On April 1, following several hours of intense floor debate in the Texas House on a string of budget amendments seeking to reallocate funds designated to provide basic women's health care services, the dust was settling. Conservative Republicans claimed victory: Seven amendments had successfully stripped from the roughly $99 million pot almost $62 million intended to fulfill the state's commitment to provide family-planning and reproductive health services for thousands of low-income, uninsured women. Meanwhile, another successful amendment enacted a funding matrix designating to which health care providers, and in what order, the remaining funds would be allocated – a move designed specifically to yank public funds from Planned Parenthood.

Foes of reproductive choice with the statewide group Texas Right to Life were quick to post to the group's website a self-congratulatory statement taking credit for dismantling the state's family-planning program: "Texas Right to Life removes $61M tax funds from abortion industry!" proclaimed the headline. Indeed, says TRL's Elizabeth Graham, her organization helped lawmakers orchestrate a strategy to strip the family-planning program of as much of its federal funding as is legally allowable. "Spearheading [that effort] means that members [of the Legislature] had come to Texas Right to Life asking about family-planning revenue and how to take money away from abortion," she said during a recent interview, and "to redirect the funds to more deserving and more worthy" programs.

With a $27 billion state budget deficit for existing services, there's no shortage of underfunded programs, and some of the programs to which the family planning funds were diverted are certainly worthy – one amendment moved funds to mental health care for children, for example, while another diverted funds to services for children with multiple disabilities. Yet conservative opponents of family planning, including TRL and the amendment sponsors, refuse to acknowledge that none of the federal money that the state has traditionally used to fund women's reproductive health care is used to fund abortion services. Federal law expressly prohibits using the funds for that purpose.

Instead, the funds used for family planning provide low-income women with guaranteed access to very basic health services – including annual gynecological exams, counseling on pregnancy planning and access to birth control, screening for breast and cervical cancers, testing for hypertension and tuberculosis, and screening for sexually transmitted infections, including HIV. Taken together, these preventative services make up what is commonly referred to as a "well-woman check": For hundreds of thousands of Texas women, the services provided with these funds represent their only regular and reliable access to medical care. Not surprisingly, therefore, advocates for women's health care viewed the debate somberly. "Devastating," said Fran Hagerty, CEO of the Women's Health and Family Plan­ning Association of Texas, a group that represents a diverse mix of 58 family-planning providers across Texas. "There will be very quick consequences for the state," she says – including increased costs for unplanned pregnancies, costlier cancer treatments begun in later stages of disease, and, ironically, a likely increase in the number of abortions.

The facts about what the federal money actually pays for – and the long-term risks and costs of failing to fund these preventative health services – have not prevented anti-abortion lawmakers and advocates from alleging that the opposite is true. Some simply ignore the facts (TRL insists that family-planning funds are merely "blood money"), while others draw a direct line from family-planning funding to abortion via their favorite target, Planned Parenthood. In fact, the vast majority of the 90-year-old nonprofit's services are dedicated to preventative health care, and less than 5% of its Texas operations – not supported by government funds – involve legally protected abortion services.

That remains too much for these staunch defenders of "life." For years, Texas lawmakers have declared that they would love nothing more than to defund Planned Parenthood entirely – regardless of the effect that would have on the larger women's health care network – and this year, with a GOP supermajority at the Capitol, the rhetoric has been ratcheted up. The assault on family-planning funding in Texas is just one symptom of this singular focus nationwide. In Washington, D.C., GOP lawmakers recently tried and failed to ram through a budget amendment authored by Indiana Rep. Mike Pence to ban Planned Parenthood from getting any federal funding for any purpose whatsoever; they're not about to quit the fight. Concurrently, conservative lawmakers propose cutting all funding for teen pregnancy prevention programs and for Title X, the 41-year-old source of revenue dedicated to women's reproductive health services – and the one pot of money that Texas lawmakers are powerless to divert to other programs. "They are going after women's health," said Cecile Richards, president of the Planned Parenthood Federation of America, during a February press call. "This is the most extreme assault on [women] in decades. They want to eliminate vital health care for more than 5 million American women" served by Planned Parenthood, including 3 million women its clinics serve nationwide using Title X funds.

