By Mary Tuma
When Texas decided to exclude Planned Parenthood clinics from its Medicaid-funded women’s health care program, women like Crystal Gonzalez were left scrambling for a new provider.
Using a state-crafted database with more than 200 practitioners listed within 30 miles of her ZIP code, the college student was initially impressed by the scope of options. But soon after calling around, she realized the entries were somewhat misleading. She ended up with a much smaller pool of actual providers than anticipated, a discouraging revelation for the already worried patient.
She called one doctor’s office that was listed twice in the database.
“Oh, no. This is a children’s clinic,” the voice on the other end of the line replied. “Have you tried Planned Parenthood?”
Noting the irony, Gonzalez sighed and moved along to the next entry listed.
Gonzalez’s story has the potential to be repeated across the country, as conservative state legislators move to cut off funding to Planned Parenthood and GOP presidential candidate Mitt Romney pledges to “end federal funding” for the organization.
Gonzalez, 20, has relied on Planned Parenthood in the South Texas border city of Weslaco as her only form of health care for the past two years. On financial aid, she works part time at the local grocery store and helps support her mother, who hopes she will see her daughter become a first-generation college graduate.
Her medical visits supported by the WHP not only help ensure her reproductive health, but also safeguard the young woman against the prospect of one day contracting diabetes, a hereditary disease that is widespread in her family.
Gonzalez is not alone in depending on the program. In Hidalgo County -- an area riddled with poverty and high uninsured rates -- the family planning service is integral to maintaining a healthy life for many.
However, a rule signed earlier this year by then-state Health and Human Services Commissioner Tom Suehs -- and promoted by conservative Republican legislators and Texas Gov. Rick Perry -- barred Planned Parenthood clinics from participating in the program because they are affiliated with an abortion provider. The state did this despite the fact that federal and state money was already prohibited from being used for abortion.
Arguing that Texas’ actions violated federal law, the federal government announced it would not renew its 90-percent share of the WHP, leaving obstinate Texas leaders to offset the sizable financial loss with their own source of funding.
As a result, Gonzalez and more than 50,000 low-income, uninsured women are slated to be kicked out of Planned Parenthood, the most widely used provider in the program, by Nov. 1. Now, they must obtain their basic reproductive health care, like pap smears, preventative breast and cervical cancer screenings, diabetes and hypertension exams, birth control, and STD tests, elsewhere.
In an effort to make the transition smoother for women, the health commission directed women to a searchable online database for the displaced Women’s Health Program clients and vowed that they would still be able to locate a provider within 2.5 miles of their home.
Yet, instead of making the process less complicated for women, the list is garnering complaints from providers and patients alike for its questionable search results. Among the issues are duplicate entries, listings unrelated to reproductive health, and providers that do not enroll WHP clients.
The problems reinforce serious uncertainty from health care organization leaders statewide over the feasibility of displaced Planned Parenthood clients finding services in their area. Other care providers cannot realistically absorb the high volume of expelled patients, they warn, especially since nearly half of women in the program depend on Planned Parenthood for its services.
State legislators have expressed skepticism over health commission claims that “96 percent” of women would not have to travel any further for care under the new rule. In an August letter, eight Democratic state senators wrote, “To date, no credible evidence exists that shows other providers could increase their capacity to fill” the void created by Planned Parenthood’s exclusion from the program.
A study conducted by George Washington University’s School of Public Health and Health Services found that in order to realistically make up for the loss of Planned Parenthood, the state’s community health centers would have to expand their Women’s Health Program capacity “five-fold,” from about 10,000 to more than 62,000 patients. In light of the simultaneous loss to family planning funds due to deep legislative budget cuts, “such an expansion in a short time period is virtually impossible,” the study found.
Moreover, the study found that the state’s estimates of the rule’s impact “appear to contain numerous methodological flaws.” The study warns that the estimates “may overstate remaining provider capacity in communities” where program participants live and fail to “take into account the fact that unlike PPFA clinics, many WHP providers treat only a handful of patients.” The study also suggested that the state may be counting “reference laboratories as sources of direct patient care.”
‘You would think we were five different providers’
Those who have searched the state’s online database of eligible WHP providers have voiced similar concerns. In a May RH Reality Check article, Andrea Grimes reported a number of problems with the database. Grimes found that many of the providers were duplicate entries, were not currently enrolling Medicaid patients, or did not even accept Women’s Health Program patients.
Regina Rogoff, CEO of Austin-based People’s Community Clinic, told The American Independent the list is “misleading” and points to her clinic’s appearance on the database five times in one search. (Indeed, in a search of the database for “78751,” three entries list individual physicians who work at the clinic -- one of them is listed twice -- and the clinic itself is listed twice.)
