No Real Alternative
In the name of "promoting childbirth," the state finds yet another way to deny health care to thousands of Texas women
In March of 2005, during the last hour of a nearly five-hour-long meeting of the state Senate Finance Committee, Chair Steve Ogden, R-Bryan, called for consideration a rider attached to the health and human services appropriations bill by Republican Tommy Williams of The Woodlands. Under his rider, Williams told the committee, $5 million would be diverted over the biennium from the state's $54 million annual family-planning budget the bulk of which is federal money for a new pilot program for administering grants to nonprofit agencies to assist "all pregnant women seeking alternatives to abortion."
That is, Williams' rider would remove $2.5 million for each of FY 06 and FY 07 from distribution among established health-care providers a group that includes Planned Parenthood that traditionally have been granted the funds to provide basic health-care services for indigent and uninsured women. In addition to yearly gynecological exams, the funding provides screenings for breast cancer, diabetes, hypertension, and sexually transmitted diseases, among other medical services, and also provides access to contraceptives and to comprehensive counseling designed to help women better plan their reproductive lives. For many low-income women, health-care advocates say, these annual visits, known as "well-woman checks," are the only consistent medical attention they receive.
The Williams rider was not intended to support this health-care mission. Instead, it aimed to divert money to a nonprofit group that in turn would oversee a network composed mainly of "crisis pregnancy centers" that do not typically employ any medical professionals or even offer any real medical services. These CPCs, founded and run primarily by groups that are vociferous foes of abortion, provide "counseling" and support services such as referrals for other taxpayer-funded programs, like food stamps or workforce services to women experiencing unintended pregnancies. In fact, this redundancy is acknowledged, explicitly, in the language of the contract the Health and Human Services Commission eventually crafted to fulfill the mandate of the Williams rider: "HHSC recognizes that many organizations in Texas already provide support services that promote childbirth and alternatives to abortion," reads the contract. "The [Williams] program is intended to supplement and expand the availability and use of such services."
Many of the health-care entities that would otherwise receive the funding are barred from seeking funds under the Williams rider, which provides that grantees pledge that they won't "promote, refer, or perform abortions," Williams told the Senate Finance Committee although it is already illegal to use public money to provide abortions. In short, to be eligible for state funds, all groups funded under the rider would have to promise to provide only such counseling services that extoll the virtues of childbirth.
During the 2005 Senate Finance discussion, only four of the Finance Committee's nine members expressed skepticism about Williams' proposal among them former Sen. Gonzalo Barrientos, D-Austin, and Sen. Eliot Shapleigh, D-El Paso. "Does your rider require that [the CPCs or other service providers] be licensed by the state?" Shapleigh asked.
No, Williams said, "This rider does not do that."
"Don't you want to license them, [to] make sure that the information being given out is accurate?" Shapleigh asked.
"Uh, you know, that wouldn't be proper," Williams responded. That might be the proper way to craft a "general law," he said, but not for a rider.
"Well, we could restrict [the funding to make sure it goes] to licensed agencies, couldn't we?" Shapleigh continued.
"No," Williams replied, that's "not necessary."
Sen. Judith Zaffirini, D-Laredo, noted that the rider was never discussed by the committee's work-group (in fact, until that day, the committee as a whole wasn't aware that the rider even existed). Sen. Royce West, D-Dallas, wanted to know if the diversion would affect funding for traditional women's health-care providers, like Planned Parenthood. Williams responded to the effect that he would be pleased if such legislation had, indeed, cost Planned Parenthood suggesting that one significant aim of the funding diversion was simply to punish any health-care organization that might, in addition to its other medical services, provide access to abortion.
The rider passed quickly out of committee, despite Barrientos' stern and final objection: "The bottom line, it appears to me, is that [in] transferring the money [to the CPCs], are we are saying it's OK to get pregnant and then deal with it as a crisis?" he asked. "I really think we need to think about this item a little more." Only Barrientos, Shapleigh, and Zaffirini voted against the measure.
No Health Care Here
It's been nearly two years since the enactment of the Williams rider. During the current legislative session, lawmakers will have to decide whether to allocate additional funds for the next biennium. This time, however, the program has a track record and it's the sort of record that should make legislators less inclined to keep the program alive.
In March 2006, a year after initial passage, the HHSC finally signed its contract with the Texas Pregnancy Care Network, founded by three businessmen and one female assistant attorney general, who formed a nonprofit in August 2005, apparently in response to the new government-funding opportunity. Since that time, to date, the state has forked over more than $1.7 million in tax money to pay for "pregnancy services that promote childbirth." By contract, TPCN agreed to recruit individual service providers across the state, and documents indicate that TPCN identified more than 200 CPCs and maternity homes that could be brought into the Alternatives to Abortion program loop, whereby these subcontractors would provide counseling services to women for which they'd be reimbursed by TPCN.