The Texas Senate has yet to debate its somewhat less draconian budget draft, but whatever the differences between the chambers that remain to be hashed out before final passage, it is clear that thousands of low-income and uninsured women will have little or no access to health care for at least the next two years. Amid all the supposedly high-minded and abstract debate about "where life begins," one overwhelming reality is all too easily ignored: What is misleadingly described as defunding "the abortion industry" is in fact the wholesale shredding of the health care safety net for women, in Texas and the U.S.

The Financial Shell Game

In Texas, attacks on funding for women's health care are nothing new, and the specific attacks on Planned Parenthood are as old as the organization itself. "No question. Planned Parenthood has been around for 90 years; from day one we've had a handful of folks who didn't think birth control should be legal," says Sarah Wheat, vice president of communications for Planned Parenthood of the Texas Capital Region. Those attacks have come from foes of birth control, of equal treatment for women, from those opposed to nonprocreative sex of any kind, and simply from opponents of abortion. "We believe that women's health is important and that women and families are healthier when pregnancies are planned and spaced," Wheat says. "Health care should be just as accessible and affordable for low-income women as it is for the rest." Planned Parenthood takes that commitment seriously, and over time it has come to be the nation's leading provider of reproductive health care for women. At one time or another, 20% of women nationwide have used Planned Parenthood's services; currently, the organization operates more than 800 clinics across the country, performs a million Pap tests and more than 800,000 breast exams each year (both critical to the early detection of cancer), and provides nearly 4 million tests and treatments for sexually transmitted infections. These preventative services, combined with dispensing birth control to more than 2.5 million women annually, help each year to prevent more than 600,000 unplanned pregnancies, according to PP statistics. Accord­ing to the federal government, $1 invested in family-planning services saves taxpayers nearly $4 in other health care costs.

In 2010 alone, more than 260,000 Texas women, men, and teens were served by the state's 81 PP clinics; more than 120,000 were screened for cervical and breast cancers, and more than 380,000 received testing and treatment for STIs. In 2010, more than a quarter of PP's Texas patients were low-income women served by the state's pass-through of federal funding, including from the state's pot of Title X funds.

Planned Parenthood is not the only provider of health care to low-income Texas women. Each year, some 78 contractors across Texas (funding roughly 286 providers) receive federal funds allocated by the state to provide this basic care. In fiscal year 2010, these providers used roughly $47.6 million in funds to provide basic health care to a total of 257,895 low-income clients. Of these groups, the public providers saw the most clients at just more than 86,000 – 37% of all low-income reproductive health clients served with these funds – but, at $219, these groups' cost per client was higher than that of Planned Parenthood. The other contractors include city and county health departments, hospitals, community health centers (like Austin's People's Com­mun­ity Clinic), stand-alone family planning clinics, and federally qualified health centers. However, Planned Parenthood's long institutional history has allowed the organization to hone its delivery of preventative reproductive health care to women across the country and in Texas, making it uniquely able to provide services in a cost-effective manner in even the most isolated communities. Last year, PP clinics in Texas used federal funds to see more than 73,000 patients at an average cost of just $168 per client.

These economic realities haven't prevented lawmakers from trying to find a way to defund Planned Parenthood. Before this session, the last major attack came in the 2005 legislative session, in a budget rider authored by Sen. Robert Deuell, R-Greenville. Deuell walks an interesting line on women's health care; he's a doctor, and neither the benefits of preventative care nor the unique needs of women are lost on him. Deuell is openly hostile toward PP, though his explicit reasoning is supposedly magnanimous. Planned Parenthood's services are limited and occupy a niche, he argues, and the state should focus its limited health care dollars on first funding more comprehensive medical providers, namely federally qualified health centers. These FQHCs aim to serve any and all indigent clients in need of a "medical home," serving as a portal for care for a variety of health services – such as mental health and dental care – in addition to reproductive health care.

Lawmakers approved the Deuell rider, directing the Department of State Health Services to direct $10 million each year from the state's family-planning money first to fund FQHCs before allocating the remaining money to the rest of state's providers, including PP clinics. This would seem to make sense – providing low-income patients a single point of entry for medical care is not a bad thing. In practice, however, it hasn't helped to expand access to care. For starters, there are fewer than 70 FQHCs across the state, and because they aim to address so many different health issues for a needy population, many of them are already bursting with patients.

