Early this year, Congress will work to
renew welfare reform by reauthorizing the Temporary Assistance for
Needy Families (TANF) program. As part of this process, Congress
will also seek to reauthorize the Title V abstinence education
program that was created, along with TANF, in the original 1996
welfare reform act, the Personal Responsibility and Work
Opportunity Reconciliation Act (PRWORA). It is expected that
advocates of "safe sex" programs will use the welfare reform debate
as an opportunity to push for additional federal funding for
comprehensive sex education and contraception promotion programs in
the name of reducing the occurrence of teen pregnancy and
out-of-wedlock childbearing.
In
fact, programs promoting contraceptive use already receive very
large amounts of government funding. In 2002, the federal and state
governments spent an estimated $1.73 billion on a wide variety of
contraception promotion and pregnancy prevention programs. More than a
third of that money ($653 million) was spent specifically to fund
contraceptive programs for teens.
By
contrast, programs teaching teens to abstain from sexual activity
received only an estimated $144.1 million in the same year.
Overall, government spent $12 to promote contraception for every
dollar spent to encourage abstinence. In addition, most
contraceptive promotion or comprehensive sex-ed curricula contain
material that is alarming and offensive to most parents.
This
funding asymmetry seems out of line with general social priorities.
Early sexual activity has harmful effects on the health,
psychological well-being, and long-term life prospects of teens,
and these harmful effects will be reduced only slightly by
contraceptive use.
Regrettably, relatively few teens receive
a clear message about the harmful effects of early sexual activity;
few are taught that society expects teens to delay sexual activity.
Instead, most safe sex/comprehensive sex-ed programs send the
clear, if implicit, message that society expects and condones teen
sexual activity. The main message is that it's okay for teens to
have sex as long as they use condoms.
Any
new monies devoted to preventing pregnancy should be directed not
to amply funded contraception programs, but to abstinence education
programs that teach teens to delay sexual activity, reveal the harm
caused by casual sex with multiple partners, and help young people
to prepare for fidelity, intimacy, and healthy marriage.
Government Funding for Contraceptive
Promotion and Services
Government-funded contraceptive programs
promote the use of contraception for two purposes: to prevent
unwanted pregnancy and to reduce the risk of infection by sexually
transmitted diseases (STDs). To meet these goals, government
contraceptive programs may provide contraceptive services, promote
and encourage contraceptive use, or both.
A
substantial amount of government funding is devoted to encouraging
and facilitating contraceptive use among teens. Programs pursuing
this goal are often called safe sex programs, comprehensive sex-ed
programs, or STD prevention programs. These programs are also
misleadingly characterized as "abstinence plus" or "abstinence
first" programs although, in fact, they contain little or no
abstinence content.
Federal Funding
The
federal government currently supports contraceptive programs to
prevent pregnancy and STDs through eight separate funding streams.
These include Medicaid; Temporary Assistance for Needy Families
(TANF); Title X Family Planning; Indian Health Service funding; the
Division of Adolescent School Health (DASH) of the Centers for
Disease Control and Prevention (CDC); the Social Services Block
Grant (SSBG); the Community Coalition Partnership Program for the
Prevention of Teen Pregnancy; and the Preventive Health and Health
Services Block Grant.
Medicaid Family Planning Funding
The
Medicaid program is administered through the Center for Medicaid
Services (CMS) in the Department of Health and Human Services
(HHS). Established through the Social Security Amendments of 1965,
Medicaid is the third largest source of health insurance in the
United States and the largest source of funding for health-related
services for America's poorest families. It is a joint federal and
state program, with eligibility standards, benefits packages,
payment rates, and administration established by each individual
state under the same broad federal guidelines. Because it is a
means-tested program, eligibility for Medicaid is based on a
combination of income and resource standards.
According to federal law, the provision of
family planning services and supplies is a mandatory component of
the Medicaid program; such services must be provided by all states.
The federal government reimburses Medicaid family planning services
at a 90 percent matching rate--a rate far higher than that for most
medical services. (The 90 percent matching rate means that the
federal government pays for 90 percent of the costs of family
planning services provided by the states through Medicaid.)
The
government defines Medicaid family planning services as
follows:
Family planning
services are those provided to prevent or delay pregnancy or to
otherwise control family size. Counseling services, laboratory
tests, medical procedures, and pharmaceutical supplies and devices
are covered if they are provided for family planning purposes....
Only items and pro-cedures clearly provided or performed for family
planning purposes may be matched at the 90 percent rate. The 90
percent matching rate is not available for procedures that are
performed for medical reasons.
The types of contraceptive services offered through
Medicaid are determined by the individual states. Currently, most
state Medicaid programs offer a wide variety of contraceptive
services, including oral contraceptives, condoms, diaphragms,
spermicides, natural family planning, sponges, cervical cap,
vaginal film, and sterilization through vasectomy or tubal
ligation. In many states, Medicaid family planning funds are also
used to support school-based clinics.
Medicaid is the largest source of publicly
funded family planning services in the United States. Due to
federal waivers, Medicaid funds available for family planning have
increased very rapidly in the past several years, reaching $926.9
million in fiscal year (FY) 2001. Of this amount, 90 percent
($834 million) was federal. An estimated $63 million in
federal funds went to pregnancy prevention and contraception
services among teens.
