Millions for Propaganda ... Nothing for Women's Health

Anti-choice crisis pregnancy centers (orange) vastly outnumber the state's dwindling number of abortion care clinics (green). Some 200 CPCs, including 25 state-funded (red), seek to dissuade women from undergoing abortions and typically offer limited to no medical services.

To your right, a basket full of free pocket-size Bibles and Christ-centered booklets; to your left, as you enter Austin LifeCare, a prayer request bowl. The unassuming pastel green building on West Anderson Lane advertises, ambiguously, "pregnancy support." However, the center offers no medical services, only free pregnancy testing and non-diagnostic sonograms. It does, on first visit, offer plenty of literature discouraging abortion. You may leave with a glossy magazine, published by national Christian-based network Care Net, claiming to help pregnant women make the "best choice," and doing so by interspersing misleading information about abortion with personal narratives of shame, remorse, and sadness. The magazine cover, referring to abortion-inducing drug RU-486, reads, "RU Sure? The 'Safe' Drug That Can Kill You." Or you could pick up a pink pamphlet that erroneously links breast cancer to abortion. Or a pocket Bible with a preface recounting the story of abortion regret – overcome by the love of Jesus Christ.

Persuading women to "choose life" is the core mission of Austin LifeCare; in fact, under the terms of their state funding as well as their stated mission, the center cannot refer clients for an abortion, no matter if their clients need or request the service. Despite the religious overtones, overt anti-choice agenda, and documented claims of dispersing medical inaccuracies, LifeCare and 24 other "crisis pregnancy centers" – from Dallas to Houston – are generously subsidized by the state of Texas. And even as the women's health network drastically erodes at the hands of conservative lawmakers, taxpayer dollars to CPCs stand to receive an unprecedented increase in funding this legislative session.

An Unhealthy Diversion

Texas crisis pregnancy centers – pseudo-clinics designed to discourage abortion – have seen an infusion of taxpayer funding over the years, beginning with a 2005 effort by Republican legislators who succeeded in diverting funding intended to assist low-income households into the "Alternatives to Abortion" program. Former state Sen. Tommy Williams, R-Woodlands, initiated a new program redirecting $5 million of Temporary Assistance for Needy Families funding to instead offer "pregnancy support services that promote childbirth," underwriting organizations that do not refer clients to any group that provides abortions. In following sessions, lawmakers redirected funding dedicated to family planning into the Alternatives program.

In each subsequent session, lawmakers have maintained or increased funding for the Alternatives to Abortion program – starting with $2.5 million in 2008, steadily rising to $5.15 million allocated for 2015 – while deeply slashing family planning funds and otherwise blocking women's access to health care. For example, in 2011: As conservatives cut the family planning budget by $74 million (two-thirds of the previous allotment) and blocked state dollars to Planned Parenthood, they simultaneously raised funding for the unregulated, unlicensed CPCs. By the Department of State Health Services' own estimation, some 180,000 women lost access to basic care each year following the cuts as 82 state-funded family planning clinics eventually closed their doors or stopped offering services.

The latest statistics reaffirm the drastic reduction in services – in 2012-13, organizations served 54% fewer clients than they had in 2011, according to a March 19 study published in the American Journal of Public Health, by the Texas Policy Evaluation Project, Ibis Reproductive Health, and the University of Alabama at Birmingham. By drawing from state data as well as surveys and interviews with clinic leaders, researchers concluded the Texas case demonstrates "how the patchwork of programs that have supported low-income women's access to reproductive health services can come apart at the seams when specialized family planning providers are marginalized or systematically excluded from public programs."

While the lawmakers, motivated by their ideological abhorrence of abortion care and providers, reduced the basic preventative care network to ruins, the Alternatives to Abortion program has received (to date) more than $26 million from the state, and stands to gain millions more.

Calculated Deception

Anti-abortion materials from a crisis pregnancy center

As various media outlets and reproductive health advocacy organizations have reported, the problems at crisis pregnancy centers range from lack of accountability, to religious proselytizing, to spreading medical falsehoods. A 2014 investigation by NARAL Pro-Choice Texas found that some state-funded CPCs provide false or misleading information while employing scare tactics to pressure clients into continuing their unplanned pregnancies. Sending undercover investigators to CPCs in Austin, Dallas, Houston, Bryan/College Station, and El Paso, the group discovered clinic counselors routinely spout medically inaccurate information.

One oft-perpetuated falsehood espoused by CPC counselors is a purported link between breast cancer and abortion (long discredited by the National Cancer Institute, and other medical authorities) found in the state-funded "Woman's Right to Know" pamphlet, which also propagates the notion that abortion causes psychological trauma to women or "post-abortion stress syndrome" (a condition not recognized by the American Psychological Association). Some CPCs even linked abortion, incorrectly, to a higher death rate, all to dissuade women from undergoing the procedure. "CPCs frequently use lies, deception, and intimidation to achieve their end goal," said Heather Busby, executive director of NARAL-Texas.