The rider took effect beginning with the 2006 funding cycle, and the consequences were immediate: That year alone, more than 41,000 fewer women were provided with reproductive health care funded by three main pots of federal money – Title V (the Maternal & Child Health Block Grant), Title XX (the Social Services Block Grant), and Title X; together, the three provide services for women not eligible for Medicaid. In the following year, more than 28,000 women lost services, according to Hagerty of the Women's Health and Family Planning Assoc­ia­tion of Texas, who regularly compiles statistics and crunches numbers provided by DSHS and the Health and Human Services Commission that pertain to women's health care.

The FQHCs simply could not absorb the clients who were hemorrhaged from the more traditional family-planning providers that lost funding because of the FQHC allocation. And the FQHCs that have received funding have not been able to spend all of it, each year returning a significant amount of money to the state for reallocation. And though the 26 FQHCs that are now receiving funding for these services have steadily increased the amount of money they're using, their average cost per client is $225, so they're still not picking up as nearly as many clients as have lost care since the imposition of the Deuell funding scheme. In 2010, FQHCs saw just 13% of clients for reproductive health funded by family-planning dollars, according to DSHS numbers.

In short, say health care advocates – if the intention was indeed to improve access to health care – the Deuell plan hasn't worked out so well. Put simply, says Randall Ellis, senior director of government relations for the well-respected Houston FQHC Legacy Com­munity Health Services, it takes the entire spectrum of providers, including Planned Parenthood, to meet the needs of the growing population of low-income people without access to reproductive and other basic health care services. "We work in conjunction with Planned Parenthood for family-planning and HIV services. We do referrals back and forth, so that people can receive services in the setting that they're most comfortable in," he said. "These family-planning providers, providers that specialize in family-planning services, provide these services in a much more cost-effective manner than do the other [providers] without the know-how – much more [cost-effectively] than Legacy or the other FQHCs ... that don't have the background" or expertise in providing reproductive health care.

The Road to Hell ...

These facts on the ground have done nothing to prompt lawmakers to reconsider the allocation scheme – and things are about to get worse. While Deuell's approach might be well-intended and based on his medical experience, the same cannot be said of most of the folks who have jumped on the funding-scheme train. Those include prominent foes of abortion, most without medical background or health care expertise, whose primary objective reflects no desire to see that as many low-income women as possible have access to basic health care but only that Planned Parenthood be defunded as the visible incarnation of "the abortion industry."

During testimony at a House Human Ser­vices Committee hearing last month, Joe Pojman, executive director of Austin-based Texas Alliance for Life, argued passionately that defunding PP would open up the doors to other providers – FQHCs and actual private physicians who accept Medicaid – to serve women. "These are where our tax dollars should be spent," he told the committee. "Don't women in Texas deserve better care? If Planned Parenthood in Texas was defunded ... those women will be far better off because they would [be given] a medical home."

The rallying cry of Pojman and others – dismissing the reality of how the funding is actually being allocated – has been bolstered this year by the addition of a charismatic new voice. Abby Johnson, former director of a PP clinic in Bryan, Texas, left that job and joined the pro-life movement, she says, after she witnessed during an ultrasound-guided abortion procedure a fetus struggle not to be terminated. Johnson is young, charming, and well-spoken – although there are serious questions about the veracity of her tale. She blames Planned Parent­hood for trying to discredit her. "The holes in the story don't come from me," she insists. Johnson has been embraced by pro-lifers who see PP as an especially nefarious evildoer, simply a portal through which the stated goal of providing health care is in fact secondary to somehow enticing women facing unplanned pregnancies into abortion.

Johnson promotes that notion. At least half of the women in her clinic seeking abortion care had been using contraception when they got pregnant; therefore, she claims, Planned Parenthood may be good at providing birth control "to the masses" but not at providing good contraceptive and related education. "That's a pretty significant problem. Their health education is promoting sex without consequences, which ultimately is what abortion is really about," she says.

