, SCHIP offers states substantial flexibility and freedom to employ innovative and creative ways to find, enroll, serve and retain children in the program.

States have three options under SCHIP: to expand Medicaid, create a state-designed health plan, or use a combination of the two. All states and territories had an approved SCHIP plan by September 30, 1999 and nearly 2 million children were enrolled in SCHIP. As of May 2000 there were 23 Medicaid expansions, 15 state-designed plans and 18 combination plans, and 49 states and the District of Columbia cover teens aged 15 to 18 at least to the poverty level.(74) Some states have made eligibility levels equal for all children under SCHIP.

Under the Medicaid expansion option, states are obligated to cover all federally mandated services, including family planning services and supplies. Therefore, children enrolled in a SCHIP Medicaid expansion will have access to the full range of Medicaid reproductive health services required by law. In addition, children may not be required to pay any cost-sharing for family planning services and supplies. Also in line with Medicaid "freedom-of-choice" regulation, teens who wish to seek family planning services and supplies from a provider outside the managed care network serving them are free to do so, with full Medicaid coverage. In contrast, state-designed plans are free to decide whether they will offer and cover reproductive health services, including family planning. In addition, cost-sharing may be imposed if it is required for other services, as long as it meets the criteria set by SCHIP regulations for cost-sharing.

Most states have opted to cover reproductive health services under SCHIP. Prenatal care is covered by all SCHIP plans except Pennsylvania. Although most states have chosen to cover family planning services and supplies, some have specific stipulations about which ones will be covered, and some have limits on coverage. The reproductive health services covered vary according to the managed care plan from which an adolescent receives services in Iowa, Kansas, Massachusetts, New Jersey, Oregon and Wisconsin.(75) In Texas, the state-designed SCHIP plan covers "prenatal care and care related to diseases, illnesses, or abnormalities related to the reproductive system," but does not cover other reproductive health services.(76) Pennsylvania's SCHIP plan currently does not offer any "prenatal and pre-pregnancy family services and supplies."(77) Utah's SCHIP plan covers contraceptive medications and supplies with the exception of Norplant. New Hampshire limits contraceptive coverage to oral contraceptives and Depo-Provera.(78) Further information about reproductive health services covered by SCHIP is included in Appendix A.

A number of states are using school-based health centers (SBHCs) to deliver services in their SCHIP plans. As of January 1999, SCHIP plans in 27 states encouraged the participation of SBHCs in SCHIP.(79) These centers provide a wide scope of primary and preventive health services for children in the school environment. Of all services used by students in SBHCs, reproductive health services represent about 19 percent.(80) These centers operate in 45 states and the District of Columbia, and almost half of all centers already receive some state funding.(81) Approximately 86 percent of SBHCs offer family planning counseling; 81 percent offer pregnancy testing, 81 percent have laboratory testing, and 83 percent fill and dispense prescriptions.(82) SBHCs represent an important vehicle for reaching and serving children, especially teens. They are not, however, without controversy. There is opposition to SBHCs from some families and legislators who feel that the reproductive health services provided by these centers undermine parental authority and trespass into the realm of traditional family roles. SBHCs have addressed this issue by requiring students to obtain consent forms signed by their parents before they receive services.(83) Other obstacles to SBHCs being used for service delivery under SCHIP are reimbursement, confidentiality and administrative issues. SBHCs will need to contract with health plans in order to participate in SCHIP and be reimbursed as a participating provider.(84)

Because adolescents have the highest uninsurance rate of all children, SCHIP could have a significant impact on teen health, including reproductive health. Insuring uninsured adolescents is key to increasing their knowledge and use of reproductive health services and supplies because research has shown that health insurance coverage is a "key determinant" of adolescents' use and access to health care services.(85)

In 1996, the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) replaced Aid to Families with Dependent Children (AFDC) with Temporary Assistance to Needy Families (TANF). PRWORA ended the individual entitlement to cash assistance under AFDC. Under TANF, states receive a block of funds that they can spend with a high degree of flexibility and discretion. Spending must be directed toward meeting one of the four purposes of TANF. The first two purposes relate to assisting families so they may care for their children in their own homes and ending the dependence of needy parents on the government. The third and fourth purposes of TANF are:

• "Prevent and reduce the incidence of out-of-wedlock pregnancies and establish annual numerical goals for preventing and reducing the incidence of these pregnancies; and
• Encourage the formation and maintenance of two-parent families."(86)

These two goals can readily apply to programs that provide reproductive health services to adolescents. Furthermore, states can spend their TANF funds on people in and out of the welfare system,(87) allowing them to reach a broader population. States can target their programs towards children.

State legislatures have the authority to appropriate TANF funds.(88) There are two sets of funds under TANF: federal TANF funds and state funds called "state maintenance of effort" (MOE) funds. These two pools of money have different restrictions and limitations. To receive federal TANF funds, states must meet state maintenance of effort requirements.

Federal TANF funds can be used to fulfill the two reproductive health purposes listed above, and do not need to be targeted only to "needy families." This gives states greater leeway to decide who can benefit from programs; programs funded with state MOE funds are subject to income eligibility requirements to be set by the state. Here again, however, states have great flexibility. Different services funded by state MOE funds can have different eligibility levels, hence targeting diverse populations.(89) States set and define program eligibility levels.

Federal funds cannot be used to cover "medical" services, whereas state MOE funds can with the exception of funding for Medicaid.(90) States define what is a medical service. Family planning can be covered by both sources of money.(91) Medical services can be defined by states in such a way that referral, screening and counseling services by non-medical workers are allowed under federal TANF funds. TANF legislation applies time limits for people who are receiving "assistance." Regulations define services such as family planning, teen parenting programs, and youth or family support and counseling services as "non-assistance."(92) A further difference is that people who receive services funded by state MOE funds under a separate state program are not subject to the federal time limits, work participation or child support requirements.(93) Because these pools of money function under such different rules, states can separate them to retain the greatest degree of flexibility in spending them.(94) There is no requirement that states use TANF funds on abstinence-only programs.

