From 'Abstinence-Only' to Plan Z

Luz Hernandez (l) and Doresia Gutierrez at a February 2012 Planned Parenthood rally in support of birth control as part of health care coverage provided by Catholic or other religious-affiliated employers opposed to contraceptives (Photos by Jana Birchum)

Growing up in Houston, money was tight for Tiffany Vo's family. The now 21-year-old's mother was the family's breadwinner, and that money had to stretch to support Tiffany and her three siblings. The family couldn't afford private health insurance, but the kids were covered by the Medicaid Children's Health Insurance Program. When Vo turned 18, she aged out of CHIP but, by then a young student at the University of Texas, was able to transition smoothly into what was then the Women's Health Program: a federally backed health program for women of child-bearing age who would not otherwise be eligible for subsidized health care unless pregnant.

This is no small issue in Texas, where more than half of all births are paid for by Medicaid. The WHP, launched in 2007, was designed to give low-income and uninsured women better access to basic, reproductive health care – including cancer screenings, testing for sexually transmitted infections, and access to a variety of highly effective birth control options – to reduce the incidence of unplanned pregnancies, and in turn, thanks to 90% federal funding, to save the state millions. It met those goals: In 2009 alone, the program saved the state $46 million in all funds, and averted 10,300 unplanned, Medicaid-paid births.

Women in the WHP were able to choose from several providers; Vo chose Planned Parenthood, the provider she'd used and trusted. At least that's how it was until 2011, when state lawmakers reauthorized the WHP (originally a five-year demonstration project), but with new provisions designed to specifically exclude participation by Plan­ned Parenthood, which was serving more than 40% of all WHP clients. Conserv­ative lawmakers objected to Planned Parenthood because, through other, independent programs, it also provides legally protected abortion care.

Those objections have motivated several moves aimed at preventing the nearly 100-year-old nonprofit from providing any state-subsidized health care, such as that accessed by Vo and well more than 100,000 others then-enrolled in the program. (To reiterate: Pregnant women are not WHP clients.) And because federal law prohibits discrimination against any Medicaid-qualified providers, removing Planned Parenthood from the WHP in turn led the feds to discontinue funding.

For Vo, politics have kept her from obtaining health care from her preferred provider. Worse is that although the state has refashioned the WHP – expending almost as much money per year to do so as it had previously saved – and recruited new providers in an attempt to fill the gap left by Planned Parenthood, Vo has not been able to find a new provider. She is a full-time student with limited means and no car, and the state's WHP shake-up has become a burden that she has not been able to overcome, leaving her with no meaningful access to health care.

No Money, No Access

As a young woman, Vo is not alone. Although it is hard to determine precisely how many young women in Austin or the rest of Texas lack meaningful access to health care, data recently released by the Census Bureau reflects that, once again, Texas has the highest rate of uninsured residents in the nation – and, at nearly 30%, the highest rate of uninsured women in the country, according to the National Women's Law Center – and that, nationally, more than 27% of all college-aged individuals (19-25, by federal standards) lack health insurance. (Accord­ing to city demographer Ryan Robinson, college-enrolled students make up 9.4% of the entire Austin metropolitan area, which includes San Marcos.) Mean­while, local rates of two of the most common sexually transmitted infections are highest among college-aged persons, and nationally, women 25 and younger account for 51% of all new STIs; in Texas, college-aged women annually account for a high percentage of terminated pregnancies.

Those are the kinds of statistics that health care providers say make it all the more important for young women to have good information about and access to women's health services. Yet in Austin, access to family planning remains difficult, complicated greatly by limited access to comprehensive sex education statewide and more recently, drastic cuts to the state's family planning budget, leaving women like Vo on their own to seek out information and to figure out how to afford – and where to find – basic care.

Indeed, as access to some aspects of family planning care has expanded (newly mandated over-the-counter access to emergency contraception, sold as "Plan B," for example), access to basic care remains restricted in Texas. And because of this larger, more restricted legal and cultural context, Plan B – which costs $50 at drug stores for a single dose – might as well be called "Plan Z." "When it comes to birth control, it's like, well, if you don't have money, you can't have it. That's unfortunate," Vo said. "If you can't get access to birth control the odds of you getting an unplanned pregnancy [are] higher." Living without access, she said, "you're just taking a risk."

