Appendix: Study State Discussion Summaries

This document summarizes the major comments made by participants during a call with representatives from relevant agencies in Alabama. The call took place on November 20, 2001.

Call participants included representatives from:

The Family Assistance Division within the Department of Human Resources (DHR), which administers the State TANF program.
The Bureau of Family Health Services (BFHS) within the Department of Public Health (DPH).

1. Changes in State Efforts Since the Passage of PRWORA

Participants reported that during the last two and a half years the State has expanded both its abstinence education and family planning:

The State has directed the federal abstinence education funds to support the State's Abstinence-Only Education Program. This program uses the federal funds to underwrite the costs associated with three abstinence initiatives: (1) community-based grants that implement abstinence-only education projects; (2) a media campaign and web site; and 3) a comprehensive, five-year longitudinal evaluation in two counties to assess what citizens want in an abstinence program, and to better understand why some individuals, especially adults, do not choose to marry before having children.
Family planning Medicaid waivers were implemented as part of a five-year demonstration project. The program expands Medicaid eligibility for family planning to people who are living at 133% of the poverty level. This waiver program is designed to cover women age 19-34, and complements coverage available under the Children's Health Insurance Program (CHIP).
In 1999, the State launched the Alabama Unwed Pregnancy Prevention Program (AUPPP), a partnership between DPH and DHR, to reduce non-marital births among all women of childbearing age in the State. This program was started as a complement to the waiver program to target teens not covered by the waiver. Administered by the Division of Women's and Children's Health, Bureau of Family Health Services within DPH, AUPPP funds three media campaigns and 28 community-based projects that work to reduce nonmarital births through a variety of mechanisms. Funding for AUPPP programs is provided through TANF.
AUPPP media campaigns are modeled after the National Campaign to Prevent Teen Pregnancy, and include:
- The Alabama Campaign to Prevent Teen Pregnancy, a statewide media campaign that provides information about available medical and social service support programs. The campaign includes the AUPPP web site, pregnancy prevention brochures, and television public service announcements, including four announcements that run during prime time hours.
- The Montgomery Campaign to Prevent Teen Pregnancy, a countywide media campaign.
- The Tuscaloosa Campaign to Prevent Teen Pregnancy, a countywide media campaign.
AUPPP grants provide funding through a competitive application process to local communities to develop multi-component strategies that will assist women of childbearing ages not engage in unprotected sexual activity. The grant budget for fiscal year 2002 is $1.6 million. Grants to date have included:
- Funding to 10 health departments to provide home visitation, ⁽¹⁾ comprehensive health care, and parenting services to adolescents and other at-risk women.
- Funding for three family resource centers that provide youth leadership opportunities, parenting and life skills programs, male responsibility programs, and job skills education.
- Funding to 15 community-based organizations and schools to provide a variety of comprehensive interventions, including abstinence awareness and abstinence-only education programs, case management services, job skills education, self-esteem workshops, mentoring and counseling programs, supportive services for non-custodial adolescent fathers, and school-based pregnancy prevention programs.
AUPPP is also providing funding to the Alabama Chapter of the American Academy of Pediatricians to conduct a survey of State pediatricians and to provide a series of conferences designed to improve pediatricians' skills in delivering health care to adolescents.
The Alabama State University is conducting an evaluation of AUPPP programs.
The State implemented a Care Coordination program that provides risk assessment and case management services to women who are enrolled in family planning. The State expanded this program in June 2001 to include teens age 18 and under, realizing that risk assessment services are particularly apt for teenage clients, who are at particular risk for non-marital childbearing.
The Alabama Fatherhood Initiative provides grants to community-based organizations to prevent early and unplanned fatherhood, strengthen relationships between fathers and children, and to increase child support payments by providing work and training opportunities. Programs were originally funded through TANF and funding is now provided through the Children's Trust Fund. The initiative has provided 35 grants to date. Funding for FY 2002 is $1.2 million.

2. Extent to Which Efforts Focus on Teens and/or Adults

Participants noted that State efforts target both groups, with abstinence education serving primarily teens and family planning services serving primarily adults. Public service campaigns to reduce unintended pregnancy are targeted to both groups.

3. Barriers or Challenges to Program Development and Implementation

Participants said that Alabama has faced a number of challenges reaching the State's growing Hispanic population. For many Hispanic families, the first-generation immigrant parents are not citizens and are therefore not covered by Medicaid; as a result, linking the families to needed services is more difficult than among the Medicaid-eligible population. Language barriers within this population also inhibit service delivery.

Identifying appropriate and effective service delivery models that target adults remains a challenge. Participants said they believe that activities, policies, or programs that attempt to influence the childbearing decisions of adults are likely to be poorly received. Concern about this obstacle served as one of the motives for funding the university survey effort.

Abstinence-only education had very strong support within the State. When Alabama received its abstinence grant, the State decided to create separate funding streams for abstinence and contraception education. The abstinence education programs were developed outside the Division of Women's Health, which operates the Title X program, and grants were awarded to CBOs. This split has enabled local communities to have substantial influence over the content of local abstinence education programs.

An obstacle that they often faced was that it is challenging to get contracts through State system. Some of the contracts that are sent to the governor's office for approval get rejected or slowed down. There is no determined date for when the contracts will be approved. This presents a challenge, especially for smaller CBOs that often have other deadlines or are uncertain about when they should begin the hiring process. Contracts that have higher priorities, such as major health service contracts, are pushed through faster. Smaller contracts such as the ones that are with CBOs are less likely to be on the fast track.

4. Changes in Traditional Roles of State Agencies and Community-Based Organizations

Although TANF has increased the amount of money that is available for State programs, agency roles have not changed substantially since the adoption of PRWORA, participants said. CBO grants remain centrally controlled and originate from the same agencies as under the previous welfare system, but the State is endeavoring to give the CBOs more freedom in program design and implementation. ⁽²⁾ Participants believe that the availability of funding under this system has helped to encourage development of local clinic services, as well as family planning and child heath services. Of the 31 pregnancy prevention grants awarded by AUPPP in fiscal year 2002, three were awarded to develop public awareness campaigns, 10 were awarded to community health departments, three funded family resource centers, eight were awarded to CBOs, three were awarded to school systems, one was awarded to a cooperative extension, and three were awarded to boys and girls clubs.

Since the passage of PRWORA indicated participants, DHR and DPH have enjoyed increased collaboration. The TANF and Public Health agencies have good working relationships. Furthermore, the State legislature does not get involved with TANF money, and the agencies have more latitude in the way that they can spend their money.

Both agencies have engaged in a joint leadership effort to win the bonus in which the Department of Public Health delivers services, and the TANF office ensures the DPH has sufficient funding.

Because DHR is more familiar with the requirements of TANF than the Department of Health, DHR has provided technical assistance to DPH in program design. Primarily, DHR provided contractual and legal assistance, since the money was funded with federal dollars and there were guidelines on how the TANF dollars could be spent.

Collaboration efforts have been successful to some degree because the departments have complementary goals and client bases. Access to family planning can have an impact on self sufficiency by preventing unintended pregnancies. To ensure access to such services, DHR staff refer TANF clients with family planning needs to DPH. DPH staff also refer family planning clients that are in need of TANF services. The State has also co-located some services, establishing outpatient clinics in the Women, Infants and Children (WIC) program offices to provide the family planning services.

One participant State d that the infusion of TANF funding helped to integrate various units of social services. Since PRWORA, DHR and DPH have had more contact with each other at the county level. DHR is more aware of the community programs offered and will generated lists of programs to which they can refer TANF clients.

5. Changes in the Sources of Funding

Approximately $8 million dollars is being spent from the TANF funds on all the programs designed to reduce the number of non-marital births in the State. The amount of TANF funding directed toward efforts to reduce non-marital childbearing has increased since the passage of PRWORA.

