HHS Funding for Abstinence Education, Education for Teen Pregnancy and HIV/STD Prevention, and Other Programs that Address Adolescent Sexual Activity

12/16/2008

Health and Human Services Funding for Abstinence Education, Education for Teen Pregnancy and HIV/STD Prevention, and Other Programs that Address Adolescent Sexual Activity

December 16, 2008

This report is available on the Internet at:http://aspe.hhs.gov/hsp/08/AbstinenceEducation/

Transmittal Letter to Representative Mark Souder

December 16, 2008

The Honorable Mark Souder Senior Member, Committee on Oversight and Government Reform U.S. House of Representatives Washington, D.C. 20515

Dear Representative Souder:

In response to your request, I am pleased to send you the report Health and Human Services Funding for Abstinence Education, Education for Teen Pregnancy and HIV/STD Prevention, and Other Programs that Address Adolescent Sexual Activity.

The report presents a detailed breakdown comparing Departmental funding for abstinence education, adhering to the A-H definition, with other Departmental funding used to prevent unwanted pregnancies and sexually transmitted infections. In FY 2008, the Department estimates that the HHS federal funding levels for programs addressing sexual activity among adolescents was $785.8 million, of which $176.5 was spent for Abstinence Education (as defined by A-H), $300.2 million was spent for Pregnancy/STD/HIV Prevention and Education programs, and $309.1 million was spent for Family Planning services.

I hope you will find this report useful.

Sincerely,

[Signature]

Michael O. Leavitt

Enclosure

Contents

Appendices

  1. Social Security Act Definition of Abstinence Education
  2. Program Descriptions

Endnotes

Background

Over the past few decades, policymakers as well as the general public have become increasingly concerned about the prevalence of sexual intercourse among adolescents and the associated rates of teenage pregnancy and sexually transmitted diseases (STDs) among young people.

While rates of teenage sex, pregnancy, births, and abortions have generally declined since the 1990s concerns about teen sexual activity persist.  In 2007, 48 percent of all high school students and 65 percent of graduating seniors reported having had sexual intercourse.[1] About 22 percent of high school seniors reported having had sex with four or more partners in 2007.[2] In addition, there is still a significant proportion of youth who are sexually experienced at very young ages; in 2007, 4 percent of teen girls and 10 percent of teen boys reported having had sex before age 13.[3]

Although the teen birth rate has generally been declining since 1991, approximately 440,000 babies were born to teens in 2006, and more than 80 percent of these births were to unmarried teens.[4] The consequences of teenage sexual activity and non-marital childbearing are many and serious for teens, their families, their communities, and society.  Although the direction of causality is not always clear, being a teenage mother is associated with a number of adverse conditions.  Over three-fifths of teen mothers live in poverty at the time of their childs birth, and over four-fifths eventually live below poverty.[5] There are substantial disparities in the educational attainment of teen mothers compared to young women who delay child-bearing.[6] Compared with children born to mothers who delay childbearing until age 21 or older, children of teen mothers are more likely to grow up in homes that are not emotionally supportive or cognitively stimulating, to suffer from abuse and neglect, to repeat a grade in school, and to drop out of high school.[7]

Another major concern about teen sexual activity is the transmission of STDs. Compared to older adults, sexually-active adolescents 10 to 19 years of age and young adults 20 to 24 years of age are at higher risk for acquiring STDs for a combination of behavioral, biological, and cultural reasons.[8] Approximately half of all new STD infections occur in teens and young adults (ages 15-24) each year.[9]  The human and monetary costs of STDs are very high.  STDs can cause lifelong health complications. Ten to 20 percent of women with gonorrhea and Chlamydia develop pelvic inflammatory disease (PID), which can lead to lifelong complications, such as infertility and potentially fatal ectopic pregnancies.[10]  Many sexually transmitted diseases can cause adverse pregnancy outcomes, including, but not limited to, miscarriages, stillbirths, intrauterine growth restriction, and perinatal (mother-to-infant) infections.[11]  Recent estimates indicate that the economic burden of the nine million new cases of STDs that occurred among 15-24 year-olds in 2000 was $6.6 billion (in year 2000 dollars).[12]

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Overview of Report

The U.S. Department of Health and Human Services (HHS) funds programs that address adolescent sexual activity directly.  Other funded programs (e.g., TANF) address adolescent sexuality as part of a broader focus but the amount of funding addressing adolescent sexuality can be estimated. This report describes those programs and presents estimates of federal funding within HHS over the last several years.  This report will provide a better understanding of how much federal funding is available for programs that address adolescent sexual activity. 

The Department funds three categories of programs that address adolescent sexual activity.  While these categories are explained in more detail below, the following is a brief summary--

  • Abstinence education, as defined by Title V, Section 510(b)(2) (A-H) of the Social Security Act (SSA);
  • Education or awareness about pregnancy and/or STD/HIV prevention programs; and
  • Family planning services. 

The Department recently conducted a review of its funding streams to make the best possible estimate of the federal funding levels for programs in these three groups.  Given that most HHS programs do not specifically target adolescent sexual risk behaviors, this assessment required a careful review. 

The review of activities to address the prevention of sexual risk behaviors among adolescents focused only on domestic programs and included:

  • federal efforts that specifically target the prevention of sexual risk behavior; and
  • federal efforts that indirectly fund activities aimed at preventing sexual risk behavior (e.g., where some funds are used to provide such services even if the program is not targeted this way).