“You would think we were five different providers, five different options for these women, but we are not,” Rogoff said. “I think the overall number is suspicious and needs to be examined carefully. Maybe there are technically 20,000 providers listed, but most only see a handful of patients or at least don’t see the volume of patients that Planned Parenthood does.”
A frustrated Crystal Gonzalez experiences a similar scenario.
While the state has promised she would find a reliable clinic within 2.5 miles,
Gonzalez extends her search to 5.19 miles to choose from a pool she finds more substantial.
In a search of the “78537” ZIP code for a new reproductive health clinic in Weslaco, several duplicate entries were listed, making the list of providers appear more diverse than it really was. Some were direct duplicates, listing names twice. Others listed the clinic once and separately listed a physician at that clinic at least once. In one case, four separate entries included the same address and phone number. Of those four, doctors Rita Eye and Pablo Rivera were listed twice, once with a middle initial or name and once without. Ultimately, neither of those doctors was accepting new Women’s Health Program clients at the time, a problem that occurred with at least one other provider in the list.
And a familiar name appeared in the search results -- Planned Parenthood. Technically, the clinic stands as a provider, but it should not be found on the database after October.
When duplicate entries were accounted for and eliminated, Planned Parenthood clinics and those not accepting the Women’s Health Program were removed, the displaced patient was left with nine actual providers to choose from out of 29 entries.
Even so, many of the practices that did accept the Women’s Health Program presented hurdles Gonzalez does not have to confront with her provider of choice, Planned Parenthood. For example, the Rio Grande Valley Adult and Internal Medicine Clinic (listed three separate times) only offers pap smears and sexual health counseling within the program, but no birth control.
And most of the providers stressed their capacity is not comparable to Planned Parenthood. One private practice listed only takes between five and 10 program clients a year, while the larger clinics take on fewer than 50. The figures stand in stark contrast to the Planned Parenthood in the area, which sees more than 1,000 Women’s Health Program patients.
Lucy Ramirez, executive director of the Nuestra Clinica Del Valle -- a primary care center that specializes in women’s health and accepts WHP patients -- told TAI that her female patients typically choose Planned Parenthood for their well-woman exams and pap smears. Of the patients that may start opting for her clinic in lieu of Planned Parenthood, Ramirez says they can probably handle “some” of the extra clients but certainly not everybody. For the ones that try to schedule an appointment, wait times to see a doctor will be long.
“Well, that’s exhausting and confusing,” said Gonzalez after making a round of calls in search of a new provider. “I’m pretty offended that some of these unavailable options are listed. Why are they making this more difficult for us?”
The young woman is skeptical that working, poor women in her impoverished community can easily navigate the database, let alone find a reliable mode of transportation to their appointments given the possibility of longer travel time.
“I really doubt many of these women, working multiple jobs and with little extra time on their hands, are going to be able to go through this list or even be able to drive to a new provider,” she says. “I’m lucky enough to have a car, but many of them don’t have cars, and public transportation in the area isn’t very reliable.”
In response to duplicate entries and inflated results, Stephanie Goodman, spokesperson for the Health and Human Services Commission, told TAI the agency is “looking at ways to improve the online search.”
“Many of the duplicate entries are because providers have multiple sites or register under multiple specialties. But some are because a provider may have entered their address different ways -- maybe one entry includes ‘Drive’ on the address and another doesn’t,” said Goodman in an e-mail message. “We’re looking at ways to eliminate those types of duplicate entries.”
Overall, Goodman continues to assure Texans that the commission has been working to recruit new doctors and clinics into the program. Goodman says the state has increased the number of providers by 500 since the spring.
“We’re confident that we’ll continue to have enough providers to serve women in the program,” she said.
But according to the Houston Chronicle, Kyle Janek, the current head of the commission, said last week that he couldn’t “guarantee” that providers would be available for every woman in the program by Nov. 1.
As for those providers listed who say they don’t accept Women’s Health Program patients, Goodman says according to her records, they still completed the certification process to be part of the program and are able to bill for the service -- even if they are currently not accepting new patients.
‘A domino effect’
Gonzalez and her fellow Hidalgo County residents have the most to lose when Planned Parenthood is forced to exit the program and are, therefore, the most reliant on the accuracy of the database.