Several elements under the TANF legislation address the issue of teen reproductive health. Out-of-wedlock births are specifically discussed in the legislation.(95) Elements relevant to teen reproductive health are:

• The illegitimacy bonus;
• National goals for preventing and decreasing teen pregnancy;
• Statutory rape law enforcement under TANF;
• The abstinence-only education fund (discussed earlier under Title V); and
• Coverage of family planning services and supplies.

As a part of the 1996 welfare reform law, the federal government set aside $100 million each year from 1999 to 2003 to reward up to five states that have the greatest decline in out-of-wedlock births without increasing their abortion rates above their 1995 level.(96) Many states have made focused efforts on reducing teen birth rates, some with the intention of winning this "illegitimacy bonus."(97) (98) Federal TANF rules apply to the illegitimacy bonus money received. Three general approaches to decreasing out-of-wedlock births have been identified in states:

• Increase contraceptive use by welfare recipients and low-income women (e.g., Alabama, Alaska, Kentucky, Montana and North Carolina);
• Teen pregnancy prevention (e.g., Arkansas, Georgia, New York, South Carolina); and
• Local initiative support via grants (e.g., Tennessee, Utah, Virginia, Wyoming).(99)

Many of these efforts are supported by TANF funds.(100) The first recipients of the bonus, Alabama, California, Massachusetts, Michigan and the District of Columbia, were announced in September 1999.(101)

TANF legislation mandates that the secretary of the Department of Health and Human Services establish goals and strategies for preventing out-of-wedlock pregnancies, and for assuring that one-quarter of U.S. communities have initiated teen pregnancy prevention programs.(102) Progress reports must be developed and submitted to Congress every year.(103)

Statistics show that one in five children born to teenage girls are fathered by men five or more years older.(104) Because of this fact, statutory rape has become an issue linked with teenage pregnancy and reproductive health under TANF. The proportion of older men fathering younger teens' children is even higher, with about 30 percent of 15-year-olds becoming pregnant by men six years or more their senior.(105) To this end, states are asked to identify education and training programs for the prevention of statutory rape in an effort to involve men in teen pregnancy prevention, and to aid in the prosecution of such crimes.(106) Skepticism has been expressed about the effectiveness of enforcing statutory rape laws because teen mothers may be unwilling to turn in a partner upon whom they depend economically and emotionally.(107) Current research evidence does little to support this approach.(108)

As of September 1999, programs specifically targeting teen pregnancy prevention with TANF and MOE funds exist in eight states- California, Georgia, Iowa, Louisiana, Minnesota, North Carolina, Oklahoma and Wisconsin.(109) However, many programs exist that do not directly have pregnancy prevention as their intended goal, but that do, in fact, have reproductive health, general health and even pregnancy and STD prevention components. For example, a number of after-school programs funded with TANF and MOE funds incorporate pregnancy prevention components.(110) Some states transfer a portion of their TANF funds to the Social Services Block Grant before using the funds for reproductive health services.

States- especially those with large immigrant populations- face an additional challenge regarding teens who emigrated after the welfare law was enacted in 1996. Because these teens are ineligible for both SCHIP and Medicaid, they could experience a decrease in use of family planning and other reproductive health services. Fear of becoming a public charge may inhibit immigrant teens from seeking reproductive health services from public programs. This is of particular concern because Latino teen birth rates are the highest in the nation.(111) Legal immigrants, both pre- and post-enactment, are eligible to receive services funded by MOE money.(112) Federal TANF money may be used to serve only pre-enactment immigrants.(113)

States need not seek federal permission for the development of new programs under TANF. As noted above, there are some restrictions on use of TANF. However, as long as the programs serve low-income people and serve one of the four goals of the law, states have vast flexibility and freedom on what to fund, including programs and services that are not traditionally thought of as welfare. States have successfully reduced their welfare rolls, in many cases by more than 40 percent,(114) and have achieved their work force participation rates. This frees federal TANF funds and provides states the opportunity to focus TANF funding on the goals of pregnancy prevention and the formation of two-parent families.

Programs that are supported with TANF and state MOE funds are varied and diverse. Teen reproductive health programs that can be funded by TANF and MOE include family planning services and information, youth development programs and home visiting programs.(115) State examples are included below to illustrate the wide range of programs that can be funded under TANF to decrease teen pregnancy and provide reproductive health services.

Two programs administered by the Department of Health Services receive TANF funds to provide reproductive health services to teens: the Partnership for Responsible Parenting (PRP) and the Male Involvement Program (MIP). These programs receive a level of state MOE money estimated by the number of welfare recipients who will be served in either program.(116)

Partnership for Responsible Parenting. This program receives funding from state MOE funds. This program, initiated in 1996, has four components :

• Public awareness campaign. This campaign uses a combination of paid and public service media ads through both mainstream and ethnic channels. The goals of the campaign are to heighten awareness of the issue, promote abstinence, increase male responsibility, and make people aware of the legal consequences of statutory rape.
• Male responsibility campaign. In August 1997, California launched the second phase of its partnership campaign, the male responsibility media campaign. This component addresses an issue in the TANF legislation as well as the fact that more than half of babies born to teen mothers in California are fathered by men over age 20.(117) The campaign encourages abstinence as the only sure way to prevent pregnancy as well as economic and emotional involvement in the event of a pregnancy. The campaign includes TV and radio spots, billboards, bus-benches and public service announcements with messages about pregnancy prevention, fatherhood and statutory rape and its consequences.
• Mentoring campaign: The third phase of the PRP program promotes adult involvement and volunteering in youth programs, particularly those serving at-risk youth. A study completed a year into the program found that half of the participating communities experienced an increase in adult volunteers at youth programs in their communities.(118)
• Community challenge grants (CCG). The three goals of this component are reducing the number of teenage and out-of-wedlock pregnancies, reducing the number of children growing up in fatherless homes, and promoting responsible parenting and involvement of the father. In FY 1998, California allocated $770,000 of state MOE money for these grants.(119) The program targets teens who are not yet sexually active, those who are sexually active and pregnant, and parenting teens. In 1997, 112 agencies were selected for funding to develop and implement effective, local programs to prevent teen pregnancy and absent fathers. The agencies include religious agencies, local health departments, schools, and youth and community organizations in both rural and urban counties. These agencies provide mentoring, abstinence-education and life-skills training among other interventions.(120) These agencies will be evaluated independently by the University of California at San Francisco.(121)