To date, HHS has identified 13 programs.  Three are programs that provide an abstinence education message, as defined by Title V, Section 510(b)(2) (A-H) of the Social Security Act; six include education or awareness about pregnancy and/or STD/HIV prevention; and four provide family planning services.

The sections below present an analysis of federal funding and the current HHS estimate for the total level of funding.  This funding is also broken out by the three categories for addressing sexual activity among adolescents.

This report documents the federal funding levels for these programs within HHS, briefly describes the methodology used determine these estimates, briefly describes the programs, and discusses the analysis in detail.

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Methodology

To identify the full range of activities that HHS supports, Operating Divisions from the Department were asked to provide information on programs they administered aimed at preventing sexual risk behaviors among adolescents.

The following three mutually exclusive categories of program activities were the focus of the request:

  1. Abstinence Education: Programs that adhere to the A-H provisions as stated in Title V, Section 510(b)(2) (A-H) of the Social Security Act (P.L 104-193). See Appendix A for additional information.
  2. Education or Awareness about Pregnancy and/or STD/HIV Prevention: Programs that include a component addressing sexual activity among adolescents, including, but not limited to:
    • Abstinence education not required to follow Title V, Section 510(b)(2) (A-H);
    • Pregnancy prevention and awareness activities, such as education about contraception use;
    • STD and/or HIV prevention and awareness activities, such as education about the importance of prevention, early identification, and treatment of sexually transmitted diseases; and
    • Clinical services, outreach services, media campaigns, training programs, research and evaluation activities, and technical assistance.
  3. Family Planning Services: Programs that provide family planning services to adults and adolescents including, but not limited to:  Title X Family Planning Clinics, Medicaid and the State Childrens Health Insurance Program (SCHIP), HRSA health centers, TANF, and others.

Although the term adolescent has been used to refer to children and teenagers anywhere between the ages of 10 and 21 through HHS, for the purposes of this exercise, Operating Divisions were asked to define adolescent as any youth aged 19 and younger.  Operating Divisions were asked to use this definition even if the program uses a different definition or does not have a specific definition of adolescent.  Programs that use an alternative definition for youth are identified within the program descriptions below.

Operating Divisions were asked to use a table to provide funding levels for activities addressing the prevention of sexual risk behavior for adolescents for domestic programs only.  For programs that support the prevention of sexual risk behavior as part of a broader mission, funding was included if the amount used for the prevention of sexual risk behavior could reasonably be estimated.

In addition, Operating Divisions were asked to provide a program narrative using a template with the following information: 

  • Program description and the kinds of activities funded;
  • Target population for the program or services;
  • Alternative definitions of adolescent if the program routinely uses a different definition of adolescent other than any youth aged 19 and younger;
  • Funding mechanism (e.g., block grant, individual grants, cooperative agreement, or contracts) and the grant recipients, in addition to the methodology used to estimate funding levels (if applicable).

The program narratives describing the programs are contained in Appendix B.

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Analysis of Federal Funding Levels

In order to estimate federal funding levels for programs that address adolescent sexual activity, the Department collected three fiscal years of federal funding data from HHS operating divisions:  FY 2007 enacted; FY 2008 enacted; and FY 2009 Presidents Budget.  The narrative below uses FY 2008 enacted levels to estimate federal funding levels.  More details are presented in charts and tables, as well as in the appendices. 

Based on the estimates collected within HHS, in FY 2008 the Department estimates that the HHS federal funding levels for programs addressing sexual activity among adolescents was $785.8 million.  Estimated funding levels, broken down by category are:  

  • Abstinence Education, as defined by Title V, Section 510(b)(2) (A-H) = $176.5 million

  • Pregnancy/STD/HIV prevention and education programs = $300.2 million

  • Family Planning services = $309.1 million

Figure 1 displays these numbers as a percentage and shows that almost three-quarters of federal funding in FY 2008 went to family planning or STD/HIV education and awareness activities and less than one-quarter went to abstinence education activities as defined by Title V, Section 510(b)(2) (A-H) of the SSA.

Figure 1.
FY 2008 Federal Funding for Adolescents

Source: HHS

Three slice pie chart shows 22% for Abstinence Education, 38% for Pregnancy and/or STD/HIV prevention, and 40% for Family Planning.

Total federal funding in FY 2008 at any age was $2,405.7 million, of which $176.5 million was for abstinence education; $309.9 million for pregnancy and STD/HIV education and awareness; and $1,919.3 million was for family planning services. This figure does not include funding for pregnancy and STD/HIV education and awareness programs that do not serve adolescents.

The following describes the federal funding levels for each of the three categories.

Under the abstinence education category, which only includes abstinence education programs as defined by Title V, Section 510(b)(2) (A-H) of the SSA, all three HHS programs specifically target adolescents.  Two of the programs are in the Administration for Children and Families and the third is administered by the Office of Population Affairs.  The FY 2008 federal funding level for all three programs is $176.5 million.  The table below lists the three programs and their specific federal funding level for three fiscal years.