Johnson also argues that if Planned Parent­hood is taken out of the funding mix, plenty of providers will pick up the slack. Asked about the experiences of the last few years under the Deuell rider, Johnson responds that it simply doesn't go far enough. The problem, she argues, is that under Deuell's rider, PP remains eligible for some funding, and thus is still siphoning funds away from other providers – additional FQHCs and public health entities, for example, that might otherwise be able to provide more comprehensive services, including reproductive health care. "So I'm not concerned about where these women could go," she says. "It's not just FQHCs; it's rural health services, community hospitals. There are 10 to 20 times the number of places that women could go" for care. Johnson says that while "you can't deny" that PP does provide health care to low-income women, those services are too limited in scope to be an appropriate recipient of tax dollars. "What I try to reiterate is that while they are providing those good services, they're also providing more than 320,000 abortions each year" in the U.S., she says.

Johnson insists that she's "not a hardcore conservative" and that she isn't just "pro-life. I say, I'm 'pro-quality-of-life.' I am for social programs," she says. "It doesn't just stop at birth for me. ... Women, men, and children should get health care that they deserve and that they need." So while she supports defunding Planned Parenthood, she's against any move to take money away from providing reproductive health care to low-income people – such as the proposal in Congress to eliminate Title X. "I am not for any kind of restrictions on funding that would take away money from women who need services. I don't want tax money to go to clinics that perform abortion services," she says. "But I am not in any way in favor of taking money away from health services."

Making More Abortions

Unfortunately, despite Johnson's demurrals, defunding health care is in actual fact the current plan in Texas. Under the seven budget amendments passed this month in the Texas House, there will be very little left to fund reproductive health services at all. In the effort to attack Planned Parenthood, lawmakers have thrown the proverbial baby out with the bathwater. The amendments strip nearly $62 million over the biennium from family planning – moving virtually all Title V and Title XX money to other "strategies," each move presumably allowable under federal law. What is left is only the biennial funds allocated for Title X, money that lawmakers could not redirect from reproductive health services. In all, there's roughly $38 million left for two years.

With the Deuell rider still in effect, that means there's $18 million over the biennium – just $9 million per year – to provide money to more than 50 non-FQHC contractors currently serving more than 227,000 women. Since 2005, those providers have had access to between roughly $35 million and $40 million a year to provide services to these women – who are but a fraction of the hundreds of thousands of women who actually need services in Texas; with Texas' dubious claim to fame as the state with the highest percentage of uninsured people (about 26% in 2009, according to the Kaiser Family Foun­da­tion), the number of Texas women in need of reproductive health care is roughly 1.5 million, according to the Guttmacher Institute.

Moreover, in an attempt to deliver a death blow to PP, conservative lawmakers also approved an eighth amendment, authored by Rep. Warren Chisum, R-Pampa, that expands the 2005 Deuell funding rider by spelling out how the remaining $9 million per year should be allocated. First, the money would go to "public entities" that provide family planning, including community clinics and county and city health departments; second in line would be "non-public entities" that provide "comprehensive primary and preventative care" in addition to reproductive health services; third, whatever is left – and the presumption, of course, is that there won't be anything left – would go to "non-public entities" that provide only reproductive health care, including Planned Parenthood.

Texas Right to Life's Graham was nearly giddy about the amendment in a posting to the TRL website: "[T]he final amendment earned 113 votes to snatch the last $9 million!" she wrote. In an interview with the Texas Tribune prior to the debate, Rep. Sid Mil­ler, R-Stephenville (author of the ultrasound-before-abortion bill the House passed in March), foreshadowed the floor debate: "I would say [Planned Parenthood will] have a tough time getting any government funds, state funds," he said. "The state of Texas is not interested in proliferating the abortion business. ... I don't see that the Legislature views [reproductive health care and abortion] as two separate entities." Miller's bland assurances, of course, are willfully blind to the reality that when you reduce the availability of reproductive health care, you inevitably increase the number of abortions – including more dangerously unsafe abortions, at that.

