In pursuing health care reform, federal and state policymakers
alike need to respect and protect parental rights and
responsibilities. Currently, they are not doing so.
A 14-year-old grade-school girl in Kentucky arrives at the local
health clinic seeking birth control. Who should decide whether she
receives it? The doctor? The girl? Or her parents? The state
legislature says that the girl is not even old enough to consent to
sexual activity. Yet public officials, under authorization from
Congress, have written rules that allow the girl to enroll in one
of a number of federal programs, and this federal law would
overrule state law and prohibit the clinic from informing her
A Common Problem
Thousands of similar situations occur each year- not
surreptitiously, but legally, under the authority of policies and
laws, some of which have been in place for decades. In exercising
this authority, government intrudes into some of our most intimate
living arrangements, separating parents from children, and
putting the family doctor at odds with the wishes of the
As a result, the moral values of ordinary people are often
replaced by those of a health care establishment composed of
government bureaucrats, liberal professional organizations,
industry lobbyists, and major hospital systems. Because they
control the funding and set the health care policies, they can, and
often do, pre-empt many Americans from making health care decisions
that reflect their own values.
In the continuing debate over major reforms in federal health
care policy, these moral concerns are often overshadowed by other
challenges-such as controlling health care costs and providing
accessible health insurance to low-income Americans. But in
addressing these problems, policymakers at the state and federal
level must not choose solutions that would override individuals'
deeply held convictions. This is especially important in our
religiously and morally pluralistic society.
The debate over health care solutions is focused on two broad
and very different approaches to comprehensive reform. One is a
government-controlled insurance program, either centrally managed
and regulated or based almost exclusively on government payment.
The other is based on personal choice and market competition, where
individuals and families make the key financial decisions,
particularly when it comes to insurance coverage, benefits,
medical procedures, and treatments. On the question of whose moral
values are controlling the sensitive matter of health care
decision-making, these two approaches are worlds apart.
A national health insurance program, government-run or
government-controlled, would centralize control over health
care financing and delivery, and would centralize the power of
approved third-party payers to impose their values on a morally
pluralistic society. Political decisions would, in effect, supplant
moral ones. A reform based on personal choice and competition in a
pluralistic market would ensure that patients-or in the case
of minors, their parents-exercise the primary control over how
their health care dollars are spent, allowing them to make health
care decisions that are consistent with their values. A
market-based reform, in other words, is inherently compatible
with parental authority.
The Bureaucratic Suppression of Moral
Current federal health insurance programs routinely govern
the health care of minors in ever larger numbers, and in so doing,
government officials pre-empt or interfere with important
decisions that should be made by parents. In contrast, new
policies that would inject principles of consumer choice and
competition into the financing and delivery of health care can
restore respect for the primary relationships between parents and
children, leaving families free to live according to their moral
To better understand how government currently intrudes on these
relationships, consider again the 14-year-old girl in Kentucky
requesting birth control at a health clinic. Examine further
the details from this real-life case:
The girl told the doctor that she was not yet sexually active,
but that the mother of her boyfriend, who had driven her to the
clinic, wanted her on birth control so that her son would not
father a child out of wedlock if they were to have sex. The girl
wants her boyfriend to like her, she told the doctor, and she
wanted to remain on good terms with his mother. That's why she was
asking to be put on prescription birth control. However, she does
not want her parents to find out. Because the girl requested
confidentiality, the doctor had her enroll in a federal
program to pay for the contraception, so that the charges
would not show up on her parents' insurance bill.
Unless they pay close attention to the health care debates in
state legislatures, typical Americans are unaware of the
intrusiveness of current government policy. Representatives of
professional health care organizations often argue that minors
should be allowed to receive reproductive health care without their
parents' knowledge or consent. The American
Association of Pediatrics states bluntly, "Comprehensive
health care of adolescents should include a sexual history that
should be obtained in a safe, nonthreatening environment through
open, honest, and nonjudgmental communication, with assurances of
confidentiality… The primary reason adolescents hesitate or
delay obtaining family planning or contraceptive services is
concern about confidentiality." Specifically for this
reason, Congress enacted a federal law, popularly known as Title X,
which provides that whenever a sexually active minor seeks
confidential birth control, she is to be treated independently from
her parents. Therefore, she can accept birth control without
consulting her parents, and if she requests confidentiality without
parental knowledge, the government will foot the bill for her
contraception and related medical costs, regardless of her parents'
Under current law, Congress makes confidential access to birth
control for school-age girls such a priority that it picks up the
tab even for services that the girl's family insurance would cover.
Since federal law trumps state law, it does not matter that the
laws of her state deem her too young to consent to sex.
