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.

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 National Survey of Americans on AIDS/HIV

Public Knowledge And Attitudes About AIDS/HIV : Survey II

Princeton Survey Research Associates For The Kaiser Family Foundation

Questionnaire and National Toplines

December 4, 1997

Methodology

The 1997 National Survey of Americans on AIDS/HIV was designed by staff of the Kaiser Family Foundation and conducted for the Family Foundation by Princeton Survey Research Associates. The survey was conducted by telephone with 1,205 adults (age 18 or older) nationwide between September 17-October 19, 1997. The margin of sampling error is plus or minus 3 percentage points.

The Foundation last surveyed Americans on AIDS/HIV in December 1995. Where available trend data or information are noted. Some select questions also provide further trend information from other sources, each source is noted by an appropriate footnote reference.

Select questions were asked of a random half of the respondents. These questions are identified by “Form 1” or “Form 2,” indicating which half answered that particular question. There were 598 respondents in the “Form 1” group and 607 respondents in the “Form 2” group. The margin of error for this split sample is plus or minus 4 percentage points.

National Topline

1. My first question is… What do you think is the most urgent health problem facing this nation today? (Open-end. Do not read answer categories. Wait for reply before probe) Is there another health problem you think is almost as urgent?

Current 12/95 1/90¹ 38 AIDS 44 49 38 Cancer 27 31 21 Health insurance/access/cost 25 13 16 Heart 11 na² 5 Drugs 4 17 3 Smoking/Cigarettes na na 2 Elderly 4 12 2 Excess weight/Obesity na na 2 Diabetes *³ na 14 Other 15 na 8 Don’t know/Refused 8 9

Total exceeds 100% due to multiple responses.

2. Now I’d like you to think about the way the problem of AIDS is affecting this country today. Do you think the problem of AIDS is about the same as it has been, that the country is making progress in this area, or that the country is losing ground?

Based on form 1 respondents.

Current 12/95 3/94⁴ 14 About the same 15 22 52 Country making progress 32 23 27 Country losing ground 48 49 7 Don’t know/Refused 5 6 100 100 100

3. Thinking about the way AIDS is affecting your local community today, is the problem of AIDS about the same as it has been, is your community making progress, is your community losing ground, or has AIDS never been a problem in your community?

Based on form 1 respondents.

Current 12/95 19 About the same 23 14 Community making progress 11 11 Community losing ground 18 41 Never been a problem 38 15 Don’t know/Refused 10 100 100

4. Now I’d like you to think about the way the problem of AIDS is affecting this country today. Do you think AIDS is a more urgent problem for the country than it was a few years ago, is it a less urgent problem, or is it about as urgent as it was?

Based on form 2 respondents.

48 More urgent 12 Less urgent 38 About as urgent 2 Don’t know/Refused 100

5. Thinking about the way the problem of AIDS is affecting your local community today, do you think AIDS is a more urgent problem for your community than it was a few years ago, is it a less urgent problem, is it about as urgent as it was, or has AIDS never been a problem in your community?

Based on form 2 respondents.

25 More urgent 9 Less urgent 28 About as urgent 25 Never been a problem 13 Don’t know/Refused 100

6. How serious a problem do you think AIDS is for people you know? For people you know, do you think AIDS is…(read)

Current 12/95 34 A very serious problem 43 19 A somewhat serious problem 17 17 Not too serious a problem, or 15 25 Not a serious problem at all? 22 5 Don’t know/Refused 3 100 100

7. Bearing in mind the different ways people can be infected with H-I-V, the virus that causes AIDS–how concerned are you, personally, about becoming infected with HIV? Are you…(read)

Current 12/95 5/91⁵ 24 Very concerned 22 27 17 Somewhat concerned 18 21 21 Not too concerned, or 22 22 38 Not at all concerned? 38 30 * Don’t know/Refused * * 100 100 100

8. Are you more concerned about becoming infected with HIV than you were a few years ago, less concerned, or about as concerned?

27 More concerned 24 Less concerned 47 About as concerned 2 Don’t know/Refused 100

9. Do you, yourself, have any sons or daughters aged 21 years or younger?

43 Yes 57 No * Don’t know/Refused 100

10. How concerned are you about a son or daughter becoming infected with HIV? Are you…(read)

Based on parents of children aged 21 or younger.

