Jumping the Shark on Women's Health
For the sake of anti-abortion politics, the governor and the Legislature are putting women in danger
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But in 2010, Deuell asked Attorney General Greg Abbott if PP could be excluded as an "abortion affiliate" – and Abbott agreed that it could. State officials spent more than a year crafting language to do just that – and the same amount of time defending their right to do so in federal and state courts. Thus far, the courts have agreed that it is unlikely that PP can be excluded from a Medicaid-funded WHP, and that the state can't draw federal Medicaid dollars while discriminating among Medicaid providers. As a consequence, the state has opted to let the federal funding end, and to install a newly branded Texas Women's Health Program that is exclusively state-managed and funded – enabling the state to determine which providers women may see if they wish to continue receiving subsidized care. For the women this program is meant to serve – those between 18 and 44, uninsured, and at 185% of the federal poverty level, yet too flush to receive traditional Medicaid unless pregnant – this is really no choice at all.
That is what Marcela Balquinta says about the state's new program. Balquinta lives in McAllen, where she works part-time as a sexual violence prevention education coordinator. She has joined a lawsuit filed in state court last month by Planned Parenthood that challenges the state's exclusion of PP, where Balquinta has been receiving WHP services for four years. The suit argues that the exclusion conflicts with state laws that, like federal law, prohibit discrimination among providers. The suit also challenges a poison-pill provision in the rules that would kill the program altogether should PP prevail in court – a provision added by state health department officials without the consent of state lawmakers who last session rejected such a drastic measure. (See "Texas vs. Planned Parenthood.")
Should the state prevail and PP be barred from participation, it appears that there will simply not be enough providers to absorb the more than 40,000 women left without access to their provider of choice – let alone take on additional clients should the program continue to grow. In 2007, 91,683 women were enrolled; by 2011, that number had grown to 205,354. Not all of the women who could seek service actually do so in a given year; in 2012, the number who received services declined slightly – from 106,093 in FY 2011 to 103,668 in FY 2012.
The decline, argues Fran Hagerty, CEO of the Women's Health and Family Planning Association of Texas, is due directly to the fact that the WHP was designed to take advantage of the state's previously robust network of family planning providers; after shredding the family planning budget and with it the provider base, there is simply no way any program can pick up the slack, let alone increase services. "It's supposed to work hand in hand," she says. "You can't have one without the other."
The state continues to insist that the TWHP can succeed without Planned Parenthood. On Jan. 7, it ratcheted up that optimism another notch with the release of a report by the Health and Human Services Commission that purports to show not only that the TWHP can function without PP, but that the providers that have signed on to the new program can actually see many more clients than did PP, thereby increasing overall program capacity by more than 67,000 clients. "We've added more than a thousand new doctors and clinics to the program since this spring, and we found that they are ready and willing to serve these patients," said HHSC Executive Commissioner Kyle Janek in a press release.
Women's health advocates remain quite skeptical: Why would there suddenly be so many doctors ready to sign on for a program that has existed for five years? Why wouldn't they have done so by now? There is a relatively simple answer, says HHSC spokeswoman Stephanie Goodman: "the capacity may have existed in the past, but the demand wasn't there," she wrote in an email to the Chronicle. Hence the agency's report, based on surveys administered to providers, querying them about their intentions to serve poor women in the program.
HHSC's numbers haven't convinced health policy experts such as Stacey Pogue, a senior policy analyst at the Center for Public Policy Priorities who previously worked for HHSC. In a post to the CPPP's blog, Pogue notes that providers who in the past have seen very few clients are now claiming they're ready for hordes of new patients. "Take the Abilene area, for example," she wrote. In brief, the PP clinic there (which closed in November) saw 601 WHP clients in 2012. The other 16 WHP providers within 30 miles of Abilene saw a combined total of 285 clients, and the seven that actually responded to the HHSC survey saw just 106 clients in 2012. Nonetheless, the seven providers now project that together they can serve 5,750 TWHP clients in 2013. "An increase of that magnitude is astonishing," Pogue wrote.
Not just astonishing. Unbelievable.
"As you know, Planned Parenthood was the single largest provider in the [WHP], caring for nearly 45% of women in the program," PP's Wheat wrote in an email. "The simple fact is – regardless of what new statements are issued by the health department – there is not the capacity for other providers to absorb the tens of thousands of Planned Parenthood patients statewide."
Women Serving Women
Despite the relatively bleak outlook for women's health going into the 83rd session, there are nonetheless two potential bright spots. Under the Dome, talks are ongoing among lawmakers about how to put some of the money slashed from the family planning budget in 2011 back into the coming biennial budget, says Rep. Donna Howard (D-Austin). "We're all trying to search for what we can do here," she said. While money may be found – in federal funds stripped from the budget last year and moved to other programs – it seems unlikely that those funds would be given back to the family planning budget without restrictions placed on providers – that is, Planned Parenthood. "So, I find myself in the position of wanting to work with those who are working to get some restoration of the funds and those who are working to get all qualified providers" back into the system, Howard said. And that may be too tall an order: "There is still clearly a strong cohort here at the Legislature who are opposed to Planned Parenthood," she said. "I don't know what we're going to be able to do, and I'm very concerned about it."
