Native Americans and Medicaid:Coverage and Financing Issues

Prepared by Andy Schneider and JoAnn Martinez, The Center on Budget and Policy Priorities for The Kaiser Commission on the Future of Medicaid

December 1997

Table Of ContentsHighlights ii I: Background On Native American Health Care 1 II: Medicaid’s Role For Native Americans 4 1. Medicaid as a Source of Health Coverage 4 2. Medicaid as a Source of Revenue for Hospitals and Clinics 6 3. Medicaid and Managed Care 10 4. Medicaid as Medicare Premium Assistance 14 5. Medicaid as a Source of Long-Term Care Coverage 15 III: Policy Issues For Native Ameircans In Managed Care 16 1. Policy Issues 16 2. Conclusion 18 Endnotes 20 Tables 22 Highlights

There are an estimated 2.3 million Native Americans — American Indians and Alaska Natives — in the U.S. About half of the Native American population lives on or near reservations; the other half resides in other rural areas and in urban areas. The Native American population includes 554 tribes recognized by the federal government as well as other tribes, largely in California, that do not have federal recognition.

Medicaid plays several significant roles for Native Americans. The Medicaid program acts as:

• An insurance program covering physician, hospital, and other basic health care services for eligible Native Americans, especially families with children;
• A source of revenue for Indian Health Services (IHS) and tribally-operated clinics and hospitals;
• A purchaser of managed care products;
• A source of financial assistance for low-income elderly and disabled Native Americans to meet Medicare premium and cost-sharing obligations; and
• A source of coverage for nursing home care and other long-term care services for frail elderly and disabled Native Americans.

All Native Americans that are members of federally recognized tribes are eligible to receive services from the IHS. Because of high rates of poverty among Native Americans, Medicaid is an important publicly funded health program for Native Americans. In 1996, it is estimated that Medicaid covered nearly 40 percent of the Native American population.

Medicaid as a Source of Revenue

Medicaid is an important source of revenue for Native American health facilities. In fiscal year 1997, IHS and tribally operated facilities were projected to receive $184.3 million in Medicaid reimbursements. This amount is equal to about 10 percent of the $1.8 billion appropriated for IHS and tribally-provided health services that year. Medicaid is an open-ended entitlement program. In contrast, the IHS receives funding through the domestic appropriations which are subject to broad caps over the next five years. As a result, Medicaid payments will become an increasingly important source of funding for many IHS, tribal, and urban programs.

The structure of the Medicaid program provides financial incentives for states to encourage beneficiaries to use tribal health facilities. Medicaid is a matching program under which the federal government contributes money to the states to pay for covered services on behalf of Medicaid beneficiaries. The federal government’s share of these costs ranges from 50 percent in wealthier states to nearly 80 percent in the poorest states. On average, the federal government pays 57 percent of a state’s Medicaid costs. In contrast, the cost of services provided to Medicaid beneficiaries by a hospital, clinic, or other facility of the IHS or by a tribe or tribal organization is matched by the federal government at a 100 percent rate in a Memorandum of Agreement (MOA) between IHS, the Health Care Financing Administration (HCFA), December 19th 1996. Thus, the state is fully reimbursed by the federal government and is not required to contribute any of its own funds toward the cost of care. This provision does not apply to urban Indian programs.

Medicaid and Managed Care

Over the past few years, Medicaid in many states has been shifting from a predominantly fee-for-service program to a program that purchases services from managed care organizations (MCOs) or primary care case management organizations (PCCMs). This shift presents critical policy issues for the IHS, tribal health programs, and urban Indian health programs. Provisions in the Balanced Budget Act of 1997 will accelerate these changes.

• Mandatory Beneficiary Enrollment in Managed Care. Under the Balanced Budget Act, states have the authority to require most Medicaid beneficiaries to enroll in MCOs or PCCMs. States can only require Native Americans in Medicaid to receive services through an MCO or PCCM if the MCO or PCCM is the IHS, a tribally operated program, or an urban Indian health program. States do not have authority to require Medicaid-eligible Native Americans to enroll in MCOs that are not operated by the IHS, a tribe, or an urban Indian organization. States do have the authority to require such enrollment under “section 1115” demonstration waivers or under “section 1915(b)” program waivers. Native Americans, who are eligible for Medicaid, have the choice of enrolling in any participating, Medicaid MCO operating in their area.
• Capitation Payments under Medicaid Managed Care. The December 1996 MOA does not expressly address payments to MCOs. Presumably, the 100 percent federal matching rate is payable to MCOs or PCCMs operated by the IHS or tribes. This interpretation would be consistent with the clear policy for fee-for-service arrangements.
• Strategic Choices for Native American Health Facilities. Managed care dramatically affects the strategic choices available to Native American health facilities.
  • IHS facilities can establish their own MCO or PCCM and seek to contract with the state to enroll Indian and non-Indian Medicaid beneficiaries; subcontract with a private MCO or PCCM and provide services to the Indian and non-Indian enrollees of that MCO or PCCM; or continue to be reimbursed by Medicaid on a fee-for-service basis and remain unaffiliated with any Medicaid MCO or PCCM.
  • Tribally owned and operated services face similar choices with two important differences. If they are also a Federally Qualified Health Center (FQHC), then they have additional financial protections until 2003. Second, they may be able to assume financial risk, allowing them the option of becoming an MCO.
  • Because urban Indian facilities are historically underfunded and do not benefit from the 100 percent matching rate, they face considerably greater challenges in adapting to the managed care environment. Their most viable option is to attempt to subcontract with an MCO or PCCM although there are no guarantees that this approach will be successful.

Native Americans and Medicaid: Coverage And Financing Issues

Traditionally, Native Americans have relied upon the facilities and programs of the Indian Health Service (IHS) for access to health care. Although the IHS remains the primary source of health care delivery and financing for most Indian tribes, public programs such as Medicare and Medicaid are playing a larger and larger role in the financing of care for Native Americans living on or near reservations as well as those in urban areas. Because of the high incidence of poverty among American Indians and Alaska Natives, Medicaid – the federal-state health care program for low-income people – is of particular importance.

