Policy Paper

G O V E R N M E N T , L A W , A N D P U B L IC H E A L T H P R A C T IC E

The Impact of Reproductive Health Legislation on Family Planning Clinic Services in Texas Kari White, PhD, MPH, Kristine Hopkins, PhD, Abigail R. A. Aiken, MD, PhD, Amanda Stevenson, MA, Celia Hubert, MA, Daniel Grossman, MD, and Joseph E, Potter, PhD

W e examined the impact of legislation in Texas that dramat­ ically cut and restricted partici­ pation in the state's fa m ily planning program in 2011 us­ ing surveys and interviews with leaders at organizations that re­ ceived family planning funding.

Overall, 25% of fam ily plan­ ning clinics in Texas closed. In 2 0 1 1 ,7 1 % o f org an izatio n s w id e ly o ffe re d lo n g -a c tin g reversible contraception; in 2012- 2013, only 46% did so. Organi­ zations served 54% fewer clients than they had in the previous period. Specialized family plan­ ning providers, which were the targets of the legislation, expe­ rienced the largest reductions in services, but other agencies w ere also adversely affected.

The Texas experience pro­ vides valuable insight into the potential effects that legislation proposed in other states may have on low-income women's access to family planning ser­ vices. {Am J Public Health. 2015; 105:851-858. doi:10.2105/AJPH. 2014.302515)

PUBLICLY FUNDED FAMILY planning dinics have been a key component of the health care safety net for low-income women in the United States and will remain essen­ tial points of access under the Af­ fordable Care Act12 Title X, the federal program dedicated to family

planning provides crucial infrastruc­ tural support for a network of clinics and subsidizes the cost of family planning services for uninsured women In many states, Medicaid family planning waivers or state plan amendments constitute another source of support, and they reim­ burse clinics for services provided to eligible women. These programs can help fill gaps in coverage for those who lose other insurance because of changes in income or employment or other life events.3

However, the degree to which low-income women can rely on publicly funded providers for sub­ sidized family planning services has become increasingly dependent on policies enacted by state legislatures, which recently have taken on a large role in determining not only the amount of funding that goes to family planning but also the types of organizations that are eligible to receive i t Since 2010, several states have made significant cuts to their family planning budgets, and in 5 states, funding for family planning services was disproportionately re­ duced relative to other health pro­ grams.4 Additionally, since 2011, 16 states have proposed legislation that effectively blocks specialized family planning providers from re­ ceiving any public funding such as Title X or bars those that also pro­ vide abortion services from receiv­ ing funds, including Medicaid.5,6

This legislation may be aimed at defunding entities providing abor­ tion care, such as Planned Parent­ hood, even though federal dollars cannot be used to pay for abortions in almost all cases.

One o f the most striking exam­ ples of legislation affecting the de­ livery of publicly funded family planning services took place in Texas, which in 2011 both dra­ matically cut and restricted par­ ticipation in the state’s family planning program. W e examined the impact of the 2011 legislation on family planning providers in Texas. W e have reported on our findings from surveys and in-depth interviews with leaders at organizations across the state that received public funding before the legislation and our analysis of state administrative data. The Texas experience provides valuable in­ sight into the potential effects that legislation proposed in other states may have on low-income w om en’s access to family planning services.

FA M ILY PLANNING PR O G RA M S IN TEXAS, FISCAL YEAR 2 0 1 1

In fiscal year (FY) 2 0 1 1 (Sep­ tem ber 2 0 1 0 through August 2011), the Texas D epartm ent of State Health Services (DSHS) ad­ ministered $49.3 million in Title X funding and Title V (Maternal and

Child Health) and XX (Social Ser­ vices) federal block grants, which funded 7 2 organizations through­ out the state to provide family planning services to low-income populations. These organizations included public health depart­ ments, federally qualified health centers, Planned Parenthood affil­ iates, and other private nonprofit health centers. In F Y 2 0 1 1, 2 7 % of the 2 1 7 8 8 4 w omen served by these funds received care at Planned Parenthood health cen­ ters; an additional 13% of women obtained services from other spe­ cialized family planning agencies.

T he state Health and Human Services Commission also oper­ ated the W om en’s Health Pro­ gram (WHP), a Medicaid family planning waiver program that covered services for women aged 18 to 4 4 years with incomes o f up to 18 5 % of the federal poverty level, who had been legal US residents for at least 5 years. The waiver program served 119 08 3 w omen in F Y 2011, nearly half of whom received services at Planned Parenthood clinics.

LEGISLATIVE CHANGES, FISCAL YEARS 2 0 1 2 - 2 0 1 3

In the 2 011 session, Texas state legislators passed 3 measures that expanded on initiatives carried out

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in previous years to defund Planned Parenthood affiliates. First, the family planning budget was cut from $ 111.0 million per biennium to $37.9 million for the 2 0 1 2 - 2 0 1 3 budget period by diverting state and federal funds to other programs.7 T he remaining funds, most of which w ere Title X because the legislature could not reallocate those funds to other services, were combined into a single program that followed Title X regulations. Title X re­ quires organizations to provide confidential family planning ser­ vices to adolescents, thereby su­ perseding the state’s parental con­ sent requirem ent, and enables providers to offer services regard­ less of immigration status. Both of these are im portant exemptions in a state that has high rates of adolescent pregnancy and a large undocum ented immigrant popu­ lation.8,9 Receipt of Title X also enables organizations to partici­ pate in the 340B drug-pricing program through which they can purchase contraceptives at dis­ counts of 50°/o to 80% .

