Physicians Worry About Women's Access to Care
Cover Story – July 2012
Tex Med. 2012;108(7):18-25.
By Crystal Conde
Sharp funding cuts in state family planning services and changes in a state health program for women threaten women's access to vital preventive services, Texas physicians say. They say the situation is a crisis and they want lawmakers to restore money to programs that provide low-income women with recommended screenings and birth control.
Celia Neavel, MD, is the director of the Center for Adolescent Health at People's Community Clinic in Austin. The clinic has provided primary care to medically underserved and uninsured Central Texans for 42 years. Dr. Neavel says family planning services are part of a "holistic approach to patient care" at the clinic, which 10,000 patients call their medical home.
Cuts to the state's family planning program have affected the clinic, which also accepts Children's Health Insurance Program (CHIP), Medicaid, and Medicare patients, she says.
The 2011 Texas Legislature drastically reduced funds for family planning services by 66 percent, which caused at least 150,000 low-income women to lose access to preventive care and birth control. The state budget for family planning services plummeted from $111.5 million for fiscal year 2010-11 to $37.9 million for fiscal year 2012-13, including federal funds. The family planning program doesn't provide abortions but gives low-income women and men access to screenings for cancer, sexually transmitted diseases, and other diseases and conditions.
People's Community Clinic can no longer offer contraceptives at a discount, Dr. Neavel says, because the nonprofit lost more than $500,000 in family planning funding. Preventive screenings are no longer free at the clinic either, thanks to the cuts. Patients will have to pay for the services on a sliding scale beginning at $25.
"The annual exam and birth control prescription used to be a covered visit for women at our clinic. Now we have to bill them. At this point, we're not sure whether we've lost patients because of this, but we're scrambling to fill in the funding gaps so we can continue to provide these services," said Dr. Neavel.
People's Community Clinic also participates in the Women's Health Program (WHP), which provides preventive care, screenings, and birth control (not abortion) annually to more than 110,000 Texas women aged 18 to 44 whom Medicaid would cover if they become pregnant. To participate in the WHP, a woman must be an uninsured U.S. citizen or legal immigrant. She must have an income at or below 185 percent of the federal poverty level. WHP patients receive one exam each year that covers birth control and screenings for breast cancer, cervical cancer, diabetes, sexually transmitted diseases, and high blood pressure.
"I have several patients who are college students and young working women in the WHP. It's a helpful program for them and allows them to access birth control at any pharmacy, not just the one we have at the clinic," Dr. Neavel said. She says the clinic will remain in the program even though it's undergoing major changes.
The 2011 Texas Legislature excluded affiliates of abortion providers, including Planned Parenthood, from the WHP. The Centers for Medicare & Medicaid Services (CMS) then said it would cease funding the program because federal law gives women the right to choose from whom they receive health care. The state pledged to take over funding the WHP and developed a transition plan that phases out federal funding by November.
Like many physicians, Dr. Neavel fears Texas will witness increased unplanned pregnancies and preventable diseases as a result of insufficient funding for and reduced access to family planning services.
"This is an especially big concern among teens who have children already. They need access to birth control so they have an opportunity to finish school and have a shot at a second chance. We need to invest in prevention to ensure the health and economic future of our state," she said.
Texas Department of State Health Services (DSHS) Commissioner David Lakey, MD, says the Centers for Disease Control and Prevention recognizes family planning as one of the 10 greatest public health achievements of the 20th century.
"Access to disease testing, contraception, cancer screenings, and education is important and leads to improved health. These services can help identify health problems sooner rather than later, reduce unintended pregnancies, and ultimately lower costs," Dr. Lakey said.
The Texas Medical Association House of Delegates demanded that the state restore full funding for the WHP and the family planning program during its meeting at TexMed 2012 in Dallas in May. (See "Medicine Stands Up for Women's Health.")