 

 

Federal Programs Addressing Sexual Activity among Adolescents

Abstinence Education, as defined by Title V, Section 510 (b)(2)(A-H)

FY 2007 Enacted

FY 2008 Enacted

FY 2009 PB

 +/-

FY 08

OPHS

 

 

 

 

Adolescent Family Life:

 

 

 

 

Prevention Demonstrations........................

13.1

13.1

13.1

 

ACF

 

 

 

 

State Abstinence Education[13] (mandatory)...

50.0

50.0

50.0

 

Community Based Abstinence Education (discretionary)

113.4

113.4

141.1

+27.7

PHS Evaluation Funding (non add).......

4.5

4.5

4.4

-0.1

Subtotal, Abstinence Education.........................

176.5

176.5

204.2

+27.7

 

The Administration has increased funding levels in the Community-Based Abstinence Education Program (CBAE) since FY 2002 to address its commitment to increase a risk avoidance approach in the federal funding levels of federal domestic programs that address adolescent sexual activity. It increased the federal funding level from $40.0 million in FY 2002 to $113.4 million in FY 2008.  Over this six year period, the federal funding for these three abstinence education programs has increased 74% (from $101.8 million to $176.5 million).  In FY 2009, an increase of $27.7 million is proposed.

 

Education and Awareness about Pregnancy and/or STD/HIV Prevention

There are six programs that fall under the category of education and awareness about pregnancy and/or STD/HIV prevention.  Most of the programs in this category provide services to youth.  In FY 2008, HHS estimates that $300.2 million was provided to adolescents for education and awareness about pregnancy and/or STD/HIV prevention.  For all ages, the FY 2008 estimate is $309.9 million.  In this category, nearly all of the federal funding goes to adolescents, as the table below shows.  This estimate does not include funding for the Maternal and Child Health Block Grant (MCH) program, administered by the Health Resources and Services Administration (HRSA).  Funding estimates are not available for activities that address adolescent sexual activity because HRSA does not break out MCH funding for pregnancy prevention from funding spent on other aspects of maternal health.

 

Federal Programs Addressing Sexual Activity among Adolescents

Education or Awareness about Pregnancy and/or STD/HIV Prevention  *

FY 2007 Enacted

FY 2008 Enacted

FY 2009 PB

+/-
FY 08

OPHS

 

 

 

 

Adolescent Family Life:

 

 

 

 

Care Demonstrations

 

 

 

 

Services or Activities provided to people of any age ...

11.0

11.0

11.3

+0.3

Services or Activities provided to adolescents .............

11.0

11.0

11.3

+0.3

IHS 

 

 

 

 

Clinical Services, Prevention, and Urban Health a

 

 

 

 

Services or Activities provided to people of any age ...

4.4

4.6

3.6

-1.0

Services or Activities provided to adolescents .............

1.7

1.8

1.4

-0.4

  CDC b

 

 

 

 

Health Promotion

 

 

 

 

School Based HIV Prevention Education

 

 

 

 

Services or Activities provided to people of any age ...

40.9

40.2

40.1

-0.1

Services or Activities provided to adolescents .............

40.9

40.2

40.1

-0.1

Safe Motherhood -- Preventing Teen Pregnancy

 

 

 

 

Services or Activities provided to people of any age c

11.0

13.8

10.8

-3.0

Services or Activities provided to adolescents .............

5.5

6.9

5.4

-1.5

School Based Programs to Promote Delay of Sexual Debut

 

 

 

 

Services or Activities provided to people of any age ...

2.3

2.3

2.3

 

Services or Activities provided to adolescents .............

2.3

2.3

2.3

 

  ACF

 

 

 

 

TANF

 

 

 

 

Services or Activities provided to people of any age ...

238.0

238.0

238.0

 

Services or Activities provided to adolescents .............

238.0

238.0

238.0

 

Subtotal, Education and Awareness Activities

 

 

 

 

Services or Activities provided to people of any age ...

307.6

309.9

306.2

-3.7

Services or Activities provided to adolescents .............

299.4

300.2

298.5

-1.6

a  Funding represents amounts targeted specifically for HIV/AIDS. 

b  Funding is only included for programs focusing on STD prevention through sex education.  For other STD prevention activities, CDC is not able to break out funding for sex education from funding for other types of STD prevention (e.g., teaching people what they should do it they are diagnosed with an STD).

c  Funding amounts for this program are based on calculated estimates. 

 

The six programs are administered across several HHS operating divisions:  Office of Public Health and Science, Indian Health Service, Centers for Disease Control and Prevention, and the Administration for Children and Families.  For the Indian Health Service and CDCs Safe Motherhood program, services are provided to people of any age and the amount of funding used to provide services  to adolescents is estimated. Funding over the three years noted has been constant, with a slight increase from FY 2007 to FY 2008 and a slight decrease proposed in the FY 2009 Presidents budget.

Family Planning Services

HHS provides significant funding for family planning, including family planning services specifically targeted to adolescents.  In FY 2008, estimated federal funding levels for domestic family planning services provided through HHS programs totals $1,919.3 million, of which $309.1 million is estimated to be provided to adolescents. 

As the table below shows, Medicaid is the largest program providing family planning to all individuals, with $1,350 million provided to individuals at any age and $140 million provided to adolescents.  The Office of Population Affairs Title X Family Planning Clinics (Title X Clinics are administered by OPA but the appropriations account is through HRSA) is the next largest federal funding source, with $300 million provided to individuals of any age and $75 million provided to adolescents.  Other family planning services are provided through the Indian Health Service and through ACFs SSBG Program. 