Calculating the cost of contraceptive
services funded through Medicaid is complicated by the fact that
Medicaid "family planning" charges often include such ancillary
medical services as gynecological exams, pap smears, STD tests, and
pregnancy tests. Medicaid rules are clear that these services are
not fundable as family planning if they are provided independently
or for purposes other than pregnancy prevention.
However, if these services are routinely
integrated as part of the contraceptive service provided to
individuals, they could be counted as family planning expenses. For
example, if a clinic performs gynecological exams and pap smears as
a routine procedure when providing contraceptives to individuals,
these services could be included as part of overall family planning
costs.
The
share of overall Medicaid family planning expenditures resulting
from these ancillary medical services is unknown. For purposes of
this paper, we have estimated that two-thirds of Medicaid family
planning costs covers contraceptives per se, while one-third covers
ancillary medical services. Thus, excluding expenditures
for ancillary services, we estimate that federal Medicaid
expenditures for contraceptive services were $555 million in 2002
(two-thirds of $834 million). Expenditures for teens were $42
million. These reduced figures, excluding ancillary medical costs,
are included in columns B and C of Table 1.
Temporary Assistance for Needy
Families
The
Temporary Assistance for Needy Families program was created as part
of the 1996 Personal Responsibility and Work Opportunity
Reconciliation Act. TANF is operated by the Administration for
Children and Families (ACF) within the Office of Family Assistance
in the Department of Health and Human Services.
One
of the major goals of the TANF program is to reduce out-of-wedlock
childbearing; therefore, states are free to use federal TANF funds
for pregnancy prevention. According to TANF financial data, 37
states spent federal TANF funds on pregnancy prevention in FY 2002.
Overall, some 2 percent of federal TANF expenditures ($323.9
million) was spent on pregnancy prevention programs in that year. State
approaches to preventing teen pregnancy can be divided into several
categories, including sex education curricula, reproductive health
services, youth development programs, media campaigns, efforts to
prevent repeat teen births, and multiple component
interventions.
A
small amount of TANF pregnancy prevention funds was spent on
abstinence education. Eight states--Florida, Illinois, Kentucky,
Louisiana, New Mexico, Pennsylvania, South Carolina, and
Virginia--clearly describe funding of abstinence education as part
of their formal TANF state plan. However, contacts with abstinence
educators at the state level suggest that relatively little TANF
funding is actually going to abstinence.
Based on a survey of state TANF plans and
contacts with abstinence educators, we estimate that, overall, no
more than 5 percent of TANF pregnancy prevention funds was
channeled into abstinence education. On the basis of that
estimate, 95 percent of federal TANF pregnancy prevention funds
($307.7 million) would have been spent on contraceptive-based
pregnancy prevention, and 5 percent ($16.2 million) would have been
spent on abstinence, in 2002. These figures appear in column A of
Table 1.
According to the TANF Fifth Annual Report
to Congress, "Most pregnancy prevention programs have focused on
teenagers." Our analysis assumes,
therefore, that two-thirds of federal TANF spending on
contraceptive-based pregnancy prevention was directed to teen
programs and services. This would mean that $204.9 million was
spent on contraception promotion for teens through the TANF program
in 2002.
This figure appears in column C of Table 1.
Title X Family Planning
The
Title X program is operated by the Office of Population Affairs
(OPA) within the Office of Public Health and Science in the
Department of Health and Human Services. It is the only federal
program exclusively focused on the provision of family planning
services on a nationwide basis. Grants are provided for voluntary
family planning services through the family planning program,
established by the Public Health Service Act of 1970.
Title X funds are allocated among 10
regional offices, which then award grants and monitor services
among a national network of community-based clinics, state and
local health departments, hospitals, university health centers,
Planned Parenthood affiliates, independent clinics, and public and
nonprofit agencies. The program supports a nationwide network of
more than 4,600 clinics that provide reproductive health services
to approximately 4.4 million people each year. In nearly 75 percent
of counties in the United States, at least one provider of
contraceptive services is funded by the Title X family planning
program.
The
program is designed to provide access to a broad range of family
planning methods and services. It provides Food and Drug
Administration-approved methods of contraception, contraceptive
supplies, and information to all who want or need them, with
priority given to low-income persons aged 15 to 44. In addition to
contraceptive services and related counseling, Title X-supported
clinics also provide preventive health services, including breast
and pelvic examinations; cervical cancer, STD, and HIV screenings;
and pregnancy testing and counseling.
Despite the fact that legal authorization
for the program expired in 1985, Congress continues to appropriate
money for Title X. Federal appropriations for this program for 2002
totaled $265 million. This figure appears in
column A of Table 1. As in the case of the Medicaid program, our
analysis assumes that one-third of Title X funding goes for
ancillary medical services such as gynecological exams and pap
smears; this would leave $177 million of federal Title X funding to
promote contraception services. According to the U.S.
General Accounting Office, roughly one-third of the program's
clients are teens. Therefore, in 2002, roughly $59 million was
spent on teen pregnancy prevention and contraception. These
figures appear in columns B and C of Table 1.
Direct Health Care Services for American
Indians and Alaskan Natives
Health care services for American Indians
and Alaskan Natives are administered by Indian Health Services
(IHS) within the Department of Health and Human Services. The IHS
is responsible for providing health services to members of
federally recognized tribes as part of the special
government-to-government relationship between the federal
government and Indian tribes. As the principal federal health care
provider and health advocate for Indian people, it currently
provides health services to approximately 1.5 million American
Indians and Alaska Natives who belong to more than 557 federally
recognized tribes in 35 states.
