The Trump Administration Proposed Cutting Funding to Clinics Like Planned Parenthood. We Know How That Plays Out Because Texas Did It in 2011.

A look at the research on what happens to contraceptive access for low-income Americans when the government withholds funding to family-planning clinics.
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A woman sits in the exam room at a Planned Parenthood health center on in West Palm Beach, Florida.

A woman sits in the exam room at a Planned Parenthood health center on in West Palm Beach, Florida.

The White House published a proposed rule on Monday barring federal funding to any clinics that provide abortions or refer their patients to abortion providers. Among those organizations that would be affected by the rule: Planned Parenthood, which has pledged to continue offering abortions.

Not surprisingly, the White House's proposal has been condemned by supporters of abortion rights and celebrated by anti-abortion activists (many of whom President Donald Trump addressed at a pro-life gala Tuesday night).

The new federal rule bars abortion providers and referring facilities from getting funding through Title X, a government program that supports free or low-cost contraception, treatment for sexually transmitted diseases, and reproductive cancer screenings for low-income Americans. In 2016, the latest year for which numbers are available, Congress allocated $286 million to Title X, supporting hospitals and clinics that served four million Americans. Federal funds are already banned from paying for abortions directly: Currently, if a clinic provides abortions, it can't use Title X funds to pay doctors who perform the procedure; it must use other money to pay for use of its waiting room by abortion patients. But the Trump rule states that Title X hospitals and clinics must separate their abortion and non-abortion services even further, though it doesn't specify how.

Planned Parenthood is the most recognizable of the potentially affected clinics. In 2015, Planned Parenthood served 41 percent of America's Title X patients. It stands to lose $60 million, the Washington Post reports.

But what does the rule actually mean to the four million Americans—most of them young women living under the poverty line—who receive health care at the clinics that would be affected?

To find out, Pacific Standard combed through the work of a group of researchers at the Texas Policy Evaluation Project, who have spent seven years tracking the family-planning policies in their state. As far as pro-life legislation goes, Texas is a pioneer: Even as previous conservative efforts to defund Planned Parenthood have failed nationally, they've been successful in the Lone Star State. Texas may offer a preview of the effects of the Trump administration's policies on reproductive health-care centers and their patients, nationwide.

The policies Texas passed in 2011 are a bit different from what the Trump administration has proposed. The Texas legislature cut its family planning budget by two-thirds and de-prioritized specialized family-planning clinics, such as Planned Parenthood, from getting the remaining money. The effect of Trump's rule could be similar, however, if Title X clinics that provide or refer for abortions don't change their practices and take the financial hit instead, says Kari White, a sociologist with the Texas Policy Evaluation Project.

Not long after Texas cut its family planning budget, fewer clinics were able to offer their patients the most effective, long-acting, but more-expensive birth control options, such as intrauterine devices and contraceptive implants. Before the 2011 legislation took effect, 71 percent of Texas organizations that received federal money for family-planning purposes offered IUDs and implants to their patients, White and her colleagues found. In 2013, only 46 percent did so. Overall, the organizations saw less than half as many patients after the cuts, compared to before.

The women and teenage girls the researchers talked to in 2012 generally didn't know that the law had been changed in their state. But they felt very acutely the effects of that change: Birth control and exams that used to be free now cost, say, $50, or $70. Some said they forewent these services in favor of other needs. "That's hard when you're a single parent and have kids. That's expensive," one woman said. "With the $50, we pay [for] gas, we buy the Pampers," said another.

If family planning clinics are hampered by the federal rule, will other types of facilities—such as doctor's offices or hospitals that don't perform abortions—pick up the slack? Conservatives often argue that they will. (Axios reports that presidential counselor Kellyanne Conway showed Trump a map of clinics that don't provide abortions while she was trying to convince him to go through with the rule.) The Texas Policy Evaluation Project's work, however, suggests there will be a steep learning curve.

In 2013, the Texas government set up a $100 million fund with rules that encouraged primary-care offices that served low-income women to pick up the slack and start offering reproductive care. In 2014 and 2015, a team from the Texas Policy Evaluation Project interviewed staff members at 30 organizations, including women's health organizations and primary-care clinics. The researchers found clinics that weren't used to offering reproductive care often had a hard time performing their new duties.

Some clinics were slow in figuring out how to order the devices and medicines they needed. Others didn't have doctors or nurses who were trained to insert IUDs and birth-control implants. They had to either hire new staff or train their workforce. Some implemented protocols that aren't medically necessary, such as not offering IUDs and implants to teens and women who didn't already have children, or requiring STD results to come in before inserting implants. Leaders at several clinics that were located near now-closed Planned Parenthoods said they