One investigator was falsely informed she would be four times more likely to die in months following an abortion, while another was told she would be eight times more likely to be diagnosed with breast cancer. "Those are crazy, false statistics. That's not true by any stretch of the imagination, and they don't even have a fake study to support it," said Busby. Instances of victim blaming (in sexual assault scenarios) and refraining from discussing contraception altogether – or claiming contraceptives are ineffective at preventing pregnancy – also made the list of CPC strategies.

One CPC tactic, in particular, has the potential to place pregnant clients' health at risk; delaying doctors' visits and ultrasound appointments are integral to the CPC strategy. Counselors assure clients they have ample time to decide whether they want an abortion, while pushing visits further into the future – making pregnancy increasingly irreversible. As costs associated with abortion increase after the first trimester, and the procedure itself has been made illegal after 20 weeks of pregnancy, the delay can add substantial barriers to access.

A NARAL investigator recounted the strategy to the Chronicle. When she called Austin LifeCare to make an appointment, counselors persisted in delaying by weeks both her initial appointment and a potential sonogram. When vulnerable abortion-seeking women, in crisis mode and understandably drawn to the offering of a "free sonogram" – perhaps not realizing the procedure fails to fulfill the Texas law's pre-abortion, 24-hour requirement – finally reach actual health clinics, they often arrive with false information about their own gestation, say reproductive rights groups, and dangerously late in the timing for a safe abortion.

Tina Hester of Jane's Due Process said she has met young women who were intentionally or unintentionally provided wrong information about the date of their pregnancy term at CPCs. Similarly, Susy Hemphill of the Lilith Fund, which assists women in paying for their procedures, said she often hears from clients who have first visited a CPC under the impression it was a medical facility where they could get assistance and advice in terminating pregnancy. "I've certainly talked with clients who were misdirected by crisis pregnancy centers," said Hemphill. "In the end it results in people getting misinformation and delays in individual choice and access to abortion procedures. These women thought they had more time, which is just devastating to people who are trying to decide what's best for them and their family."

Texas is hardly alone – undercover investigations in California, North Carolina, and Virginia have produced similar results. And over the years, news outlets – including the Chronicle, the American Independent News Network, and the Texas Observer – found program providers distributing evangelical, anti-choice educational materials, delivering overtly Christian messages, and incurring several program violations during site visits by the state contractor.

Moreover, the nonmedical centers are often located in proximity to actual health care and abortion clinics, while providing no indication that they do not offer legitimate health services. Hoping to provide warnings for Austin women, in 2010, City Council passed a "truth in advertising" measure (sponsored by former Council members Bill Spelman, Laura Morrison, and Mike Martinez, and revised in 2012) that would require centers to display a sign indicating they do not provide medical services. That ordinance, however, was overturned after a lawsuit by local CPCs, claiming it infringed on free speech and religious liberty. Nationally, the pattern of deceptive marketing prompted Google to remove online CPC advertising last year, after a report showed nearly 80% of the CPC ads listed on the major search engine "indicated that they provided medical services such as abortions" when they, in fact, did not.

Despite all this, state lawmakers continue to be more than eager to subsidize CPCs.

Millions for CPCs ... and License Plates, Too

Texas-area CPCs annually receive thousands of dollars from the state budget – for some, hundreds of thousands. In a mockery of accountability, the program funds are distributed to clinics by one state contractor, the anti-choice nonprofit, Texas Pregnancy Care Network, rather than the Health and Human Services Commission. Oversight, in the form of pre-announced site inspections, is also the responsibility of TPCN, not HHSC. And unlike abortion clinics or food trailers or even nail salons, the largely faith-based CPCs are not regulated or licensed by state health agencies. (Calls to TPCN Executive Director John McNamara were not returned.)

While adoption and maternity homes are included in the 58 total centers funded by the state, the majority of recipients (41%) are crisis pregnancy centers. Data provided by the Health and Human Services Commission of CPCs' request for annual funding, from Sept. 1, 2013 – Aug. 31, 2014, shows up to hundreds of thousands awarded to CPCs. A selective snapshot: the Life Center in Midland: $146,332; Fifth Ward Pregnancy Help Center of Houston: $303,294; Austin's Gabriel Project Life Center: $130,963; and Waco's Care Net Pregnancy Center of Central Texas: $158,722.

Where is that money going, exactly? The amount billed in counseling time – one-on-one "mentoring" – consistently far outweighs the social services CPCs often tout, like parenting, childbirth, pregnancy classes, baby clothing, and food pantry provisions. From September 2013 to August 2014, counseling amounted to nearly $3 million, or 54% of the TPCN's budget for the centers; 15% went to classes; and just 2.47% was spent on goods.