The
IHS provides teenage pregnancy programs through a wide array of
community-based services and programs. Teen pregnancy prevention
activities are provided through the hospitals and clinics, as well
as local community and school-based adolescent health care centers.
Services provided for teens include pregnancy testing and
counseling, family planning counseling, and contraceptive
education.
In
2002, out of $3.06 billion that was available for direct health
care services for American Indians and Alaskan Natives, $119
million was spent on pregnancy prevention efforts. This
figure appears in columns A and B of Table 1. It is unknown how
much of that funding is specifically directed to teens, although,
according to an HHS document, "Many IHS programs aim to improve the
health of Indian children and adolescents."
Division of Adolescent School Health
The
Division of Adolescent School Health (DASH) is operated by the
Centers for Disease Control and Prevention in the Department of
Health and Human Services. DASH exists to support the development
and implementation of health promotion policies and programs that
address priority health risks among youth.
DASH
provides funding and technical support for coordinated school
health programs, HIV prevention, teen pregnancy prevention, and the
prevention of STDs and other related diseases. It supports
national, state, and local organizations, including national
nongovernmental organizations that work with and target various
populations; state and local education agencies; a nationwide
network of training centers that help teachers in every state
provide HIV education within coordinated school health programs;
demonstration centers that train policymakers and program managers;
and universities.
DASH
expenditures for 2002 were $47.6 million, all of which went to
programs for teens. Our analysis assumes that
80 percent of that sum ($38 million) went to support safe sex and
contraceptive programs for teens. This figure appears in columns A,
B, and C of Table 1.
Social Services Block Grant
The
Social Services Block Grant is operated through the Administration
for Children and Families in the Department of Health and Human
Services. The program exists to enable each state to furnish the
social services that are best suited to the needs of its residents.
General Block Grant funds may be used to provide services directed
toward one of the following five goals specified by law: to
prevent, reduce, or eliminate dependency; to achieve or maintain
self-sufficiency; to prevent neglect, abuse, or exploitation of
children and adults; to prevent or reduce inappropriate
institutional care; and to secure admission or referral for
institutional care when other forms of care are not
appropriate.
The
program was designed to consolidate federal assistance to states
for social services into a single grant, increase state flexibility
in using social service grants, and encourage each state to furnish
services related to its five goals. States and other eligible
jurisdictions determine their own social services programs and
receive grant awards quarterly on a fiscal-year basis.
Family planning services are included in
the program's goals and are defined as "educational, comprehensive
medical or social services or activities, which enable individuals,
including minors, to determine freely the number and spacing of
their children and to select the means by which this may be
achieved." Services available include
contraceptive services, counseling and education, reproductive
health care, and fertility services.
The
Social Services Block Grant received $1.7 billion in 2002
appropriations, of which $23.8 million was used for pregnancy
prevention programs. This figure appears in
columns A and B of Table 1. While the amount specifically directed
toward teen pregnancy prevention efforts is unknown, states are
encouraged to use the funds received under this block grant to
offer special services to at-risk youths.
Community Coalition Partnership Programs
for the Prevention of Teen Pregnancy
Community Coalition Partnership Programs
for the Prevention of Teen Pregnancy (CCPP) is operated from and
funded by the Centers for Disease Control and Prevention in the
Department of Health and Human Services. It is a consortium of
several agencies whose aim is to reduce pregnancies among high-risk
adolescents through outreach programs in 11 states among 13
different communities.
Initiated in 1995, the program awards
grants to communities in order to mobilize resources to support
comprehensive teen pregnancy prevention programs. It also provides
support for national nongovernmental education organizations to
help schools implement teen pregnancy prevention programs. In FY
2002, $13.1 million was spent on community coalition pregnancy
prevention programs, all of which focused on teenagers. This
figure appears in columns A, B, and C of Table 1.
Preventive Health and Human Services Block
Grant
The
Preventive Health and Health Services (PHHS) Block Grant is
administered through the Centers for Disease Control and Prevention
in the Department of Health and Human Services. Grants awarded
through this program provide states with funds to improve their
residents' quality of life and reduce high-risk behaviors and
activities. This program serves as the primary source of funding to
states for health education and risk-reduction activities. The PHHS
Block Grant provides states with flexibility to tailor disease
prevention and health promotion programs to their health priority
needs while enabling states to implement new programs and respond
to unexpected emergencies.
The
PHHS Block Grant is the primary source of flexible funding that
gives states the latitude to fund any of 265 national health
objectives identified in the nation's Healthy People 2010 health
improvement plan, including family planning and pregnancy
prevention services. Its funding is used to support, among other
things, clinical services, preventive screening, laboratory
support, public education, data surveillance, and program
evaluation.
Because of the variance in the allowable
uses of the funds, no two states allocate their block grant
resources in the same way, and no two states provide similar
amounts of funding to the same programs or activities. A strong
emphasis is being placed on adolescents, communities with little or
poor health care services, and disadvantaged populations. The
states depend on this block grant to support public health funding
where no other adequate resources are available.
In
FY 2002, PHHS Block Grants totaled $134.9 million, a portion of
which went toward pregnancy prevention efforts. In that year, states used
$1.4 million to fund maternal and child health programs and family
planning programs. Additionally, states used $2.03 million on
sexually transmitted disease programs, emphasizing contraception.