B. Role of the Illegitimacy Bonus on Efforts to Reduce Non-marital Births

Alabama, which has experienced declines of 2.0%, 0.3%, and 0.3% during the respective eligible periods, has received the Illegitimacy Bonus in each of the award years (i.e., 1999, 2000 and 2001).

Participants noted that prior to winning the bonus, the State did not expend much effort evaluating bonus provisions or in designing programs with an eye toward influencing outcomes relevant to the bonus. However, after winning the bonus the first time, State officials were motivated to continue to win the bonus and studied the bonus regulations to ensure the State remained eligible to compete in subsequent years. They suddenly had the resources to fund programs community programs, something they had been discussing for years prior to receiving the bonus money. One participant thought that the reason that the Alabama keeps winning the bonus is, in part, because the State has been dedicating the bonus money to expansion and improvement of existing non-marital birth programs, which are working.

The State received $65 million from winning the bonuses. Of that, approximately 50% was spent on non-marital birth programs. Eight million dollars was given to the health department and $1.2 million per year was spent on fatherhood programs. Care coordination programs are used to broaden family planning programs and combine them with a youth development program that will focus on a range of issues including encouraging teens to stay in school.

DHR is currently working on developing several new initiatives in partnership with the Governor's Office, but participants expressed concern about the fate of those programs if the economic downturn continues and the budget surplus is depleted. Participants said that some budget analysts expect that availability of State funding is going to be a problem in three years. Some of the bonus money has been set aside as a "cushion" in the event that the economy sours, which should help ensure that the programs will be able to continue.

One participant said that some agency staff are concerned about the outcome measure being employed for bonus eligibility and competition, noting that States that begin the competition with relatively low non-marital birth rates have a bigger challenge than do other States.

Another participant noted that attributing declines to the non-marital birth ratio to any particular intervention or set of interventions might be problematic, because of the difficulty isolating those interventions from other factors influencing the ratio. The University of Alabama is helping conduct an economic impact study on the State's non-marital birth programs, determine the costs and benefits of the programs and their relative success in reducing teen pregnancies and births. They hope the study will reveal that the programs produce long-term cost savings, and that they will be able to present these findings to the State legislature.

Arizona

This document summarizes the major comments made by participants during a call with representatives from relevant agencies in Arizona. The call took place on November 20, 2001.

Call participants included representatives from:

The Teenage Pregnancy Prevention Program within the Department of Health Services (DHS), and
The Department of Health Services.

1. Changes in State Efforts Since the Passage of PRWORA

Participants noted that in 1997 the State developed a Teen Pregnancy Prevention program, administered by the Department of Health Services (DHS) and funded by the Department of Economic Security through the State's TANF block grant, among other sources.
- Through the program, DHS has awarded contracts to 17 local abstinence-only education programs that serve school-age children (ages 10 - 19) in 12 counties. The programs are delivered in a variety of settings, including schools, after-school programs, detention centers, group homes, and residential treatment centers. Service providers include community-based agencies, schools, hospitals, local health departments, private mental health providers, and faith-based organizations, with the majority of programs delivered in schools as part of the health curriculum or as an elective.
- The State has also awarded a contract to a public relations firm to conduct a statewide media campaign promoting abstinence through television, radio, print and an interactive web site. The State sponsored conferences in 1999 and 2001 on abstinence-only education curricula.
- A contractor is conducting a formal evaluation of the short-term and long-term outcomes of both components of the program (i.e., direct service delivery and the media campaign). The evaluator has completed a third-year report, and the State has renewed the evaluation contract for an additional term.
Through the Nurse Home Visitation Program, child care, work preparation and other health services are provided to pregnant or parenting individuals who are at risk of becoming dependent on cash assistance. Clients also receive counseling regarding childbearing and other decisions about their future. One participant noted that this program is intended, in part, to prevent second pregnancies. ⁽³⁾ This program received $250,000 in TANF funding during 2001, but funding for the program has been eliminated for 2002 due to budget cuts forced by declining State revenue.
According to participants, the State intends to launch a Statutory Rape Initiative, which will provide educational materials to school and law enforcement officials and local counseling and education associations outlining the provisions of the State's statutory rape law and the responsibilities of school officials (and others) to report incidences of statutory rape.
The State ensures access to family planning services, which are intended to reduce rates of second-order pregnancies and births. The State's family planning programs receiving funding through the Medicaid program and are administered through the Arizona Family Planning Council.

2. Extent to Which Efforts Focus on Teens and/or Adults

Participated reported that while State programs serve both teens and adults, a greater share of the State's efforts focus on teens:

The abstinence education program serves 22,000 teens annually, up from about 11,000 at implementation.
In addition to providing family planning services for adults, the State operates a small abstinence program for adults in substance abuse rehabilitation clinics, and has served approximately 350 adults through this program.

3. Barriers or Challenges to Program Development and Implementation

Participants reported that substantial debate over appropriate content for proposed "abstinence-based" education programs motivated the State legislature to fund exclusively abstinence-only programs.⁽⁴⁾

The State's abstinence-only programs serve primarily teens, and efforts to serve adults have been contentious, said some participants, because of the concern that residents would perceive State promotion of abstinence for adults as a personal intrusion. In any case, participants said that they have had little success in identifying effective curricula to provide non-marital birth prevention services to adults.

One participant said that the family planning program faces challenges in reaching out to some of the State's hard-to-serve populations; another participant disagreed, saying that all target populations receive adequate service.

4. Changes in Traditional Roles of State Agencies or Community-Based Organizations

According to participants, since the passage of PRWORA, the relationships between and among the State and local agencies have changed little. Prior to welfare reform, State agencies provided funding and technical assistance to the CBOs, and the CBOs engaged in service delivery. These traditional roles have remained intact.

The State did not engage in much interagency collaboration regarding the design or implementation of non-marital birth prevention activities. A few State -level offices sought assistance with program development from DHS; such assistance was limited in scope, however.

5. Changes in Sources of Funding

Participants said the passage of PRWORA provided additional funds for abstinence-only education through both the block grant and through Title V Section 510. In FY 2001, $2 million in TANF block grant funds were budgeted for abstinence-only education programs. However, the State's recent economic downturn, which has led to a shrinking State budget, has led to shifts in the sources, and possibly, amounts of funding. In FY 2002, $2 million in funds from the State tobacco settlement replaced TANF block grant funding, and participants expressed concern that this funding level might be reduced in the future. Whether, and to what extent, TANF funds will be available to support the program in 2003 is uncertain.

Arizona is one of the few States that does not contribute State funding toward family planning programs. The Governor vetoed a bill that would have directed State funds to family planning initiatives, citing revenue shortfalls.

Through a Medicaid waiver, Arizona provides family planning services for two years after pregnancy occurs to families eligible for Medicaid under the Sixth Omnibus Budget Reconciliation Act of 1986 (SOBRA). Currently, the Arizona Public Health Association is working to increase access to family planning to individuals who have not yet experienced a pregnancy.

B. Role of the Illegitimacy Bonus on Efforts to Reduce Nonmarital Births

Arizona, which experienced a 1.4% decline in its illegitimacy ratio during the eligible period, was one of five States receiving the Illegitimacy Bonus in 2000.

Participants said that State agencies did not focus on winning the bonus, nor did they implement or modify policies with an eye toward competing for the bonus money. Participants from DHS said they had been surprised when Arizona received the bonus, and only after receiving the bonus did the some State officials examine the bonus's eligibility provisions.

Upon bonus receipt, several State agencies lobbied the legislature to spend the funds on increasing nonmarital birth prevention activities, but the Governor, who has line item veto authroity, chose to assign the money to a "rainy day" fund within DES instead. One participant noted that substantial support exists within several agencies to expand the nonmarital birth prevention activities, but funding is lacking. Some funds were assigned to increase support for abstinence-only education, which one participant noted serves teens almost exclusively. No additional funds to serve adults have been assigned from the bonus funds.

Massachusetts

This document summarizes the major comments made by participants during calls with representatives from relevant agencies in Massachusetts. The calls took place November 26, 2001 and January 18, 2002.

