It’s been four years since former Texas governor Rick Perry signed a budget that basically ended funding for clinics in Texas that are affiliated with abortions providers, specifically clinics like Planned Parenthood.
The organization, which had received federal funding under the Medicaid Women’s Health Program for roughly five years, was the state’s biggest women’s health care provider, accounting for 40 percent of the WHP’s family-planning services. But after a protracted battle, the state effectively shut off funding for any organizations linked to abortion providers, prompting the federal government to turn off its own spigot of money for the Medicaid Women’s Health Program. Turning down the $9-to-$1 federal match left Perry and the Lege responsible for filling a gap of nearly $40 million needed to keep low-income women from losing access to affordable health care.
The solution? Create the state-funded Texas Women’s Health Program, which was launched on January 1, 2013. In order to make sure this new program is functioning properly and doing its promised duty of serving women and saving money, the Texas Health and Human Services Commission is required to initiate a biennual report on its effects and progress. Last week the first report was released, and we now have some hard data on how the Texas WHP is working.
The introduction to the six-page report states that despite slashing the family-planning budget by two-thirds, “it is the full intent of the Legislature” to take corrective measures if the report finds a more than 10 percent reduction in women enrolled compared to 2011. The report found that roughly 188,000 Texas women were enrolled in the health program in 2013, compared to just over 200,000 in 2011, a 9.1 percent drop.
The decrease in enrollees isn’t shocking. It was long-ago predicted that the change in the program, when accompanied by the 2011 cuts to the state family-planning budget, would mean far fewer women in Texas would have access to health care. In her 2012 cover story for Texas Monthly, Mimi Swartz refers to the 2011 meeting of the Legislature as “the most aggressively anti-abortion and anti-contraception session in history.”
There are some surprising figures though. For example, every region in Texas saw a drop in the number of clients served (not enrolled, but actually served) by the WHP, except the Upper Rio Grande Valley, which saw an increase in clients served, from 3,804 in 2011 to 4,716 in 2013.
Amanda Stevenson, a graduate researcher with the Texas Policy Evaluation Project, attributes this anomolous uptick to a significant cut in family planning funding from the Department of State Health Services. The Rio Grande Valley it one of the most impoverished and highly uninsured regions in the country, and to make sure women in the area could continue being covered, providers looked elsewhere for funding. “Because clinics in the Rio Grande Valley were so hard hit by the DSHS family planning grant cuts in 2011, those ultra-dedicated providers turned to the Women’s Health Program to continue serving women,” Stevenson says. “They are very serious about doing a good job about providing these services to the women that need them in their communities.”
Another illuminating takeaway from the report is data on contraception claims, broken down by method of birth control:
When comparing to Fiscal Year 2011 we can see that, the claims for injections and condoms went up as a percentage of the total and claims for oral contraceptives went down as a percentage of total claims. It is important to note that this shift does not just reflect a change in utilization over time, but a shift from less effective methods (e.g., oral contraceptives) to very effective methods of contraception (e.g., LARCs and injectables).
This wording is tricky and somewhat misleading. While the proportions of claims per method shifted between 2011 and 2013, the overall number of claims decreased across the board by more than 50 percent. About 191,000 contraceptive claims were made in 2011 under the old Women’s Health Program; 88,000 claims were filed under the new, Texas-modified, Planned Parenthood-devoid program in 2013.
The sharp drop in oral contraceptive claims really illustrates how the loss of Planned Parenthood clinics made an impact on the WHP. In 2011 claims for the pill accounted for 31 percent of all contraceptive claims under the Women’s Health Program. In 2013 that percentage dropped to 16.8, a rapid decline that doesn’t jibe with the fact that oral contraceptives are still the most widely used form of birth control in the country. It would seem the dip is simply a matter of access. “Planned Parenthood administers a lot of oral contraceptives, and when you exclude a provider that provides more of a certain kind of method, that method is going to decrease,” Stevenson says.
So when the report highlights the small but encouraging shift from oral contraceptives to things like injections and IUDs, it doesn’t necessarily mean claims made for the pill decreased because women were switching to different methods because they could no longer go to Planned Parenthood under their health program. One can presume that some women stopped using birth control altogether or continued going to Planned Parenthood without filing a claim.
Stevenson adds that while the proportion of claims for Long-Acting Reversible Contraception—or LARC, which includes IUDs—increased among clients served by WHP, Texas women are still largely underserved when it comes to IUD access.
A study by Stevenson’s policy evaluation group surveyed 803 women postpartum in Austin and El Paso during 2012 and found that the expressed desire for LARC is greater than the ability to actually receive those methods of birth control, particularly among young, low-income, uninsured women. “We have found, through interviews with providers, that the availability of LARC in general at sources of care for publicly subsidized family planning in Texas has been going down,” Stevenson says.
The availability of those methods at publicly subsidized family planning clinics in Texas went down further after the 2013 introduction of WHP. To cope with the decreased state funding, clinics were forced to start limiting the types of birth control they offered—specifically options like IUDs, which carry high upfront costs.
Another purpose of the report is to outline savings and expenditures. According to the report, the monthly caseload average of 115,400 women costs the state $31.67 million. But the savings is harder to pin down, in part because the “lag of nine months for the realization of the births.” The report, however, does publish the health commission’s estimations:
The monthly caseload average in Fiscal Year 2013 of 115,440 women will represent a reduction of 8,359 births in Fiscal Year 2014. At an estimated cost of $11,193 per birth, HHSC estimates a total savings of $93.6 million for Medicaid. Of this total, $55.5 million are federal funds savings and $38.1 million in savings for the state.
Subtract that cost from the savings, and the commission estimates that the state will net $6.4 million.
But there’s still that gaping difference in the number of women enrolled in the two programs in 2011 and 2013. If those women are no longer being served and contraception claims are down across the board, could there be a substantial increase in publicly subsidized births? Stevenson predicts that that will be the case. When the final numbers are released, they will likely show a significant increase in Medicaid-funded birth costs compared to 2011. This prediction was also made back in 2011 by the Legislative Budget Board. They released a memo warning that reduction of family planning–related expenditures as proposed by legislation in HB 1 would lead to more than $200 million in Medicaid birth costs. The predicted cost to the state’s General Revenue fund, which now entirely funds the new Women’s Health Program, was more than $98 million.
Even though these numbers are only initial figures, they reveal a pretty significant decrease in the population served by the WHP. In response to these low numbers, the report says that the Texas Health and Human Services Commission “undertook corrective measures to expand client outreach,” including a “target[ed] mailing effort,” as required by the same piece of legislation that mandates they compile a biennual report.