Beyond the counseling network, TPCN contracted to maintain a Web site, establish a toll-free crisis pregnancy hotline to which callers could turn for help finding a crisis pregnancy counselor in their local area, and compile educational materials (subject to HHSC approval) for distribution or use as on-site resources by service providers including pamphlets, brochures, and books on various topics, such as fetal development, parenting skills, and developing healthy relationships.
In FY 06 alone from mid-March through the end of August the state paid TPCN more than $600,000 toward meeting these goals. Yet most of the funds TPCN has spent thus far have gone toward start-up and administrative costs. According to its invoices and the monthly vendor reports TPCN filed with HHSC, it wasn't until July of last year five months into the first year of the contract that TPCN reported spending any money at all on core "Client Services." Specifically, in its July invoice, TPCN finally reported spending a total of $50.98 on client services. In the same invoice, it reported its first expenditure $8,644.12 on "Outreach, Education and Referral Programs and Services" which, according to the contract with HHSC, includes all costs associated with developing and maintaining the Web site, a toll-free help-line service, and the purchase and distribution of educational materials. As this article went to press in late January, the help line was functioning minimally, and the Web site was finally operational.
Most remarkably, during all of FY 06 (as TPCN reported in an Aug. 31 quarterly status report), the Alternatives to Abortion program served a statewide total of just 11 clients. Furthermore, although TPCN reported it had already identified more than 200 possible providers, as of mid-September only four the Annunciation Maternity Home in Georgetown, the Pregnancy Help Center in Katy, the Life Center in Midland, and the House of Hope in El Paso had actually signed on as part of the program. Overall, according to TPCN reports, in FY 06 a total of 89 people actually visited one of the four centers. It wasn't until late August that the toll-free help line was actually up and running and according to TPCN's FY 06 report, during the funding year, just two calls were received.
Some observers might expect such a minimal performance during the first year of a start-up program. But consider how much, in previous years, the same funding now allotted to TPCN had accomplished. According to state health officials, the $5 million in biennial funding redirected from the family-planning budget for the Williams set-aside program would have provided comprehensive health-care services for some 17,000 low-income, uninsured, or underinsured women. In FY 06 alone, because of the redirection of $2.5 million, 8,500 women were left without access to preventative health care.
"They've served 11 women. Basically, in the same time period, we could've served over 8,000," commented Sarah Wheat, director of public affairs for Planned Parenthood of the Texas Capital Region. "Our frustration from the beginning has been that these are dollars that help women prevent unintended pregnancies [or] are for early breast-cancer detection this is money well spent no matter what you feel about [reproductive] choice," she said. "These are dollars [that are supposed to] pay for high-quality preventative health care. I think it is crystal clear what the choice should be for the Legislature."
Sens. Zaffirini and Shapleigh agree: "They served 11 clients, and only 89 [people] were seen," says Zaffirini. "That's shocking." Zaffirini, who consistently describes herself as "pro-life," says the Alternatives to Abortion program has thus far failed exactly as she expected. "It is unfortunate, [but] our fears are confirmed," she said. "I do believe that the consequence of riders like these are a detriment to pro-lifers, because they result in more abortions and more health risks [for women], and the consequences can be dire." Shapleigh adds that Texas ranks 50th in the country for the number of women with health insurance and 44th for the number who receive yearly mammograms (critical for the early detection of breast cancer) facts that do not support a legislative decision to shift money away from health care to a program that appears to have amounted to little more than a political pet project. The vast majority of pregnancies in Texas (68%, according to the Alan Guttmacher Institute) result in live births, says Wheat, and traditional women's health-care providers, including Planned Parenthood, consistently provide counseling and access to the same community and state resources that TPCN and the Alternatives to Abortion program are supposed to be providing. The real difference, it seems, judging from TPCN's own reports, is that the Alternatives to Abortion program isn't doing that work. "What we saw last session [were] extreme ideologies driving [the] women's health-care" agenda, said Shapleigh. "We're fifth in [the number of cases of] cervical cancer and dead last in women's health care."
On the other hand, it appears that Sen. Williams is, at least for the record, unconcerned about the documented lack of progress of his program. He failed to respond to repeated requests for comment for this story made through his aide, Jason Baxter. Baxter told the Chronicle that, as far as he's been able to determine, Williams is "pretty happy with the way things are going" and is pleased with the "folks getting the money." Judging from his off-the-cuff remarks at the Senate Finance hearing, Williams may well be sufficiently satisfied that his rider is certainly doing its real work: directly depriving Planned Parenthood and other family-planning health-care providers of funding, in retribution for their also providing with entirely distinct, and private, funds abortion-related services.