In total, the PHHS Block Grant provided at least $3.4 million to
states for contraceptive and pregnancy prevention programs, many of
which were likely to have been directed at teens, although the
specific amount is unknown. This figure appears in
columns A and B of Table 1.
State and Local Funding
State Funding for Programs to Prevent Teen
Pregnancy
Many
states have large-scale programs to reduce teen pregnancy that are
funded by state revenues. Most of these programs focus on
encouraging or facilitating contraceptive use among teens.
One
survey published by the Urban Institute found that states spent
$328.3 million of their own revenues on teen pregnancy prevention
programs in 1999. The survey found that 44
states had specific policies to provide contraceptive services to
teens; 28 states had specific pregnancy prevention programs in
public schools. More recent data on state spending to prevent teen
pregnancy are not available, but it seems unlikely that funding has
fallen below the 1999 levels.
It
is likely, however, that some state teen pregnancy prevention funds
were used to support abstinence education. Our estimates assume
that 10 percent of teen pregnancy funds went to abstinence
programs, while 90 percent ($296 million) was used to support
contraceptive-oriented programs and services. This figure appears
in columns A, B, and C of Table 1.
State Funding for Title X Family
Planning Clinics
Title X clinics are supported by a variety
of funding sources. In 1999, for every $1.00
received by clinics in direct federal Title X funds, state and
local governments provided an additional $1.20.
Assuming that a similar spending ratio
continued in subsequent years, we estimate that Title X clinics
would have received $318 million in state and local funding in
2002. This figure appears in column A of Table 1. As in the case of
federal Title X funds, we estimate that a third of this spending
went to ancillary medical services; this would leave $212 million
in state and local of funds for contraceptive services in Title X
clinics.
This figure appears in column B of Table 1.
As
noted above, one-third of Title X spending is for teens. Roughly
$71 million in state and local Title X contributions went to
provide contraceptives to teens in 2002. This figure appears in
column C of Table 1.
State Funding for Medicaid Family
Planning Services
Under the Medicaid program, states pay 10
percent of family planning costs. In 2002, state Medicaid spending
on family planning came to $93 million. This figure appears in
column A of Table 1. Assuming that one-third of this spending was
for ancillary reproductive health services such as gynecological
exams and pap smears, direct spending on contraceptive services
would have been $62 million. This figure appears in column B of
Table 1. Of that sum, approximately $5 million would have gone to
contraceptives for teens. This figure appears in
column C of Table 1.
State TANF Matching Funds for Pregnancy
Prevention
States are required to contribute matching
or "maintenance of effort" (MOE) funds to the Temporary Assistance
for Needy Families program; these expenditures are financed by
state rather than federal revenue. TANF financial reports for FY
2002 show that $293 million in state TANF Maintenance of Effort
funds was allocated to pregnancy prevention.
These expenditures are likely to overlap
considerably with state spending figures for Title X and for teen
pregnancy prevention, described above. Because of the overlap,
state TANF MOE spending on pregnancy prevention has not been
included in the spending figures in Table 1.
State and Local Funding for STD and HIV
Prevention, Safe Sex, and General Sex Education
State governments also place a heavy
emphasis on STD and HIV prevention among teens. In 1999, 41 states
had a specific state policy requiring or encouraging HIV education
in the public schools; 35 states required or encouraged STD
education in the schools.
Nearly all STD/HIV education programs
place a heavy emphasis on encouraging contraceptive use and "safe
sex." In addition, most public school systems use state and local
funds to provide general sex education; most sexuality education
has a contraceptive orientation. Figures on state and local funding
for STD/HIV education and general sex education are not available,
but given the widespread official policies supporting these
programs, funding is likely to be substantial.
Abstinence Education Programs
Funding for abstinence education is far
more limited and recent than funding for contraceptive services and
promotion. There are only four federal programs that fund
abstinence education.
Title V Abstinence Funding
A
major source of abstinence funding is the Section 510 Abstinence
Education Grant Program, found in Title V of the Social Security
Act, established under the 1996 welfare reform legislation.
Administered as block grants by the Health Resources and Services
Administration (HRSA) of the Department of Health and Human
Services, Title V funds provide abstinence education and, at the
option of states, mentoring, counseling, and adult supervision to
promote abstinence from sexual activity, with a focus on those
groups who are most likely to bear children out of wedlock.
These programs encourage teen abstinence
as preparation for healthy adult marriage. Grants are awarded to
states based on the proportion of all low-income births in the
entire country that occurred among their residents, and states can
use these funds either to create abstinence education programs or
to augment existing programs.
Congress authorized $50 million per year
in Title V grants for FY 1998 through FY 2002. However, as California has
consistently elected not to receive Title V funds, actual spending
has been less than that amount. In 2002, the federal government
spent a total of $43.4 million to fund Title V abstinence
programs. This figure appears in
columns A, B, and C of Table 2.
In
1999, states provided direct service to 1.28 million young people
with Title V funds; two-thirds of these clients were age 14 or
younger. The low numbers of high school students receiving
abstinence education is in line with the states' apparent practice
of focusing primarily on contraceptive promotion in high schools.
SPRANS Abstinence Funding
Funding for abstinence programs is also
available through the Title V Special Projects of Regional and
National Significance (SPRANS) program, administered by the Health
Resources and Services Administration of the Department of Health
and Human Services. Included in SPRANS is the Community-based
Abstinence Education Project Grant Program, which provides direct
grants for public and private entities to develop and implement
abstinence-only education programs for adolescents of ages 12
through 18 in communities throughout the United States.