 

Federal Programs Addressing Sexual Activity among Adolescents

Family Planning Services

FY 2007 Enacted

FY 2008 Enacted

FY 2009 PB

+/-
FY 08

HRSA a

 

 

 

 

Family Planning

 

 

 

 

Services or Activities provided to people of any age ...

283.1

300.0

300.0

 

Services or Activities provided to adolescents + .............

70.8

75.0

75.0

 

IHS:

 

 

 

 

Family Planning Services b

 

 

 

 

Services or Activities provided to people of any age ...

223.3

231.8

225.0

-6.8

Services or Activities provided to adolescents .............

86.2

89.5

86.8

-2.6

ACF:

 

 

 

 

Social Services Block Grant (SSBG) b

 

 

 

 

Services or Activities provided to people of any age ...

37.6

37.6

26.6

-11.0

Services or Activities provided to adolescents .............

4.6

4.6

3.3

-1.4

CMS  c

 

 

 

 

Medicaid b, d

 

 

 

 

Services or Activities provided to people of any age ...

1,250.0

1,350.0

1,460.0

+110.0

Services or Activities provided to adolescents ............

130.0

140.0

150.0

+10.0

Subtotal, Family Planning

 

 

 

 

Services or Activities provided to people of any age ...

1,794.0

1,919.3

2,011.6

+92.2

Services or Activities provided to adolescents .............

291.6

309.1

315.1

+6.0

a  Funds for Health Centers are not included because HRSA's Uniform Data System does not break out funds for family planning from funds for other health services.

b  Funding amounts for this program are based on calculated estimates. 

c  CMS does not currently have an estimate of SCHIP funding for family planning.

d  FY 2009 estimates assume current law.  They do not include the impact of the Administration's proposal to match States' family planning expenditures at their regular FMAP.

Of the total spent for family planning services at any age, about 16 percent of that total is provided to adolescents.  There has been about a 7 percent increase from FY 2007 to FY 2008 in family planning funding for all ages and an estimated 6 percent increase for family planning services to adolescents.  The largest increase in family planning services is in the Medicaid program with an 8 percent increase from FY 2007 to FY 2008 in services provided at all ages and an estimated 8 percent increase in services provided to adolescents during this time period. 

The current estimate does not include funding from two Departmental programs:  1) Community Health Centers; and 2) the State-Childrens Health Insurance Program (SCHIP).  HRSA administers the Community Health Centers program.  Estimated funding for family planning services are not available for Community Health Centers because HRSA's Uniform Data System does not break out funds for family planning from funds for other health services. The Centers for Medicare and Medicaid Services administers the State-Childrens Health Insurance Program, and they do not currently have a way to estimate the amount of funding that goes toward family planning.

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Conclusion

Surveillance data indicate that rates of teenage sex, pregnancy, births, and abortions have generally declined since the 1990s.  However, concerns about teen sexual activity persist. Nearly two-thirds of graduating seniors reported having had sexual intercourse, and about one-fifth of high school seniors reported having had sex with four or more partners in 2007.[14] The consequences of teenage sexual activity and non-marital childbearing are many and serious for teens, their families, their communities, and society.  Although the direction of causality is not always clear, being a teenage mother is associated with a number of adverse conditions including higher rates of poverty, lower educational attainment, and worse outcomes for their children. In addition, a significant number of sexually active teens are infected with STDs.  Approximately half of all new STD infections occur in teens and young adults (ages 15-24) each year.[15]  There are substantial health and economic costs associated with acquiring sexually transmitted diseases, including infertility, miscarriages, and mother-to-infant infections.  Recent estimates indicate that the economic burden of the nine million new cases of STDs that occurred among 15-24 year-olds in 2000 was $6.6 billion (in year 2000 dollars).[16]

As this report shows, the Department of Health and Human Services has a wide array of programs that can be classified into three categories:  abstinence education, as defined by Title V, Section 510(b)(2) (A-H) of the Social Security Act; programs on education and awareness about pregnancy and/or STD/HIV prevention; and family planning services to adolescents.  Over the last six years, the Administration has proposed and the Congress has enacted increases for abstinence education, to better align federal funding for abstinence with funding for other types of programs that address adolescent sexual activity.  With these increases, the amount of federal funding for abstinence education is slightly more than half of the estimated amount spent for either adolescent family planning services or for STD/HIV and pregnancy prevention and education awareness funding for adolescents. 

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Appendix A

Social Security Act Definition of Abstinence Education

Sec. 510. [42 U.S.C. 710] (a) For the purpose described in subsection (b), the Secretary shall, for fiscal year 1998 and each subsequent fiscal year, allot to each State which has transmitted an application for the fiscal year under section 505(a) an amount equal to the product of

(1) The amount appropriated in subsection (d) for the fiscal year; and

(2) The percentage determined for the State under section 502(c)(1)(B)(ii).

(b)(1) The purpose of an allotment under subsection (a) to a State is to enable the State to provide abstinence education, and at the option of the State, where appropriate, mentoring, counseling, and adult supervision to promote abstinence from sexual activity, with a focus on those groups which are most likely to bear children out-of-wedlock.

