by Kim Krisberg

In the west Texas city of San Angelo, Planned Parenthood has been serving local women since 1938. It was one of the very first places in Texas to have a family planning clinic.

“We have grandmas bringing their granddaughters in,” Carla Holeva, interim CEO of Planned Parenthood of West Texas, told me. “We’re very much part of the community.”

Today, the San Angelo clinic is preparing for some big, and unfortunate, changes. Last year, Texas lawmakers voted to exclude Planned Parenthood and other organizations affiliated with abortion providers from the state’s Women’s Health Program. The Medicaid program does not cover abortions (no state funds pay for abortion procedures), but provides low-income women with a range of reproductive health services, from contraception to basic health screenings. If the decision stands — a judge has issued an injunction against the policy and the case is still in court — it would effectively eliminate access to one of the program’s biggest providers. Nearly half of Texas women who access services via the Women’s Health Program do so through Planned Parenthood.

In San Angelo, Holeva said she’s heard from local providers who say they simply cannot absorb the extra demand that would come if the Planned Parenthood clinic were shut out of the Women’s Health Program. In turn, she said the clinic is now exploring different fee scales — “we’ll make ourselves as affordable as we can and work with our clients. We’re not going anywhere; we’ll just look a little different,” she said.

The attempt to shut out Planned Parenthood from the Women’s Health Program is one half of a double whammy that Texas’ family planning services are now facing. (Because cutting these clinics out of the Women’s Health Program is breaking federal Medicaid rules, Texas is losing tens of millions in federal Medicaid dollars. Here’s a good timeline of how the policy change unfolded.) The other hit is a devastating cut in family planning funds — in 2011, Texas legislators cut such funds by two-thirds, reducing them from $111 million to $37.9 million and cutting the number of providers who receive such funds from 76 to 41. Not surprisingly, the effects of such changes are already unfolding across Texas, according to an article published Sept. 27 in the New England Journal of Medicine (NEJM).

In interviews with Texas family planning providers, researchers found that clinics are having to restrict access to effective contraceptive methods due to higher up-front costs; women are being provided with fewer birth control pill packs — “a practice that has been shown to result in lower rates of continuation…and that may increase the likelihood of unintended pregnancy — and therefore that of abortion;” and many providers are instituting new fees for services.

“Those who cannot pay are turned away, whereas previously their visit would have been covered by public funds,” the NEJM article reported. “Women who can pay the newly instated fees are choosing less-effective methods, purchasing fewer pill packs and opting out of testing for sexually transmitted infections to save money.”

The article notes that there’s “considerable variation” in communities’ abilities to fill in the new funding gap. It’s an especially considerable challenge for more impoverished parts of the state.

“Disadvantaged women must choose between obtaining contraception and meeting other immediate economic needs,” stated the article, authored by Kari White, Daniel Grossman, Kristin Hopkins and Joseph Potter. “And, as one of our interviewees pointed out, providers are put in the position of ‘trying to decide, out of the most vulnerable, who is the most, most vulnerable.’…We are witnessing the dismantling of a safety net that took decades to build and could not easily be recreated even if funding were restored soon.”

Co-author Potter, a professor at the University of Texas-Austin, told me that in counties home to Planned Parenthood, the clinics provide the great majority of services via the Women’s Health Program — “and it doesn’t seem likely by anyone’s argument that others can step in to provide these services…it’s reasonable to project that there will be a continued loss of services.”

“I’m old enough to have lived through the 70s and remember the bipartisan support for family planning both internationally and domestically…and I was dismayed when (family planning) started to get politicized,” Potter said. “But I never thought I’d see a day like today.”

‘Where will they turn?’

Texas’ family planning funding cuts have resulted in 160,000 women losing access to critical preventive health services, including STD and cervical cancer screenings, and the shuttering of about 60 women’s health clinics across the state. According to the National Campaign to Prevent Teen and Unplanned Pregnancy, Texas is already home to some of the nation’s highest teen birth and unintended pregnancy rates.

In east Austin, a Planned Parenthood clinic that’s been receiving state funds to provide care since 1974 no longer has a contract with the state, said Sarah Wheat, vice president for community affairs at Planned Parenthood of Greater Texas, which serves central and north Texas. It’s a story that’s repeating itself throughout the state, she told me.

“There’s no question: If you’re uninsured or on a low income and you’re looking to get an annual Pap test or to talk to someone about birth control, it’s becoming extraordinarily harder to access those services,” she said.

Wheat noted that the funding disaster is about more than just contraception — “for many women, we are their medical home.” A woman may initially come to Planned Parenthood for birth control, “but we’ll also screen her for diabetes, cholesterol, cervical cancer, hypertension…we’re that frontline preventive care.”

“Anybody who works in public health was just stunned by what occurred,” she said about the funding cut. “It wasn’t based on any public health data or research, it’s not backed by widespread support…That leaders in the Texas legislature would choose to dismantle a very important safety net, it’s stunning for sure.”

To the south, the Community Health Centers of South Central Texas Inc. serves more than 900 women via state family planning funds and the Women’s Health Program. And because fellow providers in the region have lost family planning funds and are no longer able to see patients, the health centers are working to fill the gap. But Henry Salas, the organization’s CEO, told me they’re nearing full capacity and are now looking for excess operational funds to shift into women’s health services.

“Most of the women we serve are coming in uninsured and can’t afford insurance, so we’re helping in any way we can to get them the services they need,” Salas said. “Luckily, so far we haven’t had to turn anybody away, but you never know with the way things are moving.”

Salas noted that oftentimes the Women’s Health Program acts as a doorway for women to access other important health care services as well — “it’s kind of the foot in the door to get into other services because they’re all available at our clinics.”

“At a clinic like ours, we’re determined to not let people go without health care, but the realistic view is that sooner or later we’re going to have to figure out a different way of existing,” he said. “We’re in good shape, but only because we’re able to maneuver excess funds around. If we don’t have those, then we’re hurting just like everybody else.”

Back in rural west Texas, Planned Parenthood is by far the lead Women’s Health Program provider in the three communities it serves: Midland, Abilene and San Angelo, said Holeva of Planned Parenthood of West Texas. The clinics serve about 14,000 women every year, with about 60 percent of patients accessing services via the Women’s Health Program. Unfortunately and directly due to state funding cuts, Planned Parenthood’s Odessa location was forced to shut its doors in March. Staff were moved to the Midland clinic — only about 20 minutes away — to help build the capacity to absorb patients now traveling in from Odessa, Holeva told me.

“In a state where the governor (Rick Perry) has been very vocal on abortion…he’s cutting off the one thing that actually lowers abortion rates: access to family planning,” she said.

Holeva noted that it’s amazing that family planning providers are still facing the kinds of barriers that the 12 women of San Angelo faced when opening their family planning clinic in 1938. Those women wanted to create a place where low-income, disadvantaged women could turn to for family planning help; now, more than 70 years later, the question of “where will they turn” is back at the forefront, she said.

“We will continue to be here and to fight for women in our state,” Holeva said. “We are committed to staying open.”

To read the NEJM article on Texas family planning cuts, click here.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for a decade.