In
FY 2002, SPRANS received $40 million for the Abstinence Education
Project Grant Program. This sum was increased to $55 million in FY
2003.
This figure appears in columns A, B, and C of
Table 2.
Title XX Adolescent Family Life
Demonstration and Research Program
In
addition, abstinence education funding is available through the
Title XX Adolescent Family Life Demonstration and Research Program
in the Office of Population Affairs within the Office of Public
Health and Science in the Department of Health and Human Services.
Enacted in 1981 as part of the Public Health Services Act (P.L.
97-35), Title XX provides funding for a variety of adolescent
health programs.
Total funding for Title XX in FY 2002 was
$28.9 million. Of this amount, only an estimated $12 million was
directed toward teen abstinence programs. This figure appears in
columns A, B, and C of Table 2.
TANF Funding for Abstinence
As
noted previously, states spent $323.9 million of federal TANF funds
on pregnancy prevention in FY 2002. Based on a review of state TANF
plans and contacts with abstinence leaders, we estimate that
approximately 5 percent of that sum ($16.2 million) went to
abstinence education. This figure appears in columns A, B, and C of
Table 2.
State Funding for Abstinence
State governments are required to match
federal funding for the Title V abstinence program at a 75 percent
rate. Funding from any source--state, local, or private--can be
used in the match.
Abstinence educators report that a large
portion of Title V matching funds takes the form of in-kind
contributions made by local abstinence organizations backed by
private donations. Our analysis assumes, however, that state
funding for abstinence in 2002 was roughly $32.5 million, or 75
percent of federal funding for Title V. This figure appears in
columns A, B, and C of Table 2.
Overall Spending On Pregnancy Prevention,
Safe Sex, and Contraception Promotion Compared to Abstinence
Overall spending totals are shown in both
Tables 1 and 2. Total government spending allocated to family
planning, pregnancy prevention, safe sex, and contraceptive
promotion was approximately $2.23 billion in 2002. However,
these figures are likely to be substantially below real expenditure
totals, since figures on state and local spending on STD/HIV
prevention and general sex education are not available. Individual
program spending figures are shown in column A of Table 1.
As
noted in the prior discussion, accurate spending estimates are
complicated by the fact that some portion of family planning
spending in the Medicaid and Title X programs goes to ancillary
medical services such as gynecological exams and pap smears. We
have attempted to adjust for this in column B of Table 1. In that
column, federal and state spending totals for Medicaid and Title X
have been reduced by one-third to exclude estimated costs of
ancillary medical services. After this adjustment, total government
spending on pregnancy prevention, safe sex, and contraceptive
promotion is estimated to have been $1.73 billion in 2002.
Expenditures on teens, with a similar
adjustment, are shown in column C of Table 1. After adjustment,
total spending on teens for pregnancy prevention, safe sex, and
condom promotion is estimated to have been $653 million in 2002.
Summary spending figures are shown in Chart 1.
An
overall comparison of spending on pregnancy prevention and safe sex
compared to abstinence is shown in Chart 2. Total government
spending on family planning, safe sex, and contraceptive promotion
(after the exclusion of funding for ancillary medical services and
non-related expenditures) was $1.73 billion for adults and teens
combined. By contrast, total spending for abstinence was only
$144.1 million. Thus, the government spent $12 on contraception
services and promotion for each dollar spent on abstinence.
A
similar disparity exists in funding for teens. Total government
spending on family planning, safe sex, and contraceptive promotion
for teens (after the exclusion of funding for ancillary medical
services and non-related expenditures) was $653 million. By
contrast, total spending for teen abstinence was only $144.1
million. Thus, the government spent nearly $4.50 on contraception
services and promotion for teens for each dollar spent on
abstinence.
However, these spending priorities are
exactly the opposite of what parents in the United States say they
want taught to their teens. In a recent Zogby poll, only 8 percent
of parents surveyed said they believe that teaching teens how to
use a condom is more important than teaching teens to abstain from
sexual activity. Instead, an overwhelming majority--85 percent--of
parents said that the emphasis placed on abstinence for teens
should be equal to or greater than the emphasis placed on
contraception. (see Table 3).
Uncertainties in Estimates
The
figures in Table 1 involve a number of uncertainties. The largest
of these is the share of Medicaid and Title X family planning
funding that goes to ancillary medical services such as
gynecological exams and pap smears. These procedures are often
treated as essential components of the provision of contraceptives.
Therefore, they could reasonably be included as a component of the
overall cost of contraceptive services.
However, our analysis has assumed that
ancillary medical costs represented one-third of total family
planning costs in the Medicaid and Title X programs, and we
excluded these ancillary medical costs from the contraceptive
spending totals in columns B and C of Table 1 and from the
comparisons in Chart 2. Others may estimate that the costs of these
ancillary services are higher or lower than our figures.
A
second major uncertainty or inaccuracy is the absence of figures
for state and local spending on HIV/STD prevention and general sex
education. This sum is likely to be
considerable, but information is not available at the present
time.
Other smaller uncertainties exist. The
amount of TANF funding directed to abstinence education is
uncertain, as is state and local funding for abstinence. However,
contacts with abstinence educators suggest that the funds received
from these sources are limited.
