Jumping the Shark on Women's Health

In mid-December, before a friendly crowd at the Source for Women, a Houston anti-abortion "pregnancy resource" center, Gov. Rick Perry announced his women's health priorities for the 83rd legislative session: Increase regulation on abortion facilities and doctors, and outlaw all abortion after 20 weeks gestation, the point at which, Perry said, "a baby can feel the pain of being killed. We have an obligation to end that type of cruelty," he proclaimed to vigorous applause. "We cannot, and we will not, idly stand by while the unborn are being put through the agony of having their lives ended."

Whether a fetus can in fact "feel pain" that early in a pregnancy is unclear; a 2005 review of available research, published in the Journal of the American Medical Assoc­i­ation, found that while a fetus may exhibit base reflexes by 20 weeks, it isn't until the third trimester that the nervous system is sufficiently developed to actually register pain. In any case, the incidence of abortion after 20 weeks of gestation is exceedingly rare: Of the 77,592 abortions performed in Texas in 2010 (the most recent year with complete statistics), just 420 procedures occurred after 20 weeks – and many if not most of those procedures were the result of serious medical complications.

Last week, in his opening day address to the Lege, Perry reiterated his claim, and may designate passage of a "fetal pain bill" as a legislative emergency item – more urgent than public education, water planning, or addressing the $4.5 billion Medicaid shortfall. In 2011, Perry designated an ultrasound-before-abortion bill an emergency item, touching off a protracted legislative battle. The law eventually passed, requiring women seeking an abortion to first undergo an invasive, narrated ultrasound procedure.

As of press time, Perry spokeswoman Lucy Nashed said there were as yet no announcements to be made on potential emergency items. Sarah Wheat, vice president for community affairs for Planned Parenthood of Greater Texas, said Perry might well wait until later this month, when the annual Texas Rally for Life converges on the Capitol. At that rally, Perry often delivers his most pointed attacks on reproductive rights. "It will be interesting to see," said Wheat, "if he designates something that is clearly not a public health emergency as a public health priority."

The Real Crises

For when it comes to women's health, state lawmakers have very real, serious, and broadly significant matters to address. Most obviously, the family planning and basic reproductive health services budget meant to serve low-income, uninsured Texas women was all but destroyed in 2011. As a consequence, dozens of veteran family planning providers closed, and more than 100,000 women lost access to basic health care.

The dismantling of the traditional family planning program also had a ripple effect on the vibrancy of the Women's Health Pro­gram, which until Jan. 1 was a Medicaid-waiver program designed to amplify the state's ability to serve low-income women in need of reproductive health services. The WHP was created in 2005 to take advantage of a 90% federal funding match in order to reduce the number of unplanned pregnancies in the state paid for by Medicaid – roughly 56% of Texas births are paid for by taxpayers (more than 220,000 in 2010) – by extending government-paid family planning services to women who wouldn't be eligible for Medicaid unless pregnant. The program has by all accounts been a great success, but during the legislative interim, state officials instituted new rules for providers – rules written expressly to exclude Planned Parenthood, the state's largest provider of WHP services, from participation in the program, because some Texas lawmakers consider the nearly century-old nonprofit nothing more than an abortion "promoter" and provider. Neither the fact that pregnant women are ineligible for the WHP, nor that none of the PP clinics involved in it actually provide abortion services, has dissuaded Texas officials.

That rule change – which is contrary to federal law – resulted in the feds pulling all federal funding for the WHP. Meanwhile, more than 40,000 additional women will no longer be eligible for state health services unless they leave Planned Parenthood and choose a state-approved provider. The new rules have also kept the state involved in litigation for more than a year, defending its right to choose the health care providers for low-income women. In court, the state has argued that furthering a "pro-life" message is as important as actual health care and preventing unwanted pregnancies – and that the involvement of PP dilutes that message.

In that political context, women's health advocates aren't optimistic about the new Legislature. Will lawmakers comprehend how recent policies have led to the destruction of the health care safety net, or will they continue to push a social agenda wrapped in regulations and budget cuts, despite its disastrous effects on the state's most vulnerable women and families? "It is irrefutable, the public health damage that has been done," says Wheat. "Texas is on such a misguided path when it comes to women's health right now. We are on track to be one of these states where people just roll their eyes because what we're doing makes no sense."

Collateral Damage

The pressure on women's health care providers across the state had been building over the years, but the 2011 session was the most brutal in recent memory. The dismantling of the women's health care network proceeded on two distinct but related tracks – drastically reducing the state's budget for traditional family planning programs, and then rewriting rules for the WHP. The efforts shared the common political goal of defunding Planned Parenthood.

On April 1, 2011, lawmakers stripped about $61 million from the roughly $100 mil­lion biennial budget traditionally used to fund the Department of State Health Services' family planning services. Since 2005, those funds had provided screenings for cancer and related health concerns, testing and treatment for sexually transmitted diseases, and birth control supplies for 244,000 low-income and uninsured women (and men) a year. That cut left just $38 million over the biennium to accomplish the same mission.