Male Involvement Program. The Office of Family Planning within DHS administers this program. Funding is provided through grants using a competitive process. The program uses primary prevention skills to motivate male teens and young men to take responsibility for their sexual behavior. The program promotes its messages at shopping malls, community forums, teen theater, town hall meetings and local media. The local agencies conducting this program use culturally appropriate and locally-focused initiatives and interventions in their educational activities. Activities includes peer education, rites of passage programs, workplace programs, youth conferences and mentoring programs.

Florida TANF appropriates $10 million to 12 million annually to teen pregnancy prevention efforts in the state.(122) Three types of projects are funded with TANF funds.

Local WAGES coalitions.(123) WAGES is Florida's TANF office. The state has 24 local coalitions that report annually on local teen pregnancy prevention activities. These activities, funded by TANF, are part of the state's efforts toward the goal of promoting two-parent families.

Abstinence education.(124) The Florida Department of Health (FDH) funds abstinence-only education programs through the public school system and community-based organizations. The department uses a "saturation model" that includes both abstinence-education activities and a widespread media campaign.

Demonstration Project. TANF funds provide $4.5 million over three years for a five-site pilot project. The project is a public-private partnership, funded by WAGES and the health department and administered by the Ounce of Prevention Fund, a nonprofit organization that provides technical assistance, contract management and evaluation services. The purpose of the project is not only to prevent teen pregnancy and improve outcomes for participating teens, but also to evaluate different models of intervention. The state hopes to replicate these efforts throughout the state. The sites, selected through a competitive process, were required to be a collaborative community program and involve a "community engagement plan" in their approach. Each site will be awarded $235,000 per year for the duration of the project.(125) Three of the five sites will function under the intensive intervention model, while the remaining two will offer services via case management and referral. There are certain requirements for all program curricula; however, each site is allowed a level of creativity to adapt the curricula to the particular needs and the availability of resources of its community.(126) The sites offer a diverse set of services to approximately 1,600 middle school teens who are considered at risk for early childbearing. Services provided include: mentoring programs, sports, tutoring, community services, family life and sexuality education, medical and mental health services, parental involvement, career activities and self-expression through art. Contraceptive information is provided within the abstinence-plus education component, but contraceptives are not distributed. Parents of high-risk teens will be asked to participate in the program with their children.(127) The state hopes the findings of this evaluation will help it, and the nation as a whole, apply the lessons learned to implement more effective and successful teen reproductive health programs. The demonstration project results also will be shared with the WAGES coalitions as a "best practices" piece. The first annual survey of participating teens will take place in the summer of 2000.

Georgia created a pregnancy prevention program called the Adolescent Health and Youth Development Program (AHYD), formerly known as TeenPlus, in 1996. AHYD receives about half its budget from TANF.(128) The Department of Human Resources administers this and other teen pregnancy prevention programs.(129) The purpose of AHYD is " to improve the health status and reduce high risk behaviors of adolescents through opportunities and programs developed in collaboration with families, communities, schools, and other public and private organizations."(130) AHYD currently has four statewide programs in the state's 19 health district units:

• Comprehensive adolescent health centers: $3.45 million in FY 1999 from TANF;
• Community involvement: $1.5 million in FY 1999 from TANF;
• Male involvement; and
• Abstinence.

All programs are modeled on the youth development approach (see Promising Models section), but only the comprehensive adolescent health centers provide reproductive health services to teens. These centers are located in 39 sites and 34 counties statewide. AHYD also provides clinical services for teens. In some areas, mobile vans bring services to hard-to-reach communities.(131) The centers are open after school and on weekends to make them more accessible to teenagers. In addition to the programs, AHYD also engages in outreach and awareness activities for hard-to-reach youth and families. A resource mother or father who serves as a mentor to teens staffs each center. These adults are former welfare recipients and often conduct outreach to involve teens in the community.(132) According to Lucretia Washington, program manager of AHYD, legislative support for the program has been strong and positive, with the youth development components receiving recognition both at the state level and in local communities. Georgia is investing in a program evaluation with TANF funds providing more than one-third of the evaluation budget.(133) The evaluation will gauge the program's effectiveness and demonstrate results. The youth development initiative is promising, but the Office of Adolescent Health and Youth Development acknowledges the benefits probably will be apparent only in the long-term.

In 1997, Kentucky allocated $500,000 in TANF funds to increase access to family planning services. The funding level was increased for 1998-99 in two separate agreements of $1 million and $2.8 million in TANF funds.(134) An additional $800,000 in TANF funds was allocated to a teen pregnancy prevention program administered by the Kentucky Department of Public Health (DPH) for 1997-99.(135) For the family planning program, the Department of Public Health entered a two-year memorandum of agreement with the Cabinet for Families and Children for TANF money to purchase and administer Depo-Provera to reduce unintended pregnancies.(136) The TANF funds do not exclusively target teens, but cover unmarried women of all income levels, while married women are covered to 200 percent of the FPL.(137) The goals of the family planning program are to decrease teen pregnancy and out-of-wedlock births.(138) The objective of the funds was to increase the number of Depo-Provera users. Specific activities funded with TANF money include the following.