Clearly, it would be possible to produce
estimates for contraceptive and abstinence spending that are
somewhat higher or lower than the figures in Tables 1 and 2.
However, no matter how the figures were adjusted, it would be
extremely difficult to produce figures that contradicted the
primary finding that government funding for contraceptive services
and promotion is many times greater than funding for abstinence
education.
For
example, if spending on ancillary medical services were assumed to
be two-thirds of family planning totals in the Medicaid and Title X
programs, rather than one-third as our analysis assumes, total
government spending on contraception would still remain at $1.36
billion and $603 million for teens. The overall spending figure
would be still be 10 times higher than spending on abstinence, and
the teen spending figure would still be four times higher.
Efforts to Expand Contraceptive
Funding
Despite the large current imbalance
between contraceptive funding and abstinence funding, strong
efforts exist to further expand contraceptive funding and to reduce
or eliminate funding for abstinence. For example, as part of the
welfare reform reauthorization process, Representative Henry Waxman
(D-CA) joined with many other liberals on the House Energy and
Commerce Committee in an unsuccessful effort to abolish the
existing Title V abstinence education program and replace it with
new sex education funding that state bureaucracies could use for
either safe sex or abstinence programs. Since the public health
bureaucracies that would control the allocation of these funds are
largely wedded to the "safe sex" approach and are hostile to
abstinence education, the net effect of this legislative change,
had it been enacted, would have been to eliminate a substantial
portion of the abstinence education funds that are currently
available.
Similarly, the Family Life Education Act
(H.R. 3469), sponsored by Representative Barbara Lee (D-CA), seeks
to provide $100 million per year in new funding for "comprehensive
sexuality education" programs. Advocates of this type of
legislation often try to solicit support by claiming that safe sex
or comprehensive sex-ed programs support abstinence. They
frequently mislabel these programs as "abstinence plus" or
"abstinence first" curricula.
These terms, however, are very misleading;
most "abstinence plus" curricula contain little or no abstinence
content.
Typically, comprehensive sex-ed curricula contain only a few token
sentences on abstinence in a text devoted almost exclusively to
promoting condom use. In reality, most of these curricula convey
the message that society expects and condones widespread teen
sexual activity; none conveys the message that society expects
young people to avoid sexual activity throughout their teen
years.
Another effort to expand funding for
contraceptive education is the Work and Family Act,
co-sponsored by Senators Evan Bayh (D-IN) and Tom Carper (D-DE).
This bill would provide $50 million to states' contraceptive
programs to prevent teen pregnancy. The bill's contraceptive
programs are labeled "abstinence first." However, as noted above,
safe sex curricula are habitually passed off as "abstinence"
curricula because they contain a few token references to
abstinence. Advocates of the Bayh-Carper legislation have been
unable to explain how "abstinence first" programs would differ from
existing comprehensive sex-ed/safe sex programs.
Finally, as part of his overall TANF
reauthorization bill, the Work, Opportunity and Responsibility for
Kids Act (WORK) Act, Senator Max Baucus (D-MT) included a new
program to provide $50 million per year in funding for safe sex and
contraception education. The sex education provisions of this bill
closely followed those of the Bayh-Carper Work and Family Act. The
Baucus WORK bill was passed by the Senate Finance Committee in the
summer of 2002 but was never brought to the Senate floor.
Sex-Ed Curricula Materials Deeply
Offensive to Parents
As
noted above, given the popularity of abstinence education among
parents, safe sex and comprehensive sex-ed programs are often
misleadingly labeled "abstinence plus" or "abstinence first."
Advocates of these curricula will disingenuously assert they are
pro-abstinence because they contain a few perfunctory references to
abstinence among materials that are overwhelmingly devoted to
encouraging contraceptive use.
In
addition, safe sex/comprehensive sex-ed curricula generally contain
materials that are deeply offensive to most parents. Most
government-funded safe sex programs contain explicit demonstrations
of contraceptive use, especially condoms. Often, comprehensive
sex-ed programs require middle school students to practice
unrolling condoms on dildos or bananas, and they have students
practice shopping for condoms.
For
example, the sex education program "Focus on Kids" teaches middle
school and high school students that "there are other ways to be
close to a person without having sexual intercourse.... The list
may include body massage, bathing together, masturbation, sensuous
feeding, fanaticizing watching erotic movies, reading erotic books
and magazines." This program is widely
promoted by the Centers for Disease Control.
Another well-known "abstinence plus"
sex-ed curriculum promoted at the CDC is "Be Proud! Be
Responsible!" This curriculum has students engage in homosexual
role-playing; it also encourages middle school and high school
students to "think up a sexual fantasy using condoms" and to "use
condoms as a method of foreplay." Students as young as 13 years old
are taught to "act sexy/sensual when putting condoms on, hide them
on your body and ask your partner to find it" and "tease each other
manually while putting the condom on."
Another aggressively promoted CDC
"abstinence-plus" program, "Becoming a Responsible Teen
(B.A.R.T.)," has students practice putting condoms on a plastic
phallus. In addition, students receive instruction about using
condom lubricants and are told to "find something around the house
or at a convenience store to use as a substitute." If they "don't
have a water-based lubricant handy," they are told that "grocery
store lubricants...grape jelly, maple syrup, and honey" can serve
as substitutes.