In short, many more low-income and uninsured women in Texas need access to basic reproductive health and family planning than there are women who have that access. According to a report from the Gutt­macher Institute, even before 2011, when state lawmakers stripped two-thirds of the roughly $50 million annual budget to provide subsidized health care access to women (also prompted by a desire to cripple Planned Parenthood), the state was reaching just a fraction of the nearly 1.7 million women in need of family planning. Since 2005, state funding had served an average of 244,000 women per year – just 14% of those in need; after the budget cuts took effect, more than 127,000 additional women lost access.

Tinkering with the WHP has had a similar effect: From a statewide monthly enrollment peak of more than 130,000 women in August 2011, the number of women being served by the new, state-funded WHP has dropped 26%, to 96,686 enrolled in August 2013. For college-age women, the numbers look similar: Enrollment in the WHP by women 18-24 peaked at just more than 50,000 in November 2011, and has dropped 26% by this September, according to data provided by the state Health and Human Services Commission.

While the overall percentage of college-age women enrolled in the WHP remains relatively strong compared both to the number of women enrolled statewide, and to the number of women enrolled in Travis County – that's roughly 39% and 33% of all women in each group, respectively – students like Vo say the numbers may not reflect actual access to care: She's enrolled, after all, but hasn't been able to find a provider.

The reality for young women in Austin – as it is for many women of all ages across the state – is that health care is available from a patchwork of providers, at prices that are often quickly out of reach for women without health insurance. "Who can afford a doctor?" asks 22-year-old college senior Nancy Cardenas, who grew up in the Rio Grande Valley. "It's still a luxury."

On-Campus Access: Mixed

Sherry Bell, senior program coordinator for the University of Texas' University Health Services, understands well the economic challenges students face in accessing health care. For more than 30 years, she's worked with UHS and has been part of its evolution into a sophisticated primary care clinic that provides a host of specialized services – from general medicine to urgent care, from the sports medicine clinic to the women's health clinic. UT's total enrollment stands now at just over 52,000 students – more than 40% of them women ages 18-24 – and last year alone UHS saw nearly half of those, with 23,367 unique patient visits.

Of the students who used services between Sept. 2, 2012 and Aug. 31, 2013, there were 4,723 unique patients who visited UHS' women's health clinic; of those, 3,493 came to the clinic for contraceptive care, and of those, 79% were there for oral contraceptives. UT's health services operation is among the most sophisticated and is certainly the most comprehensive of those offered by the city's main institutions of higher learning.

St. Edward's University, for example, also has a dedicated and well-promoted health services operation (of a student population of roughly 5,000, there were some 4,000 appointments at the campus' health and counseling center last year) where office visits are free, but where some services may be limited by Catholic doctrine. Birth control may be prescribed to a woman for a medical purpose, but not a contraceptive one; for birth control and other reproductive services outside the scope of the university operation, students are provided referrals.

Huston-Tillotson University requires its students to provide proof of health insurance coverage at registration. Roughly a third of the 918 enrolled will use the on-campus health center, which is staffed by a nurse and provides basic health care, Linda Jackson, HT's director of public relations wrote in an email. While HIV testing is available, neither STI testing nor contraceptive care is provided, though pamphlets "on a variety of health topics" are available to students, she wrote.

UT encourages students to obtain health insurance when possible, and each year selects a cost-conscious insurance plan for students; for those without insurance, UHS offers a self-pay discount. In short, says Bell, UT, like many other schools, does what it can to remove as many barriers to care as possible – there is an in-house laboratory, for example, and the Forty Acres Pharmacy. "We do encourage students to be insured, and that can be tough for people," she said. So UT's UHS does "whatever we can to get the best deal for students."