Massive legislative budget cuts made last session (separate from the rule excluding Planned Parenthood from the WHP) slashed more than $74 million in family planning funds and crippled the network of providers. According to the non-partisan Legislative Budget Board, the cuts will lead to nearly 284,000 women losing services. In Hidalgo County alone -- an already beleaguered and impoverished area along the Texas-Mexico border -- four Planned Parenthood clinics were forced to close due solely to the budgetary cutbacks. The Hidalgo association lost $3 million in funding, amounting to nearly 50 percent of its budget, and reduced its staff by half. As one of the largest family planning providers in Texas, the cuts to Planned Parenthood in Hidalgo affected about 15,000 women, according to the association.
Patricio Gonzales, CEO of the county’s Planned Parenthood system, says residents are heavily dependent on the clinics for care, and the need keeps growing in the face of more cuts. In 2010, about 23,000 clients, including men and teenagers, accessed health care at one of the centers, a 40 percent increase in four years. The dependence stems from the region’s status as a socioeconomically stunted area. The Hidalgo centers serve one of the poorest counties not just in the state but the country, with 90 percent of the clientele living at or below the federal poverty level. Overall, more than a third of Hidalgo County residents live in poverty.
“For our patients, Texas family planning is their safety net,” says Gonzales. “We are their only doctors for many, many years before they can get a job and get insurance and get ‘real’ doctors – we sometimes joke.”
A recent article published in the New England Journal of Medicine details the devastating effects family planning budget cuts have had on Texas clinics, including more than 50 closures and a reduction in hours and services. For example, clinics have reduced the number of birth control pill packs provided to patients per visit -- a practice that, according to the researchers, “has been shown to result in lower rates of continuation with the method and that may increase the likelihood of unintended pregnancy.”
Gonzales says the study’s findings mirror the situation of the shredded health care network he oversees.
He says that in 2008, 6,056 women received birth control pill packs. But following the budget cuts in 2011, the number dropped to 5,201. Gonzales expects that number to fall even further this year.
“Because we are having to charge now, working poor women cannot afford to pay, so they are just not coming to us,” he says.
Still experiencing the heavy blow dealt by budget cuts, Gonzales says the dismantling of the Women’s Health Program will push the remaining clinics to the brink of shutting down.
According to a George Washington University study release earlier this month, more than 80 percent of the Women’s Health Program enrollees in the area come to Planned Parenthood, making it the largest provider for the program in the region. The second-largest provider serves less than 10 percent of the number of Planned Parenthood’s clients. Gonzales says that when his Planned Parenthood network is cut out of the program, it will be forced to stop seeing 6,500 patients.
Planned Parenthood centers in McAllen, Edinburg, and Weslaco -- which heavily rely on the Women’s Health Program to stay afloat -- and a clinic in San Juan survived last year’s budget cuts. But when the program is axed at the end of the month, Gonzales says at least half of the centers will likely close.
And if they do, health care facilities nearby cannot absorb the number of clients Planned Parenthood sees, says Gonzales.
“There is no feasible way the surrounding clinics can take in that many women. Where do they go? I can’t refer that many women to the county health department or the federally qualified health center. There is no way they can see that number of clients,” he says.
The October George Washington University study found that because of the high number of Women's Health Program clients using Planned Parenthood clinics in Hidalgo County, other facilities in the area would need to increase their caseload by 531 percent in order to replace Planned Parenthood.
The study also found that non-Planned Parenthood clinics are “generally at, or close to, the limits of their capacity and will not be able to expand much, if at all, due to other resource or staffing constraints.”
The researchers single out the severe effects the strain would have on Hidalgo, writing that “problems would be particularly serious in poorer, less urban areas, like Hidalgo or Midland Counties, where there are fewer alternative providers.”
Moreover, the researchers point out that one reason so many women have chosen Planned Parenthood is that they simply “prefer Planned Parenthood facilities, whether because of their locations, the nature and quality of services provided, their reputations, the quality or attentiveness of staff, or for other reasons.”
“The bottom line is that you should have the freedom of choice to select your own provider and not be subject to a preapproved or preselected list,” says Patricio Gonzales.
Straddled with additional barriers to access, poverty-stricken clients are oftentimes unable to secure reliable transportation or pay for travel to clinics that are can see them. And so for many women in the border area, that means forgoing basic care.
“I’ve talked to a lot of women and they are just going without,” says Gonzales. “They are taking a risk of getting pregnant, taking a risk of not getting pap smears; a risk of not detecting cancer early; a risk of not getting treated for a sexually transmitted infection.”
“We are going to see a domino effect,” he adds. “When access to family planning decreases, pregnancy and abortion rates will rise. The health of the community is jeopardized and we all suffer down the road.”