Conclusion
Early sexual activity has manifold harmful
effects. Teens who are sexually active are more likely to be
depressed and are more likely to attempt suicide. Beginning
sexual activity at a young age greatly increases the probability of
becoming infected with sexually transmitted diseases. Girls who
begin sexual activity at an earlier age are far more likely to have
abortions.
Women who begin sexual activity at an
early age are far more likely to become pregnant and give birth out
of wedlock and to be single mothers. Since single mothers are far
more likely to be poor, early sexual activity is linked to higher
levels of child and maternal poverty.
Early sexual activity seriously undermines
the ability of girls to form stable marriages as adults. When
compared to women who began sexual activity in their early 20s,
girls who initiated sexual activity at ages 13 or 14 were less than
half as likely to be in stable marriages in their 30s. Beginning
sexual activity at an older age, however, is linked to higher
levels of personal happiness in adult years.
Abstinence education programs seek to
encourage a delay in sexual activity. Abstinence is widely
popular, and many evaluations show that abstinence education
programs can substantially reduce teen sexual activity. Despite
this, there is currently relatively little government funding for
abstinence education.
Total government spending for abstinence
was only $144.1 million in FY 2002. By contrast, total government
spending on family planning, safe sex, and contraceptive promotion
was $1.73 billion in the same year. In other words, the government
spent $12 on contraception services and promotion for each dollar
spent on abstinence.
A
similar disparity exists in funding for teens and youth. In FY
2002, government spending on family planning, safe sex, and
contraceptive promotion for teens was $653 million. By contrast,
total spending for teen abstinence was only $144.1 million. Thus,
the government spent nearly $4.50 on contraception services and
promotion for teens for each dollar spent on abstinence.
This
term, the Senate will act to renew welfare reform by reauthorizing
TANF. This legislation will also include reauthorization of the
Title V abstinence program. As part of TANF reauthorization, it is
likely that some in the Senate will seek to establish new funding
for safe sex/contraceptive promotion programs. Given the alarming
content of most comprehensive sex-ed programs, and given the
current funding imbalance between contraceptive promotion and
abstinence, efforts to increase contraceptive programs for teens
would be dangerously counterproductive.
Melissa G. Pardue is Harry and
Jeanette Weinberg Fellow in Social Welfare Policy in the Domestic
Policy Studies Department, Robert E. Rector
is Senior Research Fellow in Domestic Policy Studies, and Shannan
Martin is Research Assistant in Welfare Policy at The Heritage
Foundation.
Spending Calculations
Medicaid:
Federal Family Planning Funding
Medicaid spending on family planning has
expanded very rapidly in recent years due to federal waivers that
have allowed states to expand the number of beneficiaries. In FY
2000, Medicaid expenditures on family planning were $577.6 million;
of that total, 7.6 percent went to services for youth. See Table 7
at www.dhhs.state.sc.us/NR/rdonlyres/ea5iyls55hidbqvgvj3amti6
uqke4cbibb2nnyd3m5y5n4ic3qlxn27u4lsvcdapbmol
bv6yjozpcj/208200partial.pdf. According to preliminary internal
Center for Medicaid Services (CMS) documents provided by
congressional staff, total Medicaid family planning expenditures
rose to $926.9 million in FY 2001. (These documents are available
from the authors upon request.) Of this amount, some 90 percent
($834.2 million) was federal spending; this figure appears in
column A of Table 1. Our analysis assumes that one-third of
Medicaid family planning spending goes to ancillary medical
services, leaving two-thirds ($555.6 million) for contraceptive
services in 2001. Of the total of $555.6 million, we estimate that
some $42.2 million (7.6 percent) went to services to teens, based
on historic spending patterns.
Federal TANF
Funding for Pregnancy Prevention (ACF)
According to 2002 TANF Financial Data
available at
www.acf.dhhs.gov/programs/ofs/data/tableA_break_2002.html, $323.9
million (2 percent of total federal TANF expenditures) was spent on
pregnancy prevention efforts. Our estimate assumes that 95 percent
of this funding goes to contraceptive promotion and 5 percent to
abstinence education ($307.7 million and $16.2 million,
respectively). According to the TANF Fifth Annual Report to
Congress, "Most pregnancy prevention efforts have focused on
teenagers." The estimate of $204.9 million in funding for
contraception for teens in column C of Table 1 assumes that 66.6
percent of $307.7 million in TANF contraceptive funds went to
teens.
Federal Funding
for Title X Clinics (OPA)
According to the Office of Family Planning
in the Office of Population Affairs at the Department of Health and
Human Services, federal funding for the Title X program was $265
million in FY 2002. See . Our
estimate assumes that one-third of Title X funding was used for
ancillary medical services, leaving $176.6 million available for
contraception promotion; this figure appears in column B of Table
1. Estimated funding for teens appears in column C of Table 1.
According to the General Accounting Office, approximately one-third
of the program's funding is for teens. See Teen Pregnancy: State
and Federal Efforts to Implement Prevention Programs and Measure
Their Effectiveness, GAO/HEHS-99-4, November 1998, p. 34. See also
"Background on the Federal Title X Program," Republican Study
Committee Policy Brief, April 2003, at . One-third of $176.6
million is $58.8 million, spent on teen pregnancy prevention. See
also "Surveillance of Family Planning Services at Title X Clinics
and Characteristics of Women Receiving These Services, 1991," at .