Call participants included representatives from:

Division of Family and Community Health, Department of Public Health (DPH); and
Policy and program management, employment services, and program assessment within the Department of Transitional Assistance (DTA).

II. General Discussion

1. Changes in State Efforts Since the Passage of PWRORA

In 1995, Massachusetts created the Transitional Aid to Families with Dependent Children (TAFDC) program, the main cash assistance program operating under TANF. It is administered through the Department of Transitional Assistance. The TAFDC program is a component of the Massachusetts' welfare reform effort (i.e., Legislative Act Chapter 5) that began in 1995, one year prior to the passage of PRWORA.

According to participants, numerous State agencies have assisted in the development, funding, and implementation of programs and policies within the Commonwealth of Massachusetts designed to influence childbearing behavior. The Department of Public Health (DPH) works with the Department of Transitional Assistance (DTA) and the State Medicaid agency in administering the State's pregnancy prevention programs and pregnancy prevention program components. The primary purpose of the State's pregnancy prevention and other efforts differ in an important way from the parallel purpose within PRWORA. While PRWORA focuses on reducing nonmarital childbearing, Massachusetts focuses on reducing the incidence of unintended childbearing. In doing so, the State hopes to improve the health and well-being of children and families by ensuring that every child born is a wanted child.

Since the passage of PRWORA, the State has expanded existing efforts to reduce unintended pregnancies and childbearing, as well as implementing a number of new efforts. We summarize below major efforts identified by participants.

Existing and/or expanded efforts include:

Securing additional funding from Medicaid and the Department of Public Health (DPH) to expand outreach, access to contraception education, and access to family planning services. Through this program, DPH staff provide contraception education training to health care providers to ensure that low-income individuals have access to family planning information and services when receiving primary care.
Initiating in 1996 a re-bid process for the Young Parents Program, a component of the Employment Services Program (administered through DTA), which comprises the State's employment training programs for welfare recipients. The Young Parents Program provides education, counseling and training to young parents (age 14 - 22) on welfare who have not yet graduated high school. The objective of the program is to assist young parents in earning a diploma (or its equivalent), and in gaining marketable skills through education and training. Currently, there are 36 programs statewide serving 1,000 clients a year (up from the original 16-20 programs serving approximately 500-600 clients annually). As part of the program expansion, program providers who deliver parenting and life skills training are now required to include family planning education.
The Bureau of Family and Community Health (within DPH) works with local schools to develop sex and health education curricula that incorporate pregnancy prevention efforts.
The Teen Pregnancy Prevention Challenge Fund supports community-based, primary prevention efforts that target youth age 10 - 19 and are designed to increase abstinence, delay sexual onset among adolescents, and reduce teen pregnancy rates. The Challenge Fund currently supports 17 coalitions that provide a variety of services including peer leadership programs, mentoring and tutoring models, job and life skills training, reproductive health services and HIV/AIDS and STD education.

New efforts include:

The implementation of an Abstinence Education Media Campaign that focuses on youth and families in Hispanic and black communities, which account for a disproportionate share of the Commonwealth's teen births. This campaign, developed by DPH using Title V Section 510 funding, delivers abstinence-only messages to pre-teens (age 9 - 12) and teens (age 15 - 17) through radio and television messages, brochures and a peer educational film. All materials were developed with the input of local community members.
The creation of the Young Men's Initiative, which provides grants to schools or community organizations not receiving Teen Challenge Fund money to develop programs designed to engage young men in pregnancy prevention efforts, and to promote the perception that young men and young women are equally responsible for preventing pregnancy. One participant noted that while the Teen Challenge Fund has historically targeted both young men and young women, the State has long recognized that the two populations are not served equally. The availability of additional funds through the TANF block grant enabled the State to increase its outreach to young men through this initiative. In fiscal year 2000, the initiative supported programs in nine communities.
The imposition of a Family Cap. Under the family cap provision, no additional cash benefits are provided for children born to families receiving welfare. Children born under the Family Cap remain eligible for MassHealth (i.e., Massachusetts's combined Medicaid and Children's Health Insurance Plan [CHIP] program) and food stamp benefits.
The State has increased its efforts to prevent and prosecute statutory rape. In 1996, the Department of State Police (DSP) dedicated additional resources to investigating and prosecuting individuals charged under the State's statutory rape law, and currently the DSP Domestic Violence Unit conducts classes targeting youth, teachers, counselors, health-care workers, State employees and police officers to recognize and help prevent statutory rape.
The creation in 1996 of the Governor's Commission on Responsible Fatherhood and Family Support, in part to recommend policy initiatives to reduce the rate of teenage pregnancy and nonmarital birth rates among both teens and adults. The Commission consulted with State agency secretariats and department heads for guidance. Commission recommendations include: defer fatherhood by unmarried young men through expansion of mentoring programs; expand teen primary and secondary pregnancy prevention and abstinence programs to include a special focus on males (who are typically underserved) and teen parents (a large proportion of whom have additional children out of wedlock)
The Dads Make a Difference program, a peer-to-peer education initiative of the Department of Revenue with support from the Departments of Health and Education, in which older teens teach middle-school adolescents about the financial and emotional responsibilities of parenthood. The program began as a pilot in 1994.
The Healthy Families Newborn Home Visiting program, administered by the Department of Public Health, which provides home visiting services to any first-time teen parents, regardless of income. The program works to prevent subsequent births (many of which are nonmarital ⁽⁵⁾), to protect the health of the child and the mother, and to promote educational attainment and economic self-sufficiency.
The Teen Living Program, a Second Chance Home, provides pregnant and parenting teens who receive TANF assistance but are unable to live with a parent or guardian, the opportunity to live in a structured, supportive residential environment. Developed in 1996, the program includes 21 group home and shared apartment networks serving 120 teen families that provide 24-hour adult supervision, pregnancy prevention counseling, family planning services, case management services, child care, job training, and counseling. The program is administered for the Department of Social Services for the Department of Transitional Assistance.⁽⁶⁾

2. Extent to Which Efforts Focus on Teens and/or Adults

Participants noted that the majority of the State's efforts focus on the teen population, in part because the very large majority (91%) of births to teen mothers are nonmarital. However, the State's family planning programs mainly serve adults, who comprise 70% of all users of State family planning services. In addition, Title X providers engage in outreach and education efforts at State and community colleges within the Commonwealth.

3. Barriers or Challenges to Program Development and Implementation

One participant said that competing with the implied messages regarding sexual behavior that are present in much commercial media (such as television and film) is extraordinarily difficult. The State's Abstinence Advisory Committee believes that its efforts to promote abstinence through the Abstinence Education Media Campaign are overwhelmed by opposing messages implicit in the sexual content delivered by television and movies. Although a program evaluation demonstrates that the Media Campaign has been effective in delivering its message to its intended audience, Committee members believe that the behavioral impact of that message will likely be very limited.
DPH provides guidelines and criteria to local school districts regarding the content of sexual education curricula, but because the local districts control the specific content of the curricula, DPH has occasionally encountered some difficulty in persuading the districts to develop content that is consistent with a public health model.
Participants indicated that to some extent, the State has struggled with developing adolescent health and health education programs that satisfy both contraception education advocates and abstinence-only advocates within State agencies and within local communities. In part, this conflict was resolved by using Title V Section 510 abstinence-only funding to develop the statewide abstinence education media campaign. No funds were provided to the State's Teen Pregnancy Prevention Challenge Fund programs, because such programs offer abstinence education, contraception education, and family planning services, and Title V Section 510 funds may not be used for purposes other than abstinence-only education.
Participants agreed that the biggest challenge currently facing the State in its efforts to reduce nonmarital childbearing are declining State revenues. The State is reducing staffing by 15% overall, including reductions within DPH. The budget for the Teen Challenge Fund Pregnancy Prevention programs has been reduced by about 40% for fiscal year 2002, and the Young Men's Initiative has been discontinued.