Medicaid plays several different roles of significance to Native Americans. Medicaid is an insurance program, offering coverage for physician, hospital, and other basic health care services to eligible Indians, especially families with children. It is a source of revenue for IHS and tribally-operated clinics and hospitals that deliver those basic services. Through its purchase of managed care products, Medicaid is reshaping the health care delivery system for many Native Americans and other underserved low-income populations. Medicaid also assists low-income elderly and disabled Indians who are eligible for Medicare in meeting their premium and cost-sharing obligations. Finally, Medicaid offers coverage for nursing home care and other long-term care services needed by frail elderly and disabled Native Americans.

This Policy Brief provides an overview of Medicaid from the standpoint of Native Americans with an emphasis on Medicaid as an insurance program and a purchaser of managed care. This Brief supplements other Policy Briefs and background materials on Medicaid issued by the Commission.¹ It incorporates the changes to Medicaid made by the Balanced Budget Act of 1997.² This Policy Brief focuses on those federal policies common to all state Medicaid programs and does not review the details of any particular state program. Because Medicaid is administered by states within broad federal guidelines, Medicaid programs vary significantly from state to state with respect to benefits, eligibility, provider payment, and administration. However, the information contained in this Policy Brief is the starting point for understanding the Medicaid program in any particular state.

I: Background On Native American Health Care

There are an estimated 2.3 million Native Americans – American Indians and Alaska Natives – in the U.S. About half of the Native American population lives on or near reservations; the other half resides in other rural areas and in urban areas. The Native American population includes 554 tribes recognized by the federal government as well as other tribes, largely in California, that for various reasons do not have federal recognition. The federally recognized tribes vary in size from less than 100 to more than 100,000 members. The economic status of these tribes varies substantially; some are wealthy, but many face conditions of high unemployment and high rates of poverty. Indians in urban areas, who are frequently not enrolled members of federally-recognized tribes, are often unemployed.

The driving force for many of the health status and health coverage problems facing Native Americans as a whole is poverty. Not all Indians are poor, but a very large proportion of them are. U.S. Census data indicate that in 1996, 30.9% of Native Americans as a whole had family incomes below the poverty line, in comparison with 13.8% for the U.S. population as a whole.

The health status of Native Americans is significantly lower than that of the rest of the U.S. population. ³ According to the Indian Health Service (IHS) of the Department of Health and Human Services, the age-adjusted mortality rate for American Indians and Alaska Natives residing in the areas served by the IHS was 594.1 (per 100,000 population) for calendar years 1991-1993, compared to a rate of 504.2 for the entire U.S. population in 1992. ,⁴ In some IHS areas, the rate is double that of the total U.S. population. For instance, in the South Dakota, North Dakota, Nebraska and Iowa area the rate for calendar years 1991-1993 was 1,045.9.

Although there are significant variations from area to area, Native Americans as a whole have higher rates of death and injury caused by accidents and violence (including suicide and homicide) than the U.S. population generally. For the same 1991-1993 period, the IHS service area population had an accident mortality rate of 83.4 (per 100,000 population), compared with a rate of 29.4 for the entire U.S. population in 1992. Many of these deaths are related to the high incidence of alcohol abuse in a number Indian communities. Native Americans have higher rates of mortality from alcoholism than the U.S. population generally. The alcoholism mortality rate for the IHS service area population was 38.4 (per 100,000 population) over the 1991-1993 period compared to a rate of 6.8 among the entire U.S. population in 1992. Finally, the incidence of diabetes among Native Americans is significantly higher than that among the U.S. population generally. The diabetes mellitus mortality rate for the IHS service area population was 31.7 (per 100,000 population) over the 1991-1993 period, in comparison with the rate of 11.9 among the entire U.S. population in 1992.

The agency responsible for providing or paying for the provision of health services to most American Indians and Alaska Natives is the Indian Health Service (IHS). The IHS estimates its 1996 patient population – i.e., those eligible for health care services provided through or paid by the IHS – at 1.4 million Native Americans, most of whom live on reservations. This represents about three-fifths of the 2.3 million Native Americans in the U.S. Eligibility for IHS care is determined under federal statute and regulation and depends largely (but not exclusively) upon membership in a federally-recognized tribe and residence on or near a reservation. Federal recognition of a tribe is generally predicated on treaty or federal statute or both.

The IHS delivers care directly to Indians who meet IHS eligibility criteria through 40 hospitals, 64 health centers, 5 school health centers, and 50 smaller health stations located in 17 states. The IHS also makes arrangements, through contracts or “compacts,” directly with Indian tribes to deliver care to their own members. Currently tribes operate 9 hospitals, 116 outpatient health centers, 5 school health centers, 56 smaller health stations, and 171 Alaska village clinics under these arrangements. Finally the IHS funds 34 urban Indian programs ranging from outreach and referral programs to outpatient health clinics. Specialized and/or expensive diagnostic and treatment services that the IHS (or tribes) cannot offer directly through their own facilities in a particular area may, subject to the availability of funds, be purchased from non-IHS (or non-tribal) providers on a fee-for-service basis through the “contract health services” (CHS) program. Urban Indian programs do not have access to CHS funds.

In 1997, 57.2 percent of the $1.8 billion appropriated to IHS for services was spent on IHS direct operations, 41.5 percent was spent on tribally-operated hospitals and clinics, and 1.4 percent was spent on urban Indian programs. Of the $1.1 billion appropriated to IHS for direct services, $235 million, or 22 percent, took the form of contract health services purchased from non-IHS providers. The comparable CHS figure for tribal providers was $133.4 million, or 18 percent of the total $750 million in fiscal year 1997 appropriations allocated to tribal providers.