Division of
Adolescent School Health (DASH)
Funding for the DASH program in FY 2002
was $47.6 million, all of which went to programs for teens. Our
estimate assumes that 20 percent of DASH funding went to general
reproductive health services, leaving $38 million available for
contraception promotion programs for teens. See . See also Republican Study
Committee, "2002 Federal Sex-Ed/Contraception vs. Abstinence
Funding," September 6, 2002, at .
Social Services
Block Grant (ACF)
The
Social Services Block Grant received $1.7 billion in 2002
appropriations, of which $23.8 million was used for pregnancy
prevention programs. While the amount specifically directed to teen
pregnancy prevention efforts is unknown, states are encouraged to
use this money to offer special services to at-risk youth. See
"2002 Federal Sex-Ed/Contraception vs. Abstinence Funding" at .
Community
Coalition Partnership Program for the Prevention of Teen Pregnancy
(CDC)
According to the CDC, $13.1 million was
spent on pregnancy prevention programs in 2002 under the Community
Coalition Partnership program. All of this funding was directed to
programs for teenagers. See .
Preventive
Health and Health Services Block Grant (CDC)
According to figures available at , states spent roughly
$3.4 million in Preventive Health and Health Services Block Grant
funds on contraceptive services and related programs in FY 2002.
This sum includes $2.03 million on programs to prevent sexually
transmitted diseases (the majority of which are contraception
promotion programs); $882,893 on family planning services; and
$518,390 on Maternal, Infant, and Child Health programs. No data
were available to determine what proportion of that funding was
spent on teen contraception promotion.
State Funding
Allocated to Teen Pregnancy Prevention
According to a study published by the
Urban Institute, states reported spending $328.3 million of their
own revenues on teen pregnancy prevention in 1999. See Richard
Wertheimer, Justin Jager, and Kristin Moore, "State Policy
Initiatives for Reducing Teen and Adult Nonmarital Childbearing:
Family Planning to Family Caps," November 2000, at . More recent data are not
available. Our estimate assumes that 10 percent of these funds may
go to abstinence education, leaving $295.5 million (in column B of
Table 1) for programs with a contraceptive focus.
State Funding
for Title X Clinics
Title X clinics are supported by a variety
of funding sources. In 1999, Title X grantees reported $737.9
million in total revenues. Of that sum, 25 percent came directly
from the federal Title X program, 12 percent came from other
federal sources, 14 percent came from Medicaid reimbursements, 29
percent came from state and local governments, and 20 percent came
from patient fees and other sources. See "Government Performance
Result Act (GPRA)" at .
In
1999, for every $1.00 received by clinics in direct federal Title X
funds, state and local governments provided an additional $1.20.
Our estimates assume that a similar spending ratio continued in
subsequent years. This means that Title X clinics would have
received $318 million in state and local funding in 2002. As in the
case of federal Title X funds, we estimate that a third of this
spending went to ancillary medical services. This would leave $212
million in state and local funds for contraceptive services in
Title X clinics. This figure appears in column B of Table 1. As
noted above, one-third of Title X spending is for teens. Roughly
$71 million in state and local Title X contributions went to
provide contraceptives to teens in 2002.
State Medicaid
Funding for Family Planning Services
Medicaid spending on family planning has
expanded very rapidly in recent years due to federal waivers that
have allowed states to expand the number of beneficiaries.
According to preliminary internal CMS documents provided by
congressional staff, total Medicaid family planning expenditures
rose to $926.9 million in FY 2001. Of this total, 10 percent ($92.7
million) was state spending; this figure appears in column A of
Table 1. Our analysis assumes that one-third of Medicaid family
planning spending goes to ancillary medical services, leaving
two-thirds ($61.7 million) for contraceptive services in 2001. Of
that $61.7 million total, we estimate that some $4.7 million (7.6
percent) went to services to teens based on historic spending
patterns.
Total Spending
figures for Contraception Promotion
The
figures for total state spending on contraception promotion are
slightly less than the sum of the individual program totals because
of overlap in the funding for some individual programs.
Specifically, the $70.5 million for state Title X funding for teens
and the $4.7 million for state Medicaid funding for teens overlap
with the $295.5 million in "State Funds Allocated to Teen Pregnancy
Prevention." Consequently, the duplicated amount of $75.2 million
has been subtracted from all the spending totals in columns A, B,
and C of Table 1.
Title V
Abstinence Program Federal Block Grants (HRSA)
See
Section 510 of Title V fact sheet at .
SPRANS
Abstinence Education Community-based Grants (HRSA)
See
SPRANS Community-based Abstinence Education Project Grant Program
fact sheet at
.
Title XX
Adolescent Family Life Demonstration and Research Program
(OPA)
According to the Office of Adolescent
Pregnancy Programs, total funding in FY 2002 for Title XX was $28.9
million. The estimate assumes that only $12 million of those funds
was spent on abstinence programs, all of which are directed at
teens. See .
TANF Funding for
Abstinence
According to 2002 TANF Financial Data
available at ,
$323.9 million (2 percent of total federal TANF expenditures) was
spent on pregnancy prevention efforts. Our estimate assumes that 5
percent of this funding ($16.2 million) went to abstinence
education.
State Funding
for Abstinence Education
The
figure $32.55 million equals the state match in the Title V
abstinence funds (75 percent of federal Title V spending). This
figure is also consistent with our assumption that some 10 percent
of the $328.3 million in state funds for pregnancy prevention went
to abstinence. See "State Funding Allocated to Teen Pregnancy
Prevention," above.