The Destruction of Texas Health Care

Carole Belver, executive director of Community Action Inc. of Central Texas, spent Tues­day, Jan. 24, closing up the CAI women's health clinic in Elgin. As she packed up supplies and prepared files to be moved to Lockhart, the closest of the group's two remaining clinics, "the phone was ringing off the wall," she says. Three staff members have been terminated, and hundreds of clients have been left wondering where they'll go to receive basic reproductive and preventative health care.

Belver doesn't know what to tell them. CAI, which until recently operated 13 clinics in medium- and small-sized communities in Central Texas, now has just two, in Lockhart and San Marcos. "It's horrible; it's just devastating," she says. "And there's really no place for these clients to go."

Indeed, CAI is among 12 women's health contractors operating 22 clinics statewide that have been completely defunded as a result of last year's April Fools' Day slashing by Texas lawmakers of the family-planning budget traditionally used to provide low-income and uninsured women with access to health services. As it stands, there remains just $38 million of a roughly $100 million biennial budget to provide these vital health services – screenings for cervical and breast cancers and for diabetes and hypertension, as well as access to birth control, among other preventative health services that together make up a "well-woman checkup." Since 2005, this money – federal dollars passed back through the state to fund services – has paid for health care for an average of 244,000 needy women a year; with the small pot that remains, just $19 million this year, the Department of State Health Ser­vices estimates that just 60,000 low-income women will be able to access basic health services in 2012.

Defunding Basic Care

Why lawmakers chose to decimate a budget that had been barely keeping pace with actual need for services – according to a 2008 Guttmacher Institute report, there are some 1.5 million women in need of reproductive health services in Texas – can be summed up in two words: Planned Parent­hood. An increasingly aggressive political campaign against the nearly 100-year-old nonprofit is at the heart of the cuts. Conservative lawmakers – and their backers at Texas Right to Life and other anti-abortion groups – were nearly giddy about the cuts last spring, proclaiming that slashing the budget would cripple Planned Par­ent­hood, one of the state's largest providers of women's health care, and thereby bring an end to the "abortion industry."

Yet the federal funds in question do not cover abortion care, and thus none of Planned Parenthood's abortion services – which, nationwide make up roughly 3% of its work – are paid for through the state's family-planning budget. Instead, what Republican lawmakers have done, with the express blessing of Gov. Rick Perry, is hurt Texas women, especially the women who most desperately need a health care safety net. "It was shocking; it was sort of unbelievable," says Paula Turicchi, senior vice president for women and infants' specialty health at Parkland Health & Hospital System in Dallas, the state's single largest provider of family planning services to uninsured women. "The bottom line is that the women who need services are the ones who suffer the consequences."

Moreover, compounding the outright cuts, lawmakers also approved a new funding matrix that first funds "federally qualified health centers" – one-stop medical clinics intended to provide the uninsured with a medical home (although a number of FQHCs across the state actually subcontract with smaller family-planning providers, including Planned Parenthood clinics, in order to provide these services) – before funding other providers. Lawmakers arranged a three-tiered system for funding women's health providers, with PP on the lowest rung and with the expectation that in fact there wouldn't be money left to fund any PP clinics. That outcome was assured – but with just $19 million per year left to spend, there also hasn't been money left for many providers other than FQHCs, including veteran community providers.

According to the funding allocations released this month by DSHS, 12 contractors, operating 22 clinics statewide, have been completely defunded. Among those are not only a number of Planned Parenthood clinics – including Austin's Downtown clinic on East Seventh Street – but also other stand-alone family-planning clinics and venerable community health clinics, such as Austin's People's Community Clinic and El Buen Samaritano Episcopal Mission.

The severe funding cuts and tiered system mean that great swaths of Texas may be left without local providers. CAI, a contractor with the state for more than 40 years, had been receiving more than $750,000 per year to deliver women's health care to clients across Central Texas. Now that they've been defunded – along with the other Central Texas providers – there remains just one provider, CommUnityCare, to serve the majority of Central Texas women. "I'm just wringing my hands; it's just horrible," says Belver. State lawmakers "have successfully torn down an infrastructure that took so many years to build," she continued. "There's no talking sense to these people. They've got it 'all figured out,' and yet they haven't figured out that this is going to be devastating – and by the time they do, it will be too late."