Current 12/95 52 Very concerned 53 21 Somewhat concerned 24 16 Not too concerned, or 10 11 Not at all concerned 11 * Don’t know/Refused 2 100 100 (n=541) (n=666)

11. Are you more concerned about a son or daughter becoming infected with HIV than you were a few years ago, less concerned, or about as concerned?

Based on parents of children aged 21 or younger.

46 More concerned 9 Less concerned 44 About as concerned 1 Don’t know/Refused 100 (n=541)

12. Do you think AIDS is a major threat to public health in this country today, or is not a major threat to public health?

83 Major threat 14 Not a major threat 3 Don’t know/Refused 100

13. I’m going to read a list of groups in your local community. For each one, please tell me how much you think they are doing to help fight against AIDS. As far as you know, how much are (insert first item — rotate) doing to help fight against AIDS? Is this group doing a lot, some, only a little or nothing at all? How much do you think (insert next item — rotate) are doing?

Based on form 1 respondents.

A lot Some Only a little Nothing at all DK/Ref. a. Local church or religious leaders 18 29 24 12 17 =100 b. Local government and political leaders 11 34 30 13 12 =100 c. Local public schools 23 34 20 6 17 =100 d. Local health care providers, such as doctors, health clinics and hospitals 38 32 12 4 14 =100

14. And how about those outside of your local community . . . As far as you know, how much is (insert items in order) doing to help fight against AIDS– a lot, some, only a little or nothing at all?

Based on Form 1 respondents.

A lot Some Only a little Nothing at all DK/Ref. a. Your state government 15 43 24 6 12 =100 b. President Clinton 21 39 21 8 11 =100 c. The federal government 20 42 23 6 9 =100

15. I’m going to read a list of groups in your local community. For each one, please tell me your impression of how much this group cares about the fight against AIDS and makes it a priority. First, what about… (insert first item — rotate)–is it your impression that they care a lot about the fight against AIDS, some, only a little or not at all? How much do you think (insert next item — rotate) care?

Based on form 2 respondents.

A lot Some Only a little Nothing at all DK/Ref. a. Local church or religious leaders 39 34 15 5 7 =100 b. Local government and political leaders 17 42 27 8 6 =100 c. Local public schools 44 31 12 4 9 =100 d. Local health care providers, such as doctors, health clinics and hospitals 59 25 7 3 6 =100

16. And what is your impression of how much those outside of your local community care about the fight against AIDS and make it a priority . . . (First/Next) (insert items in order)–do you think (it/he) cares a lot about the fight against AIDS, some, only a little, or not at all?

Based on form 2 respondents.

A lot Some Only a little Nothing at all DK/Ref. a. Your state government 22 53 19 3 3 =100 b. President Clinton 31 39 16 7 7 =100 c. The federal government 21 47 22 5 5 =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

Do Americans Think The AIDS Epidemic Is “Over”?

Many See Progress In Fight Against The Disease, Yet Support Still Strong For Spending On Prevention And Treatment

Though Still Number One, AIDS Now Tied with CancerAs Nation’s Most Urgent Health Problem

Embargoed For Release Until:10:00 am, ET, Thursday, December 4, 1997

Washington, DC — As new drugs have become available to help people with AIDS/HIV livelonger, advocates have worried that the public will perceive the epidemicas “over,” while others have questioned whether AIDS should receive specialstatus among the nation’s health concerns. Sixteen years since thebeginning of the epidemic, a new survey finds that while Americans seegrowing progress in the fight against the disease, they also continue toview AIDS as an urgent health problem for the nation and still stronglysupport spending on prevention, research, and treatment.

According to a Kaiser Family Foundation survey released today, the publicis far from thinking the AIDS epidemic is “over:” the vast majority — 88percent — give an emphatic no. But, a majority of Americans (52%) now dosee the country making progress in addressing the problems of AIDS. Only athird (32%) were as optimistic in 1995, when the Foundation surveyedAmericans on AIDS/HIV. And, in 1994, it was just a quarter (23%),according to a Times Mirror survey. Even so, the public continues to rankAIDS among the most serious health concerns facing the nation; although, itis now seen as more comparable with other diseases. Today, the samepercentages of Americans name AIDS (38%) as name cancer (38%) when askedwhat is the most urgent health problem facing the nation. Two years ago,AIDS was ranked first by 44 percent of the public, followed by cancer with27 percent. In 1990, 49 percent of the public said AIDS, and 31 percent,cancer, according to a Los Angeles Times poll.