4. Changes in Traditional Roles of State Agencies or Community-Based Organizations

Participants reported that collaboration regarding both policy and implementation between DPH and DTA has increased since the passage of welfare reform.

At the local level, the two departments work together in tracking families who lose eligibility due to time limits.
DTA staff explain Family Cap provisions to clients and provide brochures detailing the policy. Staff also refer all clients for family planning services.
In the Teen Living Program, welfare specialists visit the pregnant and parenting teens and work with the public health providers to ensure adequate service delivery. The State has required that the program show collaboration at the local level.
Staff who provide services through the Young Parent Program refer clients to DPH for family planning and childcare services. In addition, family planning issues are covered within the parenting skills and life skills classes clients are required to attend.
DTA also works with other agencies to ensure that clients in need of services receive them. DTA refers clients to appropriate agencies to receive food stamps, protection from domestic violence, treatment for substance abuse, and access to family shelters.

5. Changes in Funding Levels

The availability of TANF funds, participants said, increased the funding levels of several programs, including child care, child welfare, and prevention programs such as healthy choices, healthy families, and the outreach program.

B. Role of Illegitimacy Bonus on Efforts to Reduce Nonmarital Births

Massachusetts's two-year average nonmarital birth ratio declined from 26.1% (1994-1995) to 25.7% (1996-1997), a decline of approximately 1.5%. Massachusetts received the bonus in 1999.

Participants agreed that shortly after the passage of PRWORA, the potential for receiving bonus money inspired efforts to identify strategies for winning the bonus. An inter-agency task force on welfare reform held several meetings in which options for reducing nonmarital childbearing, and their possible impact on the State's bonus eligibility, were discussed. Although decisions regarding changes to the State's pregnancy prevention policies were not motivated entirely by the potential availability of the bonus, it did provide framework for discussions.

Among its policy recommendations, the Governor's Commission on Responsible Fatherhood and Family Support advocated that "public and private agencies and communities that are already involved in pregnancy prevention step up their efforts and coordinate their resources to win [the illegitimacy] bonus award." The Commission also recommended "that the Commonwealth consider an incentive structure to reward State and local agencies that successfully integrate pregnancy prevention into their strategies."

Participants said that while the State initially considered plans for tracking progress toward the bonus, over time interest in explicit pursuit of the bonus declined. According to the agency representatives we interviewed, bonus competition is no longer mentioned in discussions regarding State pregnancy prevention programs.

Participants said that staff in a number of agencies expressed early concerns about the outcome measure employed in the calculation to determine bonus eligibility (i.e., the percent decline in the nonmarital birth ratio). Because of the State's relatively low incidence of nonmarital births, participants said that many agency staff expected that the State could not expect to experience large percentage declines in the nonmarital birth ratio, making bonus eligibility very difficult.

Finally, a number of participants said that some agency staff anticipated that changes in behaviors important for reducing the rate of nonmarital childbearing (e.g., getting married), would be very difficult to influence through public policy.

Participants said that the State legislature was pleased with winning the bonus, and that bonus money was added to the general fund and was not dedicated to nonmarital programs.

In Massachusetts, the legislature funds TANF programs prior to receiving federal grant money; federal block grant funds are allocated to the general fund to offset amounts already contributed by the State on the block grant's behalf. As a result, State agencies must persuade the legislature to provide up-front funding. While the legislature has reduced funding in other programs, one participant suggested that bonus receipt might have influenced the legislature to not reduce pregnancy prevention program benefits earlier.

A number of participants expressed frustration that the bonus money was not dedicated by the legislature to pregnancy prevention programs. This decision discouraged agencies from continued bonus pursuit, they said.

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Bonus Non- Recipient States

Georgia

This document summarizes the major comments made by participants during a call with representatives from relevant agencies in Georgia. The initial and subsequent calls took place between October 2001 and January 2002.

Call participants included representatives from:

The Division of Family and Children Services (DFCS), within the Department of Human Resources, which administers the State TANF plan;
The Division of Public Health (DPH), within the Department of Human Resources, which administers or co-administers a number of State programs designed to reduce nonmarital childbearing; and
The Georgia Campaign for Adolescent Pregnancy Prevention (G-CAPP), a nonprofit campaign that works to reduce the rate of teen pregnancy in Georgia.

1. Changes in State Efforts Since the Passage of PRWORA

At least one participant said that a relatively high rate of turnover in the Commissioner's office within DFCS has delayed State progress in fashioning and expanding efforts to reduce the incidence of out-of-wedlock births. Since the passage of PRWORA, existing programs have received funding boosts and have been able to expand service delivery to a larger percentage of the target populations, in part by expanding statewide pilot programs targeting teens. However, most of the resources went to expanding existing programs, rather then creating new ones.

Participants identified existing programs that have increased coverage or service delivery since welfare reform:

The Adolescent Health and Youth Development initiative, which is a collaboration among the divisions of Public Health, Family and Children Services, and other State, county and community agencies, with the goal of reducing the birth rate to young women age 15-19 by 5% per year between 1999 and 2002. The initiative has three broad objectives:

To reduce the rate of sexual activity among teens through abstinence education;
To improve matriculation rates, reduce the rate of repeat teen pregnancies, and improve opportunities for employment;
To increase effective use of contraceptives among sexually active teens.

The Adolescent Health and Youth Development initiative includes four components:

The Abstinence Education Campaign, which, through Title V Section 510, funds 42 abstinence-only programs that include material on the educational, economic, social, physical and psychological consequences of early parenthood. The program also provides activities such as leadership training, character education, tutoring, and promotion of increased parental involvement to encourage youth to develop meaningful relationships with adults. The State also funds an abstinence media campaign that emphasizes the negative consequences of teen pregnancy.
Community Involvement programs, which promote collaboration among businesses, community-based organizations, faith-based organizations, civic associations, schools and volunteers to participate in activities designed to improve outcomes for youth. Activities include after school programs, mentoring, summer camps, tutoring, and youth development skills. The State currently supports 17 such programs.
Male Involvement programs, which serve young adult males at risk of becoming teen fathers. Community-based organizations design and implement programs intended to reduce risk-taking behavior and delinquent behavior. Activities among the State's 13 programs include teen parenting training, abstinence education, anger management, STD/AIDS ⁽⁷⁾ prevention, substance abuse education, and peer leadership programs.
Comprehensive Adolescent Health Centers, which are located in all 19 of the State's health districts. The Centers provide health, pregnancy prevention, and youth development programs to teens that are at high risk of pregnancy. Center services include abstinence education, drug and alcohol prevention education, violence prevention, male involvement education, health education and counseling, after school programs, life skills training, and adolescent health and reproductive health services. Thirty-four counties receive funding to provide services under the program, and priority for funding is given to those counties with the highest number of teen pregnancies.

DPH has increased access to family planning services by providing services (including counseling and family planning) in non-traditional sites, such as shopping malls, housing developments and a mobile van. DFCS encourages the use of family planning among families on welfare, and DPH advises parents to engage in two-year interconceptional periods, emphasizing the health benefits for both the mother and child.
Agencies have increased efforts at collaboration. For example, family planning clinics provide a range of counseling services, as well as providing traditional family planning services. The ability to provide a range of services, and to refer clients to other agencies, increases the probability that clients receive needed services.
The State offers an Early Intervention Services program for low-income residents that funds pregnancy tests and intensive in-home case management services.

A new program implemented since welfare reform is Second Chance Homes, which provides alternative living arrangements for minor parents and their children. The program is available to TANF recipients and provides 24-hour supervision and a structured environment with the goal of reducing repeat pregnancies. As of July 2002, six Second Chance Homes operate within the State.

