Lessons From Texas: Widespread Consequences of Assaults on Abortion Access

The recently published analysis by Gerdts et al. on the impact of abortion restrictions in Texas adds to the body of evidence showing that these laws—enacted under the pretense of protecting women’s health—actually threaten women’s health and well-being.¹ This study uses various measures of accessibility, availability and affordability to assess how Texas House Bill 2 (HB2), a multifaceted law passed in 2013, has complicated women’s ability to obtain an abortion.

Along with other restrictions, HB2 implemented two types of targeted regulation of abortion providers (TRAP) policies. Specifically, the law requires physicians to have admitting privileges at a nearby hospital. It also mandates that facilities where either surgical or medication abortions are performed be the functional equivalent of ambulatory surgical centers, which provide significantly more complicated procedures often involving higher levels of sedation than used for abortion. The US Supreme Court is now considering the constitutionality of the measure; a decision is expected this June.

As Gerdts et al. found, such policy changes have a very real impact. The clinic closures forced by HB2 created considerable burdens for many Texas women seeking abortion services. Women whose nearest abortion provider had closed were more likely to have traveled at least 50 miles, paid more than $100 and experienced various forms of hardship in obtaining an abortion compared with women whose nearest provider remained open. Notably, women wanting but unable to reach an abortion provider could not be interviewed, leaving their experiences largely untold.

RESTRICTING ABORTION ACCESS

Texas is far from alone in pursuing these types of restrictions (Table 1). Five states, including Texas, require that abortion providers have hospital admitting privileges; as of April 1, similar measures are pending in seven additional states. Another five states require abortion providers to meet especially stringent standards for ambulatory surgical centers that are comparable to those imposed in Texas. As of April 1, seven states have similar measures pending, though all may not be as stringent as those in effect in Texas.

TABLE 1—

Adopted and Pending State Restrictions to Abortion and Contraceptive Access as of April 1, 2016

Access to	Restrictions	Enacted	Pending
Abortion	Abortion providers must have hospital admitting privileges	MO, ND, TN, TX, UT	CO, FL, IA, IL, KY, NH, OH
	Abortion providers must meet especially stringent ambulatory surgical center standards	MI, MO, PA, TX, UT, VA	FL, IL, KY, MA, MN, NE, NY
Safety-net family planning providers	No state funding to agency that also provides abortion	WI	IL, MN, PA, VA
	Exclude abortion providers from eligibility from Medicaid or other funding, such as for cervical and breast cancer screening, sex education and intimate partner violence prevention	FL, OH	AZ, IA, KY, LA, MI, MS, MO, NH, NY, SC, WA

The wave of abortion restrictions adopted by states since the 2010 midterm elections swept abortion opponents into power in state capitals across the country goes well beyond TRAP requirements. In just five years, from 2011 through 2015, states have adopted 288 new abortion restrictions.² To put that number in context, this amounts to more than one quarter of the 1074 abortion restrictions adopted by states in the 43 years since the Supreme Court decision in Roe v. Wade.

ATTACKING THE FAMILY PLANNING SAFETY NET

Moreover, the assault on abortion access has grown into a widespread attack on safety-net family planning providers, such as Planned Parenthood health centers, that also provide abortion services or are affiliated with such providers (Table 1). This year, Wisconsin adopted a measure to prohibit the state from providing family planning funds to an agency that also provides abortion; as of April 1, similar measures are pending in four other states. Broader approaches have been enacted in Florida and Ohio. Florida’s law would exclude most providers from Medicaid, while Ohio’s would bar providers from funds for a range of services from sex education to breast and cervical cancer screening.

Abortion opponents have also set their sights on Medicaid, the program that provides 75% of all public funds for family planning.³ In January, Congress included a measure to deny Medicaid reimbursements to Planned Parenthood centers in a legislative package that would have also repealed key parts of the Affordable Care Act; as expected, President Obama vetoed the measure. In the wake of a series of deceptively edited sting videos that were released starting last summer, five states have attempted to expel Planned Parenthood centers from their Medicaid programs. Such moves are an attempt to shutter these centers, which would result in a significant gap in the family planning safety net.⁴ So far, federal courts and the Centers for Medicare and Medicaid Services have blocked these moves.

TEXAS AS A HARBINGER

Texas serves as a harbinger of what happens when family planning funding is slashed and the provider network dismantled. In addition to their concerted campaign against abortion rights, lawmakers have enacted a raft of measures undermining reproductive health and turning the state’s publicly funded family planning effort on its head.⁵ In 2011, Texas drastically cut the state’s investment in family planning and severely limited the availability of these funds to health centers specializing in the delivery of these services. Policymakers also rolled back the state’s expansion of Medicaid for family planning care through the Texas Women’s Health Program by denying funds to centers providing abortions or affiliated with centers that do; this resulted in the loss of federal financial support for the program.

Here again, the consequences were swift and severe. The state’s own reporting showed that in 2013, the first year in which the Texas Women’ Health Program was entirely state-run, far fewer women received contraceptive care.⁶ Yet another recent analysis found that, after Texas booted Planned Parenthood centers from its network of safety-net family planning providers, Medicaid claims declined for some methods of contraception, including long-acting reversible contraceptives and injectables.⁷ Texas women using injectable contraceptives were also less likely than before to consistently continue their chosen method and were more likely to have a Medicaid-funded birth.

Most recently, the fallout extended to state staff. In February, following publication of the analysis of how removing Planned Parenthood from the state’s provider network impacted women’s contraceptive access, a senior official at the Texas Health and Human Services Commission who had served as part of the research team stepped down from his post in the face of intense pressure.⁸

Clearly, the animus directed at abortion services and the providers of that care is, as Gerdts et al. found, seriously impacting women confronting an unintended pregnancy. But increasingly, this animus is extending beyond the provision of abortion services to women seeking contraceptive care, the family planning provider safety net, and now even to researchers looking to document the impact of policy changes. And all of that does not bode well for women and couples seeking to make the most basic decisions about childbearing.

Information on legislative proposals being considered in 2016 is available at https://www.guttmacher.org/state-policy; information on state law and policy in effect on key reproductive health and rights issues is available at https://www.guttmacher.org/state-policy/laws-policies. State policy information is updated monthly.