“After more than a decade of fighting this deadly disease, Americans arelearning to live with AIDS. While the public continues to see AIDS as anurgent issue, it is no longer a viewed as an emergent one,” said SophiaChang, MD, MPH, Director of HIV Programs, Kaiser Family Foundation.

Support for government spending to help pay for drug therapies forlow-income people with AIDS is especially strong. Three quarters (73%) ofAmericans say the government should help pay for new AIDS treatmentsregardless of income-level; 20 percent say the responsibility should beleft to individuals and their families. Two thirds (64%) support spendingeven when told it would result in higher costs to the government; 29percent say the government cannot afford it.

Overall, a majority (51%) of the American people say the government spendstoo little money on AIDS (32% say “about the right amount;” 8% say “toomuch”). Forty percent (40%) say federal spending on AIDS is too low, ascompared to what is spent on other health problems such as cancer and heartdisease (35% say “about the right amount;” 11% say “too high”). This isdown from 1995, when 50 percent of Americans said not enough was spent onfighting the disease as compared to what is spent on other health concerns(31% said “about the right amount;” 12% said “too high”). Still, thereremain high levels of support today for spending in all areas of AIDSeducation, prevention, and treatment. When asked to choose a “toppriority” for HIV spending, the public favors devoting resources toresearch to find an AIDS vaccine (47%), followed by HIV/AIDS education andother prevention efforts (32%).

The survey also finds that most people — 89 percent — think that by nowall adults should know how to protect themselves from HIV infection, and 71percent think those who become infected today are more responsible fortheir circumstances than those infected earlier. While public sentimentleans toward greater personal responsibility, the public’s attitude towardpeople with AIDS is not punitive: a majority — 54 percent — do not thinkthat adults with AIDS/HIV should have to pay more of their medical billsthemselves than those infected years ago; 42 percent say should have topay more today.

Trends in AIDS/HIV.

For the first time this decade, in February of 1997,the Centers for Disease Control and Prevention (CDC) announced a decline inAIDS deaths in the United States. Deaths from AIDS among Americans, ages13 and older, declined 23 percent between 1995 and 1996. Declines werereported in all geographic areas, among men and women, among all racial andethnic groups, and in all risk and exposure categories. The number ofAmericans living with AIDS — almost a quarter of a million today –increased by 11 percent over the same time period. This increase in peopleliving with AIDS comes at a time when new drug therapies are available tohelp treat the disease and lengthen life. Protease inhibitors, a class ofdrug commonly used in combination therapies to treat people with HIV/AIDS,was approved by the Food and Drug Administration for use in this country inDecember 1995. The use of zidovudine (AZT) to prevent the transmission ofHIV from mother to child also appears to be having an impact. New AIDScases as a result of mother to child transmissions were recently reportedto have decreased by 43 percent between 1992 and 1996.

New Drug Therapies.

More people today (86%) than two years ago (75%) knowthat drug therapies are available to help people with AIDS live longer.The public is also more aware today that certain drugs can be taken bypregnant women with HIV to help prevent transmission to their babies: 49percent today, as compared to 30 percent in 1995.

Awareness about the availability of new drugs may be one reason the publicsees progress in the fight against AIDS: 44 percent of Americans today say”a lot” of progress has been made in keeping people with AIDS alive longer,up from 24 percent in 1995. However, most people believe that the newdrugs do not benefit everyone with AIDS/HIV: 79 percent say most peoplewho want the treatments are not getting them, and 58 percent say they arenot effective for most people who are taking them. The public also appearsto have a realistic understanding of the high cost of the new drugs: 42percent know the average monthly expense can be as high as $1000; 30percent think it is closer to $500 per month.

