The End of Family Planning in Texas

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It's been a banner year for Texas' pro-life movement. In May, lawmakers approved state-issued "Choose Life" license plates, with proceeds earmarked for medically questionable, anti-abortion "crisis pregnancy" centers. A few days later they passed a bill requiring women to undergo a sonogram, listen to a fetal heartbeat and hear a "detailed description" of her fetus before having an abortion. And they also, if you believe their gleeful soundbites, "defunded Planned Parenthood," a description that painted a picture of a publicly funded abortion mill finally brought to its filthy knees.

Of all the bills passed this year, this last one makes pro-life leaders especially proud. The key provisions of the sonogram bill are stalled in court and unlikely to ever be enforced. Funding license plates doesn't have the rhetorical fireworks to anchor a campaign ad. But "defunding Planned Parenthood"? Those are three powerful words on the Republican re-election circuit.

Take Leo Berman. The representative from Smith County, in eastern Texas, backed some losing horses this year — insisting the president was born in Kenya, demanding to see his birth certificate, trying to have English established as the "official language" of Texas. But he also supported the "defunding," which in reality was the diversion of about $73 million out of the state's "family planning" budget — federal grant money that covers birth control, contraception and other services that aren't — that can't be — abortion.

But you wouldn't know that from talking to Berman.

"Since 1973, how many abortions have been performed in this country?" he asks. "I can tell you. It's 55 million. An organization like Planned Parenthood — just listen to the name of the organization, Planned Parenthood — was responsible for the large majority of those 55 million abortions. It was an easy choice for me to cut out a family-planning organization like that."

Representative Bryan Hughes, a Republican from Mineola, takes it even further, insisting that Planned Parenthood's many services — birth control, contraception, cancer screenings — are all merely pretexts to provide abortions. "The shell game is not hard to figure out," he wrote in the Texas Tribune. "For every dollar Planned Parenthood receives in taxpayer money, a dollar of Planned Parenthood's unrestricted funds are freed up to pay for abortions."

Even lawmakers who believe that Planned Parenthood actually exists to provide services other than abortions — services that in reality make up 97 percent of its work — don't always differentiate between abortion, birth control or general medical care. Representative Wayne Christian, who represents Nacogdoches and surrounding areas, told Texas Tribune: "Of course this is a war on birth control and abortions and everything, that's what family planning is supposed to be about." Women seeking real healthcare, these politicians say, can easily go elsewhere.

"Healthcare access for poor women is made possible through Medicaid and volunteer organizations in the cities and states of Texas," Berman says. "We defunded Planned Parenthood. That's what we did."

The narrative these lawmakers have constructed obscures some basic facts, as most lawmaker-constructed narratives do. Abortions, at Planned Parenthood and wherever else they're performed, aren't funded by taxpayer money. They haven't been for nearly 40 years. And in the end, the funding cuts these lawmakers tout had little impact on access to abortions.

Still, somehow, they insist they've scored a clear victory.

"We picked our battles very carefully and very measured," Berman says. "We picked them to win. And we did win."

Family-planning funding is only the latest target in Texas lawmakers' war on abortion, which this group and its predecessors have been working to make functionally illegal for decades.

"For the last 20 years, every session there's always some anti-choice legislation proposed," says Susan Hays, a Dallas attorney who's helped fight the sonogram law and is a former local Democratic chairwoman. In 2005, Panhandle Representative Warren Chisum filed a bill to protect life "from the point of conception." The bill failed, so he re-introduced it two years later, while Houston Senator Dan Patrick did the same. Both failed the same way — referred to a committee and left there to be forgotten.

This session, abortion bans were back on the table. But, like previous efforts, the bans "have been fairly easy to defeat, because they're so hardcore," Hays says. "There are plenty of moderate Republicans, even pro-life Republicans, who think they go too far, and [the bills] are quietly killed."