Direct funding from the Lege budget is only part of the story. CPCs are also underwritten by a separate pot of money, made possible through 2011 legislation. Former Dallas Sen. John Carona's SB 257 enabled the Texas Department of Motor Vehicles to manufacture "Choose Life" license plates, with the bulk of the proceeds ($22 of the $30 sale price) going toward organizations "that promote adoption as an alternative to abortion."

The fund, administered through the attorney general's office, is distributed by a seven-member AG-appointed advisory committee, stacked with anti-abortion crusaders. For example, committee member Lois Kerschen is a former CPC counselor and co-founder of Democrats for Life of America, while noted anti-choice advocate Carol Everett heads the Heidi Group, a Christian-based nonprofit which proclaims it "sets women free from abortion." (Everett and friends held a press conference in 2012 to denounce Planned Parenthood as the provider was being evicted from a Medicaid program by GOP officials.)

From the license plate fund, 13 pregnancy resource centers received a total of $41,750 – with six of the centers already benefiting from Alternatives to Abortion taxpayer dollars – according to records obtained from the attorney general's office. The Gladney Center for Adoption netted the largest sum; its former regional coordinator, Judy Canon, sits on the Choose Life committee.

A Questionable Investment

This legislative session, lawmakers plan to nearly double the funding for the Alternatives to Abortion program. A budget rider introduced by Friendswood Republican and physician Rep. Greg Bonnen would increase the program's funds from $10.3 million for the biennium, as provided in the House base budget, to $18.3 million. While the House Appropriations Committee adopted the rider on March 12, it wasn't without debate. Austin Democrat and women's health champion Rep. Donna Howard argued against the spending, in light of the paltry evidence that the program actually delivers measurable social services.

"The first striking thing about the Alternatives to Abortion program is that it's receiving a significant bump this time without any metrics that I can see," Howard told the Chronicle. "We've been talking to the agency [HHSC] to get more information about what the measurables are and how are they doing in achieving those. And we are getting very little back. It doesn't give you much confidence that there is real accountability or strong metrics here justifying the program.

"I don't need to know how many clients they've seen," she continued. "I need to know what their deliverables are; what are their goals and outcomes, and how are they showing me they are actually achieving those? I'm not seeing that."

Howard juxtaposed the Alternatives program to the state's Nurse-Family Partnership Program, which pairs registered nurses with low-income, first-time mothers to assist in prenatal care and child development education; the program reports specific metrics and goals to track success. The same goes for the state's Women's Health Program which showed a direct cost-saving fiscal impact; the HHSC estimated that the WHP saved Texans more than $37 million in averted unplanned Medicaid births in its first two years as a federal-state funded partnership. According to HHSC's latest report, Texas saw an estimated pre-net savings of $38 million in 2013 due to the (now, solely state funded) WHP. On the flip side, Alternatives to Abortion seems like a raw deal for taxpayers: Its average cost per client – while providing no medical services – hovers at $228, according to TPCN's own data. Comparatively, the average cost per client at a family planning provider that offers medical services and preventative health care isn't so far off at $240 per client in 2013 (a rise from $205 in 2011).

The boost in dollars to crisis pregnancy centers is even harder to swallow for women's health advocates when considering the lack of added substantial investment in family planning programs. While expanded primary health care for women sees a boost in the House budget, family planning funds and the funding allocated to the Texas Women's Health Program is relatively stagnant from last session. Additionally, the Senate's budget plan includes a strategy that would strip Planned Parenthood and other providers of life-saving breast and cervical cancer screenings by tiering program funding. "How do you justify almost doubling the appropriation of a program that doesn't demonstrate anything, really – when you are basically not putting more into the family planning program?" asked Howard.

Predictably, Bonnen disagrees, countering the program is "tightly monitored" (although he was uncertain who does the monitoring – TPCN or HHSC). "I think this program does an excellent job of providing services to pregnant women and new mothers and to their babies. I know abortion is a sensitive issue but this program is really not about abortion rights or abortion restrictions, it's about providing resources to pregnant women and new mothers," he told the Chronicle. The representative, who initially requested $20 million for the program over two years, said the added investment is needed for the "underfunded" program to help serve many more clients. When asked about charges of medical misinformation, Bonnen (referring to the inaccurate "Women's Right to Know" booklet) said it was unfair to criticize CPCs for distributing materials funded by the state; as for religious proselytizing, Bonnen said state-funded CPCs are "supposed to be non-faith-based."