TMA supports full and continued funding of family planning services for uninsured Texas women, including physical examinations; a contraceptive method; and screenings for diabetes, breast and cervical cancer, hypertension, anemia, and other infections and diseases. TMA also backs efforts to improve access to preconception health care, including breastfeeding education, weight management, tobacco cessation, planning families, and avoiding unplanned pregnancy.
Tearing the Safety Net
DSHS Press Officer Carrie Williams says the department used family planning money to serve about 220,000 women at about 300 Texas clinics last year. Since the legislature cut the state budget for family planning services by $73 million, DSHS can now fund only 40,000 to 60,000 women at 143 clinics.
She notes DSHS "took geographic fairness and access to care into consideration when allocating the dollars, but still, the dollars available were reduced significantly, by two-thirds."
Ms. Williams says DSHS is in the early stages of preparing for how it will approach family planning messaging and funding concerns next legislative session.
"With the reductions last session, we are communicating the scope of our family planning program and the included services," she said.
Fortunately, state funds weren't People's Community Clinic's only source of paying for family planning and other services. Dr. Neavel explains that the clinic is a full-service primary care medical home that relies on community support and private donations for about 60 percent of its $7.2 million annual budget.
"The funds we received for family planning services didn't just cover birth control. I use that money, for example, to give teens comprehensive wellness physicals that include some health education and some screenings, such as diabetes and cholesterol," she said.
Dr. Neavel says funds also benefit the clinic's adult patients, who receive breast and pelvic exams and recommended screenings.
"It's about health, bottom line. It's not just about birth control," Dr. Neavel said. "We want to continue seeing patients who rely on us. We don't want them to end up in the emergency room."
Janet Realini, MD, is concerned about cuts to family planning funds and the transitions set to occur within the WHP.
"In Texas, we're shooting ourselves in both feet, and the situation has reached crisis level," she said, adding that the state is "experiencing a 1-2 punch: The $73 million reduction in DSHS family planning funds and the possible exclusion of Planned Parenthood from the WHP threaten to tear the state's safety net."
Dr. Realini is president of Healthy Futures of Texas, the nonprofit arm of Healthy Futures Alliance, a community coalition dedicated to reducing teen and unplanned pregnancies.
José Camacho, executive director and general counsel for the Texas Association of Community Health Centers, worries about the ability of Texas' 69 federally qualified health centers (FQHCs) and 330 clinic sites to meet increased demand from Medicare, Medicaid, CHIP, insured, and uninsured patients. He's concerned because fewer facilities will be able to serve patients due to the funding cuts in family planning. Those Texans may seek health services at FQHCs that may not have the capacity to serve them.
"Health professionals at FQHCs see patients for more than just family planning services. Many women have untreated diabetes or hypertension that needs to be addressed. We're starting to see more demand for medical appointments, including family planning," Mr. Camacho said.
Cuts Could Have Consequences
Kimberly Carter, MD, an Austin obstetrician-gynecologist and member of the TMA Council on Science and Public Health, says funding family planning services for low-income women is essential to reducing the unplanned pregnancy rate in Texas. According to 2006 data (the latest available) from the National Campaign to Prevent Teen and Unplanned Pregnancy, 62 percent of pregnancies in Texas women aged 15 to 44 are unplanned, defined as "pregnancies that, at the time of conception, are either mistimed (the mother wanted the pregnancy to occur at a later time) or unwanted (mother did not want it to occur at that time or any time in the future)."
"The most effective way of preventing unplanned pregnancy is ensuring women have access to birth control," said Dr. Carter.
Texas' rate of unplanned pregnancy is much higher than the national average. "Unintended Pregnancy in the United States: Incidence and Disparities," published in 2006 in the journal Contraception, says unintended pregnancy affected 49 percent of pregnancies among American women in 2006, up slightly from 48 percent in 2001. Of those unplanned pregnancies, 43 percent ended in abortion nationwide. Research findings specify the unintended pregnancy rate was two to three times higher among women aged 18 to 24 who were poor or cohabiting. Researchers conclude that "efforts to help women and couples plan their pregnancies, such as increasing access to effective contraceptives, should focus on groups at greatest risk for unintended pregnancy, particularly poor and cohabiting women."