II: Medicaid’s Role For Native Americans

Medicaid as a Source of Health Coverage

In part because of high rates of poverty and unemployment, Native Americans are less likely than other Americans to have employer-sponsored or other types of private health insurance coverage. In addition, Native Americans are less likely to be enrolled in public health insurance programs like Medicare and Medicaid. According to U.S. Census data for 1996, 18.1 percent of Native Americans had no health insurance while 47.7 percent had private insurance, 39 percent were enrolled in Medicaid, 10.1 percent were enrolled in Medicare, and 4.1 percent were covered through the Civilian Health and Medical Programs of the Uniformed Services (CHAMPUS).⁵ The IHS data base indicates that, as of August 12, 1997, of the 1,784,000 individuals registered as IHS patients, 466,000, or 26 percent, were eligible for Medicaid.⁶

Nationally, Medicaid is the second largest health insurance program after Medicare. The Congressional Budget Office estimates that in 1998 Medicaid will cover 44 million individuals, half of whom are children. Each of these individuals is entitled to have payment made on his or her behalf for covered services received from participating hospitals, physicians, and other providers. Medicaid benefit packages vary from state to state, but they all include physician services; laboratory and x-ray services; inpatient and outpatient hospital services; early and periodic screening, diagnostic, and treatment (EPSDT) services for children; and services provided by federally qualified health centers (FQHCs).

Individual Entitlement

Individuals who meet Medicaid eligibility standards are entitled to coverage. This applies to Native Americans as it does to other American citizens. Historically, some state and local officials viewed the health coverage of American Indians and Alaska Natives as exclusively a federal responsibility and sought to exclude Native Americans from Medicaid coverage.⁷ Although Medicaid is administered and financed in part by the states, Native Americans who meet the Medicaid eligibility requirements of the state in which they reside are, as a matter of law,⁸ entitled to Medicaid coverage.⁹ This is true whether a Native American lives on or near a reservation or in an urban area, and whether or not a Native American is eligible for IHS services.¹⁰

Eligibility Requirements

To qualify for Medicaid in any particular state, an individual must be a resident of that state. In addition, regardless of the state in which an individual resides, an individual must meet both categorical eligibility requirements and financial eligibility requirements. Categorical eligibility requirements relate to the age or characteristics of an individual: children, pregnant women, elderly, and disabled are among the categories of individuals that may qualify for Medicaid. Financial eligibility requirements relate to the amount of income or assets an individual is permitted to have (standards), and how those amounts are calculated (methodologies). Individuals who do not meet the categorical requirements – for example, non-elderly adults who are not disabled and do not have children – may not qualify for Medicaid no matter how poor they are. There are exceptions to this general rule. Some states cover poor single adults under “section 1115” demonstration waivers granted by the Secretary of Health and Human Services. ¹¹

States have flexibility within broad federal guidelines to establish eligibility rules for their Medicaid programs, but there are certain groups of individuals that any state receiving federal Medicaid matching funds must cover. For example:

• with respect to children, states must at a minimum cover all infants up to age one (and pregnant women) with family incomes at or below 133 percent of the poverty level ($17,729 per year for a family of three in 1997), all children under age six with family income at or below 133 percent of the federal poverty line, and all children under age 14 with family income below 100 percent of the federal poverty line ($13,330 per year for a family of three in 1997). Many states have elected to set higher Medicaid eligibility thresholds for children under regular Medicaid law or under demonstration waivers.
• with respect to elderly and disabled individuals, states must at a minimum cover those individuals receiving benefits under the Supplemental Security Income (SSI) program. The exception to this rule is that states may use eligibility standards that were in effect in 1972 in determining eligibility for elderly or disabled individuals; 11 states have opted to do so.

Table 1 shows the Medicaid income eligibility thresholds in effect in each state as of October, 1997, for pregnant women, children, and aged and disabled individuals. These data, which were made available by the National Governors’ Association, describe the thresholds as a percentage of the federal poverty level.

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Native Americans and Medicaid: Coverage and Financing IssuesReport Part One Report Two Report Three Report Four

Teenage Sexual and Reproductive Behavior in the United States

The Changing Face of Teen Sexual Activity and Unplanned Pregnancy

Over the past two decades, the pregnancy rate among sexually experienced teenage girls aged 15-19 has declined by 19%, indicating that many are doing a better job at using contraception. But, because the percentage of teens who have had sex has been steadily increasing at the same time, in real terms, the problem of teen pregnancy is getting worse. In addition, as of the late 1980s, a higher proportion of teenage girls who get pregnant are giving birth and, over the last three decades, dramatically fewer are getting married when they become teen mothers, resulting in more children in households with single teen mothers.

Sexual Activity

• The proportion of 15- 19-year-old girls who are sexually active rose from 47% in 1982 to 55% in 1990.
• Fifty-six percent of teenage girls and 73% of teenage boys today have had sexual intercourse by their18th birthday. In the early 1970s, 35% of girls and 55% of boys had had sex by that age.
• Most very young teenage boys and girls have not had intercourse — 84% of 13-year-olds, 77% of 14-year-olds and 70% of 15-year-olds.
• While the likelihood of having intercourse increases steadily with age, 1 in 5 teenagers do not have intercourse during their teenage years.
• Seven in 10 girls who had sex before age 14 and 6 in 10 of those who had sex before age 15 report having sex involuntarily.
• Most teenagers begin having intercourse in their mid-to-late teens, about 8 years before they marry.
• Among the most common reasons teens have sex, according to 55% of teens, is that “they think they’re ready.”
• Six out of ten teenage girls say another reason why teen girls may have sex is because a boyfriend is pressuring them.

Contraceptive Use

• Five out of ten (48%) teens say they use birth control “all the time,” an additional 24% say they use it “most of the time,” and 15% say they use it “sometimes.” Only 11% of sexually active teens say they never use birth control, approximately the same percentage as sexually active adults who don’t.
• The contraceptive most frequently used by teens is the condom (44%), followed by birth control pills (40%). One-quarter of the teenagers who use the pill also use the condom.
• Two-thirds of teenagers use some contraceptive method — usually a condom — the first time they have intercourse.
• Teenage girls’ birth control use at first intercourse rose from 48% to 65% during the 1980s, almost entirely because of a doubling in condom use (from 23% to 48%).
• A sexually active teenage girl using no contraception over one year has a 90% chance of becoming pregnant.