Instead, over the years, lawmakers have increasingly settled for trying to make abortions harder to get, through an ever-more tangled thicket of restrictions and conditions. The first significant step came in 2003, when Governor Rick Perry signed the Woman's Right to Know Act, requiring doctors to tell women seeking abortions about alternatives, and to give them material stating that abortion might increase their risk of breast cancer — a medically dubious claim disputed by virtually every major medical body. The law also put in place a 24-hour waiting period.

In 2004, lawmakers passed a law requiring teenagers under 18 to notify their parents before receiving an abortion. Two years later that morphed into a "parental consent" clause, which was criticized by pro-choice groups for its potential effects on teens who are from abusive homes or are victims of incest — kids who might fear telling their parent, lest it lead to abuse or worse. A judicial bypass exception was created, allowing pregnant teens to ask a judge to waive the consent requirement. But studies show that the bypass system often fails teens who don't know about it or can't maneuver the courts system to successfully lobby a judge.

This year brought the sonogram bill, which, while mostly languishing in court, succeeded in reaffirming the 24-hour waiting period, unless a woman can show she lives more than 100 miles from her provider. It's a seemingly benign requirement, but it could pose problems for a woman who's trying to hide an abortion from an abusive partner, or who simply isn't able to arrange childcare, transportation and time off from work twice.

For all the political points these measures scored, it's lawmakers' new zeal for attacking the broader family-planning sector that has Texas healthcare providers fretting. Attempts to outlaw abortion were like rusty bullets from an antique musket — slow, lumbering and easy to see coming. More recent bills — the sonogram law, waiting periods, misleading materials — were closer to a shotgun blast, nicking away at access and understanding. Family planning funding cuts are looking more and more like a dirty bomb.

It isn't the first time lawmakers tried to divert family-planning funding. In 2003, lawmakers prohibited the federal funds from going to clinics or doctors "that perform elective abortion procedures" or contract with clinics that do. Several Planned Parenthood clinics and doctors sued the state, unsuccessfully. So Planned Parenthood formed separate surgical centers that only provided abortions and vasectomies, and don't get any federal money.

"We're audited twice a year to make sure everything is kept separate," says Holly Morgan, spokeswoman for Planned Parenthood North Texas. "We're legally and monetarily separate, with separate boards and separate bank accounts."

That separation would have been a huge victory for pro-life advocates — if federal money actually funded abortions. It doesn't. Federal funding hasn't paid for abortions since 1976. The family-planning funding program, signed into law by Richard Nixon in 1970, is designed to help provide lower-income families with affordable birth-control and other healthcare. Only one federal program, Medicaid, will pay for an abortion, and only in cases of rape, incest or life-endangering pregnancies.

In fact, the family-planning program — which in 2006, according to the Guttmacher Institute, distributed about $1.85 billion total — actually reduces the number of abortions women have, according to the National Family Planning and Reproductive Health Association. They estimate the services funded by family-planning dollars help prevent about 1.4 million unintended pregnancies nationally every year, nearly half of which would otherwise be terminated.

So how were lawmakers able to strip family-planning funding with so little opposition? Money. The state faced a massive shortfall this session, somewhere between $15 billion and $27 billion. Under pressure from the Tea Party and preparing for his presidential bid, Perry urged lawmakers to steer clear of the state's $9.4 billion emergency Rainy Day Fund and instead make around $15 billion in budget cuts. They did, focusing largely on education (cut by $4 billion) and health and human services ($11 billion). Family-planning money made up a large chunk of those health cuts.

Texas, like most states, receives three types of family-planning funding from the feds. The most important is Title X, which is earmarked for family-planning — contraception and preventive health services — and can't go anywhere else. Titles V and XX funding can fund any number of social services, but until this year, large portions were allocated for family planning.

The clinics that rely on the funding are especially crucial in Texas, where an estimated 35 percent of women of reproductive age are uninsured, compared with 22 percent nationally. In 2008, Title X-funded centers helped Texas women avoid 45,900 pregnancies, which would have led to 20,400 births and 19,200 abortions, according to the Guttmacher Institute, a national nonprofit that studies sexual and reproductive health.