The second legislative measure allocated the remaining funds through a 3-tiered priority system in which public agencies providing family planning services (e.g., health departments) and federally qualified health centers were in the highest priority tier, tier 1, and specialized family planning pro­ viders were in the lowest tier, tier 3; the remaining agencies that provided comprehensive preven­ tive and primary care in addition to family planning were classified as tier 2.10 Finally, the legislature’s renewal of the WF1P, which was to expire on D ecem ber 31, 2011,

reauthorized the exclusion of or­ ganizations affiliated with abortion providers from the program and prom pted the Health and H uman Services Commission to adopt rules that would enforce the ban, which had not been implemented previously.11

T he first 2 measures w ent into effect on Septem ber 1, 2 0 1 1 . The DSHS immediately issued tempo­ rary funding extensions to all tier 1 organizations and temporarily funded other organizations only if no other providers were in their service area. T he DSHS issued formal contracts for the period from January 15, 2 0 1 2 , through March 31, 2 0 1 3 , when the state’s contract for Title X ended. Later, in March 2 0 1 2 , the Centers for Medicare and Medicaid Services declined the state’s W H P renewal application because the exclusion criteria restricted w omen’s abili­ ties to choose qualified providers, which is not perm itted under fed­ eral law.12 Federal funding for the WHP, which covered 9 0 % of the program ’s costs, was discontinued on December 31, 2012. On Janu­ ary 1, 2013, the state began ad­ ministering the Texas W om en’s Health Program, using state reve­ nue to cover the $ 3 0 million of annual federal funding that had previously supported the program.

METHODS

This mixed methods study in­ cluded 2 waves of surveys and in-depth interviews with leaders at organizations that received DSHS family planning funding in F Y 2 0 1 1. T he first wave of data collection took place between February and July 2 0 1 2 , and the

second wave took place between May and Septem ber 20 1 3 .

S u r v e y o f F a m ily P la n n in g

O r g a n iz a tio n s

In February 2012, we mailed a letter inviting executive directors of all 72 family planning organizations to complete a survey about services provided at their organization. After sending the invitation letter, we made follow-up phone calls and sent emails reminding them to complete the survey. W e used the same ap­ proach for the second wave.

Executive directors, medical di­ rectors, o r program administrators who were knowledgeable about the organization’s family planning program completed the self- administered structured surveys on clinic operations and services in F Y 2 0 1 1 and F Y 2 0 1 2 -2 0 1 3 . Questions included the num ber of clinics and sites offering confiden­ tial adolescent services at the or­ ganization; clinic hours; availabil­ ity of specific contraceptive methods and preventive services, such as cervical cancer screening and testing for sexually transmit­ ted infections, at the organization; and participation in discount drug-pricing programs and the WHP. T he majority of the surveys were submitted electronically through a secure online system, but a few organizations returned the surveys by mail or fax.

In -D e p th In t e r v ie w s W it h

O r g a n iz a tio n a l L e a d e r s

W e also asked leaders at a sub­ sample of organizations to partici­ pate in 2 in-depth interviews, which corresponded to each wave of the survey, to obtain detailed information about the strategies

used to adapt to changes resulting from the legislation. W e selected organizations for the subsample by stratifying across Texas’s 8 health service regions and then, within each region, sampling on the basis of probability propor­ tional to size, w here size was the num ber of family planning clients the organization served in FY 2010. W e recorded and tra n sc rib e d th e in-depth interview s.

Survey and interview respon­ dents were not compensated.

S t a t e A d m in is t r a t iv e D a ta

From the DSHS, we obtained data on family planning funding allocations and the num ber of unduplicated clients obtaining family planning services in FY2011 and FY 201 2 - 2 0 1 3 (September 1, 2 0 1 1 , through March 31, 2013). T he end date for F Y 2 0 1 2 -2 0 1 3 corresponds to the end of the Title X award period and DSHS-administered family planning funding for the legislative biennium.

At the time of this study, claims for family planning services in the W H P and Texas W om en’s Health Program were not available to assess the impact of excluding Planned Parenthood affiliates.

D a t a A n a ly s is

From the survey data, we assessed the number of clinics that closed or stopped offering family planning ser­ vices, reduced service hours, and no longer provided confidential adoles­ cent services during FY2012-2013. Project consultants provided infor­ mation on clinic closures from organizations that did not respond to the survey; in addition, some

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organizations notified us of closures that occurred between survey waves. For nonrespondents, we estimated the number of confidential adoles­ cent clinics from state administrative data on organizations receiving Title X funding in each period.