Limiting Medical Judgment. Doctors make
delicate decisions about teen health care every day, but current
federal confidentiality rules can render it nearly impossible for a
doctor to perform the medical action that his professional judgment
demands. Consider, for example, the case of the 16-year-old boy in
North Carolina who went to his pediatrician complaining of severe
daily headaches. The doctor questioned the boy after his mother
stepped out of the room, and discovered that the boy regularly used
marijuana and cocaine, and occasionally LSD, hallucinogenic
mushrooms, and Ecstasy. The doctor informed the boy that his
headaches might be related to his drug use, and
recommended that he undergo treatment for substance abuse. The
doctor asked for permission to tell his mother, and the boy said
no. He said he was not afraid of his parents' reaction; he simply
thought he had his drug use under control, it was no big deal, and
his parents would not care. Under North Carolina law, if the
child is on private insurance and the doctor judges the matter
"essential to the life or health of a minor," he can ignore the
boy's request for confidentiality and tell the mother about his
addiction. In this case, the doctor did tell the
mother, and the boy was enrolled in a drug treatment program a
few weeks later.
The Medicaid Angle. If the child's family had
been on Medicaid instead of private insurance, the story would have
been different. Under federal law, Medicaid prohibits any doctor
from breaching the confidentiality of any patient, even to the
parents of children. Had the boy's family been enrolled in
Medicaid, the law would have enforced his right to confidential
medical care, deferring to the short-term self-interest of a
drug-addicted minor and overruling the doctor's expert judgment
regarding his objective medical needs.
In both of these real cases, federal laws and the reigning ethos
of the professional health care associations intrude on
intimate health care choices of parents and families. In both
cases, they exclude parents from key decisions regarding the
welfare of their own children. In both cases, they impose one set
of values on the entire country, trampling on local and state laws
reflecting their communities' deliberate moral judgments.
Government Health Programs Separate Parents and
Problems of parental choice and control are typical in
federal health care programs, especially in Medicaid, SCHIP, and
Medicaid. Medicaid, for instance, prohibits
parental notification for any medical procedure it covers.
This means that children are not required to notify their parents
if, while on Medicaid, they receive any of the following medical
services (this list is not exhaustive):
- abortions (in the cases of rape, incest, and the life of the
- birth control,
- pregnancy tests,
- the morning-after pill,
- tests for sexually transmitted diseases,
- gynecological exams,
- prescription drugs,
- treatment for drug abuse,
- treatment for psychiatric disorders (including depression,
suicide, and attention deficit disorder),
- sexual-orientation counseling, and
- personalized sexual education.
As in the example of the drug-using teenager above, the doctor
is prohibited from informing the parent of a child on Medicaid
about the case, even if the doctor believes it is in the best
interests of the child, unless he can obtain the consent of the
SCHIP. Medicaid is a welfare program. While
children from working and middle-class families are not eligible
for Medicaid, they are often eligible for another federal program
called the State Children's Health Insurance Program (SCHIP). In a
number of states, however, this program is an extension of Medicaid
and offers many of the same services- including abortion, birth
control, psychiatric treatment, substance-abuse treatment,
prescription drugs, and sex education-but specifically for
Under SCHIP each state can elect to apply Medicaid's rules,
or to design an entirely different program from scratch.
Despite this flexibility, however, all 50 states continue to offer
Medicaid-style family planning services for children, and most
states have also continued Medicaid's policies regarding
confidential care for minors. As a result, children from
middle-class families are frequently able to receive these services
without their parents' knowledge.
Title X. In addition to Medicaid and SCHIP,
which pay for a full range of medical care, the federal
government also has a special program that funds only reproductive
health care and activities related to population control, the
above-mentioned Title X. Under Title X, a clinic charges its
clients based on their ability to pay for its services, from
wealthy clients who pay full price to lower-income patients who pay
a nominal fee or nothing at all.
While Medicaid and SCHIP only pay for children who qualify for
their programs, the Title X program will completely cover
confidential birth control for any child who is not independently
wealthy. Once a girl asks that her parents not be notified, as in
the case of the 14-year-old Kentucky girl, the government pays
for her services, which include birth control, the
morning-after pill, gynecological examinations, and abortion.
The Alan Guttmacher Institute, the research arm of Planned
Parenthood, says that Title X is the "gold standard" of teen
confidentiality rules, and it lobbies
federal and state lawmakers to incorporate these rules into
every expansion of government control over health insurance.
