The New Texas Family Planning
Slashed budgets and anti-abortion politics undermine women's health care
On Jan. 1, Planned Parenthood's East Seventh Street clinic, which has offered family planning and reproductive health services to low-income and uninsured women since the early Seventies, discontinued its popular walk-in service. The clinic also drastically reduced its hours of operation, and local Planned Parenthood officials have had to inform more than 6,000 mostly low-income, uninsured patients that they will no longer be able to obtain family-planning services at the clinic. "Your health is important to us and we are sorry that we cannot take care of you," reads a letter mailed in December to thousands of patients. "This has not been an easy decision for Planned Parenthood and we are deeply sorry that services must be cut this way."
But cut they must be, thanks entirely to two pieces of state legislation. Budget riders tacked onto the Texas Department of State Health Services' appropriation in March 2005 divert, over the biennium, a total of $25 million in funds previously earmarked for traditional family planning services and distributed among a host of providers including many (like Planned Parenthood) that specialize in reproductive health services. Instead, that money will first go to fund clinics that either provide reproductive health services in addition to a whole host of other medical services, or to nonprofit groups that do not provide any form of reproductive health care and, on top of that, are neither licensed nor regulated by the state, although they will accept funding from taxpayers.
Specifically, under a rider authored by State Sen. Robert Deuell, R-Greenville, DSHS must use up to $20 million of family planning funding over the next two years to fund Federally Qualified Health Centers community clinics required to provide a host of primary care services to indigent clients before awarding the money to other providers. More egregious is a second rider, authored by State Sen. Tommy Williams, R-The Woodlands, that sets aside another $5 million in family-planning funds over the biennium for grants to so-called Crisis Pregnancy Centers unregulated and unlicensed "support" centers that, by and large, offer no medical services, save for over-the-counter variety pregnancy tests in order to implement a "statewide program for women seeking alternatives to abortion focused on pregnancy support services that promote childbirth."
No Health Case Here
On the surface, the two pieces of legislation are quite different, and at first inspection, Deuell's rider, directing $20 million toward FQHC facilities federally authorized centers that aim to serve any and all indigent clients in need of medical services would appear a pretty good idea. Since FQHCs are designed as a portal for access to a variety of health services including mental health and dental care it makes sense in theory, and as an efficient use of funds, to ensure that the clinics offer on-site family-planning services as well, says Todd Gallaher, Deuell's chief of staff. In short, Sen. Deuell saw the rider as a way to "expand" FQHC services, Gallaher says. In actual fact, however, there are relatively few FQHCs across the state some 40 clinics statewide, compared to 80 Planned Parenthood clinics and a host of other clinics and hospitals that provide family planning, says Danielle Tierney, public affairs director for Planned Parenthood of Austin. And because the FQHCs have a mandate to provide a wide variety of services to anyone who needs them, many of the clinics are already bursting with patients.
Williams' rider, although it involves only $5 million in initial funding, is even more disturbing, only in part because of its uncertainty. Which groups will get the funds, what, specifically, will be done with the money, what the taxpayer benefit is, and exactly how that benefit will be measured all remain undetermined. At press time, the Health and Human Services Commission was still "evaluating" the two applicants that have requested the funding. According to Shirley Thompson, president of the Texas Association of Women's Resource Organization, an umbrella group of state CPCs, crisis pregnancy centers offer pregnant women the "support" they need to carry a child to term. Thompson is working with the Round Rock-based CPC known as The Heidi Group, one of the two applicants for the initial grant money. Generally, Thompson said, CPCs direct women to "resources that are available in the local area" that a woman "may not know exist" such as sources for utility or rent assistance, or for prenatal medical care. In short, CPCs are nonprofit groups that direct pregnant women to established government and nonprofit aid programs but which offer little or no direct health care of any kind.
Taken together, the Deuell and Williams set-asides diverted from a family-planning services budget that, for the 2006-07 budget cycle, was cut by 31.2% have created a statewide funding crisis not only for Planned Parenthood, but also for other health care providers, including county hospitals and hospital districts. Tierney and other advocates, including Women's Health and Family Planning Association of Texas CEO Peggy Romberg, estimate that statewide, 38,000 low-income women will be displaced as a consequence of Deuell's shift of funding, and according to DSHS, nearly 17,000 women may lose access to reproductive health care as a result of Williams' CPC set-aside. In Austin, the immediate effect of the one-two punch is that the East Seventh Street Planned Parenthood clinic will be able to serve no more than 2,400 patients per year, as opposed to the more than 8,000 last year. And to conserve remaining funds, it will no longer be able to serve anyone over the age of 24.