W e also examined the percent­ age of organizations charging un­ insured clients new fees for services, participating in discount drug­ pricing programs, and widely offer­ ing specific contraceptive methods and cervical cancer and sexually transmitted infection screening on site in FY 2011 and FY 2012- 2013. Such changes were among the adaptive strategies Title X-funded organizations in other states undertook when facing polit­ ical challenges.1 For all outcomes, we examined differences according to funding tier (tiers 1 and 2 vs tier 3). W e combined tiers 1 and 2 because there were only 6 tier 2 organizations.

We analyzed the in-depth inter­ view transcripts using open coding of text segments on changes in service deiiveiy. K W. organized coded seg­ ments into common themes and dis­ cussed these with other members of the research team, who conducted the interviews to confirm coherence within each theme. Finally, we com­ pared the themes and survey results to identify convergence between these data We have presented quotations from the in-depth interviews that are representative of these themes to highlight our main survey findings.

Using the DSHS administrative data, we calculated the total family planning funding award received in F Y 2 0 1 1 and FY 201 2 -2 0 1 3 and the percentage of organiza­ tions funded through March 31, 2 0 1 3 , according to funding tier.

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W e also calculated the total percentage change in funding and num ber of unduplicated cli­ ents served betw een F Y 2 0 1 1 and F Y 201 2 -2 0 1 3 . Because F Y 201 2 - 2 0 1 3 included 19 cal­ endar months, funding and client totals were not comparable to F Y 2 0 1 1. To address this differ­ ence, we computed 12-month equivalent totals for any organi­ zation that received m ore than 12 months of funding by dividing the total am ount of funding (or num ­ b e r of clients served) by the total m onths of funding received in F Y 2 0 1 2 -2 0 1 3 and multiplying this value by 12 months.

R E S U L T S

B etw een February and July 2 0 1 2 , 52 organizations (72% ) com pleted th e first wave of th e survey; m any o f th e nonre­ spondents were smaller organiza­ tions, and those that participated served 9 1 % o f clients obtaining DSHS family planning services in F Y 2 0 1 1. Of the 64 organizations that were still providing family planning services in May 2 0 1 3 , 52 completed the second survey, 4 2 of which also completed the first wave. Leaders at 2 7 organi­ zations participated in each wave o f in-depth interviews, and we interviewed leaders at 17 organi­ zations in both waves.

Funding C uts

DSHS administrative data showed that in F Y 2 0 1 1 4 0 % of Texas’s family planning funds went to 5 organizations; 3 were tier 1 public agencies and 2 were tier 3 specialized family planning providers (Table 1). T he majority

of organizations (66%) providing family planning services in F Y 2011 received less than $ 5 0 0 000, and very few of these were tier 3 organizations. In FY 201 2 - 2 0 1 3 , organizations had less funding overall to provide services for a longer period, but reductions in funding were sub­ stantially greater for tier 3 orga­ nizations than for those in tiers 1 and 2. Additionally, fewer tier 3 organizations received any fund­ ing during this period.

At the start of FY201 2-2013 (September 1,2011), 9 of the 17 tier 3 organizations, including 4 of the state’s 7 Planned Parenthood affili­ ates, lost all their state family plan­ ning funding, but only 5 of the 55 tier 1 and 2 organizations lost all funding. By the end of FY 2012- 201 3 (March 31, 2013), only 4 (23%) tier 3 organizations remained funded; none were Harmed Parent­ hood affiliates. By contrast 37 (67%) tier 1 and 2 organizations continued to receive family planning funds.

C lin ic C lo sures and R educed Hours

According to the survey and project consultants, 6 organizations in tiers 1 and 2 and 3 tier 3 organizations discontinued family planning services at all their 22 clinics because of decreased fund­ ing. Many other organizations also stopped offering family planning services at some locations o r closed select clinics in their network. Overall, 3 8 (40%) of the 96 clinics administered by tier 3 organiza­ tions closed, and organizations in tiers 1 and 2 closed 4 4 (19%) of their 2 3 7 clinic sites (Figure 1). Additionally, service hours were reduced at 3 0 (31%) tier 3 clinics

and 19 (8%) tier 1 and 2 locations. In the in-depth interviews, leaders at some organizations commented that they had eliminated evening or weekend hours, whereas others reported reducing service hours more significantly to only 1 or 2 days per week. In some communi­ ties, this resulted in longer waiting times to get an appointment.

There also were fewer sites w here minors could access con­ traceptive services w ithout paren­ tal consent in F Y 201 2 -2 0 1 3 , according to survey and adminis­ trative data. Organizations in tiers 1 and 2 operated 127 clinics in F Y 2011 that offered confidential services to minors. In F Y 2 0 1 2 - 2 0 1 3 , 14 of these sites no longer offered confidential services, but such services were available at 15 new sites because Title X funding was awarded to some organizations that had not previ­ ously received it. Among tier 3 organizations, adolescents could obtain confidential services at 45 clinics in F Y 2011, but by the end of FY 201 2 -2 0 1 3 , there were only 13 clinics where these services were available. In-depth interview re­ spondents said this was because they no longer received Title X funding or allocated funds to clinics serving a large num ber of clients ineligible for the WHP. They also commented that fewer Title X clinics made it difficult for adolescents, who were considered a priority population, to access services:

If they came in to the clinic and they didn’t have a parent and they didn’t get consent, we would refer those patients to [the Title X clinic], but they weren’t always able to make the arrangement to get over there, (program admin­ istrator, tier 1)

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G O V E R N M E N T , L A W , A N D P U B L IC H E A L T H P R A C T IC E

TABLE 1-Changes in Organizations’ Family Planning Funding in Texas Between Fiscal Year 2011 and

Fiscal Years 2 0 1 2 -2 0 1 3 , by Fiscal Year 2011 Funding Allocation and Funding Tier

FY2011 Funding Allocation for Each

Organization No.