• A brochure about the benefits of family planning and where to obtain these services. The brochure is written for a third-grade reading level and mailed to TANF recipients along with additional service information.
• Training for workers in 115 out of 120 county TANF offices on the benefits of family planning. Workers then can educate clients on the benefits and availability of family planning.
• Buying and administering Depo-Provera. Agencies entered a buying agreement with Upjohn (manufacturer of Depo-Provera) to deliver the drug directly to agencies and bill the DPH.
• Agencies are paid an administrative fee for each shot given to cover costs of providing Depo-Provera.
• Use of statistical monitors to track progress.

Initial monitoring by the state shows that, since the initiation of the additional funding, the number of Depo-Provera users has, in fact, risen. The state has concluded that

" funding limitations of the past have restricted contraceptive choices, preventing some women from using the most highly effective methods."(139) The state also has concluded from the first year report that the "number of low-income users of family planning clinics has increased as a result of the collaborative efforts of local agencies and the availability of a highly desired method" such as Depo-Provera.(140) Sharma Klee, director of the Maternal and Child Health branch in the DPH, calls this program and the TANF funding for Depo-Provera services, "one of the best things we've done in ages."

The second program using TANF funds is the teen pregnancy prevention program. Funds were allocated to this program via the Social Services block grant. Two specific projects within the teen pregnancy prevention program are funded with TANF funds: 1) a media campaign and 2) a five-site pilot project using the Teen Outreach Program (TOP) curriculum.

• Media campaign.(141) The media campaign is funded with TANF funds and money from the abstinence-education grant. The project received $500,000 in TANF funds over a two-year period. Four TV spots with abstinence messages are broadcast on local and cable channels. Radio spots also are used in areas with low TV penetration, but to a lesser degree. The state has conducted random telephone surveys to gauge the impact of the media campaign. The survey asked if the person had seen or heard the spot, recalled the content of the message and recognized the line, "Get a life first." The survey found a steady increase in both reach and recognition of the ads, the message, and the line. The effect of the campaign on behavior was not addressed in the survey. The DPH hopes to continue the campaign.

Pilot Project.(142) The state allocated $300,000 of TANF funds for 2000-2002 for a pilot project. The state chose five sites based on three criteria: high teen birth rates, previous health department success with programs, and interest in the program. The project began in March 2000. The health department is working with the school system on this project to serve about 250 high school students with the Teen Outreach Program (TOP). All sites have had training on how to conduct the TOP curriculum. To test the outreach program, which contains life-skills and community-service components, the project has two years of guaranteed funding; continuation will depend on the outcome of the pilot projects.

In New York, TANF funds account for approximately 16 percent of the state's reproductive health budget.(143) The state uses TANF funds for two programs.

• Family planning services. The state department of health has used about $6 million of its TANF funds since 1997 to expand its state-funded family planning services. The program provides education and outreach activities targeted at women and adolescents through a network of 62 family planning agencies, schools, community organizations and special events to increase awareness of the family planning services available.
• Community-Based Adolescent Pregnancy Prevention Program (CBAPP). The department of public health administers the CBAPP. The program has received funds since 1997 and has a five-year guarantee on TANF funding.(144) The program's budget has been written into the state budget plan every year. CBAPP received $7 million for the first two years of the program; funding was increased to $10 million for the third year. The program expects to maintain this funding level in 2000. The program uses the youth development model (described in the Promising Models section). Thirty local initiatives, in areas with the highest teen birth rates in the state receive funding for education (including abstinence education), access to family planning; and educational, vocational, economic and recreational opportunities for teens. TANF money is used for everything except direct patient services. The state collects information quarterly from CBAPP providers in addition to the state's collection of pregnancy and birth data. This allows New York to track pregnancy and birth statistics for adolescents as well as services received by adolescents through this program. Data for 1998 show that more than 121,000 youth participated in informational sessions at school and community settings from trained peer educators.(145) Almost 85,000 adolescents received free, confidential family planning services; more than 35,000 teens received school-based interventions; more than 100,000 teens attended vocational sessions; and almost 10,000 teens attended recreational sessions.(146) In addition, CBAPP community coalition meetings were attended by about 44,000 participants and more than half a million people were involved in some other type of CBAPP activity such as health fairs, conferences and youth "speak-outs." (147)

The state ELECT program helps teen parents stay in school or return to school if they have dropped out. The program receives about 60 percent of its $3.5 million budget from TANF. The Department of Education administers ELECT, which currently offers services in Philadelphia at 22 traditional high schools and 10 high schools that have non-traditional hours. All teen parents are eligible for this program, which provides case management, summer and Saturday education programs, and parenting and child development training. (148)

Through its Healthy Families America program, Texas provides child-care services for teen parents who are trying to stay in school. The funds were transferred from TANF to the Social Services Block Grant and therefore allowed the state to provide these services without holding the teens receiving them to the TANF time limits. This program promotes education as a way to break the cycle of dependency. Because teen parents are at a higher risk of dropping out of school than other teens, and because those without a high school education have a much higher chance of being poor and depending on welfare, this program attempts to prevent such potential outcomes by keeping kids in school. Texas also allotted TANF funds for the Healthy Families America home-visiting program. The Legislature appropriated $3.1 million over a two-year period to expand the program to ten new sites, bringing to 18 the total number of sites.(149) The program identifies at-risk teen parents and helps to meet their needs by linking them to support services and providing them with a home visitor. Key goals of the program are to delay a second birth and provide the young parent(s) with parenting skills to decrease the possibility of child abuse or neglect.

