For years, Texas has had the highest proportion of uninsured individuals overall, and for adult women specifically, of any state. In 2013, one in five Texans had no health insurance of any kind, including 2.1 million adult women.
Beyond limited access to health coverage, Texas consistently has lackluster health indicators—particularly with regard to sexual and reproductive health care. Yet, at seemingly every turn, state lawmakers continue to implement neglectful, or even hostile, policies that hinder access to affordable sexual and reproductive health care and information, especially among low-income Texas women and teens.
Those policies include the state’s ongoing refusal to adopt the Affordable Care Act’s expansion of full-benefit Medicaid; its frequent attacks on family planning funding and providers; its dogged insistence on an abstinence-only approach to sex education; and its escalating restrictions on access to abortion.
Indeed, a recent study found that 55% of Texas women surveyed now face at least one barrier to reproductive health care, including affordability of services and access to providers with whom they feel comfortable.
Two recent developments highlight the state’s misguided approach.
Family Planning Access
Recently released data from the state documents the declining effectiveness of the Texas Women’s Health Program. The program was established in 2007 as a joint state-federal effort, when Texas joined about half the states in expanding Medicaid eligibility specifically for family planning services for low-income women not otherwise eligible for Medicaid.
In 2011, however, the state took several major steps to reverse course, including a move to ban any health centers from participating in the program if the center provides abortion or is associated with a provider that does. This decision to unlawfully discriminate against qualified providers ultimately resulted in the state forgoing significant federal financial support for the program—losing $9 for every $1 dollar that the state would spend.
Texas continued the program as a completely state-run, state-funded effort, with a more limited provider network. (Around the same time, the state began targeting health centers that provide family planning services in other ways, such as disadvantaging them in the allocation of state family planning dollars.)
The consequences of that decision are now clear. According to the state’s recent report, in nearly every part of the state, the Texas Women’s Health Program served fewer women in 2013 (its first year as an entirely state-run program) than it served in 2011 (before the new restrictions took effect).
Statewide, there was a 9% decrease in enrollees, a 26% decrease in Medicaid claims and a 54% decline in contraceptive claims specifically, indicating a considerable decline in service utilization among enrollees. Further, from 2011 to 2013, Texas saw a 73% decline in net savings from family planning. (These government savings accrue from helping women and couples prevent unplanned births where the maternity and infant care would have been paid for by Medicaid.)
The state itself attributes these declines in part to its exclusion of many health centers that specialize in the provision of family planning services. In 2013, the vast majority of the more than 3,800 providers participating in the Texas Women’s Health Program were private physicians; only 5% were safety-net health centers specializing in family planning services, and another 5% were federally qualified health centers delivering such care as part of a broader set of services.
Low-income women are particularly likely to rely on such safety-net sources for their sexual and reproductive health care; that is especially true for women of color and immigrant women, of which Texas has particularly large proportions. Additionally, women specifically seek care for issues having to do with sex and birth control at health centers that specialize in family planning services—providers the Texas Women’s Health Program now largely excludes.
Even in 2012, only 13% of the need for publicly funded family planning services in Texas was met by safety-net family planning centers, the lowest proportion in the country—and less than half the national average.
Overall, thousands fewer Texas women received any given contraceptive method through the program in 2013 compared to 2011. Ironically, this comes as Guttmacher data show a rising need for publicly funded family planning services in the state, driven by an increase in the number of poor and low-income women: From 2000 to 2012, the number of Texas woman needing publicly supported contraceptive care grew by 34%, to more than 1.7 million. And, nearly half (45%) of these women were uninsured in 2012, the highest proportion in the nation.
Notably, even before Texas lawmakers so drastically limited women’s access to contraceptive care, the state faced high rates of unintended pregnancy. In 2010, there were 56 unintended pregnancies per 1,000 Texas women, substantially above the national median.
Restricting access to family planning services can only exacerbate women’s risk of unintended pregnancy and limit the ability of women and families to achieve other social and economic life goals. Plus, nationwide, every public dollar invested in family planning services results in $7 in taxpayer savings.
Sex and HIV Education and Care
Texas lawmakers also continue to carry out an ideological campaign against young people’s access to honest information on sex, including pregnancy and STI prevention.
In March, for example, State Rep. Stuart Spitzer (R) won the House’s approval in moving $3 million from HIV/STI prevention programs to funding for abstinence-only-until-marriage education, stating, "My goal is for everyone to be abstinent until they are married." (Whether this maneuver will become law is unclear; it is still pending before the state legislature.)
There is ample evidence the state’s abstinence-only approach to sex education has not been working. In 2010, Texas had the third-highest teen pregnancy rate in the country, the fourth-highest teen birthrate, and the highest prevalence of repeat teen births.
Asked about the questionable efficacy of the abstinence-only program, Rep. Spitzer said, "It may not be working well…But abstinence education is HIV prevention. They are essentially the same thing."
Of course, this is not the case, and if anything, lawmakers should be doing more to connect Texas teens and women to services that help reduce the risk of both unintended pregnancy and STIs, including HIV. Texas women experience rates of chlamydia, gonorrhea and syphilis well above the national average. Moreover, Texas ranks among the top 10 states in annual rates of new diagnoses of HIV and cervical cancer.
Cutting funding for prevention programs, denying access to factual information on sex, unintended pregnancy and STIs, and restricting women’s access to the safety-net providers that are particularly well-suited to delivering preventive sexual and reproductive health care can only further harm Texas women and the state as a whole.
Unfortunately, Texas is not alone in terms of the breadth and depth of its attacks on women’s reproductive health. Too many other states are going down the same path, potentially leading to similarly harsh consequences for the women and families who live there.
But as Texas lawmakers continue to obstruct access to health coverage and care—especially sexual and reproductive health services and information—their policy decisions stand as a stark warning for the rest of the nation.
This article was originally published on Health Affairs Blog.