Organizations Total Funding,

FY2011 Total Funding, F Y 2 0 1 2 -2 0 1 3

Percentage Decrease8

Organizations Funded Through March 3 1 , 2 0 1 3

$ 4 0 0 0 0 0 0 -S 6 9 9 9 9 9 9

Tiers 1 and 2 2 10 9 7 6 9 9 2 7 0 8 7 3 6 4 5 9 .2 2

Tier 3 0

$2 0 0 0 0 0 0 - S 3 9 9 9 9 9 9

Tiers 1 and 2 1 2 1 4 8 1 0 3 1 4 6 3 9 5 5 5 7 .0 1

Tier 3 2 6 7 6 3 6 1 2 1 9 9 2 10 4 7 0 .5 0

$ 1 0 0 0 0 0 0 - $ ! 9 9 9 9 9 9

Tiers 1 and 2 4 6 2 7 3 9 9 1 5 0 9 5 3 9 0 4 8 .7 4

Tier 3 5 6 3 5 0 8 7 5 1 2 0 2 6 5 4 8 5 .6 2

$ 5 0 0 0 0 0 - $ 9 9 9 9 9 9

Tiers 1 and 2 7 4 5 9 9 12 5 2 5 9 5 0 9 6 6 2 .7 5

Tier 3 3 1 6 9 4 0 5 0 4 9 6 5 2 9 8 1 .5 1

$ 3 0 0 0 0 0 - $ 4 9 9 9 9 9 Tiers 1 and 2 10 3 7 2 3 4 7 3 3 7 3 1 9 1 4 3 2 .6 5

Tier 3 5 2 0 0 9 3 6 2 5 3 4 72 2 7 3 .4 0

$ 1 0 0 0 0 0 -S 2 9 9 9 9 9

Tiers 1 and 2 16 3 4 8 1 49 1 3 2 8 1 6 0 7 3 7 .0 12

Tier 3 2 3 9 9 19 4 4 5 8 26 5 2 7 .5 1

< $ 1 0 0 0 0 0

Tiers 1 and 2 15 8 4 0 7 9 3 1 1 5 7 9 3 3 6 .4 8

Tier 3 0 Total 72 4 9 2 6 1 0 6 1 2 9 0 9 7 5 3 3 5 9 .7 41

Tiers 1 and 2 55 3 2 0 4 3 9 6 8 2 4 4 1 3 2 5 9 5 0 .6 37

Tier 3 17 17 2 1 7 0 9 3 4 6 8 4 2 7 4 7 6 .5 4

Note. FY - fiscal year. Fiscal year 2 0 1 1 : September 1, 2 0 1 0 , through August 3 1 , 2 0 1 1 ; fiscal years 2 0 1 2 -2 0 1 3 : September 1, 2 0 1 1 , through March 3 1 , 2 0 1 3 . Tier 1 and 2 organizations include public agencies (e.g., county health departments) providing family planning services and nonpublic agencies providing family planning services in addition to comprehensive primary care. Tier 3 organizations include nonpublic agencies providing family planning services only. Source. Texas Department of State Health Services data for Titles V, X, and XX family planning program funding. “The percentage decrease relative to fiscal year 2 0 1 1 reflects the 12-mo equivalent funding total in fiscal years 2 0 1 2 - 2 0 1 3 . The 12-mo equivalent total was calculated by dividing the total amount of funding by the total months of funding received in fiscal years 2 0 1 2 - 2 0 1 3 and multiplying this value by 12 mo for any organization that received more than 12 mo of funding.

C h a n g e s in C o s t o f S e r v ic e s

fo r P ro v id e rs a n d W o m e n

Although nearly all organiza­ tions reported in the survey that they participated in the W H P in F Y 2 0 1 1, in-depth interview re­ spondents commented that en­ rolling potentially eligible women in the program becam e a key

survival strategy following re­ duced DSHS funding in FY 201 2 - 2 0 1 3 . Moreover, they were now m ore stringent about women pre­ senting documentation of their W H P eligibility, such as proof of income and residence, before providing grant-funded services because funding was insufficient

to cover the costs for all clients. This was reported more often by tier 3 specialized family planning providers that were not Planned Parenthood affiliates.

