Chairman Hammen, Vice Chairwoman Pendergrass, and Members of the Committee:
My name is Ron Haskins; I am the Cabot Family Chair in Economic Studies and Co-Director of the Center on Children and Families at the Brookings Institution, and a Senior Consultant at the Annie E. Casey Foundation in Baltimore. I am honored to be invited to testify in support of the Rosenberg bill on reducing teen pregnancy.
Over the years, both the state and federal governments have developed hundreds or even thousands of programs to solve the nation’s social problems. Many of these programs are created by federal or state legislation, given an appropriation, and then implemented, usually at locations around the state and usually by government and non-profit entities. Once created, programs often have a very long half-life, regardless of their success or failure. In fact, typically, no one – including the legislative committees with jurisdiction over the programs – knows whether they are successful because they have never been evaluated.
Starting during the George W. Bush administration, and greatly expanded during the Obama administration, the federal government has initiated a series of activities to change this pattern of program creation by bringing evidence of program success to the center of the policy-making process. This movement, often referred to as the “evidence-based movement,” has two key strategic characteristics aimed at improving the effectiveness of the nation’s social programs. First, the strategy calls for government to spend most of its grant funds on programs that have been shown by rigorous evaluations to produce significant impacts on its intended outcomes. Second, programs should be evaluated by rigorous designs on a regular basis to determine whether they are continuing to have impacts. If they are not, the programs should be reformed or abandoned.[i]
Two decades ago, the evidence-based approach to attacking the nation’s social programs would not have made sense because too few programs that had been tested by rigorous evaluations and shown to be effective were available. One of the most important achievements of social science in the U.S. and other nations over this period has been the development and testing of a host of intervention programs found by rigorous evaluations to be effective. We now have well-tested programs in teen pregnancy, preschool education, home visiting, employment and training, drug addiction, reading, post-secondary education, obesity, and other areas.[ii] Equally important, additional evidence-based programs are being developed in all these areas at a healthy rate.
Employing the evidence-based approach holds great promise for reducing the nation’s social problems. That is why I find Delegate Rosenberg’s bill to contribute to the development of teen pregnancy prevention programs here in Maryland so encouraging. Teen pregnancy reduction is a fascinating success story in American social policy. In 2013 the national teen birth rate was 27 births per 1,000 girls aged 15-19 or 273,105 births. Although these figures are too high, they nonetheless represent a decline of 57 percent since the peak rate in 1991. The decline in teen births in Maryland over this period was 64 percent, even more impressive than the national decline. Yet there were still 3,700 teen births in Maryland in 2013.[iii] Despite the success the nation has had in reducing teen births, we still have the highest teen birthrate among nations with advanced economies.[iv] The fact that the nation has made such great progress in rolling back teen births is encouraging; the fact that we still have the highest teen birthrate among nations with advanced economies shows that we still have a long way to go. Taken together, these two facts suggest that now is a perfect time for the nation as a whole and the state of Maryland in particular to intensify their already impressive efforts to reduce teen pregnancy.
The Rosenberg bill (House Bill 437) on reducing teen pregnancy follows the new and potentially revolutionary evidence-based approach. First, the bill requires the Department of Health and Mental Hygiene to support programs that replicate “pregnancy prevention programs that have been proven effective through rigorous evaluation.” That requirement nicely meets the first element of the evidence-based approach. Second, the bill allows funds to be used to “conduct evaluations of teenage pregnancy prevention approaches,” thereby at least partially meeting the second requirement of the evidence-based strategy; namely, evaluating programs on a regular basis using rigorous designs to determine whether they are producing impacts on the important outcome measures. As I read the language of the bill, such evaluations would be permitted but not required of programs supported by the bill.
Maryland is rapidly developing a reputation as a state that is making substantial and effective efforts to reduce unplanned pregnancies at all ages, but especially among teens. Maryland is 6th in the nation in reducing its teen pregnancy rate between 1988 and 2010; Maryland ranks 4th in rate of decline of teen births between 1991 and 2013; and Maryland has received a Medicaid waiver to cover family planning for teen and adult women up to 200 percent of poverty.[v] In addition, one of the recipients of federal funds from the Office of Adolescent Pregnancy (OAH) – the YMCA of Cumberland County – has been officially recognized by OAH as a national success story.[vi]
To augment its remarkable success in reducing teen pregnancies, I think the approach taken by Maryland could be improved in three ways. First, the Department of Health and Mental Hygiene, if it is not already doing so, should take steps to ensure that federal and state funds designated for teen pregnancy prevention are well coordinated. Maryland receives funds to prevent teen and unplanned pregnancy, through both educational activities and clinical services, from a variety of federal programs including Teen Pregnancy Prevention, the Personal Responsibility Education Program, the Abstinence Education Program under Title V of the Social Security Act, Title X of the Public Health Services Act, Medicaid, and others. It is a formidable challenge to figure out how to coordinate these and other sources of potential funding for pregnancy prevention, but if Maryland is to get the maximum impact out of federal and state funding for pregnancy prevention, coordination is an important goal, especially for the programs that can be focused on pregnancy prevention among teens.