Sexually Transmitted Diseases (STDs)

• Three million teenagers — about 1 in 4 sexually experienced teenagers — acquire an STD every year.
• In a single act of unprotected sex with an infected partner, a woman has a 1% risk of acquiring HIV, a 30% risk of getting genital herpes, and a 50% chance of contracting gonorrhea.
• Chlamydia is more common among teenagers than among older men and women; in some studies, up to 30% of sexually active teenage girls and 10% of teenage boys tested for STDs have been found to have chlamydia.
• Teenagers have higher rates of gonorrhea than sexually active men and women aged 20-44. In some studies, up to 15% of sexually active teenage girls have been found to be infected with HPV, the virus that causes genital warts, many with a strain of this virus linked with cervical cancer.
• By the end of 1995, there were more than 2,300 teenagers known to have AIDS.
• Teens are worried about getting AIDS or other STDs. Four out of ten teens say they worry at least some about getting AIDS someday or another STD.

Teenage Pregnancy

• About one million teenage girls — 11% of all girls aged 15-19 (112 per 1,000) and 20% of those who have had sexual intercourse (204 per 1,000) — become pregnant each year.
• Eighty-five percent of teenage pregnancies are unplanned, accounting for one-quarter of all unplanned pregnancies each year.
• Fifty-four percent of teenage pregnancies each year (960,000 in 1992) end in birth (most of which are unplanned); about one-third end in abortion (32%) and the rest in miscarriage (14%).
• Among sexually experienced teenagers, about 16% of 14-year-olds, 17% of 15- 17-year-olds and 23% of 18- 19-year-olds become pregnant each year.
• Teenage pregnancy rates are much higher in the United States than in many other developed countries — twice as high as in England and Wales, France and Canada; and 9 times as high as in the Netherlands or Japan.
• Of all births to U.S. women, 13% are to teenagers.
• Twenty percent of U.S. abortions each year are to teenagers.
• A majority of teens (55%) say when teens have unplanned pregnancies, it’s “often” a result of having sex when drunk or on drugs. Forty-six percent say it’s “often” because teens have sex when they don’t have birth control with them.

Sources of Data:

The data in this fact sheet are from research conducted by the Kaiser Family Foundation, The Alan Guttmacher Institute, the National Center for Health Statistics, and/or were published in Family Planning Perspectives.

For More Information:

Kaiser Family Foundation Survey on Teens and Sex: What They Say Teens Today Need to Know, And Who They Listen To,1996.

Centers for Disease Control and Prevention.

Sex and America’s Teenagers, The Alan Guttmacher Institute, 1994.

Testing Positive: Sexually Transmitted Disease and the Public Health Response, The Alan Guttmacher Institute, 1993.

The Entertainment Media as “Sex Educators?”

And, Other Ways Teens Learn About Sex, Contraception, STDs, and AIDS

June 24, 1996

What Sources Do Teenagers Rely on for Information About Sex and Birth Control?

According to a 1996 Kaiser Family Foundation Survey of teens, teens say they currently get information about sex and birth control from a variety of sources including: their parents (72%); teachers, school nurses, or sex education classes (69%); their friends (other than boy/girlfriends) (60%); and the media, such as TV shows or movies (53%) and magazines (39%).

What Media Are Teens Exposed To?

In today’s “information age,” teens are bombarded with information from many media sources. Television and music are among those most popular with teens. According to one study, the average teen spends more time watching television than doing any other activity besides sleeping (Davies, 1993). As teens get older, however, they show a growing preference for music over TV (Arnett, 1992; Larson, Kubey, & Colletti, 1989). In one focus group study, 11-15 year-olds listened to music four hours a day as a primary activity (not including as background music), compared to three hours a day of watching TV (Liming, 1987). The Kaiser Teen Survey also found that seventy percent of teenage girls say they “regularly” read magazines, particularly those targeted to them such as Seventeen, YM, and Teen.

To What Extent Do These Media Deal With Sex and Related Issues, Such as Contraception, STDs, and AIDS?

A study that looked at TV shows most popular among those under 17 during the 1992-1993 broadcast season found that one in four interactions among characters per episode conveyed a sexual message. In three weeks of programming studied, only two of the ten shows included messages about sexual responsibility (Ward, 1995). Two Kaiser Family Foundation studies also found high rates of sexual references and incidents with few mentions of adverse consequences in soap operas and TV talk shows. (Comparatively fewer studies have been done of print media coverage of sexuality issues, although the Kaiser Family Foundation currently has a study underway to look at the coverage in special interest magazines, such as those targeted to women, men, and teens).

Do the Media Have an Impact on Teenagers’ Attitudes and Behaviors Toward Sex?

One of the issues at the crux of the debate over sex in the media is to what extent the media affects teens’ attitudes and behaviors related to sex. After reviewing the existing research about impact of the media on behavior, Jane Brown and Jeanne Steele at the School of Journalism and Mass Communications at the University of North Carolina at Chapel Hill, both experts on the media and sexuality, concluded that in response to the question of whether the media might affect teens’ sexual behaviors, the answer is a “qualified yes.” “Qualified” because research on the effects of sex in the media is sparse and because it is very difficult to document the effects of media on people’s behavior. However, based on what is known about the effects of sexual media content, along with the larger body of research on the effect of the media on violence and anti-social behavior, they found that entertainment media do play an important role in shaping American youths’ sexual beliefs, attitudes, and behaviors. (From a study prepared for the Kaiser Family Foundation entitled Sex and Mass Media).

In the Kaiser Teen Survey, three-quarters of teens say they think portrayals of teen sex on television and in the movies is one of several possible factors affecting teen sexual activity. There is also evidence that the media can be used effectively to increase awareness and knowledge about reproductive and sexual health issues and possibly to change behavior toward reducing unplanned pregnancy and HIV and other STD infection rates.