Yet despite decades of building the program, and its record of success, it took just a few amendments to dismantle much of the state's family-planning pipeline. Although Title X money can't legally be moved out of family planning, Title V and XX funding can be. That's exactly what Republican lawmakers did. Representative Randy Weber of Pearland filed an amendment that moved more than $8 million to anti-abortion and abstinence programs, as well as crisis pregnancy centers. Christian moved $6.6 million to autism programs. Dwayne Bohac, from Houston, moved $14 million to mental health services for children. Jim Murphy, also from Houston, moved $143,000 to EMS and trauma care. Sid Miller, Stephenville, moved $18 million to early childhood services and $3 million to what he called "other non-Medicaid services." About $1.8 million went to a fund for the deaf, blind and multiply disabled per an amendment by Representative Bill Zedler of Arlington, and Representative Jodie Laubenberg sent another $9 million to the STAR program for at-risk youth.

The lawmakers made it clear that their priority was to hurt Planned Parenthood. In making his amendment, Zedler announced to his colleagues that he was doing so to "defund the abortion industry." Separately, Miller said, "I think we're trying to shut down abortions in Texas and doing that through cutting off the purse strings." Meanwhile, a separate bill by Warren Chisum, a Republican from Pampa, expanded a 2005 rider that dictates how the funding should be distributed. It now goes first to state- or locally run public health clinics, then to private "full-service" health clinics. Whatever's left goes to clinics that provide family-planning and women's healthcare.

"These cuts have hit everybody," says Fran Hagerty, CEO of the Women's Health and Family Planning Association of Texas (WHFPA), a coalition of providers who treat around 800,000 low-income women. "There is not one provider out there — whether it's a public clinic, Parkland Hospital, or a tiny little community action agency — that this has not affected."

Most clinics lost two-thirds of their funding, she says, and 14 lost it all. Overall the family planning budget in the state went from $111.5 million in fiscal years 2010 and 2011 to $37.9 million — a total loss of $73.6 million.

It was a strategic dismantling, and one pro-choice advocates attribute to the organization and zeal of the Tea Party. Six of the seven representatives who moved money — Miller, Bohac, Christian, Weber, Murphy and Laubenberg — are members of the House Tea Party Caucus.

"It happened across the country," Hays says. "These Tea Partiers came in upset about economic issues, and it turned out they were a front for these extreme social views. It's some of the most extreme anti-abortion and anti-woman legislation I've ever seen. The cutoff to family planning is incredibly cruel."

They "ran on a fiscal conservative, 'Let's get our house in order' platform," adds Elizabeth Nash, of the Guttmacher Institute. "But they are social conservatives as well. That piece of their identity wasn't well-established or well-known by voters."

Even some pro-life Republicans seemed uneasy with the cuts. Representative Will Hartnett, a Republican from Dallas, claims a spotless pro-life record. In 1998 he won the Bishop's Pro-Life Award for Political Action, and he was a driving force behind the parental consent law. He's been in years-long battle with Planned Parenthood; in 2006 the group sent out mailers calling him a "mean-spirited ideologue." Plus, he says, "They compared me to Darth Vader."

After Miller announced the cuts, Hartnett stood at the House's back microphone, looking uncomfortable as he fired questions at his fellow pro-life Republican.

"What exactly are we un-funding here?" Hartnett asked.

"Family planning," Miller replied.

"What is that?" Hartnett asked again. "I don't know what that is."

"The money that goes to Planned Parenthood," Miller responded.

"I don't think that's right," Hartnett said, sounding deflated. From several corners of the room, voices could be heard shouting, "It's not!"

Hartnett doesn't want to be characterized as "defending" Planned Parenthood. "But they do provide needed services unrelated to abortion," he says. "They have a well-established track record and have done important work. To throw them out and add these new [programs] ... did not seem wise to me." Besides, he adds, "Women are the backbone of our society, in my opinion. We have to keep in mind their needs."