(2) For purposes of this section, the term abstinence education means an educational or motivational program which

(A) Has as its exclusive purpose, teaching the social, psychological, and health gains to be realized by abstaining from sexual activity;

(B) Teaches abstinence from sexual activity outside marriage as the expected standard for all school age children;

(C) Teaches that abstinence from sexual activity is the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems;

(D) Teaches that a mutually faithful monogamous relationship in context of marriage is the expected standard of human sexual activity;

(E) Teaches that sexual activity outside of the context of marriage is likely to have harmful psychological and physical effects;

(F) Teaches that bearing children out-of-wedlock is likely to have harmful consequences for the child, the child's parents, and society;

(G) Teaches young people how to reject sexual advances and how alcohol and drug use increases vulnerability to sexual advances; and

(H) Teaches the importance of attaining self-sufficiency before engaging in sexual activity.

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Appendix B

Program Descriptions

 

Abstinence Education Programs, as defined by Title V, Section 510(b)(2) (A-H)

Office of Public Health and Science Adolescent Family Life Prevention Demonstrations

The Office of Public Health and Science (OPHS) operates the Adolescent Family Life Prevention Demonstration Projects.  The Adolescent Family Life (AFL) program, authorized in 1981 under Title XX of the Public Health Service Act, is administered and directed by the Office of Adolescent Pregnancy Programs (OAPP) in the Office of Population Affairs (OPA).  The AFL prevention programs establish innovative and integrated approaches to implement abstinence education, as defined by section 510(b)(2) (A)-(H) of Title V of the Social Security Act. 

AFL prevention programs develop and test curricula, educational materials and youth development or developmental assets approaches designed to encourage adolescents to postpone sexual activity until marriage.  These programs implement and evaluate abstinence education services and activities targeting adolescents before they become sexually active.  The target population is adolescents under the age of 19 and their families.  Prevention demonstration programs are funded through competitive grants.  Grant recipients include public or private nonprofit agency or organizations, i.e., faith-based, community-based, school districts, hospitals, and tribal organizations.  The Title XX statute also requires an independent evaluation of all funded demonstration projects and authorizes research grants in the area of adolescent family life. 

Administration for Children and Families Title V, Section 510 State AbstinenceEducation*

The Administration for Children and Families operates the Title V, Section 510 State Abstinence Education program.  This program was first authorized by Congress in 1996, as part of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996.  Funds first became available to states in 1998.  The purpose of this program is to support decisions to abstain from sexual activity until marriage by providing abstinence education as defined by Section 510(b)(2) (A-H) of Title V of the Social Security Act, as amended.  Activities funded by this program include multi-dimensional programs and interventions, curriculum-based programs, media campaigns, technical assistance, and training programs.

The program targets adolescents and adults between ages 12 and 29 as recent data from the National Center for Health Statistics indicate that adolescents and/or adults within this age range are most likely to bear children out-of-wedlock. While ACF does not have data to estimate the percent of funding used to serve adolescents, ACF collects data on service recipients between ages 12 and 29. States may serve recipients in any age group if the State demonstrates with data that the proposed population represents those groups that are most likely to bear children out-of-wedlock within the State.

The program awards block grants to states, which often award sub-grants.  Grants are available to 59 States and Territories.  Grants awarded to each State are determined by a formula using the States proportion of low-income children compared to the total number of low-income children in the U.S. based on the most recent Census data for children in poverty.  For each fiscal year, the allotment for each State or Territory will be updated based on census data published in July of the previous fiscal year and will be communicated to States by August 15 of the preceding fiscal year. States must provide $3 in matching funds for every $4 in federal funds,

The Title V, Section 510 state abstinence education program has not been reauthorized since its initial funding period ended in 2002.  In lieu of reauthorization, the program has received a series of temporary extensions, some as short as several days to three months. Most recently, the program was extended for one year, through June 30, 2009.  Program providers and other supporters of abstinence education have raised concerns that the lack of secure funding interferes with program operations at the local level.  For example, chronic uncertainty in funding can hamper a community agencys ability to plan beyond the short-term, retain staff, and implement a stable program. 

States must identify groups within the State that are most likely to bear children out-of-wedlock and choose their focal population(s) from within those groups. The groups may be identified based on a number of factors such as age groups, race, regional areas of the State with higher rates of out-of-wedlock births, social conditions, or a combination of factors. 

 Administration for Children and Families Community Based Abstinence Education

In addition to the Title V, Section 510 State Abstinence Education program, the Administration for Children and Families also operates the Community Based Abstinence Education (CBAE) program.  The CBAE program supports programs that are designed to promote abstinence-until-marriage education, as defined by Section 510(b)(2) (A-H) in Title V of the Social Security Act, for adolescents aged 12 through 18.  The focus of the program is to educate young people and create an environment within communities that supports teen decisions to postpone sexual activity until marriage.  Activities funded through this program include multi-dimensional programs and interventions, curriculum-based programs, clinical services, media campaigns, technical assistance, support services, training programs, and research and evaluation. The population targeted is 12 18 year old adolescents. 

CBAE programs are discretionary grants.  Grant recipients currently include county health departments, school districts, community based organizations, faith-based organizations and others.  Organizations that are eligible to apply include state or local governments, school districts, institutions of higher education, Indian/Native American tribal governments, non-profits, for-profit organizations and small businesses.