Because Title X confidentiality rules are so strong and apply to
children, clinics supported by the program
can even facilitate statutory rape, whereby adult men molest minor
girls. In January of 1996, a 13-year-old girl went to the McHenry
County Health Clinic in Illinois to request Depo-Provera, a
long-term contraceptive injection. She told the doctor that
she was sexually active and that she did not want her parents to
know, so she received confidential services just like the
14-year-old Kentucky girl. After she received a prescription for
the injection, her sex partner-her 37-year-old former teacher at
Crystal Lake Middle School-drove her home from the clinic. They
returned for follow-up shots on multiple occasions before she
finally told her parents in February 1997. More than
two years later, when the parents tried to sue the clinic for
facilitating statutory rape, a county judge ruled that the
doctor's actions were legal under Title X.
Finally, parents should be aware that health clinics based
in public schools receive funds from all three of these federal
programs, and therefore are often governed by their rules
prohibiting parental access to their children's health records.
Nearly three-quarters of school-based clinics receive funds from
Medicaid, and over half also receive funds from SCHIP. Many of these clinics receive Title
X funds themselves or have contracts with Title X clinics to
provide reproductive services and sex education programs. In a
school-based clinic that receives Title X funds, for example, a
wealthy minor on private insurance can, at the discretion of the
doctor, enroll in a government program that permits
confidential access to birth control, STD testing, abortion,
and more. Indeed, the movement toward including more elaborate
clinics in public schools was in part to ensure that teenagers had
access to confidential birth control.
Sound Health Care Reform Can Return Power to
Parents have the primary responsibility
for their children, and thus ought to play a paramount role in any
decisions affecting their children's lives. Doctors and
government officials should certainly be allowed to contribute
their professional advice or financial support, but the parents
must have the ultimate right, in all but extraordinary
circumstances, to raise their children the way they deem best.
Medicaid, SCHIP, Title X, and other government health
insurance programs routinely violate this most basic of principles.
Members of Congress and state legislators alike should, therefore,
take decisive steps to reform all three programs.
Obstacles to Change. Reform-minded
legislators must be prepared, however, to overcome
certain obstacles. Poorer parents often have no choice but to
enroll in a government program such as Medicaid or SCHIP, and
so are at the mercy of the health care establishment that sets the
rules for the program. Because the government provides their
health care, it determines the requirements to remain
eligible-and the result is that it removes the right of the
parent to make many of the key moral decisions that are only the
parents' responsibility. Parents' only practical alternative is to
accept those rules or not have any health insurance at all. If
parents had the ability to choose from a variety of health care
options, they could walk away from a situation in which they were
not happy and seek better treatment elsewhere.
Most people receive their health insurance through the
government or their employer, and do not have the personal power to
change insurance companies except at a very high cost. As a result,
insurance companies, hospitals, and doctors are not required to be
as responsive to the demands of the patients as are suppliers of
other goods and services in a normally functioning competitive
economy. If more Americans controlled their own health
insurance, and could easily switch insurance companies
whenever a better health plan became available, the entire health
care sector of the economy would become much friendlier to
consumers and patients. Greater personal control over health care
dollars, including where to purchase health insurance and from
whom, would lead to a health care system far more responsive to
people's needs than it is today- including their wish to have their
deeply held moral views respected in the financing and delivery of
Key Principles of Sound Reform. Any reform that
gives parents control over the health care decisions for their
families should be based on four principles:
- Individual patients, not employers or government
bureaucrats, should be able to choose their health insurance
coverage for themselves and their families.
- Each person must be able to change insurance companies easily,
without requiring an employment change or suffering major tax
or regulatory penalties as in effect today.
- Each person should have a variety of insurance plans from which
to choose, including health plans that reflect different life
situations and respect individual values.
- Americans should be given ownership of their health insurance
coverage so that an unaccountable third party does not have
control over its contents and quality-and the values it
Parental Values. Parents have the right to pass
on their moral values to their children. That right is often
disregarded in the regular course of financing and delivering
The disconnect between personal values, particularly
traditional moral beliefs, and the reigning ethos is no more
clearly demonstrated than in today's government-controlled health
care programs. In these programs, the ethos governing health care
reflects the values of the bureaucrats, professional organizations,
industry lobbyists, and the administrators of big hospitals
that embody the health care establishment.
Generally speaking, the representatives of these groups share a
commitment to allowing children to receive sexual and mental health
services without their parents' knowledge, consent, or involvement.
While they may publicly warn legislators not to impose traditional
moral values in the formulation or execution of public policy, they
see no contradiction in the forcible imposition of their own
moral perspectives throughout the health care system in every state
in the country, overriding state laws and the protection of
parents' rights. They can do this because the government programs
that they control and influence are, practically speaking, the
only health care options for many people.
Only Fundamental Health Care Reform Will Restore
The experience with Medicaid, SCHIP, Title X, and other
government-funded health insurance programs illustrates the adage,
"He who pays the piper, calls the tune." If someone other than the
patient controls how the doctor is paid, someone other than the
patient controls the moral decisions embodied in the financing and
delivery of care.