"I've talked to women who have been in the Legislature since the 1970s," says Representative Carol Alvarado, a Democrat from El Paso. "And never has there been such an outlandish attack on women. Every woman, Democrat or Republican, pro-choice or anti-choice, ought to be outraged by what took place."

On a recent fall night, 40 Days For Life, a growing anti-abortion group, held a rally in Harry S. Moss Park to celebrate the start of its newest endeavor, a protest of the Southwestern Women's Surgery Center, an abortion clinic on Greenville Avenue. The praying and fasting started on September 28 and will last into November.

A chubby guy in a blue T-shirt sang hymns and strummed on an acoustic guitar, peering at an iPad on a music stand in front of him. A few priests circulated among the crowd and the tables set up by pro-life groups. About 200 people in all sat in lawn chairs or stood in the patchy grass, watching the stage as cars flashed by on Greenville. A little girl ran by in a T-shirt with a Bible verse and a photo of a sonogram on the back.

Karen Garnett, president of the Catholic Pro-Life Committee, took the stage. She talked about the funding cuts, bragging that seven metroplex Planned Parenthoods would close because of them.

"God is good all the time, but he's really good to us," she told the crowd. "The empire of the abortion industry, the mother, the root, is beginning to crumble. That empire is beginning to fall." Over applause, she added, "Every abortion center needs to be closed. Every Planned Parenthood needs to be closed. We need an abortion-free and Planned Parenthood-free Dallas, Texas, United States and world."

Despite her claim — that Planned Parenthoods are abortion factories and "a gaping wound in the side of Christ" — the reality is different. There are 21 North Texas Planned Parenthoods, but only two can perform abortions. The rest provide annual exams, pap smears, STD testing and other basic family-planning services. About 40 percent of women who are part of the Medicaid Women's Health Program use Planned Parenthood.

"Planned Parenthood has a unique position in the safety net," says Ken Lambrecht, president and CEO of Planned Parenthood North Texas. "We provide gynecology access to underserved women. It's the only healthcare many of them receive. It keeps women out of the emergency room with UTIs and vaginal infections."

For people with insurance or Medicaid, going there is much like a visit to any other doctor's office.

"This can never be emphasized too much," says spokeswoman Morgan. "Our business model operates exactly like a hospital. We get reimbursed from the government for eligible procedures, just like a hospital does. We can't shift this money around. We can't ask for reimbursement that doesn't fall into the right category." The bulk of family-planning funds Planned Parenthood uses pays for healthcare for women who can't pay out of pocket at all, although some of it also subsidizes costs to make visits and birth control cheaper.

One thing 40 Days to Life got right: Clinics are closing. Planned Parenthood North Texas plans to close five because of budget cuts and another two because of lack of use. Their clients will have to drive farther to get their birth control pills. Clinics may not be able to keep the same hours. Sliding-scale fees may increase.

But Planned Parenthood's clinics are hardly the only ones impacted. Across the state, 63 non-Planned Parenthood healthcare providers, many of them with multiple locations, received those family-planning funds. Dallas County's Parkland Memorial Hospital will lose about half of its family-planning funding, cuts that will lead about 30,000 women who are served at their eight family-planning clinics to lose access to care, officials told The Dallas Morning News.

None of those clinics performs abortions.

"This is about belief systems, not balancing the budget," Parkland's president Ron Anderson told the newspaper.

Another provider, the Community Health Service Agency, operates family-planning clinics throughout rural areas of Fannin County. Dan Shepherd, the group's CEO, says his clinics are not just the only family-planning centers in some of the areas they serve — they're the only health centers of any kind.

"We're going to have to make some severe cutbacks," he says. "We're looking at having to reduce our budget and our family planning funds, possibly as much as 60 percent or more."

"I've been here for 30 years," Shepherd adds. "And it's not ever been approached from this perspective before. ... If the state doesn't come up with an adequate plan or we can't adjust, the fact is you're going to have more women who lack birth control. You're going to have women who develop cancer because they're not screened and treated properly."