Reduced funding also led orga­ nizations in all tiers to implement or expand systems requiring women to pay fixed fees for services, instead of

using a sliding fee scale. These fixed fees applied to clients who did not qualify for the WHP and either received care at a clinic that did not have Title X funding or were unable to get one of the limited number of monthly appointments at a Title X-funded clinic

In the survey, 5 8 % of tier 1 and 2 organizations and 7 5 % of tier 3 organizations reported that a larger percentage of their clients paid for services in F Y 2 0 1 2 - 2 0 1 3 than in F Y 2 0 1 1. Some or­ ganizational leaders stated in the interviews that they developed a fee schedule by which physicals, cervical cancer screening, and other services w ere provided at a fixed cost, whereas other orga­ nizations charged fees for each service; contraceptive methods often incurred an additional charge. Prices varied across orga­ nizations, as administrators fac­ tored in both their cost to provide the service and w hat women could afford. However, this did not guarantee clients would be able to pay the new fees:

The day before, this person didn’t have a dime to put towards their health care and now they're sud­ denly expected to cough up 50, 60 bucks So it has caused a lot of anxiety at the clinics, (execu­ tive director, tier 1)

Organizations that lost Title X funding and were not federally qualified health centers lost their eligibility for 340B discount drug pricing. T he survey and adminis­ trative data showed th at only 4 organizations (33%) in tier 3 that continued to provide family plan­ ning services had 340B pricing at the end of F Y 201 2 - 2 0 1 3 com­ pared with 2 7 (81%) tier 1 and 2

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for that at this time, (program administrator, tier 1)

G O V E R N M E N T, LAW , A N D P U B L IC HEALTH PR A C TIC E

T ier 1 /T ie r 2 Clinics T ier 3 Clinics

Note. T ie r 1 a n d 2 o rg a n iz a tio n s in c lu d e p u b lic a g e n c ie s (e .g ., c o u n ty h e a lth d e p a r tm e n ts ) p r o v id in g f a m ily p la n n in g s e rv ic e s a n d n o n p u b lic a g e n c ie s p r o v id in g f a m ily p la n n in g s e rv ic e s in a d d it io n t o p rim a ry c a re . T ie r 3 o rg a n iz a tio n s in c lu d e n o n p u b lic a g e n c ie s p ro v id in g f a m ily

p la n n in g s e rv ic e s o n ly .

Source. S urvey o f F a m ily P la n n in g O rg a n iz a tio n s .

FIG U R E 1 - N u m b e r o f Texas c lin ic s t h a t re d u c e d se rv ic e hours an d sto p ped o ffe rin g fa m ily p la n n in g

services b e tw e e n S e p te m b e r 2 0 1 1 and S e p te m b e r 2 0 1 3 , by fu n d in g tier.

organizations that were not feder­ ally qualified health centers. Four tier 3 organizations (33%) were able to purchase contraceptives at a reduced cost through other dis­ count programs, b u t one third did no t participate in any discount program. Loss of 340B pricing resulted in substantially higher costs for contraception:

The fee for us is . . . significantly higher, and so that also has to be transferred to the client. . . for example, I could buy a patch for $ 1 2 ... but now, I mean the patch to us is like $60 . . . and it’s not affordable, (program administra­ tor, tier 3)

C h a n g e s in C o n t r a c e p t iv e a n d

C lin ic a l S e r v ic e s

Funding reductions and reallo­ cations also affected organizations’ ability to provide women the full range of contraceptive methods. In F Y 2011, 8 6 % of organizations in tier 1 and 2 responding to the

survey widely ofFered contracep­ tive injections (e.g., Depo-Provera) and fewer than half widely offered long-acting reversible contracep­ tives (LARCs), such as implants and intrauterine devices (IUDs; Figure 2). During the same period, all tier 3 organizations widely offered contraceptive injections and more than 8 0 % widely offered LARCs. Female sterilization was widely of­ fered by approximately 2 5 % of organizations in all tiers.

In FY 201 2 -2 0 1 3 , organizations reported that many methods were not as widely available to their clients. Almost 70% of organiza­ tions in all tiers still widely provided contraceptive injections, but 42% or fewer widely provided implants and IUDs and fewer than 15% offered female sterilization. The decrease in the availability of contraceptive injections and LARC was particularly pronounced among tier 3 organizations.

In-depth interview respondents commented that LARCs and fe­ male sterilization were less widely offered because of their high cost. At many organizations, LARCs were reserved for women with medical contraindications to other methods. However, more limited access to these methods primarily affected women whose services were covered by DSHS funding, and not those who re­ ceived contraception through the WHP:

W e’re doing IUD’s right and left on Women’s Health Program__ If we did an IUD for a Title X client, that’s $700-plus that will come out of that big pot of money. And for that $700, we can actually see 3 women for their annual exam and birth control. And so, I mean, if there is a woman who has tried every­ thing else and . . . this is the only option for her, then we’ll do that. So it’s not like we say we abso­ lutely refuse to do th a t.. . . We just tell them there’s not funding

In contrast to contraception, there was no change in the avail­ ability of cervical cancer screen­ ing, annual chlamydia and gonor­ rhea screening for w omen aged 2 5 years and younger, and HIV testing betw een F Y 2 0 1 1 and FY 201 2 - 2 0 1 3 , and all organiza­ tions responding to the survey offered these services on site (data not shown). However, clients pay­ ing fixed fees for services were less likely to opt for reproductive health screenings:

[We are charging] $60 for a Pap smear and an exam, and then the birth control pills [are] like $20 a pack, and even then, they just couldn’t afford it. Most of the time they would just take the pills [because] we could offer the pills without an exam, (executive di­ rector, tier 3)