While that may not be how Miller and his colleagues see things, that is exactly what most health care providers know. They are now facing the reality that there won't be enough money for anyone to provide the kind of basic health care and family planning for women and men that actually prevents unintended pregnancy – and abortion – and provides early detection of cancer and other chronic diseases. "At the end of the day, this is so not about abortion," says Planned Parent­hood's Wheat. "It's about whether low-income women in Texas have access to the health care that other Texans do. At heart, that's what this is about, but it's not what you see being addressed. Where do ... women who came to us for cervical cancer screenings go? What's the victory? If those cervical cancer tests are no longer provided, that's not a victory for anybody," she continues. "This idea that 'we really want to best serve women and are going to do that by shutting down clinics.' ... Con­grat­ulations, you just closed off access to hundreds of thousands of Texans. But you're not reducing the likelihood of unintended pregnancies."

Indeed, research reflects exactly the opposite result. In the absence of access to reproductive health care in Texas, the Guttmacher Institute reports, the level of abortion would be expected to rise 22%. (In 2008, the most recent year for which statistics are available, DSHS recorded a total of 78,330 abortions performed on Texas women. A majority of those women reported that they had already given birth to at least one child, and for the majority of women it was their first abortion.)

The War on Women

Obviously, with a reduction in funds as drastic as that approved by the House, not only Planned Parenthood will be hurt. Every­one will suffer – but those most hurt will be low-income women cut off from health services. There's no way to sugarcoat it, says Hagerty; with these cuts, providers will disappear – as indeed happened after the funding reduction in 2005. Clinics serving rural areas simply could not keep their doors open, and those providers have not reappeared. When Hag­erty came on as head of the Women's Health and Family Planning Association of Texas, there were roughly 120 organizations contracting with the state to provide reproductive health care; as of last year, only 78 contractors remained. "The provider base is dwindling," she says. With this new round of cuts, the pool will shrink again – contrary to what advocates for reallocation say. "I don't know what we'll end up being left with – probably not much of anything," Hagerty says. In his interview with the Tribune, Miller brushed off the notion that women would be left without access to care. "I think you do that through educational opportunities, through these faith-based organizations, counseling, things like that," he said.

Regina Rogoff, CEO of Austin's venerable People's Community Clinic, which sees some 10,000 clients each year, says the cuts (and accompanying attitudes) send a very clear message. "If the cuts were somehow supposed to punish Planned Parenthood, this is definitely overkill," she says. "This is all part of the question of how women are treated in the health care system. When you're gutting programs that are particularly important to women, [you demonstrate] that women's health is not valued." Under Chisum's funding scheme, the People's Community Clinic would fall into the second tier of organizations eligible for funding – but with just $9 million left on the table according to the House budget, it isn't clear that there would be any money available for any of these providers. "There's no way around it: More women will go without cancer screenings and will need care at more costly stages of illness," she says. "There will be pregnancies – there's no way around that. It's not like this is going to save any money in the long run. ... They're not really thinking about the unintended consequences of their actions, even though they're pretty obvious."

The list of consequences – whether unintended or simply ignored – is a long and extremely costly one, including the price tag attached to unplanned pregnancies, which, for low-income women, the government eventually pays via Medicaid. Indeed, 56% of Texas births are paid for by Medicaid – one of the highest rates in the country. Texas also has the fourth highest rate of teen pregnancies, and the highest rate of repeat teen pregnancy; 10% of Texas' Medicaid births are to teen mothers. In 2009 alone, the Texas Medicaid program paid $2.7 billion in costs related to 162,916 births to low-income women.

Ironically, before the vote this month to defund reproductive health services, there had actually been some positive movement toward reducing these costs via the successful Women's Health Program. The WHP is a Medicaid-waiver program, meaning it enrolls women for reproductive health services who wouldn't otherwise be eligible for the program unless they were pregnant. The goal, of course, is to reduce unplanned Medicaid-paid births and to encourage birth spacing, which reduces health risks for both mother and baby. The WHP was created by legislation in 2005 as a five-year demonstration project, and, unless lawmakers re-up, it will expire this fall.

Yet according to a report on the program released last fall by the Health and Human Services Commission, the program saved Texas millions in Medicaid costs. The program is financially advantageous to Texas: For every $1 the state invests, the feds kick in $9. In 2008, the program reduced Medicaid births by more than 10,000 and netted more than $92 million in savings (of both federal and state money). For Texas, the program saved more than $40 million in expenses in just one year. The Legislative Budget Board has recommended not only that the program be renewed, but that it be expanded.

