The United States health care safety net relies heavily on states to implement and administer federally funded programs. As the expansion of Medicaid under the Affordable Care Act (ACA) has so clearly shown, this reliance is proving increasingly problematic as states diverge in their policy contexts and health care health themselves become politicized.
In the case of reproductive health care, the politicization and divergence among states is particularly acute. It is well documented for abortion restrictions, but it is also increasingly true for family planning. For example, 23 states and both houses of the US Congress have considered or passed legislation prohibiting Planned Parenthood affiliates from providing care with public funds. These proposals emerge from an impetus for Planned Parenthood that may come from the organization’s political action as well as its strong association with the provision of abortion care.
The question we raise in this article is whether the politicization of this health care provider and of reproductive health care in general has led to a situation where meaningful, empirical debate about specific policies is no longer possible.
We recently assessed the impact of Texas’ exclusion of Planned Parenthood from a paid family planning program (the Women’s Health Program or WHP), editing the results in the New England Journal of Medicine. The newspaper was widely covered in the press and on social media, and quickly criticized by Texas officials. Additionally, one of our co-authors was forced to resign for participating in the research. Here we describe the origins of our article and the response it received in the media and among Texas lawmakers. We then place the reception of the article in the context of a growing polarization between American states regarding reproductive health care, and we question the place that remains in a state like Texas for an empirical analysis evaluated by peers.
In 2007, through a Medicaid waiver program, Texas began offering family planning services to women with incomes below 185 percent of the federal poverty level. The program has always excluded abortion care providers. But in 2011, the Texas state legislature ordered the Texas Health and Human Services Commission (HHSC) to exclude all abortion-affiliated organizations from the program, including those affiliated with Planned Parenthood.
The federal government said such an exclusion violated Medicaid rules and ended the Texas waiver on January 1, 2013. In response, Texas replaced the federally supported program with an otherwise identical funded program. by the state that excluded Planned Parenthood affiliates. (As we discuss in more detail below, shortly after Texas resumed the fee-for-service family planning program, the legislature introduced another new program that was widely seen as an effort to reverse a significant cut that was made to a different stream of public funding for family planning in 2011.)
In October 2012, a lawsuit was filed challenging the exclusion of Planned Parenthood affiliates. In this challenge, plaintiffs’ attorneys argued that the existing infrastructure could not meet the increased demand that would result from the exclusion of Planned Parenthood’s affiliates. In addition, they argued, specialized family planning providers were better equipped to respond to women’s desires for more effective contraceptive methods like IUDs and implants. State attorneys countered that care could continue uninterrupted because other non-Planned Parenthood providers would pick up clients who had previously received care at Planned Parenthood affiliates.
In the courtroom, Dr. Richard Allgeyer, Director of Research for HHSC served as an expert witness for the state and one of us (Dr. Potter) served as an expert witness for the plaintiffs. At trial, Potter and Allgeyer provided projections of the impact of exclusion. But we all knew, on both sides, that measuring the true impact of exclusion was an empirical matter that would require careful assessment.
The legal challenge to the exclusion was unsuccessful. But in the months following the trial, we (Potter and Stevenson), plaintiffs’ attorney Pete Schenkkan, Allgeyer, and Allgeyer’s colleague Imelda Flores-Vazquez all collaborated on an analysis to determine which of the two parts was confirmed. About three years later, the resulting document was published. We found that excluding Planned Parenthood from the Texas Women’s Health Program was associated with a 35.5% relative reduction in the provision of IUDs and implants and a 31.1% relative reduction in the provision of contraceptives injectables. Among injectable contraceptive users, we saw a 27% increase in Medicaid-paid deliveries.
As with many studies on politicized topics, some of our journal’s media coverage was sensationalized and elicited reactions from political actors. The most read news in the Los Angeles Times, had 250,000 pageviews in the first 24 hours and was the #1 trending story on reddit.com on the day the article was published. A few hours after the publication of the newspaper on the NEJM website, Texas state legislators began issuing editorials and press releases calling them “deeply flawed” and “misleading.” Senator Jane Nelson sent a forceful letter public letter to the Texas HHSC Commissioner.
A week after Nelson sent his letter, Allgeyer retired from his senior position at the agency, Event widely regarded following an ultimatum. While many liberals journalists and legislators responded to the newspaper’s unsubstantiated criticism of lawmakers and Allgeyer’s ouster, there was no response from any of the major medical organizations in the state, such as the Texas Medical Association and the Texas District (XI) of the American College of Obstetrics and Gynecology.
In Texas, as noted above, the exclusion of Planned Parenthood from the WHP followed a massive reduction in a separate stream of state grants for family planning. This cut has forced the closure of many clinics, reduced opening hours at others, and dramatically restricted uninsured women’s access to the most effective (and expensive) forms of contraception.
Meanwhile, peer review of our project editions drew attention to these impacts. The clinic closures have given the state a bad image and raised the specter of a sharp rise in unwanted Medicaid births. These concerns may have contributed to then-Governor Rick Perry’s authorization of the state-funded replacement of the Medicaid waiver program and to Senator Jane Nelson’s leadership in creating a new grant program to restore much of the previously cut family planning grant funding. In these two new programs, eligibility was limited to providers who could attest that they had no connection with abortion.
What results can be expected from this refund? The financial resources were back, but many of the most experienced and well-trained providers had been pulled from state programs, either because they had been forced out of business by the first round of cuts or because they had been excluded by the Planned Parenthood Affiliation Prohibitions. Clearly, the State of Texas has a stake in the outcome and Senator Nelson’s Letter stressed the need for “an objective evaluation of how our programs are working – and how they are not working – in order to address any gaps that may exist”. But lawmakers could only have their cake and eat it too if enough alternative providers, public and private, were available to replace those that had been shut down or excluded. Our article provided a direct test of this proposition and found it to be wrong.
As health policy analysts and citizens, we find the retaliation against our colleague, Dr. Allgeyer, disturbing. As social scientists, we view the response to our paper as part of a larger social process in which reproductive health research, such as climate science, is judged not on its scientific merits but on its conformation to political objectives in an arena of “culture war”. The larger question is whether research can play a role in curbing divergent tendencies between “red” states in which the dominant party has a strong political interest in restricting abortion rights and eliminating family planning, and “blue” states in which the dominant party has a political stake in upholding abortion rights and in maintaining the eligibility of all providers to participate in state-funded family planning programs. This discrepancy is most often hidden in nationally representative datasets based on the National Survey of Family Growth, but it can have a substantial influence on demographic indicators such as teenage fertility, use of highly effective contraception, and unintended pregnancies.
We are left with several, perhaps complementary, interpretations of the aggressive response of state legislators to our article. The first is that perhaps moral reasoning (represented in the disapproval of Planned Parenthood activities) and empirical reasoning are like oil and water and we cannot reasonably expect their integration. The second is that in politically sensitive matters, appearances can take precedence. Any widely visible claim that contradicts a party’s position should be promptly addressed through public relations. Either way, we seem to be seeing a closing of space for collaboration between academic institutions and state government agencies, and a shrinking space for empiricism in health policy debates. politicized.
Of course, the most optimistic interpretation of events is to believe Senator Nelson’s word when she expresses the desire for objective evaluations of what works and what doesn’t work in Texas family planning programs. As reproductive health researchers who care about Texas women and the integrity of health policy evaluation, we will continue to provide the objective evaluations Senator Nelson says he wants. It is up to her and her fellow legislators and policymakers to act on this evidence.
The authors’ research was supported by a grant from the Susan T. Buffett Foundation.