Texas is first to adopt legislation that bars Planned Parenthood affiliates from delivering healthcare services using public funds. The Federal Public Health Financing via Medicare, Medicaid, and the Affordable Care Act relies on various public and private organizations to effectively provide health care services.

In the past, the federal law required all medically qualified health care professionals to be eligible to offer such services through the partial or complete funding of federal entities. Recently, legislation was passed challenging this condition, by excluding Planned Parenthood associates from participating in federally funded, state-delivered family planning programs. The legislation has been proposed in 17 states, as well as both houses of Congress.

Texas, being the first to adopt the legislation, is among many such states that have banned Planned Parenthood affiliates from delivering healthcare services using public funds. Even though the federal government disallowed such a stance and courts blocked the exclusion of Planned Parenthood affiliates from the Texas Medicaid fee-for-service family-planning program, Texas declared exclusion from a state-funded replacement program on January 1, 2013.

Study conducted by Amanda J. Stevenson and published in The New England Journal of Medicine on Feb. 3, analyzed the efficacy of this decision by comparing the rates of contraceptive-method provision, method continuation, and childbirth covered by Medicaid before and after the exclusion of Planned Parenthood between 2011-2014.

“This study isolates the effect of the exclusion not only on the delivery of services, but also on subsequent deliveries paid by Medicaid”, said lead author Amanda Stevenson, a Ph.D. candidate in sociology. “We examined differences between counties that had Planned Parenthood affiliates versus those that did not to determine how the public was affected once affiliates could no longer use public funds to provide contraceptive services”.

Background: How It All Began

Texas had reduced family-planning grants by 66 percent on September 1, 2011 and redistributed the remaining funding stream away from devoted family-planning counselors and workers. This was followed by the termination of 82 family-planning clinics, of which almost one-third were associated with Planned Parenthood.

In 2007, Texas had established a Medicaid waiver program entitled the Women’s Health Program which received 90 percent of funding from the federal government. In 2011, the Texas legislature ordered the program to omit Planned Parenthood affiliates. The Federal Centers for Medicare and Medicaid Services appealed that excluding medically qualified healthcare providers was in violation of the federal law, and would result in non-renewal of the waiver and continued transition funding till the end of 2012. As the year came to an end, Texas, replaced the federally funded program with an almost identical program that was 100 percent funded by the state; the Texas Women’s Health Program. The latter excluded all clinics that provided the option of abortion, effective from January 1, 2013.

Banning Planned Parenthood: Collecting Data to Assess Implications

In order to assess whether the steps taken by the state of Texas had proved to be beneficial, claims were obtained from clients of the Women’s Health Program as well as the Texas Women’s Health Program. The idea was to identify whether modifications in the legislation had led to a change in the use of contraceptives, the continuation of methods involving injectable contraceptives and the rate of childbirth covered by Medicaid.

Data was obtained from pharmacies and medical claims between January 1, 2011 and December 31, 2014 under public fee-for-service family-planning insurance programs in Texas. Information of administrative records from the Texas Department of State Health Services and Planned Parenthood helped categorize the 254 counties in Texas as either having or not having healthcare providers associated with Planned Parenthood at the beginning of data collection. The eligibility criteria for the analysis were all fertile, legal female residents between the ages of 18 and 44 with incomes at or below 185 percent of the federal poverty level.

The use of contraceptive methods was categorized in three groups: long-acting reversible contraceptives (LARC; contraceptive implants and intrauterine devices), an injectable contraceptive (depot medroxyprogesterone acetate), and short-acting hormonal methods (oral contraceptive pills, transdermal contraceptive patches, and contraceptive rings). Among the claims for childbirth covered by Medicaid of females using injectable contraceptives, the proportion of women returning to the program for any healthcare service, on-time subsequent injections and childbirth were also assessed; this helped in analyzing any changes in rates of contraceptive continuation and childbirth before and after the exclusion of Planned Parenthood affiliates.

Finally, the data collected was analyzed using the difference-in-differences method and regression discontinuity in order to compare the number of claims for each contraceptive method in both counties. Local linear regression models were used to summarize the obtained differences. These methods excluded the need for consent forms and the requirement of data from funding parties.

Impact of Barring Planned Parenthood

The 23 counties enforcing Planned Parenthood affiliates had a 60 percent population of females within the inclusion criteria. Of all childbirths covered by Medicaid in 2012, 63 percent occurred in counties enforcing Planned Parenthood. The overall decrease in the closure of family-planning clinics was greater in counties barring Planned Parenthood as compared to those retaining it.

