In late January, on the same day that the U.S. Supreme Court’s landmark Roe v. Wade decision marked its 47th anniversary, Texas got news from the federal government that it would be allowed to receive millions in Medicaid funding to support a family planning program that discriminates among providers — the same strategy that in recent years likely caused a rise in unintended pregnancies.

“The Lone Star State is once again in partnership with the federal government to provide meaningful family planning and health services while fostering a culture of life,” Gov. Greg Abbott said of the deal, which will make $350 million available to the state over the next five years. “This collaboration is a symbol of our commitment to championing the lives of Texas women.”

At issue is Texas’s long-standing quest to avail itself of federal taxpayer funds to provide contraceptives and basic reproductive care to low-income, uninsured women, while also barring those women from choosing to seek services at Planned Parenthood or other clinics the state believes “affiliate” with abortion providers.

Medicaid rules require that patients in the federal fee-for-service program be able to access care from any qualified and willing provider — a long-standing provision designed to ensure choice when it comes to family planning and gynecological services. Texas disapproves of that rule and for years has sought to have it waived. The federal government’s announcement on January 22 gave Texas that permission — and, advocates for women’s reproductive health care fear, may now provide an avenue for other states to follow Texas’s lead. The federal government has never before allowed the provider-of-choice rule to be waived for a family planning program.

“The bottom line here is that the government is once again putting ideology ahead of patient needs,” said Robin Summers, senior counsel and vice president of health care strategy and analysis for the National Family Planning and Reproductive Health Association. “You’re supposed to be focused on furthering patient access, improving patient health. And that just doesn’t seem to be what is at the top of the priority list right now.”

A Failed Experiment

Texas has the highest rate of uninsured people in the country: nearly 18 percent. Even more abysmal, nearly 26 percent of women of reproductive age are uninsured — more than double the national average. This problem is exacerbated by stringent Medicaid requirements; parental income above $302 per month is enough to render a family of three ineligible for the program. Not only has the state refused to expand Medicaid under the Affordable Care Act, but it is also leading the charge to have the ACA ruled unconstitutional.

The kind of Medicaid waiver program that the feds approved for Texas generally allows states to opt out of certain rules in favor of innovation in health care delivery. In the mid-2000s, Texas did just that when it asked to waive financial eligibility rules in order to expand access to reproductive health care for women not poor enough to qualify for Medicaid unless they were pregnant.

Known as the Women’s Health Program, the pilot got off the ground in 2007 and expanded rapidly. In 2008 alone, the program reduced the number of unintended pregnancies that Medicaid would have paid for by more than 10,000, saving taxpayers more than $92 million. By the end of 2011, nearly 130,000 clients had enrolled in the program, with 90 percent of them accessing services. It was a clear success.

Still, Republican state lawmakers were determined to defund Planned Parenthood from all state programs by any means necessary. At the time, Planned Parenthood was serving more than 40 percent of Women’s Health Program clients, making it the single largest provider. State lawmakers came up with a new rule that would bar any group “affiliated” with an abortion provider from participating in the program. The federal government balked and said that if the state did not remove the ban, it would not reauthorize federal funding for the waiver program.

So Texas pulled out of the federal deal, rebranded the Women’s Health Program, barred Planned Parenthood, and funded the program solely with state money. It hasn’t exactly worked out. The program, now known as Healthy Texas Women, floundered for years with enrollment steadily declining — down to an average monthly enrollment of 94,851 by fiscal year 2016. The state subsequently launched a concerted outreach campaign and enrollment increased, up to 244,153 in 2018. Still, the percentage of patients served has continued to lag; in 2018, roughly 70 percent of enrolled clients actually accessed services. This is at least in part due to the fact that while the state signed up thousands of potential providers after ousting Planned Parenthood — including individual doctors’ offices — a majority of them haven’t served any clients. In 2018, according to the state’s Health and Human Services Commission, just 10 percent of providers enrolled in the program billed for services provided.

Moreover, research from the Texas Policy Evaluation Project at the University of Texas’s Population Research Center found that after the state bounced Planned Parenthood (and other smaller providers) from the program, the number of women receiving long-acting reversible contraceptives — the most effective forms of birth control — decreased by 35 percent. The number of women receiving injectable contraceptives declined by 31 percent, while Medicaid-paid births among this cohort increased by 27 percent. In other words, the policy decisions made by Texas lawmakers likely increased the number of unintended pregnancies, one of the health outcomes the program aimed to reduce.