In spite of greater awareness about the drug therapies, the percentage ofAmericans who report having been tested for HIV has remained relativelyconstant over the last two years. Currently, two out of five people (38%)say they have ever been tested for HIV, including 16 percent in the lastyear; about the same percentages as reported being tested in 1995. Just 20percent of those surveyed say they have ever talked with a health careprovider about getting tested for HIV; two thirds (66%) of whom say theybrought the topic up themselves.

Needle Exchange.

Over the two years the Foundation has surveyed thepublic on needle exchange, Americans have remained supportive of these programs, which offer clean needles to IV drug users in exchange for usedneedles, as an AIDS prevention measure. As of the end of November, 64percent of the public favor needle exchange and 30 percent oppose. Earlierin the fall when the Foundation surveyed on needle exchange, 58 percentsupported and 38 percent opposed such programs. Two years earlier, 66percent supported needle exchange, and 30 percent opposed.

Public opinion on needle exchange, however, appears to be influenced byhow the issue is presented. When presented with the major arguments forand against needle exchange (including the criticism that needle exchangeprograms give tacit approval of illegal drug use) the differences levelout: in November, 48 percent support and 46 percent oppose. A few monthsearlier, 43 percent support and 53 percent oppose needle exchange whengiven these same arguments. Better knowledge of the scientific evidence onneedle exchange, on the other hand, appears to increase support. Afterhearing that organizations such as the National Academy of Sciences haveconcluded that needle exchange programs reduce HIV infection among IV drugusers without increasing their drug use, support for the programs in themost recent survey increases. Among the first group, those asked aboutneedle exchange without arguments, support increases from 64 percent to 73percent (20% still oppose); among those given both sides of the argument,support increases from 48 percent to 60 percent (32% still oppose). (Thisquestion was not asked in the earlier surveys.)

Today, a majority of Americans — 61 percent — think current law shouldbe changed to allow state and local governments to decide for themselveswhether federal funds should be used for needle exchange.

Other Prevention Efforts.

Americans support efforts to encourage condomuse to help stop the spread of HIV:

• 62 percent say the TV networks should accept condom advertising (33%say should not);
• 55 percent say when movies and TV shows deal with sexual relationshipsthere should be more references to condoms (32% say there are enoughreferences now); and
• 44 percent say condoms should be made available in high schools, andanother 52 percent say only information about AIDS prevention should beprovided (1% oppose both).

Parents, Kids, and AIDS

The theme for this year’s World AIDS Day, held on Monday, December 1, was”Give Children Hope in a World with AIDS.” According to the Kaiser FamilyFoundation survey, parents remain a worried group about AIDS, especiallywhen it comes to their children: 52 percent of those with children 21 andyounger say they are “very concerned” about their son or daughter becominginfected with HIV, and an additional 21 percent say they are “somewhatconcerned.” Close to half — 46 percent say their concerns have heightenedfrom just a few years ago. Most parents — 57 percent — say they needmore information about what to discuss with their children about AIDS.

When it comes to other AIDS prevention efforts, parents are among the mostsupportive: 47 percent favor providing condoms in high schools; 64 percentsay more references to condoms should be included in movies and televisionshows that deal with sexual relationships; and 66 percent think condom adsshould be aired on network television. In total, 97 percent think someinformation about AIDS and how it is spread should be provided to teens inhigh school.

Methodology

The Kaiser Family Foundation’s 1997 National Survey of Americans onAIDS/HIV is a random-sample survey of 1205 adults, 18 years and older. Itwas designed by staff at the Foundation and conducted by telephone byPrinceton Survey Research Associates (PSRA) between September 17 andOctober 19, 1997. Additional questions were asked as part of a nationalomnibus telephone survey of 1,009 adults conducted November 20-23, 1997.The margin of sampling error for both national samples are plus or minus 3percent. The margin of sampling error may be higher for some of thesub-sets in this analysis.

The Kaiser Family Foundation, based in Menlo Park, California, is anindependent national health care philanthropy and not associated withKaiser Permanente or Kaiser Industries. The Foundation’s work is focusedon four main areas: health policy, reproductive health, and HIV in theUnited States, and health and development in South Africa.

Copies of the questionnaire and top line data for the findings reported inthis release available by calling the Kaiser Family Foundation’spublication request line at 1-800-656-4533 (Ask for #1346). Also availableis the top line data from the Kaiser Family Foundation’s 1995 NationalSurvey of Americans on AIDS/HIV (Ask for #1118).