The WHP, which was implemented in 2007, has helped to bring back into services some of the clients lost as a result of the Deuell reallocation scheme of 2005. In the first year, nearly 59,000 women signed on; that number was up to more than 88,000 in 2009. Still, even with the WHP, the number of low-income women provided with basic health care via family-planning funding was down 29% from 2005. With the cuts to other family-planning funding, advocates hope that the WHP, a bright spot in an otherwise bleak landscape, will be both reauthorized and expanded.

Nevertheless, it is unclear what the program would look like after reauthorization. In response to a pair of related inquiries made last year by Deuell and HHSC Commissioner Tom Suehs, Attorney General Greg Abbott opined that the state could keep Planned Parenthood from providing any WHP services – by blocking Medicaid funds for any health care provider that's "affiliated" with an abortion care provider, even if it doesn't provide abortion services itself (see "Women's Health: Ideology First!," April 15). In 2009, Planned Parenthood clinics contracting with WHP served 41% of all program clients. If those providers are cut, it isn't clear what will be there to pick up the slack – and the progress made toward reducing Medicaid births and improving access to health services via the WHP may well be cut off at the knees.

Part of the issue is that Texas' Medicaid reimbursement rates are so low – they've been cut twice since September 2010 and are expected to be cut again this year – that they "deincentivize" providers from signing up to participate, says Hagerty. "Seventy-two percent of all WHP services are provided by family-planning [clinics], 14 percent is by physicians, and 7 percent is by FQHCs," she says. "You have to ask, why? The [doctors and FQHCs] that I know and have asked say that they lose money on every client they see. There is just no incentive for them to do this." Moreover, depending on how the new definition of "affiliate" shakes out, providers other than just Planned Parenthood could be blocked from seeing WHP clients, says Hagerty.

Notably, it is individual physicians – the very group Texas Alliance for Life claims it wants the funding to support – that could be cut out of the loop. The problem, says Hagerty, is that within some of the larger doctor groups, there are often individual physicians who will perform elective abortion, and that affiliation among a group of doctors could end up striking the whole batch from participation. In short, say many health care providers and advocates, the single-minded obsession with hurting PP threatens to dismantle the entire fabric of women's health care in the state. "It doesn't do anything good for anybody," says Hagerty. "The underlying theme is to defund Planned Parenthood. And that screws with the entire system."

Ironically, however, the all-out political assault on Planned Parenthood is unlikely to force the nonprofit to close its doors. For most PP clinics, the cuts will mean only that they will be unable to serve the most needy low-income clients. In Texas, for example, the PP provider that would be most in jeopardy of shuttering its operations as a result of the budget cuts is the Planned Parenthood Association of Hidalgo County. The client base for this Valley provider is almost entirely low-income; their clinics serve a whopping 23,000 clients each year. If its funding is cut, about 20,000 of those clients would lose health care, according to information provided by Hidalgo Planned Parenthood. And the clinics neither provide abortions, nor are they affiliated with any abortion provider. And Hidalgo is not the only one; any number of Hagerty's members are in the crosshairs, though many of them, like the Teen Health Clinic at the Baylor College of Medicine, also have no affiliation with abortion providers.

Exactly what will happen – and what the Senate will do with family-planning money in its version of the budget – is uncertain. It does seem that the breadth and nature of cuts championed by the House aren't sitting as easily with their colleagues in the other chamber – including even Deuell. "I don't care for Planned Parenthood, [but] I don't want to cut access to family planning. I don't want to decrease access," he told the Houston Chronicle earlier this month. "One way to stop abortions is to prevent unwanted pregnancies." And it appears that Sen. Jane Nelson, R-Flower Mound, agrees that funding for family planning should be restored to the budget. But whether the House's hard-line stance on women's health issues can be mitigated in conference committee remains to be seen.

Health care providers argue that lawmakers have to restore some sanity by cutting the gamesmanship that is toying with women's lives. "One of the important things to say is that these are irresponsible and costly cuts that will increase the amount of money we pay down the road in terms of Medicaid births and increased costs to other entitlement programs that Republicans are generally against," says Ellis of the Legacy Community Health Center FQHC in Houston. "As we're seeing with everything, shifting the costs down the road makes it more expensive later. This is what happens when politics gets ahead of good public policy."