Second, the approach to use of evidence-based programs taken in the Rosenberg bill should be applied to all sources of funding for teen pregnancy prevention programs in the state. The federal OAH conducts a careful review of the research literature on teen pregnancy prevention and, following a set of decision rules, identifies the programs that have been show by rigorous evaluations to produce impacts on selected measures of teen pregnancy prevention. The list of programs so identified is now well over 30.[vii] It seems likely that some Maryland organizations engaged in teen pregnancy prevention education programs are using programs with little or no evidence of impacts or even activities that follow no well-defined program. Over a transition period of 3 to 5 years, any existing program that uses state funds or federal funds administered by the state should be required to use its funds to implement programs identified as evidence-based by OAH and listed on their website as spelled out in the Rosenberg legislation. The requirements to use evidence-based programs is especially important for abstinence-only programs because there so few of them on the OAH list of proven programs (although it is reasonable to expect that the number of evidence-based abstinence-only program will increase in the future). Any new initiative, including those supported by funds from the Rosenberg program, should be required to use one of the OAH evidence-based models from the beginning. Moreover, the state should conduct systematic reviews of all state programs to ensure they are effectively implementing their model programs.
Third, the approach to evaluating Maryland’s teen pregnancy prevention programs could be strengthened. The language in the Rosenberg bill could be strengthened to make it clear that programs must collect and report a standard set of outcome data, including involvement in sexual activity and number of pregnancies, on a regular basis. Not all programs can or should be evaluated with rigorous designs, such as randomized controlled trials (RCTs), because of the expense involved. However, I would recommend that the state have an evaluation plan that includes RCTs of selected programs, perhaps on a rotating basis. Both the federal Teen Pregnancy Prevention Program and the Personal Responsibility Education Program require evaluation, and many of the evaluations are using rigorous designs. A major reason for coordination between the various sources of funding for Maryland pregnancy prevention programs is to ensure that evaluation dollars are stretched as far as possible. The evaluation plan followed by Maryland programs should include specifying how the results of the evaluations will be used to improve program organization, operation, training, and so forth.
There is little question that Maryland is implementing successful initiatives to reduce teen and unplanned pregnancies. By continuing to improve its success in reducing teen pregnancies, Maryland can simultaneously save public funds and improve the futures of thousands of Maryland young people. The Rosenberg bill, especially if supplemented with the three recommendations explained above, will move Maryland closer toward the vital public policy goal of reducing teen pregnancies.
[i] Ron Haskins, Show Me the Evidence: Obama’s Fight for Rigor and Results in Social Policy (Washington, DC: Brookings, 2015).
[ii] For example, see the websites of the Coalition for Evidence-Based Policy (http://toptierevidence.org/) and the What Works Clearinghouse run by the Institute of Education Sciences (http://ies.ed.gov/ncee/wwc/).
[iii] Hamilton, B.E., Martin, J.A., Osterman, M.J.K., & Curtin, S. C. (2015). Births: Final Data for 2013. Hyattsville, MD: National Center for Health Statistics, http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_01.pdf.
[iv] United Nations. 2012 Demographic yearbook. Table 10. Live births by age of mother and sex of child, general and age-specific fertility rates: latest available year, 2003–2012. New York, NY: United Nations. 2013. Available at http://unstats.un.org/unsd/demographic/products/dyb/ dyb2012/Table10.pdf.
[v] The National Campaign to Prevent Teen and Unplanned Pregnancy, “Key Information about Maryland,” available at http://thenationalcampaign.org/sites/default/files/resource-supporting-download/md_summary_for_hill.pdf.
[vi] Office of Adolescent Health, “Success Story:YMCA of Cumberland, MD, available at http://www.hhs.gov/ash/oah/oah-initiatives/teen_pregnancy/successes/ymca_cumberland_md.html.
[vii] For a list of these teen pregnancy prevention programs determined to be evidence-based by the U.S. Department of Health and Human Services, see http://tppevidencereview.aspe.hhs.gov/EvidencePrograms.aspx.