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1997 National Survey Of Americans on AIDS/HIV:Press Release Survey ChartPack Library Index

Many Working Families Struggle To Get Needed Care And Pay Medical Bills

Three-Quarters of the Currently or Recently Uninsured Are in Working Families

Nearly Half of Uninsured Adults in Working Families Have Access or Bill Problems

Embargoed for release until: 10:00 a.m., EST, Monday, December 8, 1997

For further Information contact: Chris Ferris (202)347-5270 or Mary Mahon (212)606-3853

Washington, D.C.– Three in four American adults who do not have health insurance or who have experienced a recent gap in coverage are part of working families — they are either full- or part-time workers or the spouse of a worker — according to a new survey released by the Kaiser Family Foundation and The Commonwealth Fund. The Kaiser/Commonwealth 1997 National Survey of Health Insurance also finds that as a result of being currently or recently uninsured, many working-age adults and their families face barriers to getting or paying for needed health care.

“This survey serves as a reminder that the problems of the working uninsured are still with us,” said Drew Altman, President of the Kaiser Family Foundation. “The low-wage working uninsured deserve special attention when the country considers the next incremental step in expanding health insurance coverage.”

Going without health coverage is not a matter of choice for most of the uninsured. About half (51%) of all uninsured adults report that they do not have insurance because they cannot afford it. Another quarter (25%) say they do not have health insurance because they lost their job or their employer does not offer benefits. Only 4% are uninsured because they have poor health or were denied health benefits.

Families with incomes below the median U.S. family income of $35,000 are most affected by lack of insurance. Three in five (59%) adults in families who earned less than $20,000 annually were uninsured or had a recent gap (sometime in the past two years) in health coverage. One-third (31%) who earned between $20,000 and $35,000 annually also were currently or recently uninsured.

The survey also finds that low-wage working families are at high risk overall. Two in five (41%) adults in working families said they had problems paying medical bills or went without needed care in the past year. More than half (56%) of adults in low-wage working families who are uninsured, and 50% of those with a recent gap in coverage, had problems with access to care or paying medical bills in the last year.

“This survey shows us that people are not uninsured because of preexisting conditions or because they opted out of coverage,” explained Karen Davis, President of The Commonwealth Fund. “Many working families simply cannot afford the high cost of health insurance premiums.”

Insurance Matters

Lack of health insurance leads directly to barriers to health care and problems paying medical bills. Nearly half of the working uninsured (48%) report difficulties with access or costs, while only 15 percent of people who had continuous coverage report these problems. The survey also finds that nearly one-quarter (24%) of uninsured adults say they had not filled a prescription they needed in the past year. One in six (17%) report that they had to change their families’ way of life significantly to pay medical bills.

“Many uninsured working families incur unmanageable financial burdens due to medical emergencies or serious illness, or even worse, go without health care at all,” noted Davis.

Survey respondents who had temporary gaps in health coverage and were uninsured at some point in the past two years face problems similar to those of the currently uninsured. One in five (21%) did not fill a prescription in the past year, and two in five (40%) postponed care in the past year due to costs. By comparison, about one in four of the uninsured (24%) did not fill a prescription; about half (55%) had delayed care.

Medicare Scores Highly Compared to Insurance of Working Families

In marked contrast to the situation of working families, the elderly ages 65 and over covered by Medicare are much more satisfied with their health insurance coverage. Medicare, which provides coverage for the elderly ages 65 and older, results in beneficiaries having greater access to health care and better financial protections than most low- and moderate-income working families. Despite more serious health problems, for example, only 7 percent of the elderly report problems getting health care in the past year, compared with 20 percent of all adults under age 65, and 42 percent of uninsured working-age adults. Medicare beneficiaries are also much more likely to be very satisfied with their health insurance (64%) and choice of doctors (74%) than are adults with job-based health coverage or Medicaid beneficiaries.

Methodology:

The Kaiser/Commonwealth 1997 National Survey of Health Insurance, which was conducted between November 1996 and March 1997 by Louis Harris and Associates, Inc., was designed and analyzed by staff at the Kaiser Family Foundation and The Commonwealth Fund. The survey sample consisted of 4,001 adults ages 18 and older, including 3,761 adults surveyed by telephone and 240 in-person interviews of people without telephones in their homes. The data were weighted to the March 1996 Current Population Survey for accurate representation of Americans by sex, race, age, education, and health insurance status.