Blanca Murillo (l) and Tiffany Vo

And while UHS provides enrolled students with office visits for just $5, additional services, like labs or other diagnostics, incur extra costs. While the self-pay discounts are generous – $30 for a well-woman exam for a new patient, for example, discounted from $85, or $765 for the Mirena IUD and its insertion, discounted from $1,165 – the prices are still often more expensive than many students can afford, say Cardenas and other students who use UHS only for very basic needs, and look off-campus (and sometimes, as with Cardenas, across the border) for additional access.

Without access to an on-campus health center or similar services – too often the case for the rapidly growing number of community college students – health care access for young women can be even more limited.

No Access; No Information

Among those offering low-cost care to uninsured students in Austin is Planned Parenthood, says Sarah Wheat, vice president for community affairs for Planned Parenthood of Greater Texas, which operates three clinics in Austin. Through July, the Austin clinics in 2013 have seen 16,126 patients, 31% of whom are women ages 18-24. While state lawmakers have done their best to shutter Planned Parenthood's operations across the state, the nonprofit's services are still in demand; in Austin, donations have helped to keep the doors open at the group's East Seventh Street clinic, where care is subsidized, she said. Wheat says that has been accomplished with support from funders who have specifically asked that their donations be targeted to aid younger women, like Cardenas and Vo.

That is in part because young women are often more vulnerable to sexual health issues than their older counterparts, because they lack education and experience with reproductive health, said Wheat. "There's no question. We see patients who are 18, 19, 20 years old who've either received no sex ed or have received sex education ... with a high degree of misinformation," she said. Often, with those women, clinicians need to start with basic "health information that should ideally be given to a 13- or 14-year-old – I'm just talking about the basics about how the body works." The lack of basic information means that many young women have also never been given basic information about how to protect their health, she says.

Indeed, according to data from the Austin/Travis County Health and Human Services Department, in 2012, 18- to 24-year-olds accounted for 52% of the year's 6,555 known cases of chlamydia, and for 46% of the 1,628 known cases of gonorrhea – one of three bacterial diseases identified by the Centers for Disease Control as increasing in antibiotic resistance. (In 2008, Texas ranked 17th in the nation for chlamydia infections and 15th for the number of gonorrhea infections, reports the CDC.) Both infections can cause permanent damage to reproductive systems. Equally troubling is that college-age women consistently make up 40% or more of Texas women who have abortions; that number has remained steady for most of the last decade despite additional barriers to abortion care erected regularly by state lawmakers.

Meanwhile, lawmakers have also repeatedly refused to require comprehensive or medically accurate sexual education in public schools, compounding the problems of access that younger women face – and suggesting that the high number of STIs and abortions among this age group are unlikely to reverse trend any time soon. "You don't know what you don't know," said Wheat. "We're not giving this age group the support and services they need."

As Corpus Christi native Blanca Murillo recalls, sex education at her public middle school was "abstinence-only," and available only to "girls who were deemed smart enough to take it," she said, because it was "important to ensure smart girls know what to do – and that's to not have sex at all." That didn't entirely make sense to Murillo, now a 21-year-old senior at UT, in part because she knew girls in her school who were pregnant – shouldn't someone be taking these messages to them too? she wondered. That experience "always stuck with me," she said, and is in part what motivated her to get involved with UHS' healthy sexuality peer educator program, an outreach and education program designed to "empower students to make healthy sexual choices that are right for them, including the choice not to have sex," according to the UT website.

Like Vo – a friend of Murillo's who has also served as a peer educator for UHS – Murillo grew up on Medicaid and, after aging out of that system, had a hard time maintaining access to health care – a serious concern because she has existing health problems, including polycystic ovary syndrome, which she regulates in part through the use of hormonal birth control. Murillo too was enrolled in the WHP before the program shake-up, after which she could not find a provider. She applied for Central Health's Medical Assistance Program, but when she tried to get a gynecology appointment she was told there would be a three-month wait.