Just Throw Money
But quite distinct from the reproductive-rights controversy, the central mystery currently concerning the Alternatives to Abortion program, as it is being run by TPCN, is where, exactly, the program's taxpayer funding is going. Since the TPCN/HHSC contract was signed last March, nearly $2 million has been paid to the network yet how much has actually been spent, and on what, isn't at all clear. The contract itself offers little guidance. Each month, TPCN invoices the state for a prearranged lump sum from as little as $72,432 in May to as much as $375,000 in September; but the contract does not require that TPCN justify the amount it is to receive. That is, the state pays TPCN regardless of whether those funds are actually needed or documented in any understandable detail.
Along with each invoice, TPCN provides HHSC a "Monthly Financial Report" wherein TPCN's Executive Director Vincent Friedewald (a Houston employment lawyer with Winstead Sechrest & Minick before taking the TPCN job) describes, in the most general terms, TPCN's expenses for the previous month. For example, on March 16, the day the TPCN contract was signed, the group invoiced HHSC for $287,000, earmarked for "Capital Operating Cost; Project Administration Operating Cost; Information, Outreach, Educational Referral Program & Services and Client Services." According to the financial report filed April 16 (along with another invoice for $135,741, per the contract), TPCN reported actual March expenses of just $6,756.74, apparently spent for administrative costs.
That pattern of large payouts and relatively small documented expenditures continued for all of FY 06, so that by Aug. 31, although TPCN had invoiced the state for a total of $638,943 for the entire fiscal year, it reported actual expenses of just $212,832. Where the remaining cash more than $426,000 went, or why it was needed, is not apparent from these documents. HHSC officials repeatedly told the Chronicle that the payments to TPCN were made in compliance with the contract and that no other information is required or, notably, available to the public. HHSC spokeswoman Stephanie Goodman says TPCN would be subject to a year-end audit and that if the accounting uncovers any problems or discrepancies, TPCN will be asked to make restitution to the state.
At press time, the results of any FY 2006 audit were unavailable, although the agency says it is forthcoming.
Down the Rabbit Hole
With this mysterious form of payment and accounting in place, it's hard to say with any real certainty what TPCN has spent its money on. Planned Parenthood's Sarah Wheat says it's really anybody's guess. "I literally don't know what they're spending this money on," she said, "but it's appalling [that they seem] to think the state money is theirs to do whatever they wish." Out of a total $2.5 million in available FY 06 funding, TPCN invoiced the state for more than $638,000. In FY 07, it appears the group by contract intends to take and is well on the way to receiving the entire $2.5 million available for the year. For Wheat and others, like Laurie Felker Jones, field director for NARAL Pro-Choice Texas, Williams' program has turned out to be nothing more than a disturbing way to leech scarce funding from women's health-care services.
Because Planned Parenthood and other traditional women's health providers have long been administering these funds to provide medical services, these groups have considerably less overhead, meaning that most of the state family-planning money they get is spent directly on client services. It's an arrangement that has generally provided good health-care value to the state. Moreover, unlike the pay-first-explain-later contract TPCN has with HHSC, Planned Parenthood and the other traditional health-care providers are required to invoice only for actual expenses meaning they must provide services first before invoicing for reimbursement.
As a financial comparison, according to state health officials, if lawmakers had rejected Williams' $5 million set-aside for anti-abortion "counseling," Planned Parenthood and other providers would've served about 17,000 clients over two years, at a per capita cost of just less than $300 per client. By contrast, the per capita expenditure in FY 06 by TPCN for those 11 clients was $58,086 per client. "It's so outrageous, alarming, and a misuse of taxpayer funds," said Felker Jones. "Women are not being served because of [this program]. I don't know how [Williams] can look in the face of low-income women for most of whom [this money represents] their only access to preventative health care and give it to some jokers who have no experience with anything related to women's health care."
Speaking more literally, TPCN hasn't spent anywhere near $58,000 on each of the 11 clients who received "services" last year from one of their four providers (three CPCs and one maternity home) because the network spent virtually nothing on services at all. In fact, according to TPCN's invoices, just $50.98 was spent last year on direct client services, even though, according to TPCN's contract, the network budgeted $131,770 to reimburse their CPC contractors for counseling and referral services "promoting childbirth" to between 175 and 350 clients. But even if TPCN met that contracted expectation, it would've cost the state far more than it would have to provide actual health-care services in addition to counseling for the same number of women. Under the TPCN pro forma budget, counseling 175 clients would cost slightly more than $752 per person; counseling 350 clients would cost $376 per person still considerably more than the $300 traditional providers spend on counseling and medical services.
More generally, it's been difficult to get any concrete information about TPCN's operations. Just one example: TPCN designated at least $12,000 in FY 06 to recruit CPCs to serve as counseling-service providers (at least $7,000 more is earmarked for FY 07); at press time, it still has just four providers, although HHSC documents show that TPCN had identified an additional 30 "potential providers" that responded to its "initial invitation to participate in the Program." It also appears that the dearth of providers may be hindering the promised development of TPCN's toll-free hotline for which at least $4,000 has been allotted.
