Texas policymakers are once again demonstrating their contempt for reproductive health care, the health care providers who offer those services, and the women who rely on them. The state has spent years crippling a once-successful program supporting family planning and related services for low-income residents—all in service of an ideological agenda to shut out and shut down health centers that have any connection to abortion services. Now, the state is asking the like-minded Trump administration to provide an infusion of federal funding to support its diminished program. In the process, Texas and the Trump administration could set dangerous new precedents that could undermine family planning care in Medicaid programs nationwide.

The Need for Publicly Funded Services

Publicly funded family planning services are especially important in a state like Texas, where women are particularly likely to be poor, uninsured, and at risk of an unintended pregnancy. Sixteen percent of Texas residents—4.3 million—were living below the federal poverty level in 2015; only 13 states and the District of Columbia had higher poverty rates.

In part because Texas policymakers have refused to expand Medicaid under the Affordable Care Act (ACA) and help the state’s most underserved residents, Texas has the highest proportion of residents who are uninsured in the country—for residents overall (16%) and for women of reproductive age specifically (24%).

Moreover, according to the most recent Guttmacher data, publicly funded health centers in the state only meet 10% of the need for publicly funded family planning services in Texas—tied with Nevada for the lowest proportion in the country.

Texas is also in bad company in terms of its unintended pregnancy rate: 56 per 1,000 women aged 15–44 in 2010 (the last year for which data are available); only eight states had higher unintended pregnancy rates.

A Counterproductive Policy Response

A decade ago, Texas joined about half the states in expanding Medicaid eligibility specifically for family planning services for low-income women not otherwise eligible for Medicaid. Like other states, Texas initiated this program as a joint state-federal effort.

In 2011, however, the state sought to reverse course: State policymakers—motivated by the goal of putting Planned Parenthood out of business in the state—moved to exclude health centers that either provide abortion or are associated with a provider that does. This decision conflicted with a long-standing provision in Medicaid law that guarantees enrollees’ ability to receive family planning services from any qualified provider. When the federal government refused to allow this unlawful discrimination against qualified providers, the state chose to forgo federal financial support for the program—losing $9 for every $1 dollar that the state would spend on family planning services.

As a result, since January 2013, Texas has operated this family planning program as an entirely state-funded, state-run effort—no longer part of Medicaid—that excludes many of the very safety-net providers most able to provide high-quality contraceptive care to large numbers of women. Although the state frequently notes this program is part of a broader effort intended to deliver women’s health services, its standalone performance continues to merit specific analysis, particularly since the state is now seeking federal buy-in.

Declining Access to Contraceptive Care

The state’s own data have provided ample evidence of how the reach and effectiveness of the program (currently operating under the name “Healthy Texas Women”) have drastically declined after becoming a state-funded family planning effort. The state has published two evaluations of the program’s performance since it was divorced from Medicaid—once for 2013 and again for 2015—and both showed a considerably less effective program compared to 2011, the program’s last year as a joint federal-state program. 

The state’s most recent analysis makes it clear that the program provided less access to family planning services in 2015 than it did in 2011. By excluding numerous safety-net health centers and relying primarily on private doctors, the state developed a provider network incapable of serving high volumes of family planning clients. In turn, the state reported a nearly 15% decrease in enrollees statewide over the four-year period, with most areas of the state showing significant drops in the percentage of women enrolled in the program.

Moreover, the state reports that claims or prescriptions specifically for contraceptive methods declined 41% from 2011 to 2015. This includes drastic declines in the number of enrollees obtaining oral contraceptives, injectable contraceptives, the contraceptive patch and ring, and condoms. Claims in 2015 for long acting contraceptive (LARC) methods, such as IUDs and implants, rose back to numbers on par with 2011; in its 2013 evaluation, the state had reported a precipitous drop.

Strangely, the 2015 report used different—and considerably lower—baseline counts of contraceptive claims from 2011 than were used in the 2013 report. If those earlier baseline numbers had been used, the reported declines in claims would have been even steeper for 2015. The state also, oddly, reported a massive increase in net state savings from the program—from $6 million in 2013 to $51 million in 2015—despite simultaneous declines in enrollment and contraceptive services.

Other reports have found that the state’s program has largely failed the Texas women in need of publicly funded family planning care. For instance, a recent analysis of state-published data by the Center for Public Policy Priorities in Austin found that, by 2016, 26% Texas women who the state reported as enrolled in the program had in fact never received health care services from a participating provider, up from only 10% in 2011, pointedly showing how access to care has declined drastically. The same publication also charts how the state’s addition of thousands more private practices and clinicians—who each serve very limited numbers of family planning clients—has been no match for the gap created by excluding Planned Parenthood health centers, which, on average, serve nearly 3,000 clients annually.

That finding aligns with estimates for the country as a whole. Recent analyses from the Guttmacher Institute and from Sara Rosenbaum and colleagues at the George Washington University show that it is simply unrealistic to demand that other health care providers, particularly federally qualified health centers, make up for the loss of Planned Parenthood from the family planning safety net.

Destructive New Precedents

Despite the failures of its current approach to publicly supported family planning services, Texas policymakers are not rethinking their decisions. In fact—with the federal government now controlled by like-minded conservatives under President Trump—Texas is seeking to reinstate federal funding for the state’s program without fixing its problems. Essentially, Texas wishes to maintain its program as is, but with an influx of federal Medicaid dollars to replace some of the state’s own current expenditures. The state is not providing any clear promise or path to expand the number of women served or improve the services covered.

If the Centers for Medicare and Medicaid Services (CMS) were to approve this waiver request, the federal government would be giving its imprimatur to a program that violates decades-old Medicaid policies. Most prominently, Texas is seeking permission to exclude otherwise-qualified family planning providers that offer or “promote” abortion services, or are affiliated with providers that do so. If CMS allows Texas to carry over this policy to a federally supported Medicaid program, it will be waiving a long-standing protection under Medicaid law—a protection that CMS has consistently upheld under prior administrations, including at Texas’ prior request in 2011.

Texas’ application to CMS also indicates the state is looking to apply an existing state policy that requires minors to obtain consent from a parent or guardian to obtain publicly funded family planning services. Under Texas’ proposal, a parent or legal guardian would have to apply to the program on behalf of a minor aged 15–17 and would have to give consent for any services provided. Parental consent has never been permitted for family planning services under Medicaid, with good reason: This would impose a severe barrier for teenagers, many of whom might forgo needed family planning services if they could not get them confidentially, but remain sexually active and at risk of unintended pregnancies and sexually transmitted infections. The state’s waiver application would carry over other problematic aspects of its current state-funded program, such as its ideological exclusion of coverage for emergency contraception.

In practice, if CMS approves this waiver request, the biggest impact would not be felt in Texas, where women have already been hurt by these policies. Rather, CMS would be setting new precedents that other states led by conservative policymakers would then seek to emulate. For example, Iowa and Missouri have followed Texas’ lead by giving up federal Medicaid dollars for their family planning expansion in order to exclude Planned Parenthood; both states would most likely again follow Texas in seeking to instate federal funding for these programs. In total, since mid-2015, at least 15 states have attempted to restrict Planned Parenthood and other providers with ties to abortion from participating in Medicaid. Federal courts and the previous federal administration prevented these restrictions from taking effect, but if the Texas waiver were approved, the floodgates would open to the detriment of millions nationwide.

This article was originally published by Health Affairs Blog.