What Teenage Pregnancy and STD Prevention Approaches Appear to Have Had a Positive Effect on Risk-Taking Behavior?

Many wide-ranging attempts have been made to affect teenage sexual and reproductive behavior but many of these programs have not been rigorously evaluated. Although numerous studies have attempted to measure the effectiveness of teenage pregnancy intervention programs, scientific research has not yet provided definitive answers about their success. However, much has been learned from the experiences of the few pregnancy prevention programs that have been designed and implemented with a rigorous, scientific evaluation component. A recent review by The Alan Guttmacher Institute of the impact of five rigorously evaluated adolescent pregnancy prevention programs shows that some intervention programs are successful in helping teenagers delay intercourse, and improving contraceptive use among teenagers who are sexually active. Furthermore, some programs can effectively combine an emphasis on delaying sexual activity with education regarding contraception. The most effective programs appear to be those that combine innovative, comprehensive sexuality education; skills for making decisions about having intercourse and for communicating with partners; and access to family planning services. Measuring the impact of community programs on sexual behavior and pregnancy rates is very difficult for several reasons including the lack of information on rates of sexual activity and birth control use at the local level.

What is “Entertainment-Education”? And, How is it Being Used?

International reproductive health organizations have long used mass media entertainment for educational purposes in some developing countries. Entertainment-education involves presenting educational content in entertaining formats with the primary goal of increasing knowledge. Mass media’s pervasiveness allows it to reach a large number of people, sending messages repeatedly in a variety of forms. Television soap operas/dramas and films are widely used in entertainment-education. Radio is also used widely because of its relatively low production cost, accessability and extensive reach. However, assessing the impact of such programs is complex — usually done with pre- and post-intervention surveys; comparison of exposed and non-exposed groups; and tracking of clinic data. Though it is unclear whether entertainment-education changes behavior, it has been proven to be an effective way to increase knowledge and awareness about an issue. Evaluations have demonstrated positive results in terms of increased knowledge about HIV transmission and the need for family planning, and increases in visits to local family planning clinics. Setting up such programs is easier outside the U.S. for a number of reasons, including less competition on the airways.

Here in the United States, there have also been some recent efforts by individuals within the entertainment industry to improve the way in which sex and its possible consequences are portrayed. A significant difference is that these efforts involve changes made to programming that is meant to be entertaining, and not meant specifically to be educational. A few examples of such efforts include:

• Following a summit of soap opera producers and writers which highlighted the lack of portrayals of the consequences of sexual behavior on soap operas two years ago, three top-rated daytime dramas, “General Hospital,” “One Life to Live,” and “The Bold and the Beautiful,” adopted story lines on teen pregnancy and HIV/AIDS (Olson, 1994).

• MEE (Motivational Educational Entertainment) Productions produced an educational video targeted at inner city youth “at risk” of dropping out of school. The program uses high profile rap artists including KRS One, Public Enemy, and Black Sheep, along with interviews with teens, to encourage youth to stay in school and graduate.
• “ER,” a popular Prime Time drama, has focused several episodes on issues related to teen sexuality and reproductive health. One episode dealt with a 14 year old girl who had a positive pregnancy test and didn’t want her mother to know the results. Another episode showed “Dr. Ross” awkwardly dealing with a gay high school athlete.

What is the “V-Chip”? And, What Role are Government and Others Likely to Have in Addressing the Media’s Portrayal of Sex and Related Issues?

After much debate and numerous revisions, a telecommunications bill (S 652) was enacted by Congress on February 8, 1996. While the legislation focuses on de-regulation to promote competition among cable television and telephone services, it also introduces restrictions on sexual and violent content on television and the Internet. The law mandates a ratings system that would use a “V-chip” or equivalent technology to allow parents to screen out material they do not want their children to watch. Under this new law, the V-chip must be installed in all new TV sets with screens larger than 13 inches, as of January 1998. The law also mandates that a federally designed, voluntary ratings system be implemented by February 1997 if a satisfactory ratings system isn’t already in place — giving the entertainment industry a year to set up its own rating system. Since talks began March 1, the industry has agreed that each entertainment program will be rated by its distributor (the network or independent station carrying the program) and guidelines will be put in place to ensure consistency across networks.

Several issues surrounding the ratings system remain unresolved, particularly in regard to the forms ratings will take, and the logistical challenges of rating all relevant programming. For example, excluding news and sports programs which won’t be rated, the industry would need to rate an overwhelming 100,000 hours of programming per year — as compared to the 1,200 hours of film the Motion Picture Association of America rates each year. Some believe using a letter or number rating system may prove to be impractical and think a content description would be more effective. Another suggestion is that a single rating be assigned to each series for an entire season, while assigning different ratings to especially “objectionable” episodes. The biggest challenge may be defining the ratings for particular actions or behaviors and differentiating jokes from “responsible” discussions of topics such as teen pregnancy.

Is Contraceptive Product Advertising Restricted in the U.S.?

Although there are no laws or government regulations prohibiting contraceptive advertising in the United States, several major obstacles hinder contraceptive advertising, including: some FDA restrictions on prescription drug advertising, inconsistent efforts by advertisers, and fear of public disapproval and reprisal. While the public supports advertising of family planning methods, the minority opinion has prevailed in the decisions that broadcast media, and to some degree, print media have made regarding contraceptive advertising policies.

Television and radio. The broadcast media have historically resisted the advertising of contraceptive products, and through its National Association of Broadcasters until 1982 had a code on programming and advertising. Although the television networks ABC, CBS, FOX and NBC continue to reject contraceptive advertising, all networks have relaxed their ban on condom advertising in public service announcements as long as those commercials emphasize the prevention of disease and not pregnancy prevention.