Working outside both health care assistance programs, Murillo found that she could obtain birth control for $70 a month, but she could not afford that; instead, she rolled the dice and went for a year without any health care. Luckily, she said, her mother ultimately remarried, and thanks to provisions of the new Affordable Care and Patient Protection Act (i.e., "Obamacare"), she will be able to remain on her parents' insurance program until she turns 26. "I always think about the fact that I got lucky," she said. "It makes me upset; I wish everybody had that sort of luck, and I wish we didn't have to jump through so many hoops."

The first of those hoops is access to knowledge, Murillo says. As a peer educator, she said she was trained to teach students "everything they should've known about sex ed when they got to college, but didn't." And she says she was always amazed by "how much freshmen didn't know," she said. "Things like, they didn't know where the cervix or uterus are, or [would wonder] if a penis reaches too far would it be stuck in the cervix? They didn't know how to use condoms, or [know] about expiration dates, or how keeping condoms in a wallet [for a long period of time] reduces elasticity." Without basic knowledge, she and Vo agree, it's little wonder that young women don't know what kinds of services are available, how to access them, or how to protect themselves from unplanned pregnancies or STIs.

"From a public health perspective, 18-24 is such an important age group – they have the greatest potential and [face] the greatest risk at the same time," said Wheat. Future plans can end "with an unplanned pregnancy or with an STD, [simply] because they didn't know how to protect themselves, or to get tested, and that puts everything at risk. That's why access is so important; access to regular health care."

The Right to Control Her Future

That is something that Ramona Brown understands well. A Galveston native, she dropped out of high school before her sophomore year. She eventually earned her GED and entered college, but then, just months after enrolling, learned she was pregnant. She dropped out again, to work and raise her daughter, now 11. At 36, Brown is finally back in school, studying social work at Austin Community College. She's volunteered for Planned Parenthood and is passionate about serving women. As a nontraditional college student, she's now a bit older and wiser, perhaps, but like her younger colleagues, as a full-time student with limited income she too struggles to obtain regular access to birth control and well-woman exams.

ACC students – there are 41,627 for-credit students enrolled this fall, for example, 77% of whom are part-time and 56% of whom are women, according to ACC – do not have the opportunity to avail themselves of an on-campus health facility, though the college system does offer students access to a lower-cost health insurance plan, as do other institutions around town. Brown's been on Medicaid, and has at times had access to private insurance. She's now hoping to apply for Central Health's MAP (after she makes a drive to Galveston for needed documentation), and she's often hunted for coupons and discounts to get the health care she needs – she got a Pap smear once for just $16 on special at Planned Parent­hood, she notes. (Indeed, Vo says that out of necessity she too has learned how to find deals in reproductive health – from free STI screenings to working with Merck to secure a discounted rate for her Human Papilloma­virus (HPV) – vaccine.) "It's very, very difficult," Brown said.

What Brown hasn't yet accomplished is finding a reliable and affordable source for contraceptives – though, as a single mom and in a committed relationship, she knows well that access to birth control has, and could well again, determine whether or not she'll attain the educational goals she's set for herself. "For women in college, it is of the utmost importance that they have access to and receive information [and access to care by] medical professionals," she said. "For me, not being pregnant is going to [determine] what happens to me over the next three years," she said. "It is my future."

This story is part of the Reproductive Justice Reporting Project, an initiative of the Media Consortium in partnership with the Association of Alternative Newsmedia, made possible with a grant from the Quixote Foundation. See www.whereisyourplanb.com.

A Fraction of the Need

These two charts, compiled by Central Health, show the raw numbers of young patients (18-24) served by various clinics and facilities in Travis County – and only a fraction of the population needing access to reproductive health care. The number of women statewide who need services is about 1.7 million, and Texas women represent more than half of the nearly 30% of the state's residents who are uninsured. The number of women 18-24 served at various clinics and facilities across Travis County in 2012, and by Planned Parenthood in 2013, is merely the tip of the population iceberg.

Health Care Provided to Women Ages 18 to 24 in Travis County Fiscal Year 2012 (Oct. 2011 - Sept. 2012)

Planned Parenthood of Greater Texas:

Three Austin health centers' patient data (Jan. 1 through July 31, 2013)

Sources: Central Health, Planned Parenthood, and iCare data

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