Dr. Realini concurs.
"Supporting and expanding access to preventive care and birth control is an effective way to help reduce abortion," she said. "In my personal opinion, it's misguided to cut funds to family planning services."
Yasser Zeid, MD, chair of the TMA Committee on Maternal and Perinatal Health and a Longview obstetrician-gynecologist, echoes her opinion.
"As far as I'm concerned, limiting access to birth control inadvertently increases the risk of abortion," he said.
Based on the reductions in family planning services, approximately 20,000 additional Texas women will give birth within the next year, says Dr. Carter, citing a May 2011 Legislative Budget Board memorandum about reduced funding for family planning services. According to the document, these births will cost Medicaid $231 million in state and federal funds over the 2012-13 biennium and beyond. Of that, Texas taxpayers will be responsible for $98 million, according to the document. Compare that figure to the $73 million total state and federal dollars saved from the family planning budget cut from fiscal year 2010-11 to fiscal year 2012-13.
In fact, the Guttmacher Institute says births as a result of unplanned pregnancy cost Texas Medicaid nearly $1.3 billion per year.
"Policy Solutions for Preventing Unplanned Pregnancy," published in April by The Brookings Institution, says expanding access to publicly funded family planning services is the most cost-effective way to reduce unplanned pregnancy while saving taxpayer dollars.
Dr. Carter emphasizes the need to take into account Medicaid costs that encompass more than prenatal care, labor, and delivery.
"We're paying for the fact that many of these mothers have uncontrolled medical problems, such as diabetes, that affect their pregnancies and can lead to a lifetime of problems for their children," she said. "Additionally, when women don't have access to contraception and aren't able to space their pregnancies by 18 months, they have an increased risk of preterm labor and low birth weight."
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Preterm births cost the United States more than $26 billion annually, according to the Institute of Medicine.
Disabilities and health complications can follow some preterm babies throughout their lives. Children may suffer from asthma, poor cognitive ability and academic achievement, cerebral palsy, delayed motor skills, visual disability, or poor social adaptive functioning, Dr. Carter says. Many require care from occupational therapists, physical therapists, nutritionists, urologists, cardiologists, ophthalmologists, home nurses, social workers, speech therapists, and a slew of other medical professionals.
Unplanned pregnancy has societal costs, as well. Guttmacher Institute data show that unintended pregnancy is highest among unmarried, low-income black or Hispanic women aged 18 to 24.
"Children born to those mothers are more likely to go to prison, more likely to suffer from neglect, and have lower levels of school readiness," Dr. Carter said.
Unplanned pregnancy has negative consequences for teen mothers and their children. The National Campaign to Prevent Teen and Unplanned Pregnancy says teen mothers are more likely to drop out of school, remain unmarried, and live in poverty. Their children are more likely to be born at low birth weight, grow up poor, live in single-parent households, suffer abuse and neglect, and enter the child welfare system. Their daughters are more likely to become teen parents themselves, and their sons are more likely to end up in jail.
Failure to adequately fund preventive services for women is shortsighted, Dr. Carter says.
"If we don't fully fund family planning services, we need to be prepared to budget for more prisons, additional neonatal intensive care unit expenses, more special education teachers, and other resources to care for children who are the products of unplanned pregnancy. If we don't pay for preventive services up front, we have no choice but to pay for the consequences on the back end," she said.
WHP in Transition
Texas Health and Human Services Commission (HHSC) spokesperson Stephanie Goodman stresses women enrolled in the WHP will experience "no disruption in services" during its transition to a program funded solely by the state.
"The change will be invisible to clients and providers. It will be a behind-the-scenes change in the funding source the state uses to pay for the program. The state is not changing who qualifies for the program or how providers are paid. Texas has never limited enrollment, and we'll continue that policy of enrolling every eligible woman who applies," she said.
Ms. Goodman says HHSC is "looking at a number of options" to replace the approximately $30 million in federal funds the WHP receives annually.