Moreover, lawmakers devised a stringent funding matrix for the Department of State Health Services for the remaining $38 million. Pursuant to a rider first enacted in 2005, up to $10 million in funds per year was designated for "federally qualified health centers" (one-stop medical shops for the uninsured); next came public health institutions, followed by "nonpublic entities" that provide comprehensive care in addition to family planning services (such as Aus­tin's venerable People's Community Clin­ic). Finally, any remaining dollars could be used to fund specialty family planning (aka "Tier Three") clinics – including Planned Parenthood clinics.

The ultimate intention, of course, was that there would be no funding left for any Tier Three clinics. And there wasn't. But there also wasn't enough funding for most of the nonpublic providers – like People's – or even for county health departments, which had long been providing family-planning services in both urban and rural communities.

Consider Dallas' Parkland Hospital, which had been the state's largest single provider of family planning services. In 2010, Park­land received $6.9 million and served more than 38,000 clients; in state fiscal year 2012, the Dallas County Hospital District, which operates Parkland, received just $2.8 million, and served fewer than half the clients it had in 2010 – meaning more than 19,000 clients lost services from a single provider.

In Austin, three of the four local family planning providers – El Buen Samaritano, People's Community Clinic, and Planned Parenthood Austin Family Planning – lost roughly $1.4 million in funding that had been used in 2011 to serve nearly 9,000 clients; only one provider, CommUnityCare, an FQHC, was granted funds for 2012. Accord­ing to DSHS, in FY 2012 CommUni­tyCare spent $262,801 to see just over 1,000 clients. (One direct consequence of these massive statewide cuts is a spike in the number and public cost of unplanned pregnancies; because of the family planning cuts alone, the state is anticipating the birth of roughly an additional 23,000 Medic­aid-paid births that would not have occurred had the women had access to birth control.)

Although some lawmakers insist that prioritizing FQHCs is a better use of funds, that change has neither expanded services nor saved the state any money. Sen. Robert Deuell, R-Greenville (who is also a doctor), insists that the health centers provide a medical "home" for patients and thus are better equipped to handle the whole patient. Should a woman come in for birth control, for example, the FQHC must also provide other services like dental, without regard to cost. Yet the state's 69 FQHCs are bursting with patients, and they have more complicated billing procedures and costlier overhead than, say, a family planning clinic. It's not surprising that these entities see fewer clients in the family planning program, or that they spend more money to do so.

In 2012, FQHCs received roughly $3.2 million and served 15,555 clients – fewer than did Parkland, even with its slashed budget. "For 10 years on [the House Approp­riations Committee] I've argued that we should not put this money into FQHCs," says Austin Rep. Dawnna Dukes. "This does not support the women in need."

In other words, while legislators accomplished their goal of excluding Planned Parenthood from the subsidized family planning program, in that process, providers other than PP, and thousands of patients, have been hurt. Since the funding cuts, 13 Texas PP clinics have closed (and possibly a 14th in San Antonio), leaving 63 in operation across the state. But because of the funding cuts, a greater number of non-PP providers have either closed their doors or reduced their hours and the number of clients they serve. In all, as of this past fall, 54 providers had shut their doors – including 28 public and private comprehensive health providers and 13 non-PP specialty family planning clinics. (According to testimony last week by UT-Austin sociology Professor Joseph Potter, another six clinics have since closed, bringing the total to 60.) Another nine comprehensive health providers had to reduce their hours of service, as did 29 family-planning clinics, according to research published in the New England Journal of Medicine, part of a three-year study on the effects of cuts to women's health programs in Texas undertaken by researchers at UT's Population Research Center.

The slashed family planning budget provided care for just 75,160 clients in 2012, down 63% from the number served in 2011. In all, more than 127,000 people lost access to health care last year. Unless something radical happens this year, the number of women going without care is likely to persist or increase over the coming biennium, due at least in part to the demise of the Med­icaid-funded Women's Health Program. (The draft House budget adds roughly $8 million back into the family planning budget for the next biennium. Whether that money will remain, or even help, remains to be seen.)

Fantasy Health Care

For the overwhelmingly Republican legislative majority, cutting the family planning budget simply wasn't enough. To ensure complete defunding of Planned Par­enthood, a group of lawmakers, prompted by Deuell, insisted that the PP clinics should also be cut off from seeing patients under the Women's Health Program, a Medicaid-waiver program that provided low-income and uninsured women with access to family planning and basic health services. The feds provided $9 for every dollar spent by Texas. WHP rules had long included a prohibition on using abortion providers, but that clause had never before been used as a wedge to force out PP clinics that do not provide abortions.

Under federal law, women have the right to see the qualified provider of their choice, and former Health and Human Services Commissioner Albert Hawkins knew that to interpret WHP rules otherwise would jeopardize the federal funding. According to a 2012 report on the program, in calendar year 2010 the state spent just $3.6 million on the program, and saved more than $54 million in general revenue expenditures while averting an expected 8,215 unplanned Medicaid-paid births. In 2012 alone, Planned Parenthood saw more than 40,000 WHP clients, and the provider has historically served 40-50% of all WHP clients.