  • Claims for Contraceptives

Before the exclusion of Planned Parenthood, the claims for LARC and injectable contraceptives were declining in both groups of counties; a sharper decline was seen in the group with Planned Parenthood affiliates. However, the claims for short-acting hormonal methods were declining in both groups before the exclusion of Planned Parenthood. After the exclusion of the affiliates, a sharp decline was registered in the number of LARC methods in counties with Planned Parenthood as compared to those without it. These claims subsequently increased in both counties.

The provision of injectable contraceptives declined sharply in counties supporting Planned Parenthood which subsequently remained somewhat stable in the next two years. On the contrary, the provision of short-acting hormonal methods varied slightly between the two counties after the exclusion of affiliates and thereafter remained relatively stable.

Significant differences were observed at the beginning of Planned Parenthood exclusion for LARC methods and injectable contraceptives, but not for short-acting hormonal methods.

  • Rates of Contraceptive Continuation and Subsequent Childbirth

The proportion of females returning for subsequent on-time contraceptive injections in counties with affiliates was lower after their exclusion. The percentage decreased from 56.9 percent to 37.7 percent in counties with Planned Parenthood affiliates but increased from 54.9 percent to 58.5 percent in counties without them.

Moreover, the exclusion of Planned Parenthood was also accompanied by an increase in the rate of childbirth covered by Medicaid within the following 18 months – from 7.0 percent to 8.4 percent in counties with Planned Parenthood affiliates. This was followed by a decrease from 6.4 percent to 5.9 percent in the counties without Planned Parenthood affiliates.

  • Reduction In LARC Methods

This phenomenon represents a diversion from the general trend of increased claims for LARC in counties with affiliates in the years before the exclusion, similar to national trends. This is alarming, since an increase in the reduction of LARC methods is considered important among American College of Obstetricians and Gynecologists. Hence, the introduction of barriers for accessing LARC methods by the exclusion of affiliates could lead to a trend of lower rates of effectiveness and continuation in terms of women using injectable contraceptives.

Possible Limitations

Although the analysis reflects an adverse effect of the exclusion of Planned Parenthood on low-income women in Texas – reduction in provision of effective contraceptive methods, interrupting continuation and increasing rate of childbirth – this assessment is based on observational data and hence cannot prove causality.

Also, the analysis does not account for specific barriers encountered by clients after the exclusion, which might have come to light via interviews. For example, clients returning to affiliates after the exclusion were charged $60 fee or more for a contraceptive injection. Similarly, additional visits and examinations were also required and charged per visit.

Moreover, the data analyzed is restricted to two years after the exclusion and the statistics should have been adjusted for changes with time, such as those in health policies and county-level characteristics. Information regarding the payment of receiving contraceptive services is lacking as well, along with data for women who gave out-of-state birth or using private insurance coverage.

Discussion And Analysis

After a detailed analysis, it seems that after the abrupt exclusion of Planned Parenthood affiliates from family-planning programs, the claims for LARC methods decreased, along with the claims for contraceptive injections. For women using injectable contraceptives, a decrease was seen in the number of subsequent injections preceding the exclusion of affiliates. Furthermore, a disproportionate rise of 27% was seen in the rate of childbirth covered by Medicaid. There is limited data available on the intention of pregnancy, but it is likely that most of them were unanticipated, since the rates of childbirth increased in counties affected by the exclusion of affiliates and increased elsewhere.

Hence, it can be concluded to fairly reliable extent that the implantation of the exclusion of Planned Parenthood affiliates in 2013 by the state of Texas resulted in significant adverse effects in the rates of provision and continuation of contraceptive methods, as well as increased rates of childbirth covered by Medicaid. There are severe implications regarding the possible consequences of such a proposal, and the outcries of public funding agencies and other states must not be ignored.

  • Federal and state governments must think such policies identify the pros and cons of enforcing such a change in the legislation, in terms of monetary effects and an overall burden on the healthcare system and economy.
  • The preventive measures should be kept within range otherwise, same situation will repeat itself like it is in the US; which is observing the highest rate of unintended pregnancies as compared to other strong economies.

When women are put to struggle to achieve their reproductive prospects due to government’s lack of policy alignment, it ignites a public health issue like one in Texas.