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What Texas Tells Us About the Latest Threats to Women’s Health Care

New YorkerAugust 3, 2017Articles

Among the various chances that congressional Republicans have taken in their effort to repeal and replace Obamacare, one of the riskier moves involves the federal defunding of Planned Parenthood. In both the House and the Senate, replacement legislation has included a provision that would cut off all federal Medicaid payments to Planned Parenthood for one year. (The bill would also bar federal tax credits from being used to purchase private health plans that cover abortion.) The provision is reportedly included even in the so-called skinny repeal. The Senate parliamentarian has determined that the provision violates the Byrd rule, which states that a reconciliation bill can only address matters that affect the federal budget; if the anti-Planned Parenthood provision cannot be passed under reconciliation, it would require sixty votes to pass. Many observers expect Senate Republicans to rework the language in the bill so that it can stay in reconciliation. Ted Cruz, meanwhile, has suggested that the parliamentarian’s ruling can be ignored.

That Republicans have taken things this far is a testimony to just how important defunding Planned Parenthood has become to many of them. Planned Parenthood operates more than six hundred clinics across the country, and a majority of its patients have incomes that fall near or below the federal poverty level; the organization receives around forty per cent of its revenue from federal funding, mostly through Medicaid. Cutting off those payments would be a drastic change for women’s health care in this country. For a glimpse of just how drastic it would be, we can look to Texas, where state legislators have been systematically defunding and handicapping Planned Parenthood for years. Currently, the Texas legislature is in special session, and three more anti-abortion measures have already been passed. One of them prevents local and state government agencies from contracting in any way—including via lease agreements—with clinics that are affiliated with abortion providers. As with the federal provision attached to the repeal of Obamacare, Planned Parenthood is not mentioned by name in this Texas bill. And yet, as Texas senators acknowledged last Friday, the bill only affects Planned Parenthood. (Calls to multiple state senators who sponsored the bill were not returned.)

The campaign against Planned Parenthood in Texas kicked off in 2011, a point when, as Lawrence Wright noted recently in the magazine, the organization was serving sixty per cent of the health needs of low-income women in the state. In the 2011 legislative session, which Texas Monthly called “the most aggressively anti-abortion and anti-contraception session in history,” the state government cut family-planning spending by two-thirds and approved a budget that, starting in 2013, banned Planned Parenthood from participating in the state’s women’s-health program, now called Healthy Texas Women. Federal law requires that states allow Medicaid patients their choice of “any willing provider,” and so Texas had to give up a nine-to-one federal funding match. Millions of dollars in spending for women’s health care were turned away. Then, this past May, Texas asked the Trump Administration for that federal funding back—a request that, if approved, would signal to other states that Planned Parenthood can be banned from Medicaid family-planning programs at will and with no financial repercussions. According to the New England Journal of Medicine, sixteen additional states have already proposed or approved similar bans.

It’s possible that, even if Planned Parenthood is defunded at the federal level by current Republican efforts, funding might be restored by subsequent legislation. But Texas provides a startling example of how quickly the women’s-health landscape can be wrecked by a withdrawal of resources—and how lasting that wreckage can be. Within months of the family-planning budget getting slashed in Texas, more than sixty women’s-health clinics had closed. Such effects can take years to undo, even if laws are reversed. In 2016, the Supreme Court overturned a Texas law that had halved the number of abortion clinics in the state. Only two clinics have reopened. The sprawl of Texas is almost incomprehensible—it’s the same distance from Houston, my home town, to El Paso as it is from Houston to Kansas City—and that sprawl means that rural clinic closures bring immediate and catastrophic consequences for poor women and women without cars. Teen abortions and teen births have both been increasing in Texas since 2011, and the maternal mortality rate in Texas doubled from 2010 to 2014. It’s now 35.8 deaths per hundred thousand live births—the worst maternal mortality rate you can find in the developed world.

Last week, I spoke to Caroline Coyner-Such, a clinician who has been working in health care for forty-three years, twenty-seven of those at Planned Parenthood. She now works at a clinic in North Austin, one of three in the Austin area that collectively serve nearly nineteen thousand patients each year. “Twenty or thirty years ago,” she told me over the phone, “we saw mainly women under the age of thirty-five. These days, as Texas women lose access to other options, we’re seeing more women, and a wider range of women—preteens up to women in their fifties and sixties.” The previous day, a homeless patient had come in. The North Austin clinic provides well-woman exams, S.T.I. screenings, cervical-cancer screenings, breast-cancer screenings, and birth-control counselling, among other things. It does not provide abortion services, but the surgical center at the South Austin location, thirty minutes away, does.

As clinics in other areas have been forced to close, the Austin-area clinics have begun seeing more and more patients from farther away. “Yesterday, I saw a patient from Elgin, which is an hour away,” Coyner-Such said. “We see people from Killeen, which is another hour away. This means people have to take a whole day off from work to drive to Austin to get basic services—which often used to be available in their communities—and go back. We routinely send prescriptions out in a seventy-five-to-one-hundred-mile radius.” The Austin-area clinics have a base of private donors and local grants that they’ve been able to draw from as they’ve scrambled to replace public funding; small clinics often lack this piecemeal buffer, and rely more heavily on Title X, which is Planned Parenthood’s other federal funding source.

“People are fearful,” Coyner-Such told me. “The summer is usually lower in terms of patient numbers, but not this year.” The news is a constant presence in her workplace, she said, with patients showing up afraid that their insurance will be taken away, and with new regulations from the legislature rolling in. “We have to be constantly monitoring in order to know what we’re going to lose and what we have to recoup,” she said. “It takes a lot of effort to stay on top of—I can’t believe I’m even using this term, but—the fake news.” Patients are sometimes openly surprised that the clinic is clean and professional, or that Coyner-Such has specialty certifications. She knows the kind of campaigning she’s up against. “Years ago, I had a Planned Parenthood bumper sticker, and someone slashed my tires,” she said. “After that, I quit doing bumper stickers—it’s not worth the tire replacement.”

The Republican health-care legislation asks that the landscape of women’s care be reimagined without Planned Parenthood in it. But without Planned Parenthood that landscape, particularly for low-income women, scarcely exists. Pink billboards have gone up around Austin and other major cities in Texas advertising the Healthy Texas Women program, which does not provide abortion services and is explicitly intended to redirect patients from Planned Parenthood, yet sixty thousand fewer women are enrolled in the program than were enrolled in the Medicaid Women’s Health Program in 2011, before Planned Parenthood was excluded. Even setting aside the fact that comprehensive women’s health care necessitates the option of safe abortion—and that the Hyde Amendment has banned federal funding of abortion, with rare exceptions, since 1976—Planned Parenthood serves such a large portion of low-income women, and has done so for so long, that other clinics are logistically incapable of picking up the slack. “There is a real fear, if Texas continues along this line, if they continue to downgrade our funding—where will these women go?” Coyner-Such said. “Will they wait six months for an appointment at another clinic? Or will they be pregnant because they aren’t able to access our services?” Then she excused herself, going back to the patients who awaited her.

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