On Jan. 9 and 11, I monitored calls to the supposed hotline (888/LIFE-AID) made at my request by a pseudonymous caller, "Carrie," portraying a frightened 17-year-old, six weeks pregnant by her high school boyfriend, desperately seeking information and guidance to help her determine exactly what options she has. The TPCN hotline counselor, Nicole, suggested Carrie call the Gabriel Project Life Center in East Austin. However, Nicole said, Carrie ostensibly a high school senior attending school would have to call before 4pm, when the center closed. On Jan. 10 and 11, Carrie called before 4pm, but each time the center was already closed. (According to the CPC's answering machine, the Gabriel Project was also closed from Dec. 21 to Jan. 3 for the holidays.) Moreover, the Gabriel Project isn't on the latest list of contractors TPCN has provided to HHSC, although according to LIFE-AID counselor Nicole, it is the only provider available to Travis County callers in crisis.
The only other suggestion LIFE-AID had for Carrie was to call the crisis pregnancy hotline run by the national anti-choice group the National Right to Life Committee. (For more on the information previously provided by a NRLC counselor, see "Having Your Baby," Aug. 6.) After repeatedly trying to follow the hotline counselor's instructions without success, "Carrie" noted wryly, she might've gotten a better result had she been in distress during "normal crisis hours."
Beyond these ineffective crisis services, TPCN has also allotted at least $75,000 to pay for educational materials including brochures, pamphlets, and books for use by CPC providers. Under the contract, these materials must first be cleared by HHSC before they're distributed. At press time, HHSC had cleared 44 of the 45 publications that TPCN submitted for approval, according to HHSC spokeswoman Goodman. Ostensibly, the contract requires that the materials be reviewed to ensure that they're free of sectarian religious bias in fact, Goodman said that the one publication HHSC did not immediately approve was held because of its religious message. Yet Goodman was unable to provide any explicit criteria HHSC used to evaluate the materials moreover, at press time, she had not provided the title of the one publication to which HHSC reviewers (a group that included Goodman herself) took exception. HHSC officials initially told us that the educational materials were returned to TPCN and thus were not available for public inspection. This week, however, Goodman contacted us to say HHSC has requested and received a duplicate set of the materials and will make them available for review.
Based on a list provided by HHSC, most of TPCN's "educational" materials are published by openly evangelical groups including Heritage House 76, whose mission statement explains their commitment "to the sanctity of life at all stages and to the traditional values of the institution we call the family. With passion, pride and purpose we will help you make our world a better place to be, by saving babies and serving families," and Life Cycle Books, which promotes itself as "North America's foremost publisher of pro-life and abstinence-only educational materials."
On Jan. 9, I visited TPCN's executive offices, off Research Boulevard at Pond Springs Road. During normal office hours, the TPCN office, housed in a nondescript strip mall, was locked. An employee who answered a knock at the door opening it 2 inches or so, just enough to talk and to accept a business card said TPCN Executive Director Friedewald was unavailable and rejected my request to view the educational materials. That afternoon, Friedewald sent an e-mail, explaining that as a "small, private business," TPCN has neither the time nor the inclination to respond to the Chronicle's request. "TPCN unfortunately does not have the time or the financial resources to accommodate guests from the general public here at TPCN for non-business related purposes such as yours," Friedewald wrote. "I am sure you understand." (See "TPCN: Ask us no questions," p.30.) Yet since the nonprofit TPCN is entirely taxpayer-funded, TPCN appears in fact to be at least a quasi-public agency and therefore subject to provisions of the Texas Public Information Act. Certainly TPCN's refusal to provide any substantive accounting of its expenditures, or any access to the education materials purchased with state funding, violates the spirit of open-government laws.
Friedewald has also not responded to requests for an interview for this article, in order to address the lack of information and related confusion regarding TPCN's operations or to answer questions about its funding and programs. Last year, in a glowing Sept. 23 profile of TPCN's purported services to pregnant women, Friedewald did tell an Austin American-Statesman reporter that "at its core," TPCN's purpose is to help organizations "that provide free and confidential support, encouragement, guidance and assistance to women facing unexpected pregnancies so those women can feel confident about choosing childbirth. I would hate for disagreements about funding," he concluded, "to overshadow the potential good that this program can do."
Unfortunately, whatever Friedewald's inclinations, it would seem from the admittedly quite slim public record that any "potential good" that TPCN's programs can do remains just that: very expensive "potential." After a year's worth of direct funding and indirect state support, one might expect that Sen. Williams and the Legislature's "alternative" might have provided something more substantive to compensate for those 8,000 Texas women who have gone without health care in order to pay TPCN to do next to nothing, primarily to satisfy their peculiarly shortsighted version of political correctness.