Bleak Outcomes

And the already bleak landscape for women's health care in Texas is likely going to get even worse, unless state officials with the Health and Human Services Commission can successfully negotiate with the federal government's Centers for Medicare & Medic­aid Services to allow for the renewal of the successful Women's Health Program, a Medicaid-waiver program that provides women's health care services to clients who would not otherwise be eligible for Medicaid unless pregnant. In 2011, that program served more than 184,000 women in addition to the 215,442 unique clients served last year with the traditional family-planning budget. However, the future of the program is in jeopardy, after Sen. Robert Deuell, R-Greenville, pushed HHSC to redefine who can provide services under the WHP – a move crafted, again, to cut Planned Parenthood from funding. As with the traditional family-planning budget, PP is a major player in the WHP; in 2008, it was the WHP's largest provider. And though Texas might like to cut PP out of the loop, the feds aren't as amenable; Medicaid forbids states from discriminating against qualified providers. To women's health advocates, the attempt to exclude PP does just that – which will likely mean the program will disappear, bringing the number of women left without health care in 2012 ever-closer to the half-million mark. "This is so much more than just [hurting] Planned Parenthood," says Sarah Wheat, co-interim CEO of Planned Parenthood of the Texas Capital Region. "And it's so depressing."

As a result of all these drastic policies, health care advocates say the state is likely to see more providers close and many more women left without basic health care. That outcome will also increase the number of unplanned, Medicaid-paid births; the number of cancers detected in later stages of disease; and, inevitably, the number of abortions. "The obvious list is undetected cancers, higher rates of sexually transmitted diseases, unwanted pregnancies that end up in more Medicaid-paid births, more children enrolled in CHIP [the Children's Health Insurance Program] and more needing Head Start and other educational programs," says Fran Hagerty, CEO of the Women's Health and Family Planning Assoc­i­ation of Texas. "All of the social services and educational programs that we can't afford now, we'll be taxing more."

While cuts to the state's budget for women's health is alarming providers across the state, Perry, on the presidential campaign trail, boasted to Politico about the state's targeting of PP: "I was really proud to be able to sign legislation that we worked on with our Legislature to defund Planned Parenthood in the state of Texas," he said. "There are 12 abortion clinics that aren't open in the state of Texas today because our members of the Legislature had the courage, the wisdom to do that."

Perry's bragging may please his hardcore conservative base – but it's false. Eleven Planned Parenthood clinics across the state have indeed folded operations because of the budget cuts – including six near the Mexican border, where the need is great and there are few other options for care – but none of those clinics actually provided abortion care. Instead, those clinics combined provided health exams to 20,565 clients, including 13,184 screenings for cervical cancer; 14,163 screenings for breast cancer; and 33,974 screenings and treatment for sexually transmitted infections, according to Wheat. Moreover, the budget cuts have forced other, smaller providers – e.g., CAI – to shutter their operations.

Bringing It Home

As a result of the cuts, the statewide women's health care provider base is rapidly shrinking. In 2011, the state had 73 contractors operating clinics statewide; in 2012, there are just 41. In Austin, no provider has actually closed, even though just one of the county's four contractors has received any funding for 2012. People's Community Clinic, El Buen Samaritano, and the Downtown PP clinic – which had been a state contractor for 40 years – were all defunded, for a combined loss of just over $1.4 million in funds. The only remaining contractor in Travis County is CommUnityCare, which operates 22 clinics countywide; in 2011, the FQHC served 5,193 family-planning patients. While the allocation for CommUnityCare was in-creased slightly for 2012 – to $477,642 from $413,619 in 2011 – that's hardly a windfall, especially when you consider that those are the only funds allocated to a growing metropolitan region in which many thousands of women need services.