2. Extent to Which Efforts Focus on Teens and/or Adults

Participants noted that the majority of Georgia's programs focus on the teenage population primarily for three reasons:

Georgia experiences 17,000 teen births annually, and although that birth rate is going down, this is still a relatively large population that is generally poor, that exhibits a high need for services, and that is at-risk for additional nonmarital births.
Because the very large majority of the State's teen population attends school, structuring and implementing programs for delivery within schools is relatively straightforward. Identifying similar institutions for service delivery for adults is more difficult.
Teens are more likely than adults to be receptive to messages about the negative consequences of early and unintended pregnancy. One participant remarked that serving teens might eventually reduce nonmarital birth rates of adults if teens, who otherwise might give birth as unmarried adults, delay childbearing until marriage.

Efforts to serve the adult population center on influencing behavior of the welfare population through the State's family cap. ⁽⁸⁾ The TANF caseworker explains the family cap provision to each client, and each client is given a referral to a family planning clinic. TANF funding is used to provide family planning services to referred clients.

3. Barriers or Challenges to Program Development and Implementation

Participants noted the following challenges in developing programs designed to address nonmarital childbearing among adults:

Service providers can effectively deliver messages about the risks of sexual activity and the benefits of abstinence and contraceptive use to teens through schools and youth development programs. Because adults do not participate in these activities, finding forums for communicating similar messages to adults is a bigger challenge.
Crafting messages to adults designed to discourage nonmarital childbearing or to encourage abstinence is a challenge because adults are less likely to be receptive to such messages. In addition, one participant noted a relatively widespread perception within State agencies that attempting to influence the child-bearing decisions of adults, particularly those adults who are not dependent upon public assistance, is problematic. Because about 50% of the State's pregnancies are unplanned, public health providers typically speak to women about the benefits of planning pregnancies and do not focus on marital status per se.
G-CAPP sponsors a parenting class and has even found that encouraging single mothers to talk with their children about sexual responsibility and abstinence is difficult because many of the mothers face daily challenges that receive much higher priority.
One participant reported that some family planning services staff express opposition to abstinence programs because they perceive such programs as relatively ineffective.
Participants said the shift toward reducing nonmarital births among teens through youth development programs rather than through sexual education has increased public and provider support by avoiding the divisive debates that normally surround implementation of sexual and contraception education programs. One participant said that there is a growing understanding within the State of the effectiveness of youth development programs in motivating teens to avoid risk-taking behavior.
Participants were not unanimous regarding their perception of the relative strengths and weaknesses of the youth development approach, particularly with respect to how it might affect provision of health services. One participant felt that the more traditional health care delivery approach, such as that associated with family planning services, might provide better access to health services. However, another participant commented that the youth development efforts maintain a strong focus on adolescent health, and that each of the 39 Centers has a medical consultant in the office to ensure that the programs meet appropriate medical standards. A strong benefit of such Centers is that they provide a broad array of services, so youth can access them without fear of stigma.
Georgia's diverse population poses a substantial challenge in overcoming both cultural and language barriers. DPH now funds pilot programs to work with the Latino and Asian communities in an attempt to develop effective programs that can be implemented on a larger scale.
One participant remarked that better collaboration between the Department of Education and the Department of Human Resources at high levels is necessary. While collaboration occurs on the local level, it is lacking on the policy level, which makes program development very difficult.
Participants were generally pleased with the availability of program models and policy knowledge for implementing effective interventions among teens, although State agencies and local communities have reached no firm consensus regarding a single approach to discouraging nonmarital childbearing. Participants also generally agreed that the State had been successful in identifying and implementing best practices; however at least one participant said that the qualifications and skills of the people delivering the service is more important than the model that is being used.
Participants reported little success in identifying effective and appropriate models for influencing the childbearing decisions of adults.

4. Changes in Traditional Roles of State Agencies or Community-Based Organizations

Participants said that the level of collaboration across agencies in the State has increased since the passage of PRWORA.

The growing role of youth development has contributed to several changes among service agencies in the State:
- There is more collaboration among public health staff and social services staff regarding service delivery. Through the collaboration, agencies have coordinated the development of programs to train both youth and public health workers in identifying needs of teens and linking them to available services. This increased collaboration has increased awareness of the services offered by other agencies, which has the potential for improving service delivery.
- DPH hired youth development coordinators in each of 19 districts to serve as liaisons with community groups, and to engage public health staff regarding the benefits, challenges, and opportunities associated with youth development programs.
Welfare reform has also spurred increased coordination between social service agencies and public health agencies in the delivery of family planning services. For example, the State has increased the number of co-located offices throughout the State (i.e., offices that provide both welfare and family planning services). The Department of Family and Child Services (DFACS) also provides a referral service to family planning offices. Under the arrangement, caseworkers are encouraged to refer TANF clients to the family planning clinics for services. DFCS has also provided some TANF funding to the Department of Public Health to ensure access to dedicated family planning service resources for TANF recipients.
At the State level, DFCS and the Health Department are sister agencies under the same umbrella organization. The main challenge centers on the local level activities. Because Georgia is a county administered State d, it is often difficult to gain a consensus among the different agencies in the different counties.
DFCS works closely with the Georgia Campaign for Adolescent Pregnancy Prevention (G-CAPP), which was established in the mid-1990s to promote local efforts to reduce the rate of teen pregnancy.

5. Changes in Sources of Funding

Participants noted that prior to the implementation of welfare reform, most pregnancy prevention efforts in the State were funded through Title X. Since the passage of PRWORA, however, TANF dollars now account for substantial portions of most of the budgets of pregnancy prevention programs and components. For example, TANF funds are the only source of funding for the Second Chance Homes program, and TANF funds constitute substantial portions of the budgets of the Adolescent Health and Youth Development program, and the Early Intervention Services program. TANF funds contribute modestly to the State's family planning programs budget. In 1998, the State began using its Indigent Care Trust Fund (Medicaid funds used to compensate hospitals that disproportionately provide indigent care and to support expanding primary care programs) to help establish family planning clinics in non-traditional locations.

In short, the influx of TANF dollars coincided with a period when Georgia had the highest teen pregnancy rate in the nation. This circumstance helped produce community consensus around the goal of lowering the rate, and spurred program creation and expansion.

Participants expressed concerns about future levels of funding. Any increase in TANF rolls would likely leave less money available for ancillary programs, such as pregnancy prevention. The State cut spending on nonmarital birth programs by 2.5% for the current year, and officials project a 5% cut next year due to reduced State revenues from the economic slowdown. G-CAPP expressed concern that private funding might decline, as well, due to the recession.

B. Role of the Illegitimacy Bonus on Efforts to Reduce Nonmarital Births

Participants agreed that in the first year of potential eligibility, the State engaged in efforts to monitor performance to determine whether Georgia could compete successfully for the bonus. However, agencies have generally concluded that they cannot develop interventions capable of successfully serving all women at risk for a nonmarital birth, which would be required in order to have a large impact on the bonus's outcome measure (i.e., the proportion of births that are nonmarital). As a result, while excitement about the bonus was high initially, it soon became less of a rallying point for program development.

Reasons for the decline in interest, according to participants, included:

Awarding performance-based bonuses was viewed as inappropriate because there seemed to be a need for this money and these programs everywhere in the country, and awarding large sums of money to a few States was likely less effective than funding identified needs.
The goal to reduce all nonmarital births (including adults) was problematic because "it was an attempt to legislate morality," said one official, "and such policies are typically not terribly effective." Rather, abstinence-focused programs serving teens were easier to plan and implement, and did not suffer from the same political difficulties as targeting adults.
Winning the bonus required finding effective ways to reach the adult population and convincing them to abstain or marry, which is much more difficult than influencing teen behavior.
The existence of the bonus did not influence DFCS policy, which is to focus the majority of their efforts on reducing teen births rather than attempting to influence the private behavior of adults.
The duration between implementation of PRWORA and first bonus receipt might have been too short to observe fully the impact of State efforts. For example, the full impact of teen abstinence education on childbearing decisions might not be observed until the teens have passed through their unmarried adult years. If so, declines in nonmarital birth ratios within several years of implementation of PRWORA might not be related to some of the major interventions designed to lower such rates.

