Five years ago, Texas voluntarily gave up $30 million a year in federal funding for women's health programs, just so it could exclude Planned Parenthood from the roster of approved providers. Instead, the state established its own so-called Healthy Texas Women program in which it could set its own rules.
Now, staggering under the cost of the program and hopeful that the Trump administration will see things its way, Texas is applying for a restoration of the federal subsidy under the same terms. Signals from the White House and the Department of Health and Human Services suggest the state might succeed. If so, some other states may follow, and the cause of women's reproductive health will suffer a major blow.
"Clearly this administration is hostile to reproductive health, and clearly they are interested in reviewing this application," says Elizabeth Nash, senior state issues manager at the Guttmacher Institute, which concerns itself with reproductive health.
The Texas initiative comes in the form of an application for a demonstration waiver from Medicaid officials. It seeks $405 million in funding over five years, without giving up several features of its family planning program that run counter to Medicaid law and policies.
The state seeks permission to "favor childbirth and family planning services that do not include elective abortions or the promotion of elective abortions" — that is, any abortions not deemed necessary for the health of the mother — "and to avoid the direct or indirect use of state funds to promote or support elective abortions." That's coded language aimed at Planned Parenthood, which provides abortion services.
Texas also wants to retain its requirement that women aged 15 to 17 obtain parental consent to participate in the program. That's a rule not present in any other Medicaid program nationwide, Nash says, and one that would discourage some sexually active teenagers from obtaining medical services. And it wants to exclude emergency contraceptives such as morning-after pills from coverage, a provision that makes only political, not medical, sense. The program is expected to be covering 775,000 women and infants by 2023.
The Texas application is only one of several waiver proposals percolating in conservative states. According to a list compiled by Governing magazine, they include the following:
— In Arizona, a request to add a lifetime benefit cap and a work requirement to Medicaid. This is part of a nationwide conservative crusade that overlooks that the vast majority of Medicaid enrollees already are employed or are ill, disabled, going to school, or caring for family members at home. It's an ideologically punitive rather than practical policy. Kentucky's GOP Gov. Matt Bevin, a sworn enemy of the Affordable Care Act even though its implementation under his Democratic predecessor, Steve Beshear, was one of the most successful in the nation, also wants to add a work requirement to the ACA's Medicaid expansion.
— In Arkansas, Republican Gov. Asa Hutchinson has asked to roll back the eligibility for enrollment in Medicaid expansion under the ACA to 100% of the federal poverty limit, rather than the law's 138% ceiling. It's unclear where the 60,000 Arkansans thereby snuffed from the Medicaid rolls would obtain their coverage.
— Florida's Republican Gov. Rick Scott wants to convert his own Medicaid program to a block-grant, ostensibly to give the state more flexibility in spending. But critics observe that block grants typically don't keep pace with a program's expenses.
— Maine's GOP Gov. Paul LePage wants to subject Medicaid recipients to an asset test and bar those with more than $5,000 to their name. Asset tests are illegal under current law. He wants to charge some enrollees premiums, drop coverage for 90 days for those who miss payments, and limit benefits to 36 months for the unemployed.
— Wisconsin's GOP Gov. Scott Walker wants to drug-test Medicaid enrollees, an enormous waste of money when applied to any public assistance program.
It's unclear whether any of these proposals will be approved, although HHS has said it will be more indulgent toward waiver requests than the Obama administration, which tended to be a stickler against work requirements and any but very minimal premiums or cost sharing.
The Texas proposal is both more far-reaching and more ideological than any of these. Nevertheless, state officials told the Houston Chronicle that they'd been "encouraged" to ask the Trump HHS to reverse the Obama administration's refusal to allow them to exclude Planned Parenthood from the women's health program. They wouldn't say who delivered the encouragement, stating only that "the sentiment is that the federal government may be open to new ideas."
Texas lost federal Medicaid funding for its reproductive health program in 2012, when the Obama administration rejected its demand to bar Planned Parenthood from receiving funds. The ban violated Medicaid law, which mandates that patients be permitted to receive treatment from any provider of their choice. Texas then established a fully state-financed program, starting Jan. 1, 2013.
The effect of the change on low-income Texas women was marked, and not in a good way. Researchers at the University of Texas found that women's use of contraceptives, especially long-acting reversible methods such as IUDs and injectable contraceptives dropped sharply in counties with Planned Parenthood clinics, which had to charge patients a fee for services that previously had been free. At the same time, the percentage of women giving birth covered by Medicaid — which pays for more than half of all births in Texas — shot up.
"It is likely that many of these pregnancies were unintended," the researchers concluded, "since the rates of childbirth among these women increased in the counties that were affected by the exclusion and decreased in the rest of the state." In other words, the state's campaign against Planned Parenthood increased both state and federal healthcare costs.
The study attributes some of the increase in births to the effective cutoff of access to long-acting contraceptives. "The introduction of additional barriers to access to [those] methods by the exclusion of skilled, specialized family-planning providers," the researchers reported, "was associated with a shift toward methods that have lower rates of efficacy and continuation." Contraceptive use in counties that didn't have Planned Parenthood clinics didn't change, but remained consistently lower than in those with those clinics.
The systematic exclusion of Planned Parenthood from Texas' publicly funded healthcare system has had broader impacts on women in the state. There simply weren't enough alternative providers with adequate Medicaid practices or expertise in family planning to take up the slack after Planned Parenthood was barred, according to Modern Healthcare, which reported that "out of 298,000 providers registered in the Medicaid program, only 5,000 are a part of the Healthy Texas Women program."
"If you exclude Planned Parenthood," Nash says, "women might have to travel long distances for service or wait weeks for appointments."
Federal law already bars the use of federal funds to perform abortions, but doesn't exclude providers from receiving reimbursements for other services just because they do perform abortions. Texas' policy is echoed by the Obamacare repeal measure passed last month by House Republicans in Washington, which aims to forbid premium subsidies from being paid to any insurers who cover abortion. That provision would come into direct conflict with state laws in California and other states, which require all health plans to cover abortion.
The Department of Health and Human Services may have to twist itself into legal knots to approve the Texas waiver without violating the law allowing Medicaid patients to choose their own medical providers. "HHS will have to figure out a workaround, but clearly that is something they are interested in doing," Nash says.
Nor will Texas be the last state to apply. Missouri kissed off more than $8 million in annual Medicaid funding this year when it enacted a similar anti-abortion law and Iowa is planning the same sort of measure. Restrictions on women's health services in individual states may be just the start: If HHS approves the Texas waiver, Nash says, "it's hard to imagine that this kind of exclusion wouldn't be applied to Medicaid generally."