Newspapers and Magazines. The print media do not face the same sort of industry self­regulation as the broadcast media. Yet, until the 1980s, magazines and newspapers also resisted contraceptive advertisements seemingly due to perceived public disapproval of such advertising. Magazines now generally are open to contraceptive advertising, with the women’s magazines taking the lead. Newspapers, however, generally will not give space to public service advertising and only recently (in the wake of the AIDS epidemic) have accepted advertisements that promote condoms for disease prevention.

The Advertisers. Commercial companies, particularly the condom manufacturers, have attempted to conduct advertising campaigns. The campaigns for prescription contraceptives, however, have been limited efforts, directed mostly to the print media.

The Public. In one of the few studies of public attitudes toward contraceptive advertising on television conducted by Louis Harris and Associates in the late 1980s, it was shown that a majority of Americans believe that television stations should be permitted to advertise contraceptive products. In fact, the study found that there was more support for contraceptive advertising (53% in favor) than there was for beer and wine advertising (45% in favor). Eight of 10 Americans believed that advertising on television would encourage more teenagers to use contraceptives, and more than three-quarters of all adults felt that if teenagers saw television stars they admire use birth control, that they would be more likely to use it themselves. Seven of 10 people said that they would not be offended by contraceptive advertising. In a parallel study, Harris and Associates surveyed 259 television station managers about the same issue. Seven of 10 station managers believed that commercials for contraceptives would offend many people; however, more than seven of 10 also said that stations should air these commercials if they do not cause offense.

A fact sheet, Q&A and resource list prepared for a briefing held for journalists in New York City on December 18, 1997 in New York City as part of a joint program by The Alan Guttmacher Institute, The Kaiser Family Foundation and the National Press Foundation. This program focused on efforts to break through barriers to emergency contraception, as well as future opportunities for expanding access. New surveys conducted for the Kaiser Family Foundation of American women and men, and obstetrician/gynecologists, family practice physicians, as well as, nurse practitioners and physician assistants on emergency contraception are available separately as package #1352.

Survey of Americans on Emergency Contraception

The 1997 Kaiser Family Foundation Survey of Americans on Emergency Contraception examined public knowledge and attitudes regarding unplanned pregnancy and contraception, with a particular focus on emergency contraceptive pills. The survey, conducted by Princeton Survey Research Associates for Kaiser Family Foundation, consisted of telephone interviews with a nationally representative sample of 1000 women and 300 men aged 18 to 44 years old living in telephone households in the continental United States. The interviews were conducted from May 13, 1997 through June 8, 1997. The margin of error is plus or minus 3 percent for the national sample, plus or minus 3 percent for women, and plus or minus 6 percent for men.

The surveyors called back potential respondents 15 times before removing them from the sample, achieving a response rate of 59 percent. Averaging 15 minutes in length, all interviews were conducted by female interviewers. Respondents were told they would be participating in “a confidential national opinion survey about some important health issues.” Of those who agreed to be interviewed, 6 percent (89 people) terminated the interview before it was completed. The analyses reported here weight the data to be proportional to the actual U.S. population’s demographic characteristics with respect to gender, race, age, income and educational attainment.

The 1995 Kaiser Survey on Public Knowledge and Attitudes on Contraception and Unplanned Pregnancy, conducted by Louis Harris Associates for Kaiser Family Foundation, examined public knowledge and attitudes regarding the magnitude and scope of unplanned pregnancy and various contraceptive options, including emergency contraceptive pills. The national random sample consisted of 2,002 adults, 18 years of age and older, and was conducted between October 12 and November 13, 1994. The margin of error is plus or minus 3 percent for Americans 18-44, plus or minus 4 percent for women 18-44, and plus or minus 4 percent for men 18-44.All interviews were matched for gender of the interviewer and respondent. The surveyors called back potential respondents four times before discarding them from the sample. Among 4,000 women and men contacted by telephone, 1,000 women and 1,002 men completed the survey, for an overall response rate of 50 percent. One hundred and eighty one individuals out of the 4,000 (4%) refused the survey outright, and 1868 (46%) terminated the interview before it was completed. The analyses reported here weight the data to be proportional to the actual U.S. population’s demographic characteristics with respect to gender, race, age, educational attainment, and health insurance status.

Survey of Health Care Providers on Emergency Contraception

The 1997 Kaiser Family Foundation Survey of Health Care Providers on Emergency Contraception was designed by Kaiser Family Foundation and Fact Finders, Inc. and conducted by Fact Finders, Inc. The national telephone survey, which included 754 women’s health care providers, including 305 obstetrician-gynecologists, 236 family practice physicians, and 229 nurse practitioners and physician assistants, examined knowledge, attitudes and practices regarding reproductive health services, with a focus on emergency contraception. Using three separate random probability samples, Fact Finders, Inc. drew nationally representative samples of obstetrician-gynecologists, family practice physicians and nurse practitioners from the American Medical Association Physicians Masterfile. Obstetrician-gynecologists and family practice physicians were drawn directly from the Masterfile, while the sample for nurse practitioners/physician assistants was drawn from a separate sample of obstetrician-gynecologist and family practice offices. The statistical sampling error associated with the overall findings based on a random probability sampling of 300 ranges from plus or minus 3.4 to plus or minus 5.7 percent (+/- 3.4-5.6% for Ob/Gyns, +/- 3.7-6.2% for family practice physicians, and +/- 3.7-6.2% for nurse practitioners and physician assistants). Fact Finders, Inc., contacted providers by phone and facsimile to schedule phone interviews which took place between March 5, and June 12, 1997. Health care providers were contacted up to 15 times before being discarded from the sample, with refusal rates of 18 percent for the obstetrician-gynecologists, 22 percent for the family practice physicians, and 2 percent for the nurse practitioners/physician assistants.

