The Premature Death of the WHAC

Illustration by Jeff Crosby

A state with an already tattered family planning safety net, ideologically motivated reproductive health policies, and the highest rate of uninsured individuals didn't need any more signs of trouble for health care – especially women's health. But Texas' shocking maternal mortality rate, a crisis that's drawn national attention, cast another blow, showing Texas women die after childbirth at the highest rate in the developed world. Between 2010 and 2014, 600 Texas women died of pregnancy-related causes at six to 52 weeks after delivery. New research published early this month by the University of Maryland's Population Research Center adds to the ongoing concern: Texas saw a 36% increase in maternal deaths among women younger than 40 when comparing data from 2011-15 with 2006-10, even while acknowledging for some possible data over-reporting.

Instead of beefing up ways to mitigate the crisis, last June Gov. Greg Abbott killed the life of a committee tasked with providing recommendations and guidance for women's health programs. Senate Bill 790, approved by the state Legislature last session, would have continued the Women's Health Advis­ory Committee (WHAC) for two more years, allowing an opportunity to address access to health services, which in turn could alleviate root causes of the maternal mortality crisis. Abbott's veto pen ended its existence. The decision surprised and angered legislators and women's health advocates.

Bill author Sen. Borris Miles, D-Houston, slammed the veto as "incredibly shortsighted," while Rep. Donna Howard, D-Aus­tin, who authored the House companion bill, called it "disgraceful," saying it jeopardizes the health of women across the state. "Gov. Abbott never relayed any concern whatsoever to us about the bill, so the veto came as a total surprise," said Howard. "It's so disappointing because we've spent all this time talking about the severe maternal morbidity crisis in our state and how access to women's health programs can help the problem. The WHAC was set up specifically to address that access, so it felt like there was a discounting of this helpful recommendation. It's quite infuriating."

The Women's Health Advisory Committee was formed in 2015 to help oversee the redesign of newly consolidated women's health programs. The nine-member committee of (mostly) on-the-ground experts in women's health care aided in guiding the Health and Human Services Commission through the successful consolidation of the Family Plan­ning and the Healthy Texas Women programs, which have seen several changes over the years. While specific questions regarding Abbott's veto were left unanswered after multiple attempts, the governor said in a previously released statement that he pulled the plug on the committee because its purpose had been served: "SB 790 does nothing more than extend the expiration date of a governmental committee that has already successfully completed its mission."

But for some, that purpose was ongoing, as the programs were in nascent stages with improvements needed. "I don't believe the governor's office availed themselves of the necessary information to make an informed decision on this," said Howard of the veto. "Everyone involved with these health programs are not in a place to say 'mission accomplished.'"

"No Formal Mechanism"

In interviews, committee members expressed disappointment with the premature end of the WHAC, which came to a close in September of 2017, saying there was much left on the table to achieve. While committee members feel proud of the work they've done largely finalizing the services each program will cover, questions about logistics, provider capacity, ensuring that accurate provider info is available for patients, and that certain health services are enacted, as well as data on the overall impact of the consolidation, still remain. Vice Chair Dr. Janet Realini says the veto surprised her and many others, especially since the non-controversial bill had bipartisan sponsorship. "I don't really understand the thought process that had do with [the veto], but it was unfortunate. There is so much work still to do to get these new programs up and running," she said. "I think the committee should have gone on for a lot longer. It was a really valuable forum for the community and providers."

Dr. Moss Hampton, a committee member and OB-GYN, said the public "absolutely" would have benefited from the WHAC continuing for a few more years. "There are still concerns about how programs are going to be administered," he said. Committee member Martha Zuniga of South Texas Family Planning echoed the disappointment. "We still needed to iron out a lot of the details with these programs," she said. "Providers had a direct line to the state with this committee. Now there's no formal mechanism to express concerns."

Among the issues left on the chopping block was the committee's continuing effort to monitor and advise the state on Healthy Texas Women, which Republican state officials upended in a quest to punish Planned Parenthood. The program offers cancer screenings, STD and pregnancy testing, and contraception to low-income women. By kicking the dominant provider from the program for purely political reasons, Texas lost 90% in federal matching funds. While the state health department publicly touts a technical increase in enrolled providers today, health professionals point out that provider capacity – a more accurate measure – has never reached the same levels. Data backs up their assertion: Significantly fewer women have been served by the program since the state booted PP from the Medicaid program in 2012, dropping from 115,000 in 2011 to about 70,000 in 2016. "It's concerning that we have evidence showing we are taking care of fewer women," said Realini. "We still need that active public involvement and input."

A 2016 study in The New England Journal of Medicine suggests program recipients in counties affected by the Planned Parenthood exclusion saw less access to contraception and higher Medicaid births, a likely result of unintended pregnancy. By the Texas Health and Human Services Commission's own calculations in March 2017, clients with a HTW contraceptive claim or prescription dropped by more than 40% from 2011 to 2015. The WHAC's guidance would be "vital" to ensuring that the "precipitous drop" in contraception use does not continue, said Howard. And in a bold move, the state has requested the Trump administration allow them to restore the millions in federal funding they lost out on by excluding PP through the Section 1115 demonstration waiver, another controversial issue WHAC could have continued to vet. (That application is still under federal review.)

Evidence of Harm

Considering the mounting scientific evidence demonstrating that the state's decision caused harm to women, it may be less of a mystery when trying to understand why Abbott, a staunch supporter of those decisions, chose to end the body overseeing the fallout of the state's ideological choices. The committee, which held monthly, then quarterly, public meetings, was seen as a transparent venue that could hold the state accountable and shed light on the effects of major funding cuts in the recent past and restructuring of the programs. Bringing the curtain down on the WHAC also means not only fewer eyes on the fragile and vital women's health programs, but less accountability for the state's errors.

In the WHAC's absence, providers are turning to meetings led by the Texas Women's Healthcare Coalition, a nonpartisan organization chaired by Realini that includes 77 health providers and groups, as a way to connect with state health officials. But community forums aren't the same as a direct channel to the state line, some committee members point out.

"The end of the committee hasn't stopped providers from wanting to make sure services meet the needs of women," said How­ard. "It's just making their jobs harder."