"We have some administrative savings that can be used for that purpose. We're confident that we can find the funding needed for the WHP within our $30 billion-a-year budget without reducing other programs," she said.
State Sen. Jane Nelson (R-Flower Mound) says transitioning the WHP from a federally funded program to one sustained by state funds has benefits and challenges.
"We created the WHP because we believe in the power of prevention and are committed to ensuring that these services continue through the current budget cycle. Obviously, the federal government's decision to withdraw its support of this program presents funding challenges, but that was the administration's decision – not ours," said Senator Nelson, chair of the Senate Committee on Health and Human Services.
She is working with HHSC to identify possible funding sources.
"I am confident we will identify the necessary funds to continue these services through the end of the budget cycle," she said.
Whether funding of the program will continue beyond then worries Mr. Camacho. He says FQHCs have experienced a 50-percent reduction in funding for family planning services. Nevertheless, he says Texas' community health centers continue to care for patients using family planning funds and women enrolled in the WHP.
"We have seen cuts in staff, and one or two of our sites have had to close," Mr. Camacho said. "We haven't turned away any patients at this point, but we know some of our patients now have to travel farther to see us."
In the meantime, the situation over funding for and participation in the WHP has become litigious. Attorney General Greg Abbott sued the federal government to restore funding, and nine Planned Parenthood clinics sued the state in federal court to stop their exclusion from the WHP.
Planned Parenthood and the attorney general's office are battling it out in court. On April 30, U.S. District Judge Lee Yeakel granted Planned Parenthood a temporary injunction, giving the organization provisional participation in the WHP.
That same evening, the attorney general filed an emergency motion for stay in the Fifth U.S. Circuit Court of Appeals. Judge Jerry Smith granted that motion, allowing HHSC to enforce the rule banning abortion providers and their affiliates from the WHP. However, the Fifth Circuit Court reversed the emergency stay May 4, prohibiting HHSC from excluding Planned Parenthood clinics from the program pending the outcome of the lawsuit in district court.
"We will comply with the court's order as the case proceeds. We also will continue to work toward a state program that provides women with access to vital family planning services and complies with the law that bans abortion providers from getting those funds," Ms. Goodman said.
The Fifth Circuit Court heard oral argument in the case in June.
The state has indicated it will cease the WHP altogether if Planned Parenthood prevails. Texas Solicitor General Jonathan Mitchell said in a motion filed with the court that the state would cut all funds if the federal courts ordered Texas to allow Planned Parenthood to participate in the program. "State law prohibits Texas from continuing to operate the Texas Women's Program if taxpayer money must be provided to entities that affiliate with abortion-promoting entities," the motion said. "Consequently, the district court's preliminary injunction effectively forces Texas to choose between contravening state law and shutting down the program."
WHP Needs Physicians
Senator Nelson says physician participation in the WHP is vital to the program's success.
"As with any health program, there is no access without a robust network of willing providers, so we are very grateful for the thousands of physicians already participating in the program. We hope to see that participation continue and grow," she said.
HHSC is working with TMA, state specialty societies, and FQHCs to expand physician participation in the WHP to ensure eligible women retain access to services in their communities.
According to Ms. Goodman, the 2,562 WHP participants include 2,195 physicians, 153 non-Planned Parenthood clinics, 44 Planned Parenthood clinics, and 170 FQHCs and regional health centers.
In fiscal year 2010, Planned Parenthood served 46 percent of WHP's clients. HHSC realizes that some women enrolled in the program will need to find a new physician or health care facility.
"We've already begun meeting with other family planning clinics about expanding their capacity to serve WHP clients. Those meetings have gone really well. We're also reaching out to other provider associations to help recruit new providers," Ms. Goodman said.
Ms. Goodman says HHSC anticipates having more than 2,500 physicians, clinics, and health centers in the program, even after excluding Planned Parenthood and its affiliates.
To help women find a doctor or clinic participating in the WHP, the agency has developed a website, www.texaswomenshealth.org. Women can search by city or ZIP code on the site, get information about the program, and learn how to apply for services.