C h a n g e s in C lie n t V o lu m e

Administrative data for FY 201 2 - 2 0 1 3 showed that 151 7 1 9 clients received DSHS-funded family planning services. This is a 5 4 % decrease from F Y 2 0 1 1 after adjusting for the longer period of funding in FY 201 2 - 2 0 1 3 (data available as a supplement to the online version of this article at http://w w w .ajph. org). Most organizations in all tiers served a smaller num ber of clients than they did in F Y 2 0 1 1, and changes were correlated with de­ creases in funding (Figure 3). Or­ ganizations serving the largest num bers of clients in F Y 2 0 1 1 reported a 41%>-92% decrease in clients during FY 201 2 -2 0 1 3 , and very few organizations were able to serve a similar num ber of clients with less funding. Although

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G O V E R N M E N T , L A W , A N D P U B L IC H E A L T H P R A C T IC E

□ Tier 1/Tler 2, FY2011 E 3 Tier3,FY2011

□ Tier 1/Tler 2, FY2012-2013 ■ Tier3,FY2012-2013

N o te . FY = fis c a l year; IUD = in tra u te rin e devic e. T ie r 1 and 2 organ iza tio n s in c lu d e p u b lic ag encies (e.g., co u nty h e alth d e p a rtm e n ts) provid in g fa m ily p la n n in g services and n o n p u b lic agencies provid in g fa m ily p la n n in g services in a d d itio n to prim ary care. T ie r 3 organ iza tio n s in clu d e

n o n p u b lic agencies p ro vid in g fa m ily p la n n in g services only. The to ta l he ig h t o f each b a r is th e p e rcentage o f organ iza tio n s w idely o ffe rin g each

m e thod in fis c a l yea r 2 0 1 1 . The h e ig h t o f th e low er p o rtio n o f is th e percentage o f organ iza tio n s w idely o ffe rin g each m e th o d in fis c a l years

2 0 1 2 - 2 0 1 3 . S o u rc e . Survey o f Fam ily P lanning O rganizatio ns.

FIGURE 2 -M e th o d s widely offered a t family planning organizations in Texas in fiscal years 2 0 1 1 and

2 0 1 2 - 2 0 1 3 , by funding tier.

7 tier 1 and 2 organizations re­ ceiving greater levels of funding in FY201 2 -2 0 1 3 reported serving more clients than they did in FY2011, this increase was not proportional. In addition, these organizations served fewer clients in FY2011 than did other organi­ zations and, therefore, the impact of the overall increase in clients served in FY2012 -2 0 1 3 was small.

In-depth interview respondents reported that they did not know what had happened to their for­ mer clients but suspected that they simply were not seeking repro­ ductive health care. Those at

organizations serving Latino com­ munities frequently noted that undocumented women were “re­ ally [falling] through the cracks” after the funding cuts. Not only were they ineligible for the WHP, but they also were typically a lower priority than were other ineligible women (e.g., adolescents and those with incomes > 185% federal poverty level) for grant- funded appointments. The re­ duced client volume, overall, prompted a variety of concerns:

The women [that] are not [com­ ing in] I also worry about__ The long waiting [for] appointments,

the payments that they have to pay. They’re saying, “Forget it, I can’t afford it" So they’re kind of letting things go. Forgoing the birth control, their Pap test, their basic health care. So it’s really very tragic because you are not going to see the impact of all of that until maybe about a year from now with a lot of Medicaid births We won’t be able to tell about the undetected disease but there will be some; because we were catching some, (executive director, tier 3)

DISCUSSION

The 2011 funding cuts, tiered distribution system, and provider eligibility criteria for the WHP

were designed to prevent Planned Parenthood from receiving family planning funding from the state.7 * * 10 Our results indicate that the legis­ lative measures reduced or elimi­ nated Planned Parenthood affili­ ates’ participation in Texas’s family planning programs, leading to several adverse consequences for these organizations. Tier 3 specialized family planning pro­ viders that were not affiliated with Planned Parenthood were also hard hit. Moreover, public agencies, federally qualified health centers, and other organizations, which were not the targets of the legislation and were in the top funding tiers, also experienced significant funding losses that lim­ ited their delivery of reproductive health services. Clinic closures, reduced hours, and requiring a larger percentage of their clients to pay higher fixed (vs sliding) fees for services have likely con­ tributed to the smaller number of low-income women receiving family planning and reproductive health care in FY2012-2013.

