Football has a problem that only seems to grow by the day.
In November, the latest annual sport participation survey showed that football participation across the United States had dropped for the fifth straight year, a loss of more than half a million players since 2007. Then an academic study linked concussions in all forms to premature death. That came in the wake of an Institute of Medicine report showing football to have not only the highest rate of brain injuries, by far, of any high school sport, but a rate nearly even twice that of college football players.
While football as spectator sport has never been more robust -- a record 111.5 million Americans watched the Super Bowl -- deep concern exists that the player pipeline could shrivel. In response, the NFL is targeting mothers through education and safety messages designed to keep their kids in helmets.
Stephen Levin thinks he also has an answer, or at least one big part of an answer.
The New York City Council member wants a doctor on the sideline of every youth and high school football game played within city limits. He wants a certified athletic trainer at every full-contact practice. He's drafting legislation to mandate as much -- the Youth Football Safety Act -- and expects to have the support of his fellow council members in raising the standards tied to the use of public facilities when he files the bill within a month.
"As a local legislative body, we find ourselves with limited jurisdiction on many issues," Levin told "Outside the Lines." "But this is one area where we, and not the state or federal government, hold sway. It's the power of the permit. If an activity happens on parks or school property, we have jurisdiction. We can do this.
"We want to make sure that at all levels, from youth through high school, we are taking the responsibility and authority for [concussion and injury management] out of the hands of coaches and parents."
The assertive use of local power represents a new challenge for the game at the grass-roots level -- one that youth football leaders are lining up against.
"The financial implications make it unfeasible," said Jon Butler, president of Pop Warner Little Scholars, the nation's oldest and largest national youth football program. "In many inner city programs, it's hard enough already to get enough coaches. Adding [doctors and trainers] would be too much of a barrier."
Doctors assigned to games, and trainers at practices, are rare at the youth football level, according to experts contacted by "Outside the Lines." They are more common, but often not mandatory, in high school. Only two-thirds of high schools nationally have an athletic trainer, said Robb Rehberg, a professor of athletic training at William Patterson University.
He supports the idea of New York City using its civic authority to help fill those gaps.
"Youth football needs to establish a medical standard of care, and while it would be most desirable for such a standard to be established through culture change and 'buy-in' from all stakeholders, sometimes a legislative remedy is necessary to effect change," Rehberg said. "Perhaps the power of the permit can serve as the catalyst for that culture change."
Pop Warner coaches are trained in first aid and are required to sit a player out if he suffers a concussion. Butler said he knows that is not the ideal scenario. The national governing body recommends that local associations recruit local doctors and trainers to volunteer their time, and that they work with local ambulance companies to be stationed at games when available.
The average annual budget for a Pop Warner association comprising several teams runs about $30,000 a year, with some spending up to $100,000, Butler said. He estimates that deploying a trainer at full-contact practices and a doctor at games could add more than $6,000 a season to those budgets.
Rehberg, however, said the costs of hiring appropriate medical care are often overstated.
"Depending on the size of the program, providing this coverage could be as little as $50 per athlete per season, and perhaps less," he said. "And with the number of hospitals and medical resources in New York City, it is conceivable that these services could be provided via a partnership or sponsorship."
The greatest need for appropriate medical care is at games, said Dr. Neeru Jayanthi, medical director of Primary Care Sports Medicine at Loyola University Medical Center in Chicago and a board member with the American Medical Society for Sports Medicine. He cited one study that found that the concussion rate in youth football games is 26 times that of practices, where the action is often more instructional and thus less intense.
"Beginning the discussion around having some medical coverage is important, as the effects of early traumatic injury on the brain or even other areas may potentially have greater long-term negative effects than in a more-mature player," Jayanthi said. "Either some medical coverage would be necessary, some medical presence on each local governing body, or the consideration of elimination of tackle and helmet-to-helmet tackles, one of the highest risks for concussion, in youth football games and practices may be a reasonable suggestion."
Robert Cantu, a prominent sports concussion doctor in Boston, has recommended that children younger than 14 avoid tackle football and instead play flag football. He said Levin's proposal could push the game in that direction, as it would not apply to flag football activity.
At the same time, Cantu worries about kids dropping out of football altogether if costs rise.
"I believe a medical professional, doctor, EMT and certified athletic trainer should be in attendance at every football game at all levels," Cantu said. "More [resources] can be made available by affluent communities and perhaps through the NFL for those without the funds. If a law were in place, it would force those communities who could to come up with the funding. It would also cause those who couldn't to stop football. This is not the desired outcome."
Levin announced his proposal on Jan. 29, citing several factors, including the physical violence, head trauma and bad coaching behavior captured by cameras for the Esquire Network show "Friday Night Tykes" about teams of 8- and 9-year-olds in a Texas league. He also cited a report of a Massachusetts game of Pop Warner teams where five children suffered concussions. His staff later did its own research and found a study citing that 43,000 to 67,000 concussions are suffered in high school football annually.
Levin said he grew up playing football and wants to make it safer for this generation. Currently, athletic trainers are only required in the city's public high school league.
"Football teaches teamwork and sportsmanship, builds character, and keeps our children active, but safety has to be prioritized before winning games," he said. "'Friday Night Tykes' cannot be the norm in youth football. NFL players like Peyton Manning and Russell Wilson -- starting quarterbacks in the Super Bowl -- have to undergo extensive testing by medical professionals to return to play after suffering a concussion, yet we do not require anything close to that for our children."
His draft of the legislation is now working its way through the council process, and a refined version will be introduced later this month, Levin said. Part of that review will include a cost estimate, as well as a requirement that football leagues submit to the city's Department of Education and Department of Health a full reporting of concussions and other serious injuries sustained during the football season.
Levin noted that this isn't the first time New York City has used the power of the permit to protect youth athletes. In 2007, before he arrived, another council member led a successful push to ban the use of aluminum bats in baseball in city parks, helping to spark a national debate.
If New York adopts its requirement for on-site medical care, it could be seen as a test case elsewhere. One legal expert said there's nothing stopping others from taking the same action.
"Municipalities and public agencies clearly have the legal authority to determine the conditions under which private leagues may use public property such as football fields," said Doug Abrams, a University of Missouri law professor. "They also clearly have the legal authority to regulate public school athletic programs. The power of the permit is a valuable, but underused, way to provide playing conditions that are as safe as possible."
The greatest challenge in lining up medical support would be in rural communities, said Jim Tenopir, chief operating officer the National Federation of State High School Association. The NFHS writes the playing rules for football and 15 other sports that state associations can adopt or modify. That opinion was echoed by Michael Bergeron, executive director of the National Youth Sports Health and Safety Institute, which is based in Sioux Falls, S.D.
"I think an unintended consequence might be an excessive strain on already limited physician resources and less need, pressure and urgency to get the coaches better educated," Bergeron said. "What needs to be mandated is a higher standard of education and certification of all youth coaches. This would help with all levels of injury prevention and management."
Any legislation must be tied to mandatory coach education, said Scott Hallenbeck, executive director of USA Football. When asked by "Outside the Lines," he declined to state whether he would support Levin's proposal in the absence of coach training.
Jayanthi, though, said Levin is only asking football to play by the rules of other sports with documented safety risks. "There won't be any park district swimming pool or program without lifeguards," he said.