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.

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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

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* chart numbers rounded