Education or Awareness about Pregnancy and/or STD/HIV Prevention Programs

Office of Public Health and Science CARE Demonstrations

In addition to the Adolescent Family Life prevention demonstrations, the Office of Public Health and Science also administers CARE demonstrations through the Adolescent Family Life program (see above).  The CARE demonstrations programs develop and test interventions with pregnant and parenting teens in an effort to ameliorate the negative effects of too-early-childbearing on teen parents, their babies and their families.  Preventing repeat pregnancies is one of the major program goals. CARE demonstrations target youth aged 19 and younger.  Similar to the AFL prevention demonstrations, community-based, community supported, faith-based, and school-based applicants are encouraged to apply for Title XX grants.

Indian Health Service HIV/AIDS Prevention Program

The HIV Program within the Office of Clinical and Preventive Services in the Division of Clinical and Community Services of the Indian Health Services (IHS) is implemented at national, regional and local levels with many collaborators both internal and external to the agency.  Activities of this program include advocacy and awareness, capacity building, treatment and care, monitoring and evaluation, and prevention.  This program provides anticipatory guidance[17] to children and adolescents and their parents in traditional clinical settings as well as during school-linked and school-based encounters.  Patient education during sexually transmitted disease screening and reproductive health care visits is standard practice at facilities. 

Funding shown is for specific HIV/AIDS prevention activities.  Funding does not include HIV/AIDS treatment or HIV/AIDS prevention provided as part of a broader context (e.g., in a physician visit when many health messages are provided). In order to estimate the funding spent on adolescent services, the total estimate cost is multiplied by FY 2006 user population aged 19 and under (38.6%).

Centers for Disease Control and Prevention School Based HIV Prevention Education

Through the School Based HIV Prevention Education program, CDC funds national nongovernmental organizations and state education agencies, local education agencies, territorial education agencies, and tribal governments to support HIV prevention education programs in schools and settings that serve youth in high-risk situations.  Activities that are funded include multi-dimensional programs and interventions, curriculum-based programs, technical assistance, training programs, research and evaluation, and capacity building.  Funds also support surveillance activities through the Youth Risk Behavior Surveillance Survey (conducted every two years), the School Health Policy and Programs Survey (conducted every six years), and School Health Profiles (conducted every two years).  The funding mechanisms used include cooperative agreements and contracts.  Funds are only used to serve adolescents in a variety of settings, such as middle schools and high schools and youth in out-of-school institutions such as homeless shelters, juvenile detention centers, etc. 

Centers for Disease Control and Prevention Safe Motherhood/Preventing Teen Pregnancy: Promoting Science-based Approaches to Teen Pregnancy Prevention, HIV and STIs*

This program's purpose is to increase the capacity of state and local organizations to use a science-based approach to reduce/prevent teen pregnancy, human immunodeficiency virus (HIV), and sexually transmitted infections (STIs).  In addition, the program aims to enhance the partnership between educational authorities and teen pregnancy-focused coalitions.  Target organizations include health departments, health clinics, community based organizations, and other youth serving organizations.  Activities funded through this program include multi-dimensional programs and interventions, technical assistance, support services, training programs, research and evaluation and efforts to adapt guidelines for adolescent health and sexual health science-based programs.  The funding mechanism is through competitive cooperative agreements.

With additional funding in FY 2008 for a Teen Pregnancy Prevention Demonstration Program, CDC will work with existing state-based teen pregnancy prevention coalitions and state departments of education to continue implementing innovative science-based prevention programs in youth-serving organizations and schools.  Effective science-based prevention programs include curriculum-based sex education that addresses abstinence and contraceptive use, and strategies that promote youth development.  This initiative will build on current state-based efforts and will enable grantees to focus on localities with the highest teen pregnancy rates.  This initiative will target youth in rural, urban, and tribal areas in nine states (SC, NC, MN, HI, CO, MA, WA, PA, and OK) and will be accomplished through two key strategies: state-based partnerships and technical assistance.  This program targets young people between the ages of 10 and 24 years old. 

Centers for Disease Control and Prevention School Based Programs to Promote Delay of Sexual Debut

This program funds state and territorial education agencies and national organizations to help adolescents avoid early sexual debut, unintended pregnancies, and STDs including HIV/AIDS. The activities that are funded include curriculum-based programs, technical assistance, research and evaluation, and capacity building.  The mechanism through which these activities are funded is cooperative agreements.  The target population served is adolescents in middle schools and high schools and youth in out-of-school institutions such as homeless shelters, juvenile detention centers, etc.

Administration for Children and Families Temporary Assistance for Needy Families (TANF) Program: Prevent and Reduce the Incidence of Out-of-Wedlock Pregnancies

The TANF program provide States, the District of Columbia and territories with funding through a block grant to increase state flexibility in operating programs designed to:  provide assistance to needy families so that children may be cared for in their own homes; end dependence of needy parents by promoting job preparation, work, and marriage; prevent and reduce the incidence of out-of-wedlock pregnancies; and encourage the formation and maintenance of two-parent families.  Funds are used to provide multi-dimensional programs and interventions.  States reported spending 1.4% of their TANF funding to reduce incidence of out-of-wedlock pregnancy in FY 2006.  For purposes of this report, we assume that the percent of TANF funds spent on this activity will be maintained. Activities for reducing the incidence of out-of-wedlock childbearing target adolescents.