Tama Shaw is the executive director of Hill Country Community Action, a rural agency based in San Saba that offers a variety of services to low-income families: child care, elderly care, even a fund to help needy families pay their utility bills. They also run six clinics that provide family-planning services. Shaw expects that number will soon go down to four.

"Title XX was about 55 percent of our budget," she says. "That will be gone. If we lost our Title X funding too, we would probably have to close the program down completely." They have a budget of $680,000 to see about 2,000 clients a year.

Close to a third of those patients clients are teenagers, Shaw says. Most live well below the poverty line. If these clinics close, they don't have another option for getting birth control.

"They just won't get it," Shaw says. "Nor will they get healthcare. We provide pap smears, breast exams and screen for STDs and HIV. We're their medical home. We refer them to local doctors when it's needed. We do everything we can for them because they can't afford anything else." At their Copperas Cove clinic, they also see a number of women stationed at nearby Fort Hood. "The military clinics are so backed up," Shaw says. "They'll be pregnant before they get in."

None of her clinics provides abortions either.

"No ma'am," she says. "There's an abortion clinic in Waco, and I guess that's where they would go. We tell the women their choices, but other than that we have nothing to do with abortion. Nor does any other family planning clinic in Texas and the United States. Because it's illegal. And it has been forever."

Given the youth of their clientele, Shaw is bracing herself for a new flood of STDs and pregnancies if more of the clinics have to close. "I'm real concerned," she says. "It's just beyond me that the Legislature — the men in there particularly — just don't get it. They did not care about these women. They did not even care what it would do to the deficit. They just strictly wanted to kill Planned Parenthood, and we got caught in the crossfire."

On the ride down the recession's double-dip, it's difficult to dispute that cuts needed to be made to the state budget, especially with the Rainy Day Fund well-guarded by the Tea Party and tax increases safely off the table. If not family planning, supporters of the cuts argue, then where?

But "defunding Planned Parenthood" will cost the state far more than it saves. About a week after the budget passed, the Austin-based Texas Observer obtained a memo from the Legislative Budget Board. It predicted that 284,000 low-income women would lose access to healthcare as a result of the cuts, with around 20,000 additional births being billed to Medicaid. Children born to a woman eligible for Medicaid — the women who use state-funded family planning programs the most — cost the state around $11,000 each, for delivery and care, advocates say. That cost, then, will be around $100 million in state money over the next two years, and a total of $231 million in combined state and federal funds.

In other words: Cutting $73 million in family planning will cost the state a net $28 million.

"The best way to prevent unwanted pregnancies is family-planning services," Hagerty says. "On average, the cost of a year's worth of family planning services — a Well Woman exam, testing for STDs, breast cancer and cervical cancer screenings, birth control — all costs an average of about $200 for a patient."

She sounds exasperated.

"It should be a no-brainer and it really is a no-brainer," she says. "But in this case ideology has trumped any rational thinking."

Especially considering this: In the end, "defunding Planned Parenthood" will almost assuredly result in more abortions.

"Women who are actively involved in family planning, and who are using contraception because they don't want to get pregnant, when that population does get pregnant, for whatever reason, almost half of them will choose to terminate the pregnancy," Hagerty says, about 45 to 48 percent, statistically. "So of course the abortion rate is going to go up. That'll be very easily tracked."

It's possible, if unlikely, that the political winds in Texas will shift, that money will be poured back into family planning in some later legislative session. But even if that happens, Shepherd, CEO of the clinic system in Fannin County, isn't sure that state family-planning providers can ever recover from such a blow.

"The problem is that you're destroying infrastructure," he says. "Clinics are closing statewide. And when they shut down, they're going to have their services dismantled. This is infrastructure that's going to be much more costly if they want to rebuild it in two years."

He pauses, frustrated.

"To rebuild it," he says finally, "is not as easy as it is to tear it down."

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