Thousands of advocates have flooded the federal government with comments this week, weighing in on whether it should reverse an Obama-era decision to strip Texas of millions in federal funding for a health care program that excludes abortion providers and their affiliates.

The number of comments to the Centers for Medicare & Medicaid Services on Texas' request has doubled in recent days, from 9,000 earlier this week to over 18,000 as of Friday afternoon, hours before the public comment period ends. The deadline comes as a new report from the left-leaning Center for Public Policy Priorities suggests the state's decision to exclude Planned Parenthood from the program was responsible for stripping health care access from 45,000 women.

The federal government has historically declined to give Medicaid funding to states that don’t allow patients to choose between “any willing provider.” In 2011, Texas ousted abortion providers from the Medicaid Women's Health Program, which the Obama administration argued violated federal law, leading to an end to federal funds.

But with Republicans in control of the White House and both chambers of Congress, Texas is “asking the same question ... but hoping that it will get a different answer,” the report says.

An affirmative answer would inject more than $400 million in federal funding over five years into a program that has crippled family planning services for low-income Texas women, according to Stacey Pogue, who examined five years of state health data to author the new CPPP report.

Commenting closes at 11 p.m. Friday, and then the request goes to the federal Centers for Medicare and Medicaid Services for review. Texas has proposed an effective federal funding date of Sept. 1, 2018.

After Texas exited the Medicaid Women's Health program, the state launched its own women's health program, which is now called Healthy Texas Women. Under the program, low-income women ages 18 to 44 are eligible for services including pregnancy testing, STD testing, breast and cervical cancer screenings, contraceptive counseling, postpartum depression screenings, as well as help with chronic diseases like diabetes, high blood pressure and high cholesterol. Fifteen- to 17-year-olds are also eligible if a parent signs them up. The program does not offer abortion services.

Since excluding Planned Parenthood — which was by far the biggest provider in the state — the state has enrolled thousands of new providers to fill in the gaps. But these new providers, on average, provide care to far fewer women; even after adding 3,695 providers between fiscal years 2010 and 2016, the state served 36,375 fewer women, according to Pogue’s report.

Pogue said data from 2011–2016 make it clear that excluding Planned Parenthood has hurt women's health in Texas.

“There are two paths you can take, and you can’t have it both ways: You can either exclude providers that are tested and efficient, fundamental pieces of the safety net, or you can expand services to family planning,” Pogue said. “But you can’t do both. They are in direct conflict.”

Joe Pojman, the executive director of Texas Alliance for Life, an anti-abortion group, called the post-2011 approach "a successful program," arguing that the thousands of new providers the state has brought on since excluding Planned Parenthood provide more comprehensive and preventive primary care.

“I think low-income women in Texas deserve better care than Planned Parenthood is willing or able to offer,” Pojman said.

But the CPPP report counters that quality of service has declined even for the women who are enrolled in Medicaid family planning programs. In fiscal year 2016, one in four women enrolled in the program was never seen by a health care provider for covered services; before Planned Parenthood was excluded, that number was one in 10.

State officials have maintained that they have no plans to change their current approach on the program. But the Trump administration's decision could change the funding stream. If the federal government denies Texas’ request, the state is likely to continue funding programs at the same level.



“The access to health care — those harms have already been felt,” Pogue said. “The waiver question is about the appropriations line that says Healthy Texas Women — is it federal or state dollars?”

At stake is the precedent the federal government could set for other states.

If federal officials approve Texas’ request — while still allowing the state to exclude abortion providers — other states could feel emboldened to pursue similar strategies. Two other states, Iowa and Missouri, have already forgone federal money in order to exclude Planned Parenthood; they would likely follow Texas’ example and continue those exclusions with health programs that would be backed by federal dollars.

Dozens of other states that have made similar efforts to defund Planned Parenthood — but were unable or unwilling to forego federal Medicaid money — could follow Texas' lead as well.

“If the Trump administration bends the rules here, then we could see even more diminished access to care, by essentially granting funds for a program that doesn’t work and allowing that to be an example for the rest of the country,” said Yvonne Gutierrez, the executive director of Planned Parenthood Texas Votes.

Disclosure: The Center for Public Policy Priorities and Planned Parenthood have been financial supporters of The Texas Tribune. A complete list of Tribune donors and sponsors is available here.