Bonnen, a medical professor, readily acknowledges the Alternatives program offers no medical services and understands the funds would primarily be directed at counseling. That troubles reproductive rights advocates, considering the weight of health care restrictions, and diminished access due to systemic, ideologically motivated defunding. "We have the highest uninsured population in the nation," asked Busby, "yet we are not concerned about giving millions of dollars to organizations that don't provide any actual health care?"

While House Democrats (including Austin Rep. Celia Israel) initially proposed a flurry of amendments to cut funding to the Alternatives to Abortion program, they decided to scrap them as futile after conferring with Republicans who hoped to increase its funding – the best Democrats could hope for is maintaining the current level. As of press time, the Senate budget keeps the program at $5.15 million, unchanged from the previous funding amount – all subject to revision as the budget process goes forward. In the meantime, reproductive health advocates are following legislation filed by Rep. Jessica Farrar, D-Houston, that would require more stringent reporting requirements for CPCs and mandate information given to clients be medically accurate. Under Farrar's proposed bill, HB 3966, CPCs that fail to do so would face a civil penalty of up to $500 and be banned from state funding. The bill was last referred to the House Public Health Committee, as of press time. "I am concerned about women being misled at these crisis pregnancy centers," Farrar told the Chronicle. "They may think they are receiving health care services only to find out there's no health care provided, instead they are subjected to a persuasive argument. I understand our state leadership has made the decision to use state resources to dissuade women from having an abortion and I want to make sure these women fully understand the range of health options available." Farrar said the lax attitude some lawmakers hold when it comes to CPC reporting requirements is unlike the standards applied to other state agencies. The additional investment doubly calls for demonstrable accountability. "I don't think we know what we're getting for the money we are expending," she said.

HB 2: Good for CPC Business

Local CPC, Austin LifeCare (Photo by John Anderson)

With roughly 80 clinics closed as a result of state budget cuts to family planning, and half of Texas' remaining abortion clinics no longer providing the procedure due to last session's House Bill 2, the Texas women's health network has been left in shambles. Large swaths of the state have no abortion provider, and if the final provision of HB 2, currently under litigation, eventually takes effect, only eight clinics are expected to survive. Eighty percent of the state's population would have to travel long distances, as much as 500 miles, for abortion care.

This vacuum, say reproductive rights supporters, creates an even greater opportunity for CPCs to seize on vulnerable women experiencing unplanned pregnancies. Only 20 abortion providers remain today – yet there are 25 state-funded CPCs, and a total of 200 CPCs in the state. "When you have actual health facilities closing, people are going to look elsewhere, especially in areas where there are no or few clinics – like West Texas and the Valley," said Hemphill, who has had to correct misinformation provided to clients by a CPC, having mistaken it for an abortion provider. "Without those clinics and resources, more Texans will likely go to CPCs."

Busby agrees, adding that the state's 2011 pre-abortion sonogram law was first "perfectly positioned to benefit" CPCs, most of which offer free ultrasounds. The law also subtly ushered women to the centers by requiring abortion physicians to inform patients where they can obtain state-mandated sonograms with a list that includes several crisis pregnancy centers. The vanishing abortion landscape will only further benefit CPCs. "As clinics shut down, it helps these centers thrive because the need for abortion care is still there," said Busby. "So when women seek it and the only option available in the community is advertising as something like an abortion clinic, it may end up being the best option for some women – especially vulnerable populations, who are more inclined to seek help wherever they can get it and usually don't have a support system. So CPCs can end up preying on the most vulnerable and doing more harm than good to these women."

On the anti-choice side, Joe Pojman of Texas Alliance for Life – a dedicated supporter of crisis pregnancy centers – said he has heard, at least anecdotally, of caseload increases from CPC operators across the state. Indeed, program data confirms the likelihood more women are flowing through state-funded CPCs. Nearly 20,000 clients were served through TPCN in 2013-14, an increase of roughly 30% from 2010-11.

With a blessing from former Gov. Rick Perry, one Houston state-funded CPC – the Source for Women – has slowly begun offering medical services, like well woman exams and STD tests. The aim is to fill the void left by the state's anti-choice-motivated exclusion of Planned Parenthood from the Medicaid-based Women's Health Program – an effort the Source has insisted they have pursued since 2012 (See: "Consider 'The Source': Crisis Pregnancy Center Transforms Into Women's Health Program Provider," Sept. 21, 2012). While they bill themselves as a "comprehensive" health care center, the Source, funded in part by the Alternatives to Abortion program, fails to offer contraceptive services – a key component of preventative, holistic women's health care, and a proven method to reduce unwanted pregnancies, and thus, abortion.

"Did HB 2 have an impact on the industry? Of course it did. Are we happy to receive those women? Of course we are," said Cynthia Wenz of the Source. "The great news is that there's been a lot more awareness about CPCs since HB 2. Abortion providers know who we are now, and we would love their referral business."