The Kaiser Family Foundation, based in Menlo Park, California, is a nonprofit, independent national health care philanthropy and is not associated with Kaiser Permanente or Kaiser Industries. The Foundation’s work is focused on four main areas: health policy, reproductive health, and HIV policy in the United States, and health and development in South Africa.

The Commonwealth Fund, a New York City-based national foundation, undertakes independent research on health and social issues. Its mission is to enhance the common good by looking for new opportunities to help Americans live healthy and productive lives, and to assist specific groups with serious and neglected problems.

This press release is also available on the World Wide Web at www.kff.org or www.cmwf.org. Copies of the release and the accompanying chart pack can be ordered from the Kaiser Foundation’s toll-free publications request line (800/656-4533). Ask for document #1347.

A national random-sample survey of 1205 adults, 18 years and older, that examines Americans views on AIDS. The findings show that although Americans see growing progress in the fight against the disease, AIDS is still viewed as an urgent health problem for the nation and spending on prevention, research, and treatment is strongly supported. The survey also looks at public support for AIDS prevention efforts, including condoms in schools and needle exchange. The survey was designed by staff at the Foundation and conducted by telephone by Princeton Survey Research Associates (PSRA) between September 17 and October 19, 1997. Additional questions, asked as part of a national omnibus telephone survey of 1,009 adults conducted November 20-23, 1997, are also reported on in the release.

State Children’s Health Insurance Program Summary

November 1997

Nearly 10 million children are uninsured, often resulting in difficulties in obtaining needed health care. To expand coverage to low-income uninsured children, Congress enacted the State Children’s Health Insurance Program (CHIP) as part of the Balanced Budget Act (BBA) of 1997 (P.L. 105-33). This new program allocates $20.3 billion in federal matching funds over five years to states to expand insurance for children. States can use the federal funds to expand coverage either through a separate state program or by broadening their Medicaid programs — or both.

Eligibility

The intent of CHIP is to expand health insurance coverage to uninsured children under age 19 in families with incomes below 200% of poverty (Figure 1). Children with private insurance or who are covered by or qualify for Medicaid are ineligible for CHIP, as are those who are residents of public institutions or whose families are eligible for state employee health benefits. Undocumented children and legally resident children arriving in the U.S. after August 22, 1996 are ineligible for coverage but may qualify for emergency Medicaid assistance. States that implement their child health insurance programs through Medicaid may use federal funds to cover legally resident children in the country prior to August 22, 1996.

States that choose to operate a separate state child insurance program can establish eligibility based on geographic area, age, income and resources, residency, and disability status, as well as limit duration of coverage. States cannot exclude children based upon a preexisting condition or diagnosis, and cannot cover higher income children before lower income children.

If states use the Medicaid option, children become entitled to full Medicaid coverage. States that have already broadened Medicaid income eligibility levels above 150% of the federal poverty level (FPL) can expand coverage to children up to 50 percentage points above the current level. For example, a state with eligibility set at 175% FPL could expand to 225% FPL.

Benefits and Cost-sharing

The benefit package options available to states fall into three general categories: Benchmark, benchmark-equivalent, or Medicaid.

• Benchmark Packages: States can offer one of three existing benefit packages: including the Federal Employees Blue Cross/Blue Shield PPO plan; coverage available to state employees; or coverage offered by the HMO with the state’s largest commercially enrolled population.
• Benchmark-Equivalent Coverage: States can use a package with aggregate value greater than or equal to a benchmark plan. Hospital, physician, laboratory and x-ray, and well baby/child services must be included at a value at least actuarially equivalent to the benchmark benefit package. If prescription drugs, mental health, vision, and hearing services are included in the benchmark plan, then they must be part of the benchmark-equivalent coverage with a value of at least 75% of the benchmark plan’s actuarial value.
• Medicaid: States that expand Medicaid must provide the complete benefit package, which includes well-child care, immunizations, prescription drugs, doctor visits, hospitalization, and EPSDT, as well as long-term care for disabled children. The Medicaid benefit package for children is broad and should satisfy the benchmark requirement in a state that administers a separate CHIP program.