TANF is a block grant that has an annual cost-sharing requirement known as maintenance-of-effort (MOE).  Each state receiving federal TANF funds must spend an applicable percentage of its own money to help eligible families in ways that are consistent with the purpose of the TANF program.

Family Planning Services

Title X Family Planning

The Title X program is designed to provide access to contraceptive services, supplies and information to all who want and need them, although the legislation gives priority to persons from low-income families.  The Title X Family Planning program was enacted in 1970 as Title X of the Public Health Service Act.  Title X is the only federal grant program dedicated solely to providing individuals with comprehensive family planning and related preventive health services.  The Title X Family Planning program is administered within the Office of Public Health and Science, Office of Population Affairs (OPA) by the Office of Family Planning (OFP).  At least 90 percent of the appropriation is used for clinical family planning services as described in the statute and regulations (45 CFR Part 59), with the remainder used for training, research, and education/information.  It is estimated that in 2006, approximately 25% of clients were adolescents.

Title X grantees provide family planning services to approximately five million women and men through a network of more than 4,400 community-based clinics that include State and local health departments, tribal organizations, hospitals, university health centers, independent clinics, community health centers, faith-based organizations, and other public and private nonprofit agencies.  In approximately 75% of U.S. counties, there is at least one clinic that receives Title X funds and provides services as required under the Title X statute.  The Title X family planning program is intended to assist individuals in determining the number and spacing of their children.  This promotes positive birth outcomes and healthy families.  The education, counseling, and medical services available in Title X-funded clinic settings assist couples in achieving these goals.

Over the past 30 years, Title X family planning clinics have played a critical role in ensuring access to a broad range of family planning and related preventive health services for millions of low-income or uninsured individuals and others.  In addition to contraceptive services and related counseling, Title X-supported clinics provide a number of related preventive health services such as:  patient education and counseling; breast and pelvic examinations; breast and cervical cancer screening according to nationally recognized standards of care; sexually transmitted disease (STD) and Human Immunodeficiency Virus (HIV) prevention education, counseling, testing and referral; and pregnancy diagnosis and counseling.  By law, Title X funds may not be used in programs where abortion is a method of family planning.

With the remaining 10% of the appropriation not used for direct service, the Title X program also supports three key functions, authorized under the Title X statute aimed at improving the quality of family planning services and assisting clinics with responding to client needs.  These functions include: (1) training for family planning clinic personnel through ten regional general training programs and three national training programs that focus on clinical training, enhancing quality family planning services for males, and/or coordination of training activities on the national level; (2) data collection and family planning research aimed at improving the delivery of family planning services; and, (3) information dissemination and community based education and outreach activities.  These functions help to ensure that family planning services are evidence-based and of high quality.

Indian Health Service Family Planning Services

The Indian Health Service (IHS) is responsible for providing federal health services to American Indians and Alaska Natives.  The IHS is the principal federal health care provider and health advocate for Indian people, and its goal is to raise their health status to the highest possible level.  The IHS provides health services to nearly two million American Indians and Alaska Natives who belong to more than 560 federally recognized tribes in 35 states.

As a direct care organization IHS provides anticipatory guidance to children and adolescents and their parents in traditional clinical settings as well as during school-linked and school-based encounters.  Patient education during STD screening and reproductive health care visits is standard practice.  Estimated funding levels are based on Hospital and Health Clinic costs for family planning, pregnancy complications, public health nursing and contract health services.  In order to estimate services for adolescents, the total estimate cost is multiplied by FY 2006 user population aged 19 and under (38.6%).

Administration for Children and Families Social Services Block Grant*

The Social Services Block Grant (SSBG) is designed to reduce or eliminate dependency; achieve or maintain self-sufficiency for families; help prevent neglect, abuse or exploitation of children and adults; prevent or reduce inappropriate institutional care; and secure admission or referral for institutional care when other forms of care are not appropriate.  SSBG serves low-income children and families, the disabled, and elderly with well-documented need.  The program provides state and local flexibility in allocating federal funds and enables states to target populations that might not otherwise be eligible for services needed to remain self-sufficient and economically independent.

SSBG funds are used to support activities such as multi-dimensional programs and interventions, curriculum-based program, media campaigns, technical assistance, support services, training programs, and research and evaluation.  States may use the SSBG funds to support family planning services.  Family planning services are those educational, comprehensive medical or social services or activities which enable individuals, including minors (can be adults or children), to determine freely the number and spacing of their children and to select the means by which this may be achieved.  These services and activities include a broad range of acceptable and effective methods and services to limit or enhance fertility, including contraceptive methods (including natural family planning and abstinence), and the management of infertility (including referral to adoption).  Specific component services and activities may include preconceptional counseling, education, and general reproductive health care, including diagnosis and treatment of infections that threaten reproductive capability.  Family planning services do not include pregnancy care (including obstetric or prenatal care).  States reported spending 2.2% of SSBG funds on family planning in FY 2006.  For purposes of this report, we assume that the percent of SSBG funds spent on this activity will be maintained

Centers for Medicare and Medicaid Services (CMS) Medicaid and the State Childrens Health Insurance Program (SCHIP)

Medicaid is a program jointly funded by the federal and state governments to provide medical care to various low-income populations.  Medicaid is an entitlement program, meaning that federal law guarantees reimbursement for services provided to everyone enrolled under federal and state eligibility criteria.  For most expenses, the federal government pays for 50-76% of states' Medicaid expenditures.  By federal law, however, the federal government pays for 90% of each state's Medicaid expenditures for family planning services and supplies. Although federal law requires that each State Medicaid program cover family planning services, states have leeway in deciding what exactly is included. Using expenditure data and utilization rates, the CMS Office of the Actuary estimated the portion of Medicaid family planning expenditures that are directed towards adolescents.