Five general categories of approaches exist to provide reproductive health services for adolescents: access programs, media campaign programs, education programs, youth development programs, and multi-faceted programs. Despite the vast number of programs that address teen reproductive health issues, limited scientific research has been conducted to evaluate their effectiveness. Many schools of thought exist on what is effective. Most approaches are based on theories of human behavior and ways to modify behavior. The three factors recognized as vital in changing health behavior are:

• An individual's intention to exhibit a particular behavior;
• Environmental factors that prevent or resources that aid the behavior; and
• An individual's skills or ability to execute the behavior.(150)

Effective approaches take these factors into account and work at all three levels to change an individual's health behavior. Recent approaches have made a focused effort to involve boys and men in their activities. (For further information about this topic, see http://www.ncsl.org/programs/health/forum/teenrhs.htm)

• Access programs. These programs facilitate access to contraceptives, contraceptive counseling and information, HIV and other STDs services, and other reproductive health services. Studies conducted on this type of program have shown that large numbers of teens do access these programs and receive contraceptives from them.(151) It is assumed that these contraceptives prevent teen pregnancies that might otherwise have occurred. Analyses of the recent drop in teen pregnancy rates point to increased and more effective contraceptive use, especially condoms, as well as a decrease in the proportion of teens having sex as key factors in the decline.(152) (153) The Alan Guttmacher Institute estimates that almost 400,000 pregnancies are avoided each year among teen girls age 15 to 19 as a result of publicly funded family planning programs that provide access to contraceptives.(154) Evaluations of some access programs have shown an increased knowledge and use of contraceptives in teens who participated in such programs. Some programs have shown lower pregnancy rates in program participants than in comparison groups in the year following program participation. Overall, it has been found that programs with limited or short-lived interaction between teens and program workers are not likely to change the adolescents' behavior. Some more extensive or intensive programs have been found to change behavior and increase contraceptive use.(155)
• Media campaign programs. These programs use media channels to increase knowledge and awareness of issues, services and programs that address teen reproductive health. Evaluations of media campaigns show that this type of approach can be effective in changing individual attitudes, knowledge and behavior, social norms and even public policy.(156) Elements of a successful media campaign include:(157)
• Long-term commitment.
• Clear objectives.
• Testing message(s) prior to release.
• Targeting audience.
• Selecting media channels carefully to fit the purpose of the campaign.
• On-going monitoring and evaluation of media impact.
• Campaign parallels and complements activities at the community, individual or policy level.

According to a 1998 National Campaign to Prevent Teen Pregnancy report, at least 40 states are developing or have developed media campaigns to prevent teen pregnancy.(158)

• Education programs. These programs provide knowledge of and skills in reproductive health, contraceptives, pregnancy, HIV and other STDs and AIDS, general health, human development, sexuality, human relations, culture, and so forth. Education programs that are abstinence-only discuss sex in the context of marriage and address contraceptive use in terms of failure rates. Abstinence-plus programs include abstinence education, but also address contraceptive use and other sexuality and reproductive health issues. The teaching of contraceptive methods and sexuality has been controversial. Some parents and policymakers are concerned that this responsibility is the parents', not the schools. Currently, 34 states and the District of Columbia mandate HIV and other STDs prevention education at schools, 19 states and the District of Columbia require schools to teach sexuality education, 13 states requiring contraceptive information to be included, and 33 states have laws to allow parents to excuse their children from such classes.(159) At the school level, about 70% of school districts have a policy to teach sexuality education.(160) Of these, almost nine in 10 require an emphasis on abstinence, with 35 percent requiring an abstinence-only approach. Approximately 14 percent of school districts require a comprehensive, or abstinence-plus, approach to sexuality education.(161) Factors that influenced the type of policy the district established ranged from state directives to teacher support and funding, with state directives cited most

• Youth development programs. These programs are based on the notion that improving youths' education and work opportunities will decrease their chance of risky behavior, such as unprotected sex and pregnancy. These programs are intended to develop life skills without targeting reproductive health as the primary issue. Research conducted both in the United States and internationally support the conceptual framework of youth development programs. For many years, programs to educate young girls and provide them with increased work opportunities in developing countries have yielded a common result: decreased fertility.(166) In the United States, a strong relationship exists between educational and career plans and prospects and teen pregnancy. In addition, trends in this country imply the potential success of this type of approach: during the decades of the 1950's, 1960's and 1970's,when women were postponing marriage and childbirth for the sake of pursuing education and careers, teen pregnancy rates fell dramatically.(167) Recent research findings from the National Longitudinal Study on Adolescent Health (Add Health) indicate that risky behavior, such as early sexual initiation and unprotected sex, is influenced by family and school context as well as certain personal characteristics.(168) Protective factors-which decreased the likelihood of pregnancy- identified were "parent-family connectedness"; parental disapproval of teen being sexually active or using contraceptives; high level of "connectedness to school"; high rate of school attendance; teen's perception of early pregnancy's negative consequences; and teen's use of effective contraceptives at first and/or most recent intercourse.(169) Because youth development programs often involve school and family components, these findings are relevant to program content and design. Research conducted on youth development programs has provided mixed results. However, there have been many positive evaluations of existing programs, and further research is needed to fully understand the impact of this type of program on teen pregnancy and sexual behavior. Studies of specific youth development programs- like the Teen Outreach Program (TOP)-consistently show a decrease in pregnancy rates for participants during the duration of the program.(170) A 10-year evaluation of TOP in 25 sites nationwide found a 60 percent lower school drop-out rate, a 33 percent lower pregnancy rate, an 18 percent lower rate of school suspension, and an eight percent lower school course failure rate.(171)
• Multi-faceted programs. These programs are diverse, but all use multiple components to achieve their goals. Programs are considered multi-faceted if they involve two or more of the approaches described above.(172)

Teen pregnancy and HIV and other STDs in the adolescent population is a costly problem in economic, personal and social terms. All states currently operate programs that offer and provide reproductive health services for adolescents, using various sources of federal funds to support their efforts. In the past few years, TANF has proven to be a boon to state efforts. TANF offers a new source of support as well as a new incentive for states to decrease their teen pregnancy rates and help teens make positive choices for their future.