The Secretary has the authority to approve a different benefit package that is determined to be appropriate for low-income children. The existing New York, Florida, and Pennsylvania child health programs are deemed to satisfy federal requirements for benefits.

Under the new program, states cannot impose cost-sharing for preventive services including well-baby and well-child care and immunizations. For children with family incomes below 150% FPL, cost-sharing must be “nominal” as under the Medicaid statute. Medicaid currently permits premiums of $15 to $19 per month per family and co-payments of up to $3 per service. Cost-sharing for children with incomes above 150% FPL can be imposed based on an income-related sliding scale, but total cost sharing cannot exceed 5% of family income. Coverage can be provided directly by the state Medicaid program, an insurer, or any other entity considered to be qualified by the state.

Financing

The BBA authorizes $20.3 billion in federal funds from FY 1998 through FY 2002 and $19.4 billion over the second five years. Over the ten-year period, the funds are allocated as follows: $4.275 billion per year in FY 1998-2001, falling to $3.15 billion annually in FY 2002 through 2004, and then rising to $4.05 billion from FY 2005 through 2006, and reaching $5 billion for 2007, for a total of $40 billion.

Annual federal allocations to states are based on the states’ share of low-income and uninsured children using estimates from the Current Population Survey, conducted by the U.S. Census Bureau. The allotment formula changes over time to adjust for reductions in the number of uninsured children.

States do not receive their allotments automatically. States must have their child health plan approved by HHS and are required to contribute state funds in order to draw down, or “match” their federal allotment. The state share cannot include beneficiary cost-sharing and is subject to the same provider tax and donation limitations specified in the Medicaid statute.

Under the new state program, states receive an “enhanced” federal matching rate based on their Medicaid matching rate. The CHIP enhanced rate essentially reduces by 30 percent the share states pay as compared to what they would contribute under their Medicaid match. For example, a state with a federal match of 60% under Medicaid would receive an “enhanced” rate of 72% under the new program. In essence, the state would pay 28 cents of every dollar spent under the new children’s program. No state may receive a matching rate greater than 85% and the minimum annual payment for a state is $2 million. States can receive an enhanced matching rate for providing Medicaid coverage to an expanded group of children. All Medicaid rules, including the entitlement to coverage, would apply to the newly covered group of children. States would continue to receive the regular Medicaid matching rate after their CHIP allotment was depleted.

While the states have considerable latitude in designing and structuring their CHIP programs, there are some limits on what federal CHIP payments can be used for:

• No more than 10 percent of federal payments can be used for outreach, administrative costs or direct service payments to clinics or hospitals. The Secretary can authorize waivers to allow states to create community-based programs or to purchase family coverage.
• States cannot adopt Medicaid eligibility criteria that are more restrictive than those in effect as of June 1, 1997.
• Maintenance of effort is also required in state-only programs in New York, Pennsylvania, and Florida.
• Abortions cannot be covered by federal or state funds except to save the life of the mother or in the case of rape or incest.

Child-Related Medicaid Provisions

In addition to the creation of the new state child health insurance program, several changes to Medicaid were made to strengthen coverage for children under the Balanced Budget Act of 1997. States can now opt to:

• Extend presumptive eligibility to children — This means that services provided to uninsured children will be covered by Medicaid before eligibility determination is complete. For children who are determined to be eligible for the new program, the costs will be paid through new program funds.
• Offer 12 month continuous eligibility to children — States can provide up to one year of continuous eligibility for children under Medicaid, regardless of any changes in family income during that period.
• Accelerate the phase-in to cover poor children born before September 30, 1983. In the past, states could cover these children under Section 1902(r)(2) at state option or through a Section 1115 waiver. The BBA of 1997 clarifies this option. Some 27 states have used these options to expand coverage to older children.

States must also restore Medicaid eligibility to disabled children who lost SSI under the 1996 welfare reform legislation. The Balanced Budget Act also includes numerous provisions that grant states increased flexibility over their Medicaid programs. These include the ability to mandate managed care enrollment without a waiver and greater control over provider payment through the repeal the Boren Amendment and a phase-out of cost-based reimbursement for Federally Qualified Health Centers.