Legislation & Regulation

Texas a Test for Defunding of Planned Parenthood

Use of long-acting, reversible contraceptives dipped while Medicaid-covered births went up when Texas stopped state funding of Planned Parenthood.

Richard Mark Kirkner
Contributing Editor

To get a glimpse at what the United States might look like without Planned Parenthood clinics—or at least with far fewer clinics that have more limited hours—one only has to take a look at Texas.

Severe cutbacks to Planned Parenthood in Texas have resulted in low-income women using the most effective contraceptive methods less, along with lower adherence to contraception regimens and an increasing number of unplanned births.

Audrey Sandusky

The writing’s on the wall and Planned Parenthood funding will most likely be cut, says Audrey Sandusky of the National Family Planning and Reproductive Health Association.

And the outlook for Planned Parenthood funding is looking pretty dire at the moment. House Speaker Paul Ryan has pledged to defund Title X, the program that provides the bulk of Planned Parenthood’s federal funding. President Trump has called for defunding Planned Parenthood, although he hadn’t said—or tweeted—anything about the underlying program as we went to press. Supporters of government funding of the organization see the writing on the wall: “We are anticipating seeing a White House budget that either significantly cuts the program or potentially eliminates it,” says Audrey Sandusky of the National Family Planning and Reproductive Health Association. Overall, Planned Parenthood receives more than $500 million in federal funding from a variety of different sources, which accounts for about 40% of its revenue.

Lone Star petri dish

Texas is the petri dish of sorts for the anti-Planned Parenthood movement. Efforts to restrict Planned Parenthood funding there date back to 2011, when the legislature directed the state’s Medicaid waiver program, the Women’s Health Program, to exclude Planned Parenthood affiliates from its funding. Eighty-two family planning clinics closed statewide after the first wave of cuts, about a third of them affiliated with Planned Parenthood.

But federal law mandates that state Medicaid programs include all medically approved providers, so the CMS gave Texas Women’s Health Program a two-year reprieve, finally pulling funding after 2012. A lawsuit kept Planned Parenthood affiliates in Texas in Medicaid until the federal money ran out. In 2013, the Texas legislature replaced the Medicaid waiver program for family planning services with a fully state-funded program that excluded Planned Parenthood and other clinics affiliated with an abortion provider.

Joseph E. Potter

Bad things happened in Texas when Planned Parenthood was defunded, says Joseph E. Potter of the University of Texas.

During the first two years of the Planned Parenthood ban in Texas, 2013 and 2014, University of Texas researchers found that claims for long-acting, reversible contraceptives declined 35.5% while those for injectable contraceptives fell 31.1%. Follow-up and adherence to contraceptive regimens also declined significantly, and Medicaid-covered childbirths rose 27% among users of injectables. They reported their findings in the New England Journal of Medicine in February 2016.

“We’re going to point out some of the things that happened in Texas and argue that you wouldn’t want to do this on a national scale because bad things happen,” says Joseph E. Potter, the study’s senior author, when asked how he and his colleagues will make their case for preserving Planned Parenthood funding.

Georgia Rep. Tom Price, President Trump’s designee as secretary of Health and Human Services, has justified the defunding of Planned Parenthood by saying, in part, that there are enough other providers to pick up the slack. Potter says their research published in Contraception involving former Planned Parenthood clients in Houston and Midland shows contraceptive services aren’t that straightforward.

“The problem of actually finding a new provider is nontrivial,” says Potter, a sociology professor and an expert on contraceptive services. “Prescribing contraception is specialized and highly personalized for each individual. This general assumption that there are tons of federally qualified health centers or private providers who can step in to fill the void doesn’t work out so well, because if they’re not in the daily business of providing family planning, they probably don’t stock the birth-control methods that a person needs and they may not even have much experience prescribing them.”

Pete Schenkkan

Insurers may be on the hook if the services offered by Planned Parenthood disappeared, says attorney Pete Schenkkan.

While the University of Texas study focused on low-income women, other groups could feel the impact of defunding Planned Parenthood as well, says Pete Schenkkan, an Austin, Texas, attorney who defended the organization in Texas courts. “As a general proposition, the system—if we can be charitable enough to call it a system—of American health care is such that whenever one aspect of it comes under pressure and fails or cuts back, the people who lose access put more pressure on all the other parts of the system,” he says.

If women who are today eligible for Planned Parenthood services like birth control or breast and cervical cancer screenings have to forgo them and later have unplanned pregnancies or cancer, then transition to private or health insurance under a post-ACA scheme that mandates coverage for people with pre-existing conditions, health plans would be on the hook.

Patient care provided by Planned Parenthood affiliate health centers 10/1/13–9/30/14
STI/STD testing & treatment 45%
Contraception 31%
Other women’s health services 13%
Cancer screening and prevention 7%
Abortion services 3%
Other services 1%
Source: Planned Parenthood 2014–2015 Annual Report

As for having enough ob-gyns to provide services without Planned Parenthood, the American College of Obstetricians and Gynecologists (ACOG) isn’t buying it. An ACOG workforce study found that there were 2.1 ob-gyns for every 10,000 women in this country in 2010, the fewest in more than 30 years, and that ratio is not expected to get any better in the future.

Says Hal Lawrence, MD, executive vice president and CEO of ACOG, “For women’s health care providers, the closure of Planned Parenthood clinics would put immense pressure on existing private and unaffiliated public practices to accommodate an even larger population of patients—increasing hours, administration, and work in a specialty where doctors already report a high volume of overwork and burnout.”

Won’t happen overnight

The political and legislative dynamics of defunding Planned Parenthood may not be so simple. For one, doing so would literally take an act of Congress because Congress created Title X of the Public Health Service Act in 1970. In 2015, 4 million people got services at Title X-funded clinics, the Congressional Research Service reports. And while the bulk of Title X money goes to family planning programs, that money also covers other women’s health services, like tests for sexually transmitted diseases. “Therefore, it saves lots of lives and saves lots of the federal government’s and other people’s money,” says Schenkkan, the Texas attorney.

Even wrapping Planned Parenthood defunding in the reconciliation bill to repeal the ACA may get messy. Sen. Rand Paul of Kentucky, a Republican, has voiced objections to the legislation because it would raise the federal deficit by $9.7 trillion over 10 years. Two pro-choice Republican senators, Susan Collins of Maine and Lisa Murkowski of Alaska, haven’t committed to the bill if the Planned Parenthood provision is in it, according to CNN.

A lever the Trump administration could pull is to rewrite Title X regulations through the Office of Population Affairs (OPA) in HHS. As chair of the House Budget Committee, Price was in the driver’s seat in defunding Planned Parenthood. “Tom Price poses a grave threat to women’s health in this country,” Planned Parenthood Federation President Cecile Richards said when Price’s appointment was announced.

With Price’s oversight, the OPA could rescind a rule it finalized in December 2016 that prohibited states from redlining a subcontractor or pass-through grantee “for reasons unrelated to its ability to provide services effectively.” But even if Price’s HHS were to change regulations, they would have to comply with the underlying legislative intent of Title X along with the Medicaid mandate that states must include all approved providers.

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