As poorly as the state of Texas serves women's health already (see "Texas Health Care by the Numbers," right), the cuts and fund shifts will certainly make the situation dramatically worse. The possible long-term consequences of the cuts are deeply troubling to many advocates and to some lawmakers who suspect that the real purpose of the legislation is ideological: an unsubtle attempt to further a hard right agenda, and specifically to undermine Planned Parenthood, considered by doctrinaire conservatives as nothing more than an abortion provider. "Truly, what this is about is defunding Planned Parenthood," says Sarah Wheat, executive director of NARAL Pro-Choice Texas. "Deuell and Williams are pawns of the right-to-lifers, and it drives them crazy that Planned Parenthood gets [government] money. They're so fixated on abortion that they can't get over it."
But traditional family planning services, including those provided nationwide by Planned Parenthood, have little to do with abortion indeed, the law prohibits spending taxpayer funds for abortion services. Instead, for many low-income women, family planning services which include annual gynecological exams, as well as screenings for breast and cervical cancer, sexually transmitted diseases and HIV, diabetes, hypertension, and anemia are the most comprehensive medical care they get. In short, the legislation does nothing but reduce access to health care, says Sen. Judith Zaffirini, D-Laredo (one of only three senators who voted in committee against the riders), and as a result, would do far more damage than simply wound Planned Parenthood. "I ... believe strongly that redirecting [money for] family planning services may result in an increased number of births, an increased number of unwanted pregnancies, [or] an increased number of abortions," Zaffirini said. "It may be all three."
FQHCs: Instant Family Planning
There is no dispute that Federally Qualified Health Centers are an important cog in the community health care machine. The FQHC designation was created by federal legislation in 1989 to denote clinics that serve as a single point of access to health care by uninsured and/or indigent clients, and each is required to provide, on-site, three core services: general medicine, mental health services, and dental care. FQHCs are required to provide other medical services as well, like pediatrics and family planning, but may contract with an outside provider, say, for example, a local Planned Parenthood, to provide clients with specialty services. Additionally, FQHCs are bound by a specific form of governance and federal reporting requirements, and must serve a defined geographical area (although they are still required to see any and all patients, even those who are not residents of the service area). In short, part of being an FQHC is dealing with the federal bureaucracy, and that isn't universally appealing to community providers, many of whom such as county hospitals, which already provide a broad spectrum of services have been in business far longer than the FQHC program. And many providers, like Planned Parenthood, are not only veterans but also specialists, for whom FQHC designation is not an option. As a result, in many communities, including Austin, FQHC and nonFQHC clinics have worked together to form partnerships, referring clients among clinics in order to provide service that is as seamless as possible.
In large part, this is the reason that the Deuell-created diversion of funds has cut so deeply. According to the rider, DSHS is now required to allocate funds to FQHCs first, before distributing the remaining funds among other providers. Under the new scheme, according to DSHS, 22 FQHCs got just under $7 million, leaving about $37 million in the family planning budget for the remaining 74 providers that applied for funds. For all but one of the FQHCs, the fiscal year 2006 allocation offered a significant increase in funds, while a majority of the other providers saw significant cuts including a 40% cut for Austin's Planned Parenthood operations. "This particular set-aside for FQHCs makes no sense," Tierney says. "Yes, many [FQHCs] do family planning, but this is what we specialize in. We have the capability to see more people and to do more with the money," she continued. "[T]hey're taking ... money and setting it aside for a limited number of facilities." Consequently, says Romberg, some clinics will likely close and thousands of low-income women may lose easy access to reproductive health services. "If you close a clinic site and lay off staff with expertise, that's a resource that is just lost," she said. "To me it's a real scary thing."
Gallaher, Deuell's chief of staff, disagrees. "I wouldn't make [the] assumption," he says, that women will be left without health care "just because [some clinics] didn't get the funding." Whatever money was cut from one clinic's budget was moved to an area FQHC, he said, so "the FQHC entity should be able to serve those folks." In all, he says, Deuell believes the FQHC is simply a "better model" to deliver health care to the uninsured and he denies that the rider was in any way aimed at defunding Planned Parenthood. "I absolutely would not deny that [Deuell] is extremely pro-life in his political views, but I don't think you could draw a line to this as an attack on Planned Parenthood," Gallaher said. "If you lost funding and could yell that it was a way to defund Planned Parenthood [you would], instead of acknowledging that this other clinic may be able to serve the population better." (In Austin, the city/county health department clinics are FQHCs. With the Deuell diversion, the Austin Travis Co. Health and Human Services Department got $674,202 in funds for FY 06, a 253% increase over last year.)
