AUSTIN — Texas’ overhaul of family planning programs has left teens in the state with fewer options to get contraception without parental consent, according to a new study in the peer-reviewed Journal of Adolescent Health.

The study documents how publicly funded family planning providers struggled to provide teens with confidential access to contraception after Texas cut the state family planning budget in 2011 and excluded Planned Parenthood from funding.

“The loss of Title X funds meant that clinics had to suddenly start requiring parental consent or send adolescent clients elsewhere,” said Kate Coleman-Minahan, lead author and a University of Colorado College of Nursing assistant professor.

The researchers say Texas offers a case study of the obstacles new federal Title X funding regulations could pose for providers across the country. Among other changes, the new regulations require family planning services to be physically separated from abortion services.

“Our research from Texas foreshadows the potential negative impact that the recently implemented Title X regulations will have on teens’ abilities to receive high-quality sexual and reproductive services,” said study co-author Kari White, principal investigator of the Texas Policy Evaluation Project and an associate professor of the University of Texas at Austin.

Texas’ family planning overhaul

During the 2011 legislative session, Texas lawmakers cut the state’s $111 million family planning services budget for 2012 and 2013 by two-thirds.

The State Department of Health and Human Services redistributed the remaining budget funds, most from federal Title X grants meant to help low-income individuals access family planning services, to providers through a tiered system.

But the system favored federally qualified health centers, public health departments and primary care organizations over specialized family planning providers such as Planned Parenthood.

The researchers conducted three waves of interviews with administrators at 47 family planning organizations from 2012 to 2015 to analyze the impact of these changes.

They found 34 organizations had received Title X funding before 2013, and 79% of those organizations lost funding during the study.

“This was all in an effort to exclude Planned Parenthood from public funding,” Coleman-Minahan said. “So what happened was, because of the restructuring, by 2013 there were only half as many Title X funded organizations in Texas.”

As a result of lost Title X funding, many family planning providers struggled to serve teens seeking contraception without consent from their parents, according to the study.

Teens don’t have to abide by Texas’ parental consent requirement if they go to a Title X clinic or are on Medicaid. Teens on Children’s Health Insurance Program can’t access contraception through the program under state policy. So the availability of confidential contraception varied by organization and often depended on teens’ insurance coverage, the study found.

Interviewed providers told researchers they saw a decrease in teen clients and reported hardships providing affordable care and confusion about when parental consent was needed. Most organizations continued to offer confidential testing for pregnancy and sexually transmitted infections.

“It seems like there was confusion in the community, which can definitely affect teens and their families’ access to care because they don't know what care they can get where,” Coleman-Minahan said.

One clinical director at a state-funded public health department told researchers they lost “over 1,000 clients” when the changes went into effect.

“We had hundreds of teenagers and they just disappeared. Because for us to be able to give them their birth control refills, we had to have their parents come in and sign for them, and they wouldn't do it,” the director is quoted saying in the study.

In 2013, the federal government awarded control of Title X grants to the Women’s Health and Family Planning Association of Texas instead of the state government, circumventing the state ban on giving funding to Planned Parenthood or its affiliates.

Kami Geoffray, the chief executive officer of the association, said the association saw many of the difficulties described in the study when the it began administering the Title X grants.

“We found, much like the study, that the care that was being offered was not as efficient, not as timely,” she said. “We worked really hard to not only provide funding, which we do, but also to provide training and technical assistance to improve the quality of care and ensure the care was client-centered.”

After the association took over, the number of teens served doubled from 15,000 in fiscal 2014 to 29,000 in fiscal 2018, Geoffray said.

The state also created three new state-funded family planning programs, including one that covered teens. But the organizations under these state programs had to follow parental consent requirements, according to the study.

So the number of places where teens can get confidential access to contraception remains lower than before 2011, Coleman-Minahan said, pointing to a 2015 study from the Texas Policy Evaluation Project that found 25% of family planning clinics in Texas closed after 2011.

“There’s been a lot of effort … to expand services to teens to try to fill those gaps,” she said. “But we don’t believe that gap has been filled.”

Federal overhaul implications

Last March, the Trump administration finalized new Title X regulations. Under the new rules, Title X projects can no longer provide abortion referrals and must refer all pregnant women to prenatal care, according to the Kaiser Family Foundation.

Clinics are also now required to be physically separated from abortion services and grantees, a move advocates say is meant to target Planned Parenthood. Previously, only the financial separation of abortion and family planning services had been required.

The rules still allow teens to access confidential contraception services, but providers now are required to document attempts to encourage family participation in the teens’ health care, Coleman-Minahan said.

This has led to confusion and cost some providers’ their Title X funds, she added. The changes likely led roughly one-quarter of service sites across the country to leave the Title X network, according to a February estimate from the Guttmacher Institute, a progressive reproductive health research and policy organization.

Now, providers in states with parental consent laws could face similar difficulties serving teens as those described by Texas providers in the study, Coleman-Minahan said.

“We saw the lack of access to care for teens, a lot of frustration and distress by providers, a lot of confusion,” she said.

Correction on Feb. 24, 2020, 12:05 p.m.: A previous version of this story incorrectly said Kate Coleman-Minahan is an assistant professor at the University of Colorado at Boulder instead of the University of Colorado College of Nursing.