One participant noted that occasionally DFCS staff are asked about the bonus by State legislators, but there is no general or sustained interest in it.

Maryland

This document summarizes the major comments made by participants during a call with representatives from relevant agencies in Maryland. Initial and follow-up calls took place between November 19, 2001 and January 31, 2002.

Call participants included representatives from:

The Department of Human Resources (DHR), which administers the State's TANF program;
The Governor's Office for Children, Youth & Families (OCYF);
The Community Services Administration within DHR;
The Office of Community Initiatives within DHR; and
The Center for Maternal and Child Health (CMCH) within the Department of Health and Mental Hygiene (DHMH).

1. Changes in State Efforts Since the Passage of PRWORA

According to participants, when PRWORA was passed, the Secretary of the Department of Human Resources (DHR) approached the Governor to discuss developing a statewide plan for reducing nonmarital births. As a first step in developing a coordinated State policy, the Governor convened a group of more than 80 participants from all State agencies presumed to have a role in implementing the coordinated policy. By including all potential stakeholders from the start, the effort secured the buy-in of implementing agencies, and reduced duplication of effort among agencies, which helped ensure efficient use of TANF and other funds. The group identified the landscape of potential issues, obstacles, and challenges revolving around nonmarital birth policy, and established a long-term strategy for policy development and execution.

In addition to endorsing continued support for existing programs, the group recommended the State develop and implement two additional programs: Healthy Families, a home-visitation pilot program serving men and women at risk for nonmarital childbearing; and Best Friends, a youth development program serving girls and young women enrolled in school between the fourth grade and high school senior level.

The Healthy Families home-visitation case-management pilot program serves three populations: mothers who have already had one child out of wedlock, women over the age of twenty-one at risk for nonmarital childbearing, and the male partners of such women. The major goal of the program is to teach clients to see themselves as able to make explicit decisions regarding childbearing.
The primary mechanism for serving the intended populations is comprehensive home visits in which service needs are identified. Clients are eligible to receive family planning and services offered through the State's family planning clinics.
The program has also been designed to work with males, and includes programs designed to encourage males to engage in responsible behavior related to sex, parenting and child support. Each pilot site has a male involvement coordinator, who is trained regarding the availability and eligibility provisions for services targeted at males. The coordinator assists the males in finding jobs, and emphasizes the advantages of providing financial support for their children. Coordinators work to avoid jailing fathers for nonpayment of support, in part by serving as a mediator between father and mother.
The State identifies individuals in need through a combination of family planning clinic referrals and active recruiting on the part of the program social workers.
In order to qualify for the program, mothers must be unmarried, already pregnant (or recently given birth to first child), and meet zip code requirements. Nonmarital births occurring in Baltimore City and in Prince George's County comprise 53% of all nonmarital births in the State of Maryland. The pilot includes three caseworkers that serve the two localities.
The pilot program has served eighty families since October 1998. The pilot intentionally has kept the caseloads of each worker relatively low, so that the caseworkers can deliver intensive services. Each home visitor visits each client at least weekly. The State plans on expanding the program in the coming years. The participants said that the strength of the program lies in the intense level of contact that the caseworkers have with the clients, which enables caseworkers to identify, and secure, assistance for the families across a broad range of needs, such as housing and food purchases. By providing services across a broad range of needs, the caseworkers hope to build trust that will increase clients' receptivity toward messages discouraging nonmarital childbearing. The establishment of trust is especially relevant when trying to build bridges to male partners regarding their parenting behavior responsibilities.
The University of Maryland School of Nursing is conducting a formal evaluation of the Healthy Families pilot.
The Best Friends youth development program serves girls enrolled in the fourth grade through graduating seniors in high school. The program features abstinence education and activities designed to build self-esteem. This program has been implemented in Prince George's County, Baltimore County, and Baltimore City, as well, due to the demonstrated high need in those areas. The program also encourages the girls and young women to avoid high-risk behaviors, such as violence and drug and alcohol consumption. A second and similar pilot called Best Men, targets boys in the same age group and in the same geographic area.

Other initiatives identified by participants include:

CMCH administers the Abstinence Education and Coordination Program through OCYF. In the program's first year, the State provided 16 grants to 14 contractors operating abstinence education programs in 11 different jurisdictions across the State. The State provided training and technical assistance with grant requests and program design. The Department of Health and Mental Hygiene also provided one-year seed money grants to an additional five abstinence education programs in the State. Participants noted that funding local providers to deliver abstinence education at the community level has promoted the delivery of abstinence education to a broad range of communities, including communities of faith who receive the message from faith-based organizations. The abstinence education programs are primarily directed at youth aged 9-15.
Every year, the State also conducts an abstinence conference for approximately 500 teens and parents every year. The State also holds an annual teen pregnancy and parenting conference that provides information about abstinence, family planning and parenting skills to approximately 500 professionals.
The Governor's Office for Children, Youth and Families/Governor's Council on Adolescent Pregnancy also conducts a statewide abstinence-based education media campaign to promote sexual responsibility. The State contracts with Campaign for Our Children to administer this social marketing campaign.
In 2000, Allegheny County received a SPRANS ⁽⁹⁾ Community-Based Abstinence Education Program grant to create an abstinence education program in the county. DPH provided technical assistance in developing the grant request.
Through a partnership with Anne Arundel Community College, CMCH is also developing online training to assist teachers in providing AIDS education for students in elementary school, as well as providing life skills, such as establishing boundaries, saying "No," and making good decisions.
The Governor's Council on Adolescent Pregnancy helped develop inter-agency statutory rape reduction strategies. Through the Rape and Sexual Assault Prevention Program, Maryland elementary, middle, and high schools receive materials and funding to provide teacher and staff training on sexual assault prevention.
The Maryland Fatherhood Initiative, administered by DHR, comprises various programs designed to promote strong and healthy fathers. Programs with components designed to reduce nonmarital childbearing include:
- The Dad's Make a Difference youth education project, which teaches the importance of father involvement and parental responsibility, and encourages deferring parenthood to adulthood.
- The Responsible Choices Demonstration Project provides home visitation services to young first-time unmarried parents and two-parent families, and includes access to parenting courses, family planning counseling and services, and job training.

The State continues to support the following programs, identified by participants, which have been in existence since prior to passage of PRWORA:

The State's Family Planning Program provides contraceptive education and services through more than 90 clinics across the State. The program is administered by CMCH, which receives its funding through Title X. The family planning program serves both adults and teens.
The Three For Free program, administered by CMCH, makes available condoms for individuals who are at high risk for unintended pregnancy, sexually transmitted diseases and HIV.
The Healthy Teens and Young Adults (HTYA) program provides pregnancy prevention and other reproductive health services to at-risk young adults age 10 - 24 in areas of greatest need (i.e., Baltimore City and Prince George's County). HTYA services are provided in model clinics and include information and counseling about abstinence and delaying sexual activity as well as access to contraceptive education and services. HTYA clinics also provide special services and programs for young men emphasizing male responsibility and participation in reproductive health decisions. In addition to the clinical staff, HTYA clinics feature teen volunteers who offer general support and provide information to teens about clinic services.
Through the State's Medicaid waiver, a woman who becomes pregnant while receiving Medicaid is eligible to receive five more years of family planning services, even if during that period of time she stops being eligible for Medicaid. The waiver has been renewed for an additional three years.

2. Extent to Which Efforts Focus on Teens and/or Adults

In reviewing existing policies and programs, noted participants, the coordinating group determined that the State already offered many programs serving teens designed to prevent pregnancy. However, the group found that the State offered relatively few programs to serve either pre-teens or individuals over the age of 21. For example, the State's community-based programs target teens who are pregnant and in high school, but relatively few such programs targeted adults age twenty and older. For this reason, the group decided to focus available TANF funding on programs serving these two populations.