Whether an FQHC actually provides "better" family planning services is up for debate, says Trish Young, CEO of the new Travis Co. Hospital District and former CEO of the Austin/Travis Co. Community Health Centers, Austin's FQHC. "To me, when you don't increase the total pool of funding, you're just moving the money around," Young said. "I don't know and I wouldn't even go there to say that the FQHCs are 'better.' Nobody can prove that out." While Planned Parenthood and others may provide more "focused" services, FQHC services "happen to be more broad, so it's not quite an apples-to-apples comparison," she said. "Again, if it doesn't increase [the total amount of] funding for services, it just doesn't change anything." Indeed, there has never been enough family-planning money to cover every Texas woman in need of services before the Deuell rider, approximately 400,000 women in need received subsidized family-planning care, says Romberg, "and that leaves about 1.5 million other women still in need."
Although Gallaher disagrees, many women's health care advocates and providers say that a string of "unintended" consequences of the funding shift suggests the legislation was not well considered. There were some FQHCs that didn't even apply for funding because they didn't want to have to begin offering the services in-house, says Romberg, and several large hospitals also lost significant funding including Thomason Hospital in El Paso, which had its overall family planning budget slashed by 40% even though it provides as many, if not more, services than a community FQHC. Moreover, eight of the 22 FQHCs that got funding are first-time fund recipients, like the Georgetown Community Clinic, which is starting its own family planning operations in order to get the additional funds. "So we were made to jump into [family planning]," said Kali Kollmeyer, FQHC program manager for the Georgetown clinic. Although the Georgetown FQHC is, essentially, a winner in Deuell's rider game, Kollmeyer says the funding shift has been somewhat disruptive at press time, the clinic hadn't even begun to systematically get the word out to women that the clinic is now offering family planning. "It seems like it's kind of rushed for all parties," she said. Tierney couldn't agree more: "That proves what a hasty and political move this was; it was a midsession sneak attack, making family planning more attractive for the FQHCs," she said. "What kind of system turns you into a [family-planning provider] overnight?"
No Real Alternative but Jesus
Theoretically, in the event that less funding does create a health care gap for low-income women, the state's network of Crisis Pregnancy Centers, as a consequence of Williams' corollary set-aside, would be there to take up the slack, with the envisioned "statewide program" for women "seeking alternatives to abortion." What, exactly, this "program" would look like is unknown and to hear HHS Commission spokesman Jeff Wool tell it, the state isn't all that sure either. "Generally speaking," he said, "there won't be any provisions that go beyond [the text of the legislation]." At press time, the Commission had not yet awarded the money $5 million over the biennium earmarked by Williams for implementing his vague abortion alternative program, although two groups, The Heidi Group in Round Rock and the Bellville-based Texas Pregnancy Center Network, have applied for the funding.
According to its Web site, The Heidi Group seeks to "make a difference in the lives of women who find themselves in unplanned pregnancies" by offering women a "balanced approach to life, understanding that the unplanned pregnancy is the immediate concern, but that she needs hope offered through a relationship with Christ." Although a woman may have "practical" needs that can be met through "life skill training," her "real needs will be met through discipleship." The group's founder, Carol Everett, says her organization wants to share the "truth about the choice of life," and at the CPC, Everett says in a video clip on the Group's Web site, a woman "will be helped with the choice of life. Both physical life for her baby and eternal life for that woman through Jesus Christ." The Heidi Group program apparently makes no provision of any kind for women who may not be Christians, or otherwise ripe for proselytizing. But that won't be an issue if the group gets the CPC set-aside, insists Thompson, who is working with Everett on the group's funding proposal, since the law forbids spending taxpayer funds for overtly religious ministries. If the group gets the money, Thompson promises, there will be no "overt or covert evangelizing" and no clients will actually be sent to The Heidi Group's Web site for information.
The other applicant, Texas Pregnancy Center Network, is even more elusive: It has no Web site, and contact information for its three directors is not readily available. (The Chronicle was able to find a phone number for Randall Gabrel, one of the three directors listed on incorporation filings with the Secretary of State's Office, but, at press time, Gabrel had not returned phone calls.) The network didn't even exist, at least officially, until Aug. 15, 2005, when it filed for nonprofit incorporation status with the SOS. According to a December Associated Press report, the mysterious network is associated with a Pennsylvania-based CPC group, "Real Alternatives."