Dr. Realini says the threat to the WHP from the controversy over who is going to be able to participate in the program is "unfortunate."
"Members and friends of the Healthy Futures Alliance would like to see Texas expanding, rather than limiting, access to preventive care," Dr. Realini said.
Dr. Realini says the economic argument for fully funding family planning services didn't seem to resonate with lawmakers last year.
"Texas spends an estimated $1.3 billion a year on unplanned Medicaid births. Texans need to stand up for access to preventive care and birth control. We need to work to reverse the cuts to the family planning program," she said.
With the potential exclusion of Planned Parenthood from the program and the strain placed on Texas' FQHCs and other clinics, Dr. Realini anticipates low-income women will face increased difficulty accessing care. A recent report released by the Geiger Gibson/RCHN Community Health Foundation Research Collaborative underscores her fears.
An Early Assessment of the Potential Impact of Texas' "Affiliation" Regulation on Access to Care for Low-income Women discusses the impact of Texas' abortion affiliation regulation on preventive care access by low-income women. The report finds excluding Planned Parenthood clinics from the WHP jeopardizes access to care for nearly 52,000 low-income women. The report's authors conclude the WHP program lacks any reasonable access alternative.
The report examines the capacity of the state's community health centers to ramp up their services to compensate for the loss of Planned Parenthood clinics. The authors conclude that it would be "virtually impossible" for health centers to fill the need, given cutbacks in state family planning funding and the magnitude of the demand for health center services in the state.
Mr. Camacho says health centers would need to augment their WHP capacity to offset the loss of Planned Parenthood clinic capacity under the WHP. He adds, "We're going to try" to fill the access to care gap. He recognizes, however, that doing so will be challenging.
FQHCs have taken funding hits that Mr. Camacho says make expanding capacity impossible. Operational funds for Medicaid have been reduced 10 percent, and family planning funding for health centers has decreased 54 percent (from $7.8 million to $3.6 million).
"There are huge gaps. There is so much capacity that needs to be replaced, and it's difficult to imagine that any health system or private practice could step in and fill those gaps," he said. "We're identifying gaps in services and examining the ability of FQHCs to respond to demand," he said.
In the meantime, he says, women will have to wait in line for care until the funding is available to increase capacity.
Nevertheless, Ms. Goodman says, HHSC is "confident that many of those providers [family planning clinics and others] are ready to take on more WHP patients. We'll continue to build the capacity for the program to ensure that we can provide these family planning services to every woman enrolled in the program."
Compounding the situation, preliminary TMA data shows the number of Texas physicians accepting new Medicaid patients declined from 42 percent in 2008 and 2010 to 30 percent in 2012. Dr. Zeid says the fee structure and administrative burdens, such as precertification for ultrasounds, make it difficult for Texas physicians to accept new Medicaid patients.
"All referrals to specialists for Medicaid patients have to go through primary care physicians. My practice had to hire one employee who does nothing but handle precertification for ultrasounds and referrals," he said.
He says physicians who specialize in women's health are particularly reluctant to accept new Medicaid patients.
"From an obstetrician's perspective, a lot of these patients seek prenatal care later in their pregnancies and have increased risk for preterm labor," said Dr. Zeid, a member of TMA's Select Committee on Medicaid, CHIP, and the Uninsured.
That said, Dr. Zeid emphasizes Texas physicians want to ensure all women have access to preventive health care. Dr. Zeid accepts new Medicaid patients and WHP enrollees in his practice and says he will continue doing so for the foreseeable future. His practice, made up of two physicians and four nonphysician practitioners, handles about 725 Medicaid visits per month and about 30 WHP visits per month.
"The main reason I'm committed to seeing new Medicaid and WHP patients goes back to an experience I had early in my career. I was practicing in another town where women would have no access to health care at all if I didn't see them. Disease doesn't discriminate based on patients' insurance status; we shouldn't either," he said.
Family planning programs that provide access to screenings and birth control are vital for low-income women, Dr. Zeid says.