3. Barriers or Challenges to Program Development and Implementation

A number of Maryland's initiatives are based on nationally-recognized models, and participants noted that complying with the requirements to receive certification by the sponsoring organizations has been a challenge. The requirements range from meeting eligibility issues to generating proper documentation from caseworkers and community-based organizations (CBOs).

In order for schools to be certified as "Best Friends" sites, DHR established and maintains a set of relationships with the Department of Education to ensure appropriate adoption of the program by State schools, as well as the timely and accurate filing of reports and other documentation with the national office. Further, adoption of the program requires buy in among each school's administrators, and gaining that buy in can require substantial work. One participant expressed a great deal of satisfaction with the content of the program, but said there is a great deal of effort required to establish and maintain the program.
The Healthy Families program required similar effort. First, the State had to invest resources in deciding which of two programs they wanted to adopt, as one was more health oriented than the other. Because the sponsoring organization requires monthly reporting that duplicates State requirements, some staff complain that the reporting requirements take time away from staff who could be visiting clients.
The Best Friends program was relatively easy to implement because the curriculum had already been developed, making it straightforward for schools to adopt. By contrast, the Responsible Choices program had less structure in how the program was implemented, requiring the State to be more involved in the development of the model. One advantage of this characteristic, however, was that the State had some flexibility in program design that allowed emphasis on State priorities.

Participants cited as a challenge to State agencies the need to train CBOs to submit grant proposals for State funding of programs.

Developing consensus within local communities about the appropriate mix of services has been difficult. In order to help inform the discussion, the State is funding research and formal impact evaluations of several programs with the goal of identifying and promoting those efforts that are most effective in reducing the incidence of teen and nonmarital pregnancies.

Some participants said that delivering abstinence education to Hispanic communities has posed a challenge, and one participant said that the State has not made a concerted effort to overcome this barrier. Another disagreed, noting that a Maryland family planning brochure, "The Choice Is Yours," which includes abstinence as a family planning method, is distributed through the community in both English and Spanish versions. Maryland Law requires that this brochure be printed by DHMH and distributed by the Clerks of the Courts along with marriage licenses. For many years, this brochure was also distributed annually to recipients of AFDC in an effort to meet the requirement to provide family planning information.

Participants also identified rising costs of service delivery as an ongoing challenge. Nursing costs, for example, have increased substantially over the past few years as have costs to provide methods of contraception such as DepoProvera, Norplant, and the contraceptive patch, but agency budgets have not increased proportionately. Declining teen pregnancy rates also threaten funding, as the perceived need for pregnancy prevention programs declines. One participant said even though the rates seem to be declining, the need for services among underserved and uninsured populations remains high.

4. Changes in Traditional Roles of State Agencies or Community-Based Organizations

Participants reported that collaboration among State agencies and CBOs, and between State agencies, has increased since the passage of PRWORA for a number reasons:

The Responsible Choices program is administered through contracts with the local CBOs. The Baltimore program, for example, has one parent organization, which uses a network of local family support centers for staff and support. Additionally, the program is starting community partnerships with local management boards to give local communities more money and flexibility in designing programs.
Pilot programs are tested in the local community before being widely adopted to smooth implementation, and to give local governments time to learn about, and support the efforts, of local CBOs. The pilot programs also verify that the programs and services are designed for each local area, and meet the needs of that area. As a result, DHR has provided technical assistance to CBOs, including training in grant request development and submission.
State agencies serving overlapping clients have increased collaboration, including engaging in cross-staff training, to ensure quality service delivery. There were times that these transitions did not proceed smoothly, primarily due to the large size of the State's administrative system.

5. Changes in the Sources of Funding

Before the establishment of the TANF block grant, Maryland had little funding to develop these types of community-based, collaborative programs. TANF provides flexibility to fund such efforts, and is more involved in community services and although funding levels have stayed relatively constant since implementation, program funding has been extended for longer periods than was typical prior to the passage of PRWORA.

The fatherhood programs receive primarily separate State funds with supplemental federal and MOE funds.
The Responsible Choice pilot received $1.9 million in TANF funds.
The Governor's office has increased the funding for the Best Friends programs through fiscal year 2002.

B. Role of the Illegitimacy Bonus on Efforts to Reduce Nonmarital Births

Participants said that while development of a plan to pursue the illegitimacy bonus was initially a primary purpose of a gathering convened by the Governor, interest in bonus pursuit dissipated relatively soon. Discussants concluded that while State programs might have an impact on the non-marital birth ratios of the teen or welfare populations, such programs did not have sufficient range or size to have a substantial impact on the State's overall non-marital birth ratio. Discussants were also skeptical about the reliability of the State's data on abortion, and in being able to demonstrate that abortion rates did not increase in the State. Maryland does not require providers to report abortions, and anecdotal evidence indicates that large numbers of women cross jurisdictions to receive abortions. ⁽¹⁰⁾ As a result, members re-framed their efforts and focused primarily on developing policies that would improve the health and welfare of State residents.

Another participant noted that the Governor had assigned a high priority to efforts within the State designed to reduce nonmarital births prior to passage of PRWORA because he believed it was an appropriate policy to pursue. According to this participant, the potential availability of the bonus had no impact on policy design or implementation.

One participant believed that were Maryland to win the bonus, DHR would likely not direct the funds to DHMH programs, but would instead use the funds to support its core temporary assistance and work preparation programs. This belief, held by some portion of DHMH officials, further decreased the importance of the bonus within DHMH. Another participant, however, concluded that were Maryland to win the bonus, DHR would use the funds to expand coverage of the statutory rape and the teen pregnancy prevention programs.

Minnesota

II. General Discussion

This document summarizes the major comments made by participants during a call with representatives from relevant agencies in Minnesota. The call took place on November 26, 2001.

Call participants included representatives from:

The Department of Human Services (DHS), which administers the State's TANF plan;
The Department of Health (MDH), which administers programs targeted at reducing unintended pregnancies.

1. Changes in State Efforts Since the Passage of PWRORA

Participants noted that both the passage of PRWORA, which created the TANF block grant, as well as declining State welfare rolls, have enabled the State to enhance its efforts to reduce unintended or out-of-wedlock pregnancies. While the State funds activities serving both teens and adults, programs for teens predominate.

The 2000 and 2001 Legislature authorized the transfer of TANF funds from the Department of Human Services to the Department of Health. In addition to the $7 million in TANF funds appropriated in FY 2000, an additional $9 million was appropriated in FY 2001 to supplement a variety of existing State -funded programs directed at improving the health and well being of Minnesota children, youth and families.

A primary focus of the 2002 appropriations is on the third federal purpose: the prevention and reduction in the incidence of out-of-wedlock pregnancies.

Programs identified by participants as receiving TANF Funding include:

The MN Education Now and Babies Later (MN ENABL) program. ⁽¹¹⁾ This teen pregnancy prevention program targets youth ages 12-14 with the goal of reducing adolescent pregnancies and promoting abstinence until marriage. The program includes a media campaign, and competitive grants to community-based organizations in support of efforts that emphasize postponing sexual involvement. Programs receiving grants must incorporate community organization strategies to collaborate with other CBOs and individuals, and must include services delivered to youth, their parents, and community organizations, including schools. The State provided $1 million of TANF funding to expand the program.
The Family Home Visiting Program, which varies by county and provides a variety of services to at-risk and first-time mothers to protect child health and to reduce or delay subsequent pregnancies to unwed teens. Through this program, funds are distributed on a formula basis to Community Health Boards and Tribal Governments to expand and enhance public health nurse home visiting programs to families at or below 200% of the poverty and to support public health efforts to reduce or delay subsequent pregnancies to unwed teens. The 2000 Legislature provided $7 million in TANF funding and increased available TANF funding to $11 million in 2001.
The Youth Risk Behavior Program funds are distributed on a formula basis to Community Health Boards for public health promotion and protection activities aimed at reducing high-risk health behaviors in the following areas: alcohol use and other drug use, violence, suicide, physical inactivity, unhealthy dietary behaviors and sexual behaviors that result in pregnancy, HIV and STDs. The target population is youth age 12 to 18 years old. The program has its origins in the State's $6.1 billion settlement with the tobacco initiative. A portion of thee funds ($590 million) was set aside by the legislature as an endowment to create the statewide and local tobacco prevention endowment and also a local public health/youth risk endowment. Only the interest generated from the endowment can be used. Approximately $4 million is available in 2002. This was augmented with $2 million in TANF dollars which are used to support activities that specifically address sexual behaviors that result in pregnancy.
The Eliminating Health Disparities Initiative has two main goals, 1) by 2010 to decrease by 50% the disparities in infant mortality rates and adult and child immunization rates for American Indians and populations of color, as compared with the rates for whites; and 2) to close the gap in health disparities of American Indians and populations of color as compared with whites in the following priority health areas: breast and cervical cancer, cardiovascular disease, diabetes, HIV/AIDS and sexually transmitted infections, and violence and unintentional injuries. An additional $2 million in TANF funds was made available for competitive grants to community organizations to reduce infant mortality through implementation of strategies to reduce the high rates of teen pregnancy in ethnic and minority communities.