More assertive – and perhaps more promising – are new attempts to wrest from legislative control all of the federal money that currently remains in the family planning budget. Known as Title X money (from the federal legislation), this is the only pot of funding that lawmakers were unable to divert to other programs last year, because for four decades this money has been earmarked specifically for family planning. But Title X funds need not go directly to the state government: In a number of states – including California, Utah, Iowa, Ohio, and Illinois – the federal government grants Title X money directly to PP or another nonprofit provider, which then administers the grant and distributes funds to qualified providers across those states.
If Hagerty has her way, that's what will happen in Texas. Hagerty has been working for months with her coalition of providers on a plan to take all Title X money earmarked for Texas – money that over the last few years has gone directly to DSHS, with its disbursement subject to prevailing politics at the Capitol. Roughly $14.5 million in Title X funds will be available next year – and Hagerty says her group would like to have it all.
Hagerty has spent the last four months recruiting providers to join her lengthy federal funding application, a process that was, at times, tougher than she thought it would be. "I didn't expect the level of intimidation they felt from the state, their fears that the state would retaliate" against providers who agreed to join the effort. That shows just how political the administration of women's health services has become, she notes – and how much easier it will be to serve women when politics is taken out of the mix. "No one is going to be excluded based on any political consideration," she said. "When you're not beholden to the Legislature, or to politicians calling you and saying, 'do this, do that,' when you don't have anything else to consider, it's pretty simple: getting women served."
Hagerty's group has winnowed administrative costs to a minimum, allowing the group to provide for a "rebuilding fund" that would be earmarked to help clinics that have had to close or limit operations a chance to reopen – an important part of building for the future. It would be hard to imagine that Hagerty's group could do any worse than the state has done, and her application promises to do much more. She's lined up 34 contractors operating 121 clinics and expects to be able to serve more than 190,000 women.
If Hagerty's application is successful, it will certainly be in part because the state has made such a mess of things. The governor insists otherwise, according to his spokesperson; Perry "understands the importance of maintaining an adequate safety net for our state's most vulnerable," Nashed wrote in an email, "and expects the Legislature to take a good look at the needs of our state and [to] prioritize as they balance the budget." Yet at least at present, it does not seem there is much political will to shift the focus from ousting Planned Parenthood to serving the real needs of low-income women who continue to go without basic and reproductive health care.
Combined, more than 167,000 women have lost services through the family planning program and the WHP. And that's only the beginning: According to a 2008 study from the Guttmacher Institute, some 1.5 million women in Texas remain in need of family planning services. Advocates say the 2013 session could be a real turning point: Will the state take seriously the need to get reproductive services to women, and thereby to improve the health of Texas families while reducing the incidence of unplanned pregnancies – and, by extension, the numbers of abortions?
Or if – as seems most likely – the Legislature and the governor only harden their positions: Will women's health advocates find ways to remove the Capitol from the equation altogether, and thereby return some minimal level of services to women whose access to health care has been sacrificed in an ideological war against Planned Parenthood?
"What was done last session was so significant, so damaging," says PP's Wheat. "Are we going to deny all the facts and continue in this direction, with an extreme agenda and blocking women from health services? It just doesn't serve anyone."
By the Numbers*: Texas Women's Health Care
• Texas women in need of family planning services (est.): 1.5 million
• State family planning funding, 2009-2011: $100 million
• State family planning funding, 2011-2013: $38 million
• Annual clients served by family planning, prior to funding cuts (avg.): 244,000
• Number of Texas family planning clients served, 2011: 203,000
• Number of Texas family planning clients served, 2012: 75,160
• Number of family planning clients losing service, 2011 to 2012: 128,000
• Number of clients losing service, WHP and family planning (combined est.): >167,000
• Number of Planned Parenthood clinics closed by funding cuts: 13
• Total number of clinics closed by funding cuts: 60
• Women's Health Program clients served by Planned Parenthood, 2012: >40,000
• Women's Health Program clients served by Planned Parenthood, 2013: 0
• Number of Texas births funded by Medicaid, 2010: >220,000
• Percentage of Texas births paid for by Medicaid: 56%
• Est. additional Medicaid births due to no access to birth control, 2013: 23,000
* chart numbers rounded
women's health, Source for Women, Rick Perry, abortion, health care, fetal pain, Legislature, Lege, 83rd legislative session, Medicaid, Women's Health Program, Texas Women's Health Program, Department of State Health Services, Planned Parenthood, Dawnna Dukes, family planning, budget, Marcela Balquinta, Stacey Pogue, Center for Public Policy Priorities