The 1995 survey was a national telephone survey of 307 obstetrician-gynecologists and 154 family practice physicians, examining knowledge and attitudes toward unplanned pregnancy and contraception, including emergency contraceptive pills. Fact Finders, Inc. drew separate nationally representative samples of obstetrician-gynecologists and family practice physicians from the American Medical Association Physicians’ Masterfile and contacted them by phone and facsimile to schedule phone interviews which took place between February 1 and March 21, 1995. Physicians were contacted up to 15 times before being discarded from the sample, with a refusal rate of 23 percent. The statistical sampling error associated with the overall findings based on a random probability sampling of 307 ranges from plus or minus 3.4 to plus or minus 5.7 percent for obstetrician-gynecologists and plus or minus 4.8 to plus or minus 8.0 percent for family practice physicians. The survey respondents mostly practiced in urban and suburban locations, in solo or single-specialty group practices, were men and were between the ages of 40 and 64. Those refusing to respond to the survey were similar to the respondents with respect to practice characteristics, age and gender patterns, and geographic diversity.

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Survey of Americans on Emergency ContraceptionSurvey Fact Sheet Q&A Resource List

1997 Kaiser Family Foundation Survey of Americans on Emergency Contraception

Conducted for the Henry J. Kaiser Family FoundationBy Princeton Survey Research Associates

• Topline (pdf)

Methodology

Survey of Americans on Emergency Contraception

The 1997 Kaiser Family Foundation Survey of Americans on Emergency Contraception examined public knowledge and attitudes regarding unplanned pregnancy and contraception, with a particular focus on emergency contraceptive pills. The survey, conducted by Princeton Survey Research Associates for Kaiser Family Foundation, consisted of telephone interviews with a nationally representative sample of 1000 women and 300 men aged 18 to 44 years old living in telephone households in the continental United States. The interviews were conducted from May 13, 1997 through June 8, 1997. The margin of error is plus or minus 3 percent for the national sample, plus or minus 3 percent for women, and plus or minus 6 percent for men.

The surveyors called back potential respondents 15 times before removing them from the sample, achieving a response rate of 59 percent. Averaging 15 minutes in length, all interviews were conducted by female interviewers. Respondents were told they would be participating in “a confidential national opinion survey about some important health issues.” Of those who agreed to be interviewed, 6 percent (89 people) terminated the interview before it was completed. The analyses reported here weight the data to be proportional to the actual U.S. population’s demographic characteristics with respect to gender, race, age, income and educational attainment.

The 1995 Kaiser Survey on Public Knowledge and Attitudes on Contraception and Unplanned Pregnancy, conducted by Louis Harris Associates for Kaiser Family Foundation, examined public knowledge and attitudes regarding the magnitude and scope of unplanned pregnancy and various contraceptive options, including emergency contraceptive pills. The national random sample consisted of 2,002 adults, 18 years of age and older, and was conducted between October 12 and November 13, 1994. The margin of error is plus or minus 3 percent for Americans 18-44, plus or minus 4 percent for women 18-44, and plus or minus 4 percent for men 18-44.

All interviews were matched for gender of the interviewer and respondent. The surveyors called back potential respondents four times before discarding them from the sample. Among 4,000 women and men contacted by telephone, 1,000 women and 1,002 men completed the survey, for an overall response rate of 50 percent. One hundred and eighty one individuals out of the 4,000 (4%) refused the survey outright, and 1868 (46%) terminated the interview before it was completed. The analyses reported here weight the data to be proportional to the actual U.S. population’s demographic characteristics with respect to gender, race, age, educational attainment, and health insurance status.

Survey of Health Care Providers on Emergency Contraception

The 1997 Kaiser Family Foundation Survey of Health Care Providers on Emergency Contraception was designed by Kaiser Family Foundation and Fact Finders, Inc. and conducted by Fact Finders, Inc. The national telephone survey, which included 754 women’s health care providers, including 305 obstetrician-gynecologists, 236 family practice physicians, and 229 nurse practitioners and physician assistants, examined knowledge, attitudes and practices regarding reproductive health services, with a focus on emergency contraception. Using three separate random probability samples, Fact Finders, Inc. drew nationally representative samples of obstetrician-gynecologists, family practice physicians and nurse practitioners from the American Medical Association Physicians Masterfile. Obstetrician-gynecologists and family practice physicians were drawn directly from the Masterfile, while the sample for nurse practitioners/physician assistants was drawn from a separate sample of obstetrician-gynecologist and family practice offices. The statistical sampling error associated with the overall findings based on a random probability sampling of 300 ranges from plus or minus 3.4 to plus or minus 5.7 percent (+/- 3.4-5.6% for Ob/Gyns, +/- 3.7-6.2% for family practice physicians, and +/- 3.7-6.2% for nurse practitioners and physician assistants). Fact Finders, Inc., contacted providers by phone and facsimile to schedule phone interviews which took place between March 5, and June 12, 1997. Health care providers were contacted up to 15 times before being discarded from the sample, with refusal rates of 18 percent for the obstetrician-gynecologists, 22 percent for the family practice physicians, and 2 percent for the nurse practitioners/physician assistants.

The 1995 survey was a national telephone survey of 307 obstetrician-gynecologists and 154 family practice physicians, examining knowledge and attitudes toward unplanned pregnancy and contraception, including emergency contraceptive pills. Fact Finders, Inc. drew separate nationally representative samples of obstetrician-gynecologists and family practice physicians from the American Medical Association Physicians’ Masterfile and contacted them by phone and facsimile to schedule phone interviews which took place between February 1 and March 21, 1995. Physicians were contacted up to 15 times before being discarded from the sample, with a refusal rate of 23 percent. The statistical sampling error associated with the overall findings based on a random probability sampling of 307 ranges from plus or minus 3.4 to plus or minus 5.7 percent for obstetrician-gynecologists and plus or minus 4.8 to plus or minus 8.0 percent for family practice physicians. The survey respondents mostly practiced in urban and suburban locations, in solo or single-specialty group practices, were men and were between the ages of 40 and 64. Those refusing to respond to the survey were similar to the respondents with respect to practice characteristics, age and gender patterns, and geographic diversity.