Related programs identified by participants as not receiving any TANF funds include:

Abstinence Education Community Grant Program is a teen pregnancy prevention program to reduce adolescent pregnancies and promote the message of abstinence until marriage. Involves teens, their parents and community organizations, including schools, in activities that support and reinforce the message of postponing sexual involvement. Competitive grant program with funding available through Title V Section 510.
The Family Planning Special Projects supports voluntary planning and action by individuals to prevent pregnancy. This competitive grant program is funded by $4.9 million in State funds. Serves high risk individuals whose age (under 18 or over 35), health, prior pregnancy outcome, or socioeconomic status (at or below 200% of the federal poverty level) increases changes of experiencing an unplanned pregnancy or problems during pregnancy.
The Title X Family Planning program provides family planning services to adults and teens throughout the State. ⁽¹²⁾ The Department of Health receives a small amount of Title X money directly, which is used to provide pre-pregnancy family planning services to sexually active and high-risk adolescents who reside in South and Near North neighborhoods of Minneapolis.
The State Department of Children, Families and Learning administers an Adolescent Parenting program, which offers needed support and services for parenting teens in completing their education, acquiring school-to-career skills, developing parenting and communication skills and preventing subsequent pregnancies. Approximately $400,000 is available for the competitive grants that support these programs.
Also available through the State Department of Children, Families and Learning is the Male Responsibility and Fathering competitive grant program. This program, targeting males ages 10 to 21, helps reduce teen pregnancy, increases the establishment of paternity and teaches the responsibilities of parenthood to youth. The program awards $250,000 annually to support a variety of activities.
The State is also submitting an application for a Medicaid Waiver that would provide pre-pregnancy family planning services to individuals under 275% of the federal poverty level.

2. Extent to Which Efforts Focus on Teens and/or Adults

Participants noted that while the State engages in efforts to reduce non-marital childbearing among both adults and teens, State efforts using TANF funds emphasize activities targeting unwed teens.

3. Barriers or Challenges to Program Development and Implementation

Barriers and challenges to program development and implementation cited by participants included:

Inadequate funding of subsidized family planning services. One official reported that the State is only able to reach approximately 40% of individuals in need of such services.
Finding the delicate balance between providing abstinence and postponing sexual involvement programs, especially for younger teens, with providing comprehensive sexuality programs for sexually active or older teens.
Officials reported that public health staff in the State initially expressed concern that delivery of abstinence-only education could not be reconciled with a public health model's traditional focus on ensuring access to contraceptive information and services. The State sought input from local communities, and based on this input, implemented a range of abstinence education programs. Programs receiving federal money teach abstinence only, and programs receiving State funds provide both abstinence and contraception education. Recently, the State legislature has exhibited an increasing interest in directing the types of curricula that can be offered to youth (i.e., abstinence until marriage).
A growing immigrant population, with challenges related to language and cultural barriers.
A change in the source of funding for the Family Home Visiting Program posed a substantial challenge. This program received an additional $7 million from TANF (later reduced to $4 million), which must be spent each year to qualify for any additional funding in the subsequent year. Consequently, the State engaged in additional outreach activities to target program recipients and to recruit sufficient staff to engage in the visits. Especially challenging for the State was the task of hiring and retaining public health nurses in rural areas of the State to assist in service delivery.
Service delivery to rural populations because of limited availability of transportation for rural residents.
Increased legislative concern about State family planning funds subsidizing abortion providers even though the funds are for purposes preventing the need for abortion.

4. Changes in Traditional Roles of State Agencies or Community-Based Organizations

Participants noted that since the passage of PRWORA, State agencies have engaged in increased coordination and collaboration. This has been a critical element to the success of the Family Home Visiting program.

Increased agency collaboration at both the local and State level between DHS and DPH has been an important ingredient of the home visiting program. Part of this collaboration stems from the multi-disciplinary approach to providing technical assistance, site visits, and training for local-level public health and human services staff. For the first year of Family Home Visiting each County was required to submit a program plan. In addition, Counties were asked to review the plan with elected County Board officials. At the policy level, the home-visiting program has been able to benefit from the increased coordination occurring between DHS and MDH. To assist in this collaboration, each department hired a coordinator to serve as liaisons. These coordinators engaged in activities at the local level, allowing them both to gain insight into the operation of various State programs, as well as to assist staff in each department to understand staff roles in the other department.
An impact evaluation of the home-visiting program is being conducted, with the outcomes identified through a collaborative partnership of department staff and local public health staff. The evaluation will examine the outcomes of the program including delaying of repeat pregnancies among teens served by home visiting.
The development of a teen pregnancy prevention plan has also been shaped in a collaborative environment. Staff involved in developing the plan include: Department of Human Services, the Department of Children, Families and Learning, the Department of Health, the Department of Economic Security, MOAPPP (Minnesota Organization on Adolescent Pregnancy, Prevention, and Parenting), local public health and social services staff and various community organizations serving teens.

Minnesota has traditionally looked to the community to help plan and provide services, and have worked with a number of Community-Based Organizations (CBOs) that have been strong and active partners in teen pregnancy prevention efforts.

5. Changes in Funding Levels

Funding levels for these initiatives have generally increased since the passage of TANF, but lack of availability of funds remains a substantial problem in the State, said participants.

B. Role of Illegitimacy Bonus on Efforts to Reduce Nonmarital Births

The participants said that the potential availability of the bonus had not influenced policy design or implementation decisions.

Because bonus receipt is conditional, participants said the State made program decisions based upon estimates of non-bonus revenue only.

Participants noted that while Minnesota has a high nonmarital birth rate among minorities, the State's overall rate is very low. Officials believed further reductions in the rate, given the relatively low starting point, would be difficult.

Several participants said they would like to see the bonus discontinued; they would rather receive funds on a formula basis. They said that designing programs to affect the nonmarital birth ratio could be particularly difficult (depending on the State ). For example, States with large or particularly diverse populations are likely to pose greater challenges to efforts intended to influence childbearing behavior than would be posed by States with smaller or more homogenous populations.

New York

This document summarizes the major comments made by participants during a call with representatives from relevant agencies in New York. The initial call took place on January 11, 2002 with representatives from relevant agencies in New York. Subsequent follow-up calls occurred between the initial call date and mid-February.

Call participants included representatives from:

Office of Children and Family Services (OCFS), in the Department of Family Assistance;
New York State Council on Children and Families;
Child Support Services, in the Office of Temporary and Disability Assistance (OTDA);
Division of Transitional Supports and Policy (TSP), in the Office of Temporary and Disability Assistance (OTDA);
Community-Based Adolescent Pregnancy Prevention program (C-BAPP), in the Department of Health (DOH);
Women's Health Bureau, in the Department of Health (DOH); and
Adolescent Pregnancy Prevention Services (APPS), in the Office of Children and Family Services (OCFS).