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The Tiahrt/Graham Amendment Isolates Young People from Essential Health Services
The Tiahrt/Graham
amendment, adopted by voice vote to H.R. 1, the Elementary and Secondary
Education Act, would require written prior parental consent before a minor could
receive any non-emergency health or mental health service in a school setting.
In doing so, the Tiahrt/Graham amendment isolates young people from the
essential health-care services they need.
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Tiahrt/Graham is an unconstitutional restriction on all funds,
including non-federal dollars. The Tiahrt/Graham amendment would deny all
federal funds to schools that fail to comply with the amendment, even if they
use other non-federal sources of funding to provide health-care services to
minors. This is an unconstitutional federal condition on local and private
funds because it penalizes schools that provide constitutionally protected,
confidential health services for minors by withdrawing all federal funding. It
is also a disproportionate sanction, one that could result in a cutoff of
federal funds to an entire school district – or even a state educational
agency – if even one staff member fails to comply with the amendment.
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Addressing young people’s health needs in a timely fashion should be our
first priority. Today’s youth are at particularly high risk for health
problems and unhealthy behaviors such as alcohol and substance abuse, sexually
transmitted diseases (STDs), human immunodeficiency virus (HIV), pregnancy,
mental illness, injury, and self induced and interpersonal violence. Every day
young people suffer depression, fear, extreme anxiety and anger, and even
contemplate suicide. Regrettably, many do not take the initiative to seek help
from caring adults, yet these health threats can jeopardize an adolescent’s
development, future opportunities, and even life. As a result, our common goal
should be one of reducing, not erecting, barriers to needed health care
services. We must not inhibit school-based personnel from immediately
addressing what may be signs of physical illness, emotional or behavioral
trouble.
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Tiahrt/Graham applies to all health services in school settings.
The Tiahrt/Graham amendment would require prior written consent before a minor
can access virtually any health service in any school setting.
This includes routine visits to the nurse’s office, appointments with a
school psychologist or school counselor, sports physicals, and almost any
service offered by school-based health or mental-health service providers.
These services include both preventive-health and primary health-care services
and range from basic screenings for height, weight, vision, hearing, and
scoliosis, other developmental health checks, to counseling services to
address why a student might be having difficulties at school (the causes of
which could be poor vision, malnutrition, depression, substance abuse, or a
variety of other conditions or illnesses).
The Tiahrt/Graham amendment denies funds to any educational agency or
institution that provides or "otherwise causes" a young person to
receive a health service. The meaning of "otherwise causes" is so
vague as to present serious constitutional concerns. Moreover, it is so broad
that it could discourage any counseling, referral, assistance by school nurses
or other health professionals, mental-health providers, counselors, teachers,
or even principals from whom minors routinely seek advice.
School personnel regularly perform a broad range of activities that might
"cause" a minor to seek health care, including providing critical
referral information; offering an uninsured young person the name of a
nearby community health center; suggesting that a minor obtain substance
abuse or mental health counseling, a vision or hearing exam, or an HIV test;
or providing a young person with the phone number of a domestic-violence or
suicide-prevention hotline. A principal who calls a student who has been
disruptive in class into his/her office may violate the Tiahrt/Graham
amendment if, as a result, the conversation "causes" the young
person to seek mental-health counseling for anger management. A school
physical-education teacher may not want to risk violating Tiahrt/Graham by
talking to a visibly too-thin young woman about eating disorders – because
this might "cause" the student to seek care for her illness. These
two examples illustrate the startlingly broad sweep of the Tiahrt/Graham
amendment, and hint at its potential to place individuals’ and the public
health at risk.
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The Tiahrt/Graham amendment removes control and flexibility from local
communities. Although the Tiahrt/Graham amendment applies to all
school-based health care, it would particularly affect school-based health
centers, which comprise a critical link in our nation’s public-health system
for young people. Young people are the population most likely to be uninsured
and to lack access to traditional health-care providers. The nation’s 1300
school-based health centers were founded to address this gap. While such
centers vary in size, form, and in the services they provide, they all have
advisory boards comprised of community representatives, parents, youth, and
family organizations that participate in the planning and oversight of the
center. Decisions about how services should be provided in school settings
should be left to local decision-makers who can assess the needs of their own
communities.
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Tiarht/Graham is contrary to the recommendations of major medical, mental
health, and public health organizations, which support young people’s
access to confidential health care. Leading medical groups, including
the American Medical Association, American Academy of Pediatrics, the American
Academy of Family Physicians, the American College of Obstetricians and
Gynecologists, the American Public Health Association, the National Medical
Association, the National Association of School Psychologists, and the
American Psychological Association oppose mandatory parental consent
requirements for young people to access certain sensitive health-care
services. Health professionals have an ethical obligation to provide the best
possible care and counseling to respond to the needs of adolescents. This
obligation includes every reasonable effort to encourage parental involvement.
However, the potential health risks to adolescents if they are unable to
obtain certain health services are so compelling that lack of confidentiality
can actually jeopardize their health.
While most teens seek
their parents’ advice and counsel when making decisions about their health
care, in some cases, open family communication is not possible. This is
particularly true of sensitive services such as mental health, substance
abuse, and reproductive-health care. School-based health centers and other
school-based services personnel provide a confidential, safe place for young
people to receive essential services and accurate health-care information that
may otherwise be inaccessible or appear less convenient. Requiring parental
consent before a minor could access any health service or obtain health care
in a school setting will mean that minors may not receive the information they
need to make informed decisions about their health or be able to obtain
necessary services. Furthermore, it is highly probable that many parents and
students would fail to complete or return the necessary paperwork to consent
for the services – not because they intend to decline them, but because such
communications often fall through the cracks. These young people may be most
at-risk for health problems.
. Although
the Tiahrt/Graham amendment does not preempt explicit state laws that
allow minors to consent to health-care services without involving a parent,
state laws vary widely in express grants of authority to minors. For example,
while every state has a statute that expressly allows minors to consent for
STD testing and treatment, only 20 states and the District of Columbia have
statutes that explicitly permit minors to consent for outpatient mental health
services, and only 22 explicitly permit minors to consent for general medical
services. However, even in states without such statutes, minors are permitted
to consent to medical treatment under the state and federal Constitutions or
as a result of state common law. The Tiahrt/Graham amendment would supplant
the legal regimes in all the states in which there is no express statute on
point, but where minors are nevertheless permitted to consent for sensitive
services.
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