1. Alan Guttmacher Institute. Teen Sex and Pregnancy. Facts in Brief, New York: The Alan Guttmacher Institute, 1999. URL = http://www.agi-usa.org/pubs/fb_teen_sex.html.

2. Ibid.

3. Sheri Steisel. A Checklist for State Legislators. Taking Advantage of the New Flexibility of TANF and State Maintenance of Effort Funds. (Washington, D.C.: National Conference of State Legislatures, 1999):1.

4. U.S. Census, 1998. URL= http://www.census.gov/population/estimates/nation/intfile2-1.txt

5. Ibid.

6. Alan Guttmacher Institute, Teen Sex and Pregnancy.

7. "Teen Pregnancy Clock Ticking On The Web; New Site Dedicated To Adolescent Pregnancy Prevention," KidSource Online, May 1996. URL= http://www.kidsource.com.

8. Alan Guttmacher Institute, Teen Sex and Pregnancy.

9. Patricia Donovan, "Falling Teen Pregnancy Rates: What's Behind the Declines?" The Guttmacher Report on Public Policy 1, no. 5, (October 1999): 6-9.

10. Child Trends, Facts at a Glance (Washington, D.C.: Child Trends, December 1999): 2.

11. Deirdre Wulf, Jennifer Frost, and Jaqueline E. Darroch, Microbicides: A New Defense Against Sexually Transmitted Diseases. (New York: The Alan Guttmacher Institute, 1999.), 6.

12. Alan Guttmacher Institute, Teen Sex and Pregnancy.

13. Planned Parenthood, Reducing Teen Pregnancy Fact Sheet (New York: Planned Parenthood Federation of America, October 1999), 6.

14. J.C. Day, Population projections of the United States by age, sex, race and Hispanic origin: 1995 to 2050. 1996

15. National Campaign to Prevent Teen Pregnancy, Fact Sheet, May 1999. URL= http://www.teenpregnancy.org.

16. National Campaign to Prevent Teen Pregnancy. Fact Sheet: Teen Pregnancy and Childbearing Among Latinos in the United States, May 1999. http://www.teenpregnancy.org.

17. Ibid.

18. National Family Planning and Reproductive Health Association, Title X Facts, 1999. URL= http://www.nfrprha.org.

19. Ibid.

20. Alan Guttmacher Institute, Issues in Brief, The U.S. Family Planning Program Faces Challenges and Change, 1998. URL=http://www.agi-usa.org/pubs/ib3.html.

21. Cynthia Dailard, "Title X Family Planning Clinics Confront Escalating Costs, Increasing Needs," The Guttmacher Report on Public Policy 2, no. 2, (April 1999): 1.

Office of Population Affairs, URL= http:// www.hhs.gov/progorg/opa.

22. Office of Population Affairs, URL= http:// www.hhs.gov/progorg/opa.

23. Alan Guttmacher Institute, Issues in Brief, Title X and the U.S. Family Planning Effort. 2000. URL= http://www.agi-usa.org/pubs/ib16.html.

24. Office of Population Affairs, URL= http:// www.hhs.gov/progorg/opa.

25. Office of Population Affairs, URL= http:// www.hhs.gov/progorg/opa.

26. Ibid.

27. Alan Guttmacher Institute, Issues in Brief, Title X and the U.S. Family Planning Effort. 2000. URL= http://www.agi-usa.org/pubs/ib16.html.

28. Ibid.

29. Alan Guttmacher Institute. Issues in Brief, The U.S. Family Planning Program Faces Challenges and Change.

30. J.D. Forrest and R. Samara, "Impact of Publicly Funded Contraceptive Services on Unintended Pregnancies and Implications for Medicaid Expenditure," Family Planning Perspectives 28, no.5 (September/October 1996): 188-95.

31. Cynthia Dailard, "Title X Family Planning Clinics Confront Escalating Costs, Increasing Needs," The Guttmacher Report on Public Policy 2, no. 2, (April 1999): 1.

32. Alan Guttmacher Institute. Issues in Brief, The U.S. Family Planning Program Faces Challenges

33. Alan Guttmacher Institute, Issues in Brief. Title X and the U.S. Family Planning Effort.

34. National Family Planning and Reproductive Health Association, Title X Facts, 1999. URL= http://www.nfrprha.org.

35. Alan Guttmacher Institute. Issues in Brief, The U.S. Family Planning Program Faces Challenges.

36. Health Care Financing Administration, URL= http://www.hcfa.gov.

37. NHeLP, Medicaid Coverage for Reproductive Health Services, March 1999. URL= http://www.healthlaw.org/pubs/19990305reprofactsheet.html.

38. Abigail English, Madlyn Morreale, and Amy Stinnett, Adolescents in Public Health Insurance Programs: Medicaid and CHIP, (North Carolina: Center for Adolescent Health and the Law, December 1999): 61.

39. State Children's Health Insurance Program 1999 Annual Report, (Washington, D.C.: National Conference of State Legislatures and the National Governors' Association, January 1999):135-136.

40. NHeLP, Fact Sheet: EPSDT, prepared by Jane Perkins. March 1999. URL= http://www.healthlaw.org/pubs/19990323epsdtfact.html.

41. Abigail English, Madlyn Morreale, and Amy Stinnett. Adolescents in Public Health. 61.

42. Ibid., 68.

43. Ibid., 61.

44. Alan Guttmacher Institute. Contraceptive Services, Facts In Brief. 1998. URL= http://www.agi-usa.org/pubs/fb_contr_serv.html.

45. J.D. Forrest, and R Samara, "The Impact of Publicly Funded Family Planning," Family Planning Perspectives 28, no. 5: (New York, Alan Guttmacher Institute, September/October 1996): 188.