Additionally, many women who continued to receive services had reduced access to the most highly effective methods, such as IUDs and implants, which are consid­ ered first-line contraceptive op­ tions for preventing unintended pregnancy.15,16 The tiered funding system placed organizations that had the greatest amount of expe­ rience providing these methods at a disadvantage and instead fa­ vored those that did not offer these methods as widely to their clients. Furthermore, low-income women’s access to these methods is increasingly uneven because their choice of contraception is

8 5 6 | Government, Law, and Public Health Practice | Peer Reviewed | White e t a/. American Journal o f Public Health | May 2 0 1 5 , Vol 1 0 5 , No. 5

G O V E R N M E N T, LAW , A N D P U B L IC HEALTH PR A C TIC E

N o te . T ie r 1 a n d 2 o r g a n iz a tio n s in c lu d e p u b lic a g e n c ie s ( e .g ., c o u n ty h e a lth d e p a r t m e n t s ) p ro v id in g f a m ily p la n n in g s e rv ic e s a n d n o n p u b lic a g e n c ie s p ro v id in g f a m ily p la n n in g s e rv ic e s in a d d it io n to p rim a ry c a r e . T ie r 3 o r g a n iz a tio n s in c lu d e n o n p u b lic a g e n c ie s p ro v id in g fa m ily p la n n in g serv ice s o n ly. T h e p e r c e n t a g e c h a n g e re la t iv e to fis c a l y e a r 2 0 1 1 re fle c ts t h e 1 2 - m o e q u iv a le n t f u n d in g a n d u n d u p lic a te d c lie n t t o t a ls in fis c a l y e a rs 2 0 1 2 - 2 0 1 3 f o r a ll o r g a n iz a tio n s t h a t re c e iv e d T exas D e p a r tm e n t o f S t a t e H e a lt h S e r v ic e s - a d m in is t e r e d f a m ily p la n n in g fu n d s . T h e 1 2 - m o e q u iv a le n t t o t a l w a s c a lc u la t e d by d iv id in g t h e t o t a l a m o u n t o f fu n d in g o r u n d u p lic a te d c lie n ts s erv ed by t h e t o t a l m o n th s o f fu n d in g re c e iv e d in fis c a l y ea rs 2 0 1 2 - 2 0 1 3 a n d m u ltip ly in g th is v a lu e by 1 2 m o f o r a ny o rg a n iz a tio n t h a t re c e iv e d m o re t h a n 1 2 m o o f fu n d in g . S y m b o l s iz e re fle c ts t h e n u m b e r o f c lie n t s s e rv e d by T ex as D e p a r tm e n t o f S t a t e H e a lt h S e r v ic e s - a d m in is t e r e d f a m ily p la n n in g g ra n ts in f is c a l y e a r 2 0 1 1 . S o u rc e . T exas D e p a r tm e n t o f S t a t e H e a lt h S e rv ic e s d a t a f o r f a m ily p la n n in g p ro g ra m fu n d in g .

FIG U R E 3 - P e r c e n t c h a n g e in u n d u p lic a te d c lie n ts served and

fu n d in g received a t fa m ily p la n n in g o rg a n iza tio n s in Texas in fis c a l

years 2 0 1 2 - 2 0 1 3 , by fu n d in g tier.

co n strain ed by th e specific fund­ ing so u rc e fo r th e ir care. T h is is c o n tra ry to th e original prem ise of T itle X a n d h as p u t clinicians a n d p ro g ram ad m in istrato rs in th e dif­ ficult position o f deciding w hich low -incom e clients h ave the gre atest n e e d for th ese m eth o d s.17 T h is re stric te d access also is com ­ ing at a tim e w h e n m any o th e r places in th e U nited States h a v e

e x perienced significant increases in LARC use.18'19

A lthough T ex a s’s family p la n ­ n ing p ro g ram s co v ered only 2 6 % o f w om en in n e e d o f subsidized family p lanning services b e fo re th e 2 0 1 1 legislation,20 th e re ­ d u c ed n u m b e rs o f w o m e n o b tain ­ ing care a n d lim ited access to highly effective co n tra ce p tio n are likely to increase u n in te n d e d

pre g n an c y a n d costs to th e sta te in th e form o f M edicaid-paid births. T h e T exas Legislative B udget B oard estim ated th a t th e 2 0 1 1 legislation w o uld re su lt in a n a d ­ ditional 2 0 5 1 1 M edicaid b irth s.21 D ata a re n o t y e t available to m ea ­ su re th e actual change in M edicaid births, b u t w e p la n to assess this im pact as well as econom ic costs to th e sta te in fu tu re analyses.

In 2 0 1 3 , th e sta te legislature a tte m p ted to re p a ir th e d am age to th e re p ro d u c tiv e h e a lth care safety n e t b y allocating m o re th a n $ 1 4 0 m illion to th e b u d g e t for w o m e n ’s h e a lth services, a d m inistered th ro u g h 3 se p a ra te program s. T h e e x te n t to w hich this funding will rein sta te access to c are is u n c le a r b e ca u se th ese p ro g ram s h a d n o t b e e n im plem ented at th e tim e of o u r study. T h e family p lanning landscape h as b e e n drastically al­ te re d o v e r th e p a st 2 years, a nd the n e w p ro g ram guidelines will likely c o ntinue to shift th e com ­ position o f p ro v id ers a n d scope of services. P la n n ed P a re n th o o d af­ filiates re m a in ineligible for state- adm in istere d family p lanning funds, a n d o th e r specialized family p lan n in g p ro v id ers m ay b e u n a b le to p ro v id e th e ra n g e of n o n re p ro - ductive h e a lth services re q u ire d by som e o f th ese program s.

