Without Planned Parenthood, the new Texas Women’s Health Program (TWHP) has seen a 23 percent reduction in medical claims and thousands fewer Texans enrolled in the program in the first half of 2013 as compared to the same period last year, when the program was still the Medicaid Women’s Health Program. The state’s explanation? Women just don’t want to change doctors.
“We expected to see a drop off in the number of claims when we moved to the state program because we knew some women wouldn’t want to change doctors,” said Texas Health and Human Services Commission (HHSC) spokesperson Stephanie Goodman in a statement this week.
Goodman’s statement is at best glib and at worst a kind of victim-blaming that puts the responsibility for the state’s failure to provide low-cost reproductive health care squarely on the shoulders of the very people it is supposed to be serving.
The TWHP provides contraceptives and well-woman exams to low-income Texans. From 2007 to 2012, it operated as part of Medicaid, receiving a 90 percent federal match in funds and, at peak enrollment, saw almost 130,000 clients. But in 2012, the state kicked Planned Parenthood out of participating in the program because it considers the organization to be an abortion “affiliate” and thereby ineligible to provide health care using public funds in Texas. At that time, the federal government dropped its support of the program because the arbitrary exclusion of any qualified health provider from a Medicaid program is a violation of the Social Security Act, which dictates that Medicaid enrollees have a right to receive care from the physician of their choosing. To fund a program that denies Texans the ability to see the qualified doctor of their choice would, according to the Center for Medicaid Services, be a violation of its own law.
Undeterred, Texas launched a new, entirely state-funded Women’s Health Program in January of this year, and so far it has seen its service numbers plummet without the involvement of Planned Parenthood, which historically saw about half of all Women’s Health Program patients.
According to preliminary data provided by the Texas HHSC, current enrollment in TWHP is estimated to be about 97,000 clients, the lowest number of enrollees since September 2009, when the program was just two-and-a-half years old. This July, the TWHP counted over 10,000 fewer enrollees than it did in the same month last year. Add this to the fact that, according to the University of Texas’ Texas Policy Evaluation Project (TPEP), more than 60 family planning clinics in Texas—most of which were not Planned Parenthood facilities—have closed since 2011 due to family planning funding cuts, and it’s clear that there’s a serious, and growing, hole in Texas’ reproductive health safety net.
And yet the state says that if fewer and fewer low-income Texans are receiving publicly funded reproductive health care, it must be because women don’t want to change doctors. Considering the very real logistical, physical, and emotional challenges women face now that they have been forced by the state government to find new reproductive health providers, the HHSC’s statement seems an egregious simplification of a deeply complex and personal issue.
Amanda Stevenson, a TPEP researcher who studies the impact of family planning budget cuts on low-income Texans, told RH Reality Check that research shows changing doctors is not simply about personal preferences, but rather about the complex ways Texans choose their providers and the many factors that influence their decisions.
“There’s lots of other complexities that are hidden by [Goodman's] statement,” Stevenson said, citing spatial distribution and capacity of providers as just two factors that affect whether someone is able to switch to a new doctor. “Maybe you don’t want to go to a doctor who is 50 miles from you, but you also sort of can’t,” she said. “Preference is not the right framework for this.”
Stevenson said it’s important to consider that many patients choose dedicated family planning providers like Planned Parenthood not only because they are low- or no-cost under programs like the Women’s Health Program, but because they appreciate the confidentiality and specialization those clinics offer compared to primary care doctors or general practitioners.
“Women who had been choosing to receive care at Planned Parenthood affiliates under the old Women’s Health Program might have the low-cost part of their set of needs met by choosing a non-Planned Parenthood provider,” said Stevenson, “but the rest of the reasons they had for choosing their provider might not be met by the alternative providers.”
Despite the fact that family planning specialists provide the most cost-effective and reliable reproductive health care where public funds are concerned, the State of Texas has been pushing to include more primary care doctors and general practitioners in the Women’s Health Program to fill the gap left by Planned Parenthood’s ouster. And as part of the state’s plan to “restore” family planning funds that conservative and Republican legislators slashed by two-thirds in 2011, it has instituted a new “primary health-care expansion” that sends family planning dollars to primary care physicians, not specialty reproductive health-care providers, who are supposed to attempt to provide more family planning care as part of their general practices.
Whether state health services will actually hold doctors accountable to the proposed goal of dedicating 60 percent of their practices to family planning care remains to be seen. What is known now is that there are many reasons why Texans choose providers like Planned Parenthood, and many reasons why general practitioners are not always appropriate replacements for specialty care.
According to the Guttmacher Institute, specialized family planning providers are able to spend more one-on-one time talking to patients about their family planning needs than are more general primary care providers, and for patients without easy access to transportation or who have jobs with long hours and few opportunities to take time off, they can be a kind of one-stop shop for reproductive health needs:
Compared with sites offering comprehensive care, for example, specialized centers give women a wider choice of contraceptive methods and are more likely to offer the especially effective long-acting reversible methods, such as IUDs and implants. Also, they are more likely to provide methods on-site, rather than by writing a prescription that may require women to make multiple stops at pharmacies and health centers just to get their method.
Stevenson said there are also a number of “logistical barriers to changing providers” that affect both physicians and patients. Not every doctor’s office uses easily transferable electronic records. Spanish-speaking patients may be unable to find nearby doctors who can communicate with them easily. Many physicians may require new examinations and tests that have already been conducted at a patient’s original health-care provider.
“It’s not just travel and receiving the same level of care,” says Stevenson, “but money and time and visits. And if Texas has already paid [for a test or exam] one time, now they have to pay again.”
In light of all this, is it plausible that what has really stymied the Texas Women’s Health Program’s growth is a bunch of stubborn enrollees who selfishly refuse to switch doctors? Or might it be that a decimated funding system, 60-plus shuttered family planning clinics, and an overall statewide shortage of physicians have resulted in a safety net that cannot catch as many Texans as it did last year?
Asked if the HHSC really contends that the WHP’s declining enrollment and reduced number of medical claims has nothing to do with reduced access to health care in Texas, Stephanie Goodman reinforced her original statement: “We’re confident we’ve got the capacity to serve more women.”
But sheer capacity—if that capacity really exists at all, and I’m skeptical—does not necessarily meet geographic demands, if providers are not located in areas where need is greatest. Capacity does not automatically imply quality of care. Capacity does not guarantee confidentiality, or the availability of a full range of contraceptive options. In telling low-income Texans that state health providers have plenty of “capacity” as long as they’re not very picky about going to a doctor they may not trust or respect, the state is effectively saying that they ought to settle for whatever is available rather than the high-quality, affordable care they were receiving just last year at the provider of their choice.
It certainly isn’t the case that demand for affordable and publicly funded reproductive health care has decreased, says Amanda Stevenson: “There’s no reason to expect that the demand would go down, unless women just decided they wanted to have a lot more babies and just didn’t want to get the care they need to be healthy for that.”
When Texans are barred from seeing the doctors they have come to trust, and when there may be no alternate provider near them who provides the same level of care, respect, and confidentiality they value in a physician, it is not a matter of whether or not patients want to change providers. It is, more accurately, a matter of whether they are able to do so at all.