Real Alternatives is considerably less preachy than The Heidi Group in part, perhaps, because overt proselytizing would mean the organization wouldn't be eligible for the federal monies available for "abortion alternative" programs including, in Texas, Williams' $5 million earmark, which comes out of federal welfare grant money. (Real Alternatives notes on its Web site that its affiliates must agree to eschew religious promotion "while providing contract services to the client.")
Bible-thumping can take many forms, however, and for the CPCs the second-best alternative to the True Word appears to be the various pamphlets they offer to women seeking services including pamphlets describing the putative horrors of abortion. "The pamphlets, recently, have not been blatant proselytizing," Wheat said, "just one step removed." Among the literature available to CPCs (readily available via an online library) is an "abortion checklist" that includes a "consumer alert" about the "diabolical" late-term abortion procedure, which the literature claims was "engineered for the benefit of what is called the 'Fetal Harvesting Industry,'" fed by medical professionals who "coerce" pregnant women into having abortions for the benefit of "medical research."
Whether the CPCs that get funding under the Williams rider would actually be allowed to use this type of information is unknown. In response to a question by Sen. Eliot Shapleigh, D-El Paso, during a March 9 meeting of the Senate Finance Committee, Williams said only that the CPCs would be required to be nonprofit organizations that operate in line with state policies and that "don't promote, refer [patients to abortion providers], or perform abortions."
On the other hand, the list of what is not required of the CPCs is far longer and far more disturbing to health advocates. CPCs getting state funding will not be required to have a licensed doctor on staff; are not regulated, subject to inspections by the state health department, or required to meet any state health and safety standards; are not required to keep patient information confidential; and, says Tierney, beyond discussing abstinence, many don't offer information or referrals for birth control. "Most of the [CPCs] are evangelical and are trying to convert women," Wheat said. They're "not regulated, not licensed; so what are we getting for our $5 million? We used to know exactly what we got for our money," when it went to traditional family-planning providers. "Now, I have no idea what we're getting."
In that context, exactly what health care niche the CPCs are supposed to fill remains unclear. Licensed family-planning doctors, in FQHCs or more specialized family planning clinics, like Planned Parenthood's, offer a host of services and counseling regarding the entire range of options available for every reproductive medical condition including an unplanned pregnancy. The CPCs, apparently, will provide no such services. So, what, many want to know, is the real intent of Williams' legislation?
Asked about the legislative intent of the Williams rider, the senator's aide Jason Baxter provided two prepared statements from Sen. Williams. The first charged that according to national Planned Parenthood's own figures, "the vast majority of their pregnant client visits are abortion-related. ... Accordingly, the abortion alternatives funding rider created a new niche funding stream for organizations that specialize in providing pre- and post-natal care for women facing unplanned pregnancies who want an option other than abortion." Williams continued, "Only $5 million total of Title X funds were reallocated to TANF in order to fund agencies that specialize in assisting women seeking alternatives to abortion. Planned Parenthood and other Title X funded agencies will continue to receive tens of millions in state funds. I would be surprised to learn that pro-choice advocates oppose funding for choices other than abortion." Unfortunately, despite Williams' assurances, none of the Crisis Pregnancy Centers applying to be funded by the rider expect to provide "pre- and post-natal care for women facing pregnancies" at all.
Planned Parenthood's Danielle Tierney responded, "If Sen. Williams wants to talk numbers, let's talk about the real number of family planning visits at Planned Parenthoods each year. Over two million women [nationally] come to Planned Parenthood for family planning services each year. Planned Parenthood does more in one day to prevent unplanned pregnancy than Tommy Williams will do in his entire legislative career." Tierney also pointed out that, despite the senator's implications, none of the state or federal money allocated to Planned Parenthood clinics pays for abortion services, explicitly forbidden by law.
Thompson says the point of funding CPCs is clear: "If a woman is pregnant, then the family planning point is gone," she says. "At this point she needs other help." In other words, to the CPCs and their prospective clients, abortion will not be even a theoretical option for discussion. As an alternative, the CPCs will offer "needs assessment," to determine what social service and/or other nonprofit programs the pregnant woman can tap into, as well as "counseling" services, Thompson says. Of course, the counseling they offer is limited, since under Williams' rider, they're not allowed to do much except touch on the subject of abortion. "We provide information related to abortion issues," Thompson said, "we fully inform our clients about their options, although we don't do referrals." CPC services, she said, are focused on "childbirth, and actually promoting childbirth."