For this reason, broad health care reform cannot simply tinker
with the current system in which employers and the government
officials retain the key levers of control. A federally
administered national health insurance plan, based on a set of
moral values determined by "experts," would be particularly
threatening to parents, families, and all those who do not share
the moral values of the health care establishment or of the
reigning political party.
Parents have the primary responsibility for the welfare of their
children, and policymakers must respect their right to make
decisions for their children. A central goal of any health
care reform, therefore, must be to allow parents to own and
control their family's health insurance. This would allow them to
make key moral decisions that affect their children, restoring them
to the role that is naturally and rightfully theirs.
Moloney, Ph.D., is a seminarian for the Catholic Archdiocese of
Boston, and former Senior Policy Analyst
in the Richard and Helen DeVos Center for Religion and Civil
Society at The Heritage Foundation.
 For a more thorough discussion of this
issue, and the related matter of patients' freedom of conscience,
see Robert E. Moffit and Jennifer A. Marshall, "Patients' Freedom
of Conscience: The Case for Values-Driven Health Plans," Heritage
Foundation Backgrounder No. 1933, May 15, 2006, at http://www.heritage.org/research/healthcare/bg1933.cfm.
 Addia Wuchner, "Prepared Statement of
Addia Wuchner, Board of Directors, Northern Kentucky Independent
Health District," testimony for "Protecting the Rights of
Conscience of Health Care Providers and a Parent's Right to Know"
before the Subcommittee on Health, Committee on Energy and
Commerce, U.S. House of Representatives, July 11, 2002, pp. 47-48,
(September 3, 2008).
 See, for example, Madlyn C. Morreale, Amy
J. Stinnett, and Emily C. Dowling, eds., Policy Compendium on
Confidential Health Services for Adolescents, 2nd Edition,
(Chapel Hill, N.C.: Center for Adolescent Health & the Law,
2005), at http://www.cahl.org/PDFs/Policy%20CompendiumPDFs/
PolicyCompendium.pdf (September 3, 2008).
 This example is based on the case
described by Pedro Weisleder, "The Right of Minors to
Confidentiality and Informed Consent,"Journal of Child Neurology,
Volume 19, Number 2 (February 2004), pp. 145-148.
 Pedro Weisleder, "The Right of Minors to
Confidentiality and Informed Consent,"p. 148.
 Sections 1902(a)(7)(A) and 1902(a)(8) of
the Social Security Act; 42 CFR 31. See also the interpretation of
these Medicaid statutes in federal case law, especially T.H. v.
Jones,425 F. Supp. 823 (1975), 425 US 986 (1976) (striking
down a Utah law requiring parental notification as a condition for
a minor receiving Medicaid-funded contraception).
 Section 1937 of the Social Security Act
allows the states to opt out of the default Medicaid benefits
package, and therefore opt out of the federal rules that override
state parental consent laws. Since 2006, when this was made
possible, however, no state has opted to do so.
 Sections 1902(a)(7)(A) and 1902(a)(8) of
the Social Security Act; 42 CFR 31; 45 CFR 164.502. See also
Abigail English, "The HIPAA Privacy Rule and Adolescents: Legal
Questions and Clinical Challenges," Perspectives on Sexual and
Reproductive Health, Vol. 36, No. 2 (March/April 2004), at
(September 3, 2008); and Center for Reproductive Rights, "Parental
Consent and Notice for Contraceptives Threatens Teen Health and
Constitutional Rights," Domestic Fact Sheet No. F008, November
2006, at http://reproductiverights.org/pub_fac_parentalconsent.html
(September 3, 2008).
 42 CFR 59.2: "[U]nemancipated minors
who wish to receive services on a confidential basis must be
considered on the basis of their own resources."
 42 CFR 59.5: "(a) Each project
supported under this part must…(4) Provide services without
regard to religion, race, color, national origin, handicapping
condition, age, sex, number of pregnancies, or marital
status" (emphasis added). See also 42 CFR 59.11.
 John A. Heisler, "Protecting the Rights
of Conscience of Health Care Providers and a Parent's Right to
Know," testimony before the Subcommittee on Health, Committee on
Energy and Commerce," U.S. House of Representatives, July 11, 2002,
pp. 53-57, athttp://purl.access.gpo.gov/GPO/LPS24409(September
3, 2008). For background, see Roy Maynard, "A Public School's
Private Shame," World, August 23, 1997.
 For a more detailed discussion of the
principles of health care reform, see Edmund F. Haislmaier, "Health
Care Reform: Design Principles for a Patient-Centered,
Consumer-Based Market," Heritage Foundation Backgrounder
No. 2128, April 23, 2008, at http://www.heritage.org/Research/HealthCare/bg2128.cfm.