The entitlement to family planning also applies to expansions to Medicaid created by states under the State Children's Health Insurance Program, a companion program for Medicaid enacted by Congress in 1997 under Title XXI to provide care to low-income children.  States were also given the option to create separate, state-designed programs, which allow greater latitude in choosing what benefits to offer (family planning services are optional).

State-initiated family planning eligibility expansions through waivers have been approved by HHS under authority of Section 1115 of the Social Security Act.  In 1996, Arkansas was the first state to initiate such a waiver program to expand its income-eligibility level for family planning services above its level for Medicaid overall.  There are currently 22 states[18] that have approved family planning waiver programs.

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Endnotes

[1] Centers for Disease Control and Prevention, Surveillance Summaries, June 6, 2008.  MMWR 2008:57 (No SS-4) p 21.  http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf

[2] Centers for Disease Control and Prevention, Surveillance Summaries, June 6, 2008.  MMWR 2008:57 (No SS-4) p 21.  http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf

[3] Centers for Disease Control and Prevention, Surveillance Summaries, June 6, 2008.  MMWR 2008:57 (No SS-4) p 21.  http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf

[4] Hamilton BE, Martin JA, Ventura, SJ. Preliminary births for 2006. (December 5, 2007). National Vital Statistics Reports, Vol 56(7). Available at http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_07.pdf

[5] Maynard, Rebecca (ed.) Kids Having Kids:  A Robin Hood Foundation Special Report on the Costs of Adolescent Childbearing.  New York: The Robin Hood Foundation, 1996.

[6] Hotz at al. The Impacts of Teenage Childbearing On the Mothers And The Consequences of Those Impacts for Government. In Kids Having Kids: Economic Costs and Social Consequences of Teen Pregnancy, edited by Rebecca Maynard.  Washington, DC. The Urban Institute Press, 1997.  pp. 59.

[7] Maynard, Rebecca (ed.) Kids Having Kids:  A Robin Hood Foundation Special Report on the Costs of Adolescent Childbearing.  New York: The Robin Hood Foundation, 1996.

[8] Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2006. Atlanta, GA: U.S. Department of Health and Human Services, November 2007.

[9] Weinstock, H., Berman, S., and Cates, W.  Sexually Transmitted Diseases Among American Youth: Incidence and Prevalence Estimates, 2000.  Perspectives on Sexual and Reproductive Health, 2004, 36(1): 6-10.

[10] Center for Disease Control, Tracking the Hidden Epidemics: Trends in STDs in the United States 2000, pp. 3. Available at http://www.cdc.gov/nchstp/dstd/Stats_Trends/Trends2000.pdf

[11] National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, Workshop Summary: Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention, July 2001.  pp. 1. Available at http://www.niaid.nih.gov/dmid/stds/condomreport.pdf

[12] Chesson et al. The Estimated Direct Medical Cost of Sexually Transmitted Disease Among American Youth, 2000, Perspectives on Sexual and Reproductive Health, Vol 36:1, January/February 2004.  Available at http://www.agi-usa.org/pubs/journals/3601104.html

[13] The State Abstinence Education program allows states to serve individuals up to age 29, although the focus is usually on adolescents.

[14] Centers for Disease Control and Prevention, Surveillance Summaries, June 6, 2008.  MMWR 2008:57 (No SS-4) p 21.  http://www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf

[15] Weinstock, H., Berman, S., and Cates, W.  Sexually Transmitted Diseases Among American Youth: Incidence and Prevalence Estimates, 2000.  Perspectives on Sexual and Reproductive Health, 2004, 36(1): 6-10.

[16] Chesson et al. The Estimated Direct Medical Cost of Sexually Transmitted Disease Among American Youth, 2000, Perspectives on Sexual and Reproductive Health, Vol 36:1, January/February 2004.  Available at http://www.agi-usa.org/pubs/journals/3601104.html

* This program uses an alternative definition for adolescents other than youth younger than 19 years of age.

[17] Anticipatory Guidance is information that helps families prepare for expected physical and behavioral changes during their child's or teen's current and approaching stage of development.

* This program uses an alternative definition for adolescents other than youth younger than 19 years of age.

* This program uses an alternative definition for adolescents other than youth younger than 19 years of age.

[18] The 22 states with approved family planning waiver programs are:  Alabama, Arkansas, California, Florida, Iowa, Illinois, Louisiana, Michigan, Minnesota, Mississippi, Missouri, New Mexico, North Carolina, Oregon, Oklahoma, Pennsylvania, South Carolina, Texas, Virginia, Washington, Wisconsin and Wyoming.