But comparatively speaking, Austin may not be in as bad a shape as other regions – particularly those along the Mexican border and in broad swaths of West Texas. Thanks to Central Health, women in Austin may be less likely to lose services completely. Knowing that the axe was going to fall on the state's family-planning budget, the hospital district set out to rework a series of contracts with each of the area's big providers – including the three cut from state funds – in order to provide a backup plan once other sources of funding dry up. For example, Planned Parenthood has a $400,000 contract with the district, which it hopes will help it keep serving its clients in need at the Downtown clinic. That's less money than the clinic had received from the state, and because the funds come from local tax dollars, it also means that women from outside Travis County will be unable to access services. (Funds from the state are for all women, so, for example, a woman from San Marcos could potentially be seen in Austin for care.)

Without state funds, there are few options for women outside Austin. Such is the headache for Belver's CAI; under the current statewide map, there are no contractors in Hays County – in fact, CommUnityCare is the only provider between Round Rock and San Antonio. And it's highly unlikely that it'll be able to pick up all of the slack created by the drastic cuts. They're certainly going to try, says Leslee Froehlich, chief operating officer for CommUnityCare. "We're here to make sure that women have access to these services. We're pleased the state gave us additional funds to do that with." She says the provider has opened "additional capacity" to accommodate new clients and a single phone number for patients to call to schedule services.

The Dismal Prospects

Beyond Travis County, the effects are more disheartening. Consider Parkland Hospital in Dallas, the state's single largest provider of women's health and family-planning services. One in every 250 births nationwide is delivered at Parkland, which tallies more than 1 million patient visits per year. For family planning, it has been just as big a powerhouse. In 2010, the hospital received almost $6.9 million to provide health care for nearly 33,000 women; last year, with all sources of funding – including the state family-planning budget (from which it got $6.6 million) and WHP funds – the hospital saw more than 38,000 clients and averted 6,600 unplanned pregnancies. This year, the hospital – which serves a population in which more than 42% live below the poverty line and more than 30% are without health insurance – got just $1.4 million in state women's health funds. It has gone from nine funded clinics to just two, says Tur­ic­chi, and the hospital estimates this year it will be able to serve just 6,000 women. "It's very heartbreaking," she says. "Just because [certain lawmakers] have a particular agenda related to a particular provider," everyone will end up being hurt. "That was lost in the whole political process."

It may well get worse – especially for providers like Parkland, which also delivers thousands of babies, a majority paid for in one way or another by Medicaid. Roughly 56% of all Texas births are paid for by Medicaid, which is a far larger aspect of the state's budget than is family planning; in 2009 alone, the state paid out $2.7 billion to cover Medicaid births (most of that coming from federal funds). The Women's Health Program was designed, in part, to combat these high costs. The Medicaid-waiver program is a great deal for Texas: For every $1 in state funding, the feds provide $9. In 2009, according to Texas' Health and Hum­an Services Commission, the program saved the state $46 million and averted 10,300 Medicaid births. In 2010, the WHP served 183,537 women.

But it looks now like the program will soon be killed, thanks entirely to political forces that wish to see Planned Parenthood excluded from participation. Although the initial program contained a provision to exclude abortion providers, the provision was never used as a wedge to exclude PP. Indeed, under federal law, states are not allowed to exclude an otherwise qualified provider from participation based, in this case, on the state's disapproval of one legally protected aspect of its business. At the behest of Deuell, however, the state has redefined the word "affiliate" in order to exclude PP from WHP participation. The new definition would exclude from the WHP any provider in any way affiliated with an abortion provider. Thus, all PP clinics would be excluded – even though many don't provide any abortion care – simply because they're all members of the same umbrella nonprofit.

The prevailing wisdom has been that this new definition would not meet federal approval, and thus far it has not – thereby threatening the continuation of the program in Texas. In December, the U.S. Department of Health and Human Services (Centers for Medicaid & Medicaid Services) wrote a letter to Texas saying it would not approve continuing the program so long as it includes an "order to restrict beneficiary choice of family planning providers." The feds left open the possibility that some compromise could be achieved, but Perry has publicly gone out of his way to shut that door. During his ill-fated presidential campaign, he denounced what he called the "pro-abortion" Obama administration for meddling in Texas' determination to protect life by excluding PP. That stance, advocates say, has diminished any bargaining room there might have been for HHSC to negotiate a compromise.