Now I have just a few background questions so we’ll know something about the people taking part in the survey…

51. I’m going to read you a list of things some people do about government or politics. Many people haven’t done any of these things. As I read each one, please tell me if this is something you have done in the past 12 months. (First,) in the past 12 months have you…(read and rotate)

Yes a. Contacted a member of Congress or a U.S. Senator 17 b. Attended a public meeting on town or school affairs 35 c. Worked in the campaign of a political candidate or party 6 d. Wrote a letter to a newspaper that was published 6 e. Been interviewed or quoted by the media about an important issue 7 f. Served as an officer of some club or organization 22 g. Served on a local committee, such as school board or community council 12 h. Made a public speech 12 i. Helped organize a group or event in support of a particular cause 19

D1. What is your religious preference? Are you Protestant, Roman Catholic, Jewish, or some other religion?

D2. Do you consider yourself a Christian?

D3. Would you describe yourself as a born-again or evangelical Christian, or not?

63 Total Protestant/Christian 33 Evangelicals 27 Non-evangelicals 24 Roman Catholic 2 Jewish 5 Other religion 5 No religion/Atheist/Agnostic (vol.) 1 Don’t know/Refused 100

D4. In politics today, do you consider yourself a Republican, Democrat or Independent?

27 Republican 33 Democrat 30 Independent 1 Other Party (vol.) 5 No party (vol.) 2 Don’t know 2 Refused 100

D5. Would you say your views in most political matters are very liberal, somewhat liberal, moderate, somewhat conservative, or very conservative?

6 Very liberal 21 Somewhat liberal 29 Moderate 26 Somewhat conservative 12 Very conservative 4 Don’t know 2 Refused 100

D6. What is the last grade or class that you completed in school? (Do not read)

3 None, or grade 1 to 8 12 High school incomplete (grade 9-11) 34 High school graduate 4 Business, technical or vocational school after high school 24 Some college, but no four-year degree 15 College graduate, four-year degree 8 Post-graduate or professional schooling after college * Don’t know/Refused 100

D7. How old are you?

24 18-29 43 30-49 18 50-64 15 65 or older 100

D8a. Are you of Hispanic or Latino background, such as Mexican, Puerto Rican, Cuban, or some other Spanish background?

D8b. Is your background mainly Mexican, Puerto Rican, Cuban, or some other Hispanic or Latino nationality?

8 Total Hispanic/Latino background 4 Mexican 1 Puerto Rican * Cuban 3 Other/Mixed (vol.) 91 Not Hispanic/Latino 1 Don’t know/Refused 100

D9. What is your race? Are you white, black, Asian, or some other race?

83 White 11 Black or African-American 1 Asian 3 Other/mixed race (vol.) * Don’t know 2 Refused 100

D10. Last year, that is in 1996, what was your total family income from all sources, before taxes? Just stop me when I get to the right category.

9 Less than $10,000 12 $10,000 to under $20,000 10 $20,000 to under $25,000 10 $25,000 to under $30,000 15 $30,000 to under $40,000 9 $40,000 to under $50,000 14 $50,000 to under $75,000 11 $75,000 or more 4 Don’t know 6 Refused 100

I have just a few more questions. Let me remind you that this a completely confidential interview and that there are no right answers…

D11. In general, how comfortable would you be, personally, working with someone who has HIV — very comfortable, somewhat comfortable, somewhat uncomfortable, or very uncomfortable?

32 Very comfortable 33 Somewhat comfortable 21 Somewhat uncomfortable 12 Very uncomfortable 2 Don’t know/Refused 100

D12. In general, how comfortable are you, personally, being around homosexuals — very comfortable, somewhat comfortable, somewhat uncomfortable, or very uncomfortable?

Current 12/95 31 Very comfortable 32 30 Somewhat comfortable 29 15 Somewhat uncomfortable 15 20 Very uncomfortable 17 2 Never around homosexuals (vol.) 5 2 Don’t know/Refused 2 100 100

D13. Have you, yourself, ever been tested for HIV, that is, the virus that causes AIDS? (If yes, ask: Was that in the last 12 months or not?

Current 12/95 16 Yes, tested within past 12 months 16 22 Yes, tested but prior to this year 21 60 No, never tested 61 2 Don’t know 2 100 100

D14. The last time you were tested, did you discuss your test results with a doctor, other medical professional, or counselor?

Based on those who have been tested for HIV.

50 Yes 50 No * Don’t know/Refused 100 (n=484)

D15. What is the main reason you haven’t been tested for HIV? Is it that… (read in order)

Based on those who have never been tested for HIV.

2 You don’t like needles or giving blood, 21 You’re not sexually active, 61 You’re married or in a monogamous relationship, 1 You’re afraid you’ll test positive for HIV, or 6 Some other reason? 6 No need/No reason to suspect a problem (vol.) 3 Don’t know/Refused 100 (n=701)

D16. As you may know, HIV tests are now being developed that would not require using a needle or taking blood. For example, one new test for HIV would place a sponge inside your mouth for just a few minutes. How likely would you be to use an HIV test that does not require using a needle or taking blood? (read)

35 Very likely 20 Somewhat likely 8 Somewhat unlikely, or 32 Very unlikely? 3 Don’t know 2 Refused 100

D17. Gender

48 Male 52 Female 100

That completes the interview. Thank you very much for your time and cooperation. Have a nice day/evening.

Region

20 Northeast 24 Midwest 35 South 21 West 100

Community Type

28 Urban 49 Suburban 23 Rural 100

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1997 National Survey of Americans on AIDS/HIV:Press Release Survey Part One Part Two Part Three Part Four Part Five Chart Pack

The availability of employer-sponsored retiree health benefits from large companies has declined since 1991, according to a new study conducted for the Kaiser Family Foundation by Hewitt Associates LLC. The study also shows that the number of big businesses charging premiums, tightening eligibility requirements, encouraging use of managed care, and placing dollar caps on coverage increased. In addition, the report concluded that potential changes in the Medicare program, such as a higher eligibility age, could accelerate the decline in retiree benefits by shifting additional health care coststo employers and retirees and thus encouraging companies to scale back or eliminate retiree plans.

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