Small organizations th a t are o therw ise eligible for fu nding m ay n o t p a rticipate b e ca u se th e y can ­ n o t com ply w ith th e n e w a d m in ­ istrative m an d a tes for th e se p a ra te program s. Also, b e ca u se m an y of th e organizations th a t are cur­ ren tly fu n d e d th ro u g h th e n ew p ro g ram s a re n o t experienced family plan n in g providers, th ey m ay lack train in g a n d experience w ith LARC m eth o d s a n d m ay b e

May 2 0 1 5 , Vol 1 0 5 , No. 5 | American Journal o f Public Health White et at. \ Peer Reviewed | Government,

less likely to u se evidence-based protocols th a t facilitate co n tra ce p ­ tive access a n d c o n tinuation.22-24

F u rth e rm o re , th e funds m ay n o t allow organizations th a t stopped p ro viding family p lan n in g to begin serving w om en again because som e have closed entirely or have lost essential staff a nd infrastructure.

T h e n ew state funding also does n o t allow adolescents to obtain family planning services w ithout p a rental consent n o r g u arantee el­ igibility for u n d o c u m e n ted immi­ grants, w ho h a v e b e e n particularly affected b y the funding cuts. T hese groups m ay regain access to ser­ vices at 1 o f the 9 2 clinic sites ru n by 2 7 organizations th a t received Title X funding th ro u g h a nonprofit w om en’s h e alth association.

In April 2 013, this association was awarded the Title X contract for Texas and, as a nonstate agency, is not subject to the legislated tiering system for allocating funds. However, there are currently only half as many of Title X-iunded clinics in Texas than there were in F Y 2011, and Title X - fiinded organizations are likely to face challenges meeting the needs of low- income populations in their commu­ nities. Many are specialized family planning providers and may not be able to secure other state funding that is essential to subsidize care for women ineligible for other programs.

L im ita tio n s

This study has several limitations. Although w e contacted all organi­ zations providing DSHS-funded family planning services in F Y 2 0 11, n o t all of th em responded to ou r survey. T he impact o f the legislation m ay have b e en different for n on­ responders, which w ere typically smaller and served few er clients.

Law, and Public Health Practice | 85 7

However, our findings are repre­ sentative of the service environment encountered by most Texas women receiving publicly funded family planning services, because those or­ ganizations that did respond served the vast majority of these women.

Also, we may have overesti­ mated the num ber of undupli­ cated family planning clients served in FY 201 2 - 2 0 1 3 for those organizations that received both funding extensions and con­ tracts, because organizations had to report the num ber of clients separately for each funding pe­ riod. Finally, we do not know the extent to which changes in service delivery have affected w om en’s reproductive health outcomes, such as rates of unintended preg­ nancy, Medicaid births, and sexu­ ally transmitted infections, be­ cause these data are not yet available.

C o n c lu s io n s

Although this study focuses on th e unique case of Texas, it highlights how the patchwork of programs that have supported low-income w omen’s access to reproductive health services can come apart at the seams when specialized family planning pro­ viders are marginalized or sys­ tematically excluded from public programs. W hether this stems from political motivations, as in Texas and other states, or results from investing health resources in organizations that focus on pri­ mary care, women will lose access to essential preventive services.

Because many women are likely to rem ain in need of publicly funded family planning clinics un­ der the Affordable Care Act,1,2 it is

essential to continue funding these clinics and identify or correct pol­ icy strategies to ensure those in need can access comprehensive reproductive health care. ■

A bo ut th e A uthors Kari White is with the Department o f Health Care Organization & Policy, Uni­ versity o f Alabama, Birmingham. A t the time o f the study, Kristine Hopkins, Abigail R. A. Aiken, Am anda Stevenson, Celia Hubert, and Joseph E. Potter were with the Population Research Center, University o f Texas, Austin. Daniel Grossman is with Ibis Reproductive Health, Oakland, CA.

Correspondence should be sent to Kari White, Department o f Health Care Orga­ nization & Policy, University o f Alabama at Birmingham, RPHB 3 2 0 , 1 7 2 0 2 n d A ve S, Birmingham, A L 3 5 2 9 4 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the "Reprints" link.

This article was accepted December 10, 2 0 1 4 .

C on trib u to rs K. W hite led the writing and analysis. K. W hite, K. Hopkins, D. Grossman, and J. E. Potter designed the study A R .A . Aiken, A. Stevenson, and C. H u b ert assisted with data collection. All authors helped to interpret findings and review ed and edited drafts o f th e article.

A cknow ledgm ents This study was funded by a grant from an anonym ous foundation and the National Institute of Child H ealth and H um an De­ velopm ent (NICHD) center (grant 5 R 24 H D 0 4 2 8 4 9 ) aw arded to the Population Research C enter a t the University of Texas, Austin. Abigail Aiken was sup­ ported by an NICHD predoctoral fellow­ ship (F31 H D 0 7 9 182-01).

Note. T he findings an d conclusions in this article are those o f the authors and do n o t necessarily represent the views o f the Planned Parenthood Federation of America, Inc.

Human P a rtic ip a n t P ro te c tio n This study was approved by the institu­ tional review boards a t the University of Alabama, Birmingham, and University of Texas, Austin. All participants provided oral inform ed consent.

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