46. National Family Planning and Reproductive Health Association, Family Planning Facts, 1999. URL= http://www.nfrprha.org.

47. The Alan Guttmacher Institute, "California's Expansion of Medicaid Family Planning Approved," The Guttmacher Report on Public Policy 3, no. 1(New York, February 2000): 13.

48. Health Care Financing Administration. Medicaid Eligibility. URL= http://www.hcfa.gov/medicaid/meligib.htm.

49. Rachel Benson Gold, "Block Grants Are Key Source of Support for Family Planning." The Guttmacher Report on Public Policy 2, no. 4 (New York, August 1999).

50. Rachel Benson Gold, and Adam Sonfield, "Family Planning Funding Through Four Federal-State Programs, FY 1997," Family Planning Perspectives 31, no. 4 (New York, 1999).

51. Ibid.

52. Ibid.

53. Rachel Benson Gold, "Block Grants."

54. Mathematica Policy Research, Incorporated. Synopsis of the Evaluation of Abstinence Education Programs. URL= http://38.150.5.70/abstinencesynop.htm.

55. Mary Guiden, Teen Pregnancy Prevention, A Legislator's Guide. (Denver: National Conference of State Legislatures. 1999.

56. Ibid.

57. Douglas Kirby, No Easy Answers: Research Findings on Programs to Reduce Teen Pregnancy. (Washington, D.C: The National Campaign to Prevent Teen pregnancy, 1997).

58. Ibid.

59. Sonja Hoover, Welfare Reform and the States' Efforts to Prevent Births Outside of Marriage, (Washington, D.C.: National Conference of State Legislatures, May 1998): 9.

60. Shepherd Smith, President, Institute for Youth Development. Phone conversation with author, May 2, 2000.

61. Mary Guiden, Teen Pregnancy Prevention, A Legislator's Guide.

62. Administration for Children and Families, DHHS. Fact Sheet: Social Services Block Grant. 2000.URL=http://www.hhs.gov.

63. Welfare Academy. 1996 Green Book, Section 11. URL=http://www.welfareacademy.org/research/greenbook/SECT11/11prog.htm.

64. Ibid.

65. Rachel Benson Gold, "Block Grants."

66. American Psychological Association. Fact Sheet: Social Services Block Grant. 2000. URL= http://www.apa.org/ppo/fy2000socialser.html.

67. Welfare Academy. 1996 Green Book.

68. Ibid.

69. Rachel Benson Gold, "Block Grants."

70. Sheri Steisel, A Checklist for State Legislators.

71. Rachel Benson Gold, "Block Grants."

72. Rachel Benson Gold and Adam Sonfield, "Family Planning Funding."

73. Rachel Benson Gold, "State CHIP Programs Up and Running, But Enrollment Lagging," The Guttmacher Report on Public Policy 2, no.5 (New York, 1999): 6-9.

74. Abigail English, Madlyn Morreale, and Amy Stinnett, Adolescents in Public Health.

75. American College of Nurse-Midwives and Advocates for Youth. CHIP and Adolescent Reproductive Health table. 2000.

76. Texas SCHIP amendment, Health Care Financing Administration (HCFA), November 1999.

77. Pennsylvania SCHIP plan, Health Care Financing Administration (HCFA), May 1998.

78. American College of Nurse-Midwives and Advocates for Youth.

79. "School-Based Health Centers- National Survey 1997/1998 Report (Revised January 1999)," George Washington University, URL=http://www.gwu.edu/~mtg/sbhcs/papers/98natlreport.htm

80. Mary Guiden, Where the Kids Are: School-based Centers May Play a Key CHIP Role. (Denver: National Conference of State Legislatures, Health Policy Tracking Service, December 1998).

81. The George Washington University. National Survey of State SBHC Initiatives School Year 1995-96, May 1997. URL= http://www.gwu.edu/~mtg/sbhc/facts.htm.

82. Ibid.

83. Mary Guiden, Where the Kids Are.

84. "School-Based Health Centers- National Survey 1997/1998 Report (Revised January 1999)," George Washington University, URL=http://www.gwu.edu/~mtg/sbhcs/papers/98natlreport.htm

85. P Newacheck,. et al, "Adolescent Health Insurance Coverage: Recent Changes and Access to Care," Pediatrics 104, no. 2 (1999): 195-202.

86. Marie Cohen, Tapping TANF: When and How Welfare Funds Can Support Reproductive Health or Teen Parent Initiatives, (Washington, D.C.: Center for Law and Social Policy, April 1999). URL= http://www.clasp.org/pubs/teens/tappingtanf.htm.

87. Ibid.

88. Sheri Steisel, A Checklist for State Legislators.

89. Ibid.

90. Sheri Steisel, Senior Committee Director, NCSL -Human Services Committee, personal conversation with author, March 1999.

91. Marie Cohen, Tapping TANF.

92. Ibid.

93. Sheri Steisel, A Checklist for State Legislators.

94. Ibid.

95. National Campaign to Prevent Teen Pregnancy. Teenage Pregnancy Provisions in the Welfare Reform Bill. URL=http://www.teenpregnancy.org.

96. Patricia Donovan, "The Illegitimacy Bonus and State Efforts to Reduce Out-of-Wedlock Births." Family Planning Perspectives 31, no. 2 (March/April 1999).

97. Ibid.

98. Nicole Kendell and Sheri Steisel, "Abstinence Education," Legisbrief, Denver: NCSL, April/May 1999.

99. Patricia Donovan, "The Illegitimacy Bonus."

100. Ibid.

101. Health and Human Services News, Press Release: HHS Awards $100 Million to States Achieving Biggest Reductions in Out-of-Wedlock Births. September 13, 1999.

102. National Campaign to Prevent Teen Pregnancy, Teenage Pregnancy Provisions in the Welfare Reform Bill. URL= http://www.teenpregnancy.org.