"By cutting funding for these services, you're cutting a large portion of the female population off from their only source of preventive health care. We could wind up burdening our state health care system with preventable diseases. We could even see women showing up in the emergency room with advanced stage cervical cancer because they had no medical home where they could get Pap smears," he said.
Prevention Saves Money
HHSC implemented the WHP in 2007. The HHSC 2010 Annual Savings and Performance Report for the Women's Health Program says the "federal government's purpose for allowing family planning waivers is to limit expenditures for Medicaid-paid births."
At press time, HHSC didn't have data on the number of births to WHP clients for 2010. But the agency says in 2009 the program achieved a reduction of 6,721 expected births, decreasing Medicaid costs approximately $75.2 million in state and federal funds.
After paying costs associated with the program, savings for all funds totaled about $46 million and about $19.9 million in general revenue. That's a return on investment of nearly 20 to 1.
Dr. Realini says the premise behind WHP is simple: "By helping women better plan and space their pregnancies, mothers and babies will be healthier, and Medicaid will be able to reduce pregnancy and neonatal-related expenditures."
During the 2011 legislative session, she testified before the Senate Health and Human Services Committee in favor of legislation to continue and strengthen the WHP. She represented TMA, the Texas Academy of Family Physicians, the Texas Association of Obstetricians and Gynecologists, the Texas Chapter of the American Congress of Obstetricians and Gynecologists, and the Texas Pediatric Society.
She told legislators that Texas saved $10 for every dollar invested in the program and cited the Legislative Budget Board's estimate that continuing the WHP would save more than $83.7 million in general revenue.
She urged legislators to support measures to maximize physician and health center participation in the WHP.
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email.
Medicine Stands Up for Women's Health
The Texas Medical Association House of Delegates went on record supporting the state family planning and Women's Health programs during its May 19 meeting at TexMed 2012. Delegates adopted a resolution directing TMA to advocate for continuation and restoration of funding of the programs.
The day earlier, the house's Reference Committee on Science and Public Health examined information on how the family planning funding cuts the legislature approved last year have affected access to prenatal care. For instance, the Texas Department of State Health Services (DSHS) estimates more than 1.4 million women in Texas aged 15 to 44 are uninsured. Additionally, Medicaid pays for nearly 60 percent of Texas' 400,000 annual births. Births resulting from unplanned pregnancy cost the state $1.3 billion each year. Citing the need for access to women's health services in the state, the committee recommended the house adopt the resolution submitted by the Bexar County and Gregg-Upshur County medical societies.
San Antonio family physician Janet Realini, MD, testified before the reference committee that for more than 30 years Texas has managed a cost-effective, federally funded women's health services program providing screenings for diabetes, sexually transmitted diseases, hypertension, and cancer, and birth control to women in all regions of the state.
"This year, more than 150,000 Texans have lost access to primary health care with reductions in the state women's health programs," she said. "This resolution isn't about abortion; it's about restoring vital funding to family planning and ensuring women have access to care."
Beverly Nuckols, MD, a New Braunfels family physician, opposed the resolution both at the reference committee hearing and when it reached the House of Delegates floor for debate. She said that while the programs may be beneficial, TMA should support the will of lawmakers who oppose federal requirements for family planning funding.
Kimberly Carter, MD, a member of the TMA Council on Science and Public Health, applauded the TMA House of Delegates for passing the resolution.
"Our goal as a state and as a nation should be that all pregnancies are planned. It's an achievable goal; we actually can prevent unplanned pregnancy. Restoring funding for the state family planning program and continuing the Women's Health Program help us meet that goal and save the state a lot of money. And we'll improve the health outcomes of mothers and babies. It's the gift that keeps on giving," she said.
The House of Delegates also adopted resolutions supporting the use of only scientifically accurate information in the brochure physicians must give to all patients requesting an abortion. The resolution also said that lawmakers should reduce the loss-of-license penalty for physicians who do not comply with the new abortion-sonogram law.
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