Since the start of 2013, Texas has excluded clinics affiliated with abortion providers, including Planned Parenthood affiliates, from receiving payment through the Texas Women’s Health Program, which funds reproductive-health services for low-income state residents. The TWHP is the 100% state-funded program that replaced the 90% federally funded Women’s Health Program — because the federal funding meant Texas couldn’t rewrite the rules regarding which providers could be paid through the program. These restrictions came on top of other cuts to family-planning funds that started in 2011 and had already resulted in the closure of dozens of clinics. (See Kim Krisberg’s October 2012 post for more background.)

As the Texas replacement program began, state officials claimed that there were plenty of other providers who could fill the gaps left by these exclusion. It didn’t take long before it became clear that many of the touted sites weren’t accepting new patients or weren’t prepared to bill the TWHP. As Sara Rosenbaum (disclosure: a colleague at George Washington University’s Milken Institute School of Public Health) pointed out when members of Congress tried to cut off payments to Planned Parenthood last year, federally qualified health centers do excellent and important work providing care to low-income US residents, but they’re not equipped to provide reproductive healthcare to the millions of women currently served by Planned Parenthood clinics.

These early warnings didn’t change Texas officials’ minds about their short-sighted policy. Now, though, a study published in the New England Journal of Medicine finds that after the policy change, the program paid for fewer women to get some of the most effective forms of contraception in the counties served by Planned Parenthood affiliates.

The TWHP serves Texas residents aged 18-44 with incomes of up to 185% of the federal poverty level. Amanda Stevenson of the Population Research Center at University of Texas at Austin and her colleagues analyzed publicly funded family-planning claims data for the two years following the policy change (2013 and 2014). They compared data for counties that are home to Planned Parenthood affiliates — where women are no longer able to receive state-funded family-planning services — with those without Planned Parenthood providers. Although Planned Parenthood affiliates are only located in 23 of the 254 counties in Texas, those 23 counties contain more than 1 million women between the ages of 18 and 44 (33% of whom lack health insurance), while the other 231 counties have approximately 700,000 women in that age range (34% uninsured).

Use of more-effective contraception

Before the policy change, use of IUDs and contraceptive implants — known as long-acting reversible contraception, or LARC — was increasing in both groups of Texas counties as well as in the US as a whole. Because LARC methods have failure rates of below 1% and last for three or more years unless removed sooner, they’re one of the best options for women who want to avoid pregnancy for a year or more. They can also cost several hundred dollars if you don’t have insurance or coverage from a family-planning program, though, so it’s hard for low-income, uninsured women to get them if they’re not covered by a program like TWHP.

After the policy change, Stevenson and her colleagues found that claims for LARC dropped abruptly in counties with Planned Parenthood affiliates before starting to increase again. Sharply reducing low-income women’s access to LARC methods in some of the state’s most populous counties is a terrible idea if your goal is to prevent unintended pregnancies, and that’s what the findings suggest happened. The fact that LARC claims started to grow again after the first quarter of 2014 suggests women may have started finding other providers who participate TWHP and could provide them with IUDs, but these providers may now have long waiting lists. It’s likely that many of the women who’d like to get IUDs but are now finding them less accessible used or are ares still using less-effective forms of contraception.

Another highly effective form of contraception is injectable contraception, which has a failure rate of 6% (compared to 9% for birth-control pills and 18% for male condoms). Women who rely on injections for birth control have to get them reliably every three months; the failure rate is as high as it is because not all users are able to do this.

Before the policy change, the study authors found that 57% of the women received injectable contraceptives in counties with Planned Parenthood affiliates returned on time for subsequent injections, as did 55% of those in non-Planned Parenthood counties. After Texas began excluding Planned Parenthood clinics from its program, they found that the percentage of women in counties with Planned Parenthood affiliates who returned on time for injectable contraceptives dropped from 57% to 38%, and then remained relatively stable for the next two years. In the counties without Planned Parenthood affiliates, which were likely less affected by the policy change, the percent of women returning on time increased from 55% to 59% and remained stable.

Stevenson and her colleagues also found the percentage of births covered by Medicaid (i.e., to women who’d be eligible for TWHP) for the women who’d received injectible contraceptives increased in the counties with Planned Parenthood affiliates but decreased in the counties without Planned Parenthood affiliates. The authors point out that they have no information on whether these pregnancies were intended or not. However, I find a widespread reduction in access to more-effective contraception in the first group of counties, and substitution of less-effective methods, to be a far more compelling explanation for the difference in births between the two groups. The alternative would be that lower-income women in counties with Planned Parenthood clinics suddenly experienced a stronger and much more immediate desire to have children than their counterparts in other counties.

As the authors of this study point out, Texas is not the only state where officials want to exclude Planned Parenthood affiliates and other providers from family-planning programs. I hope elected officials acknowledge these research findings and realize that short-sighted policies like the one in Texas have serious consequences for women’s health.