The result, they believe, is that nearly 200,000 additional women will likely be cut from services, leading to a precipitous increase in Medicaid-paid births. "I lay this squarely in [Perry's] lap," says Hagerty, CEO of the Women's Health and Family Plan­ning Association of Texas, which represents a number of women's health providers that seek to ensure access to quality reproductive health services for all Texas women. "Politically, [HHSC] has been put in an impossible situation. [Texas is] writing a [waiver] application that we know violates federal law." And because of that, the Women's Health Program seems doomed. "It doesn't look good because I don't see any leeway; the politics of Texas haven't given [HHSC] any leeway in negotiations with CMS," she said. Under the law, the federal government "can't say, 'Oh! It's Planned Parent­hood; well, go ahead [and cut them out].' Or, 'Oh! It's Texas; you just go ahead [and discriminate]. But that's what Texas is asking them to do – and Texas knows it."

The cost of losing the WHP is huge, especially to providers like Parkland. Because the hospital also handles Medicaid births, it understands well the advantage of having a productive family-planning program, which costs thousands less than a Medicaid birth. And because the state has continuously reduced its Medicaid reimbursement rates, the increase in births likely if the WHP goes away will create an even greater strain on an already underfunded health care system. The state "keeps asking us to do more with less," says Turicchi. "So, if family planning goes, we'll see additional births. If family planning goes, and we don't pay for [preventative health services] we're going to turn around and have to pay it in Medicaid, and it's going to be more expensive."

A World Turned Upside Down

Although he knows the state's family-planning budget has been a political football over the years, Victor Azíos, executive director of El Buen Samaritano Episcopal Mission, was nonetheless surprised when lawmakers voted to strip the budget outright last year. "My greatest surprise was how the legislators voted. It was about as short-sighted as it comes. I don't think it was any force of logic or any rational move," he says. "I think that what they forget is what the federal government and the state government call 'family planning' is really women's health." Like other local providers and women's health advocates, Azíos knows that even if there were more money, there would remain large unmet needs for these same services. Cutting the health care budget, whatever the ostensible motive, does nothing to help ensure that we have planned, happy, and healthy families.

"I think it's going to be one of those situations where patients who need services are going to bombard the remaining providers," says Parkland's Turicchi. Indeed, says Hag­er­ty, even if state lawmakers discover they've made a grave mistake, it may be too late to fix in 2013. "The state pulled the rug out from under [women's health providers]. That's true for all these people. They're trying to make magic out of dust," says Hagerty. "They do amazing work. The organizations are unique to their counties. These are mostly women who care about women deeply, and it's all getting ripped to shreds."

Among the providers now hanging on by a thread is Belver's Community Action Inc. And if the WHP is killed, she's certain she'll have to close the two remaining clinics in what was once a multicounty network of women's health care providers. "Every­thing is upside down and backwards," says Belver. "I used to think we would prevail because we're doing the right thing. How could you in your right mind think [that cutting women's health] is the right thing? But that's the thing, they're not in their right minds."

By the Numbers

22: Clinics statewide that have been completely defunded

$38 million: Remaining biennial budget for family planning, down from $100 million

60,000: Women whom the Department of State Health Services estimates can be served with that amount, compared with the average 244,000 served annually since 2005

184,000: Women served by the Women's Health Program in 2010 – and now in danger of losing service because of the state's anti-Planned Parenthood dispute with the feds (2011 estimate: 185,000-200,000)

11: Planned Parenthood clinics closed statewide – none of which provided abortion services

33,974: Screenings for sexually transmitted infections annually provided by those 11 clinics

Cuts to Central Texas Providers

	2010		2011		2012
Provider	State Funding	Clients	State Funding	Clients	State Funding
El Buen Samaritano	$405,962	1,281	$399,575	1,481	$0
People’s Community Clinic	$626,425	2,292	$536,177	3,139	$0
PP Austin Family Planning	$483,800	2,967	$475,115	3,995	$0
CommUnityCare	$611,841	5,858	$413,619	5,193	$477,642