DSHS estimates indicate that nearly 17,000 women could lose access to preventative family-planning health care and reproductive services because of the Williams set-aside. And because the women served by the subsidized family-planning programs are uninsured, low-income women, a lack of access to services raises the concern that the number of unplanned pregnancies and, perhaps, even the number of abortions performed each year will in fact rise, a potential consequence that disturbs pro-life Sen. Zaffirini. "If you don't have family planning available, the number of unplanned pregnancies will rise, the number of children born will rise," she said. "And so women without family planning may actually consider abortion, if they are not able to rear their children."
Thompson disagrees. "I don't think that would be the end result. I think that's presumptuous to say that is what would happen," she said. CPCs "are for women who want to continue their pregnancies." But what about poor women who stand to lose their health care? "These are women who just won't get a pap smear" if they don't have easy access, Wheat said. Thompson says she really hasn't given much thought to that consequence. "What women are we talking about?" she asked. "What's wrong with those providers ... [offering] services for free?" Informed that family planning providers already provide free and reduced-fee services, and in fact have relied on state and federal grant money to do so, Thompson was unmoved and did not think that, perhaps, the CPCs should consider offering their services for free. The CPCs didn't "lobby for the funding," but are simply responding to the new state legislation, she said. In sum, Thompson is unpersuaded that there will be any women that "won't get access" to health care. "We think [funding CPCs is] good."
Don't Call It "Conservative"
Cutting services and funding CPCs may indeed be "good" for the centers that, by definition, rely on unplanned pregnancies to justify and sustain their programs. But that's certainly not a good reason to divert "dear and scarce" family-planning money to the centers, Romberg says. If Williams and Deuell want to fund FQHCs and CPCs, "they should cough up [a separate appropriation] instead of taking women's money," Romberg said. Williams' office didn't respond to questions about why the senator didn't consider a separate appropriation, but one legislator says that both Williams and Sen. Steve Ogden, R-Bryan (chair of the Senate Finance Committee in which the Deuell and Williams riders were adopted) have made their intentions well-known: "Both Williams and Ogden have said that the purpose is to put Planned Parenthood out of business," said the legislator, who asked not to be named, "and when Ogden became chair of Finance ... he turned [the task] over to Williams." (Ogden did not respond to req0uests for comment.)
As a state policy, that is just wrongheaded, say Romberg and Wheat, and it's also exponentially expensive. "Unplanned pregnancies in poor families [are] the gift that just keeps on giving," Romberg said. They're costly, not only in terms of health care, but also impact a host of other services on down the line, "the education system, Child Protective Services, foster care, food stamps, the criminal justice system," just to start the list. Indeed, preventative family planning care costs the state about $160 per woman served, per year for "physical exams, [clinic] visits, [and supplies] for family planning," she points out, compared to about $8,500 per woman, for just the "first-year costs" the state pays for carrying unplanned pregnancies to term, as a consequence of what is inevitably described as a "conservative" policy. "It makes no economic sense," Romberg said.
While the initial damage has already been done, advocates warn, the effects are likely to be even worse during fiscal year 2007. Because the provisions of the Deuell rider didn't take effect until Jan. 1, most regularly funded family planning providers, such as Austin's Planned Parenthood, still got four months of funds from Aug. 31 to Dec. 31, 2005 based on the old funding formula. As a result, just over $6.8 million of the $10 million annual earmark mandated by Deuell's rider was granted to FQHCs, for use during the eight remaining months of the fiscal year. Next year, says Romberg, the full $10 million will go first to the FQHCs, meaning there will likely be even greater budget shortfalls for other providers. "I'd be happy to let the state fall on its face [with this]," said Romberg, "but the problem with that is that you'll have a lot of victims."
And it isn't likely that sympathetic legislators will be able to roll back the provisions without help from the electorate. "When extremists run government there are extreme consequences. Elections matter," said Shapleigh, who, with Zaffirini and Gonzalo Barrientos of Austin, voted against the riders when they came before the Senate Finance Committee for approval. "So the real question is, will women respond?"
Deuell Rider: Family Planning Services at Federally Qualified Health Centers"Out of funds appropriated [for] Family Planning Services, up to $10,000,000 in each year of the 2006-07 biennium shall be set aside for family planning services provided by [FQHCs]."
"FQHCs funded under this strategy shall assure that recipients receive comprehensive primary and preventive care in addition to the family planning services."