103. Ibid.

104. Alan Guttmacher Institute, Teen Sex and Pregnancy.

105. Health and Human Services, Trends in Adolescent Pregnancy and Childbearing. URL= http://www.hhs.gov/progorg/opa.

106. National Campaign to Prevent Teen Pregnancy, Teenage Pregnancy.

107. Sonja Hoover, Welfare Reform, 7.

108. Emily Cornell, Issue Brief: State Role in Preventing Teen Pregnancy, National Governors' Association, January 14, 2000.

109. Dana Reichert and Jack Tweedie, Programs and Services Funded with TANF and MOE. Denver: National Conference of State Legislatures, September 1999.

110. Steve Christian and Julie Poppe, How States Are Using TANF for Children's Services. Denver: National Conference of State Legislatures.

111. National Campaign to Prevent Teen Pregnancy, Fact Sheet: Teen Pregnancy and Childbearing.

112. Ann Morse, SCHIP and Access for Children in Immigrant Families, Washington, D.C.: National Conference of State Legislatures, January, 2000.

113. Ibid.

114. Dana Reichert, Sheri Steisel, and Jack Tweedie, Flexibility to Meet Challenges: Using TANF Block Grant and State MOE Dollars. Denver: National Conference of State Legislatures.

115. Marie Cohen, Tapping TANF.

116. Partnership for Responsible Parenting (PRP)

117. Partnership for Responsible Parenting (PRP) URL=http://www.responsibleparenting.org/press/10_5_98.html.

118. Partnership for Responsible Parenting (PRP) URL=http://www.responsibleparenting.org/about/milestones.html.

119. Marie Cohen, Tapping TANF.

120. Partnership for Responsible Parenting (PRP) URL=http://www.responsibleparenting.org/community/program.html.

121. Ibid.

122. Terry Rhodes, Project Director, Ounce of Prevention Fund, telephone conversation with author, April 6, 2000.

123. Ibid.

124. Ibid.

125. Terry Rhodes, "Public/Private Partnership to Commence Multi-Million Dollar Project to Prevent Teen Pregnancy," (press release, March 11, 1999).

126. Terry Rhodes, telephone conversation with author, April 6, 2000.

127. Ibid.

128. Lucretia Washington, AHYD Program Manager, Georgia Department of Human Resources, personal correspondence with author, April 20, 2000.

129. Georgia Department of Human Resources URL= http://www2.state.ga.us/Departments.DHR.

130. Office of Adolescent Health and Youth Development: Fact Sheet. Georgia Department of Human Resources.

131. Ibid.

132. Ibid.

133. Office of Adolescent Health and Youth Development: Evaluation Fact Sheet. Georgia Department of Human Resources.

134. Sharma Klee, director, Maternal and Child health Branch, Kentucky Department of Public Health, telephone conversation with author, April 4, 2000

135. John Webb, Health Program Administrator. Maternal and Child Health Branch, Kentucky Department of Public Health, telephone conversation with author, April 4, 2000.

136. Sue Bell, Nurse Consultant for the Family Planning Program in the Kentucky Department for Public Health, electronic mail correspondence with author, March 31, 2000.

137. Ibid.

138. Sharma Klee, telephone conversation with author, April 4, 2000.

139. "Report of statistical monitors comparing baseline year with the first year of service," fax received from Sue Bell, Nurse Consultant for the Kentucky Department for Public Health, April 3, 2000.

140. Ibid.

141. John Webb, telephone conversation with author, April 4, 2000.

142. Ibid.

143. Ibid.

144. Michelle A. Louy, Adolescent and School Health Unit, New York State Department of Health, electronic mail correspondence with author, April 6, 2000.

145. Ibid.

146. Ibid.

147. Ibid.

148. Marie Cohen, Tapping TANF. 12-13.

149. Ibid., 14.

150. Douglas Kirby, No Easy Answers. 11.

151. Ibid. 37.

152. Jacqueline E Darroch, and Susheela Singh, Why is Teenage Pregnancy Declining? The Roles of Abstinence, Sexual Activity and Contraceptive Use,(New York: Alan Guttmacher Institute, December 1999), 12.

153. Centers for Disease Control and Prevention. Teenage Births in the United States: National and State Trends, 1990-1996. URL= http://www.cdc.gov/nccdphp/drh/pdf/teenbrth.pdf.

154. The Annie E. Casey Foundation. When Teens Have Sex: Issues and Trends. URL= http://www.aecf.org/kidscount/teen/overview/overview2.htm.

155. Douglas Kirby, No Easy Answers.

156. The National Campaign to Prevent Teen Pregnancy, Just Say Know: How Public Service Media Campaigns Change Attitudes and Behaviors, (press release, February 11, 1998).

157. Ibid.

158. Mary Guiden, Teen Pregnancy Prevention, A Legislator's Guide.

159. Ibid.

160. David Landry, Lisa Kaeser, and Cory Richards, "Abstinence Promotion and the Provision of Information About Contraception in Public School District Sexuality Education Policies," Family Planning Perspectives 31, no. 6, (November/December 1999): 280.

161. Ibid.

162. Ibid. p 294.

163. Douglas Kirby, No Easy Answers. 31.

164. Ibid.

165. Kristin Moore, and Barbara Sugland, Next Steps and Best Bets: Approaches to Preventing Adolescent Childbearing, (Washington, DC: Child Trends, January 1996.)

166. Douglas Kirby, No Easy Answers.

167. Ibid.

168. Michael D. Resnick et al, "Protecting Adolescents From Harm: Findings From the National Longitudinal Study on Adolescent Health," JAMA 278, no. 10, (September 1997): 823-834.

169. Ibid., 830.

170. Douglas Kirby, No Easy Answers, 42.

171. Resource Center for Adolescent Pregnancy Prevention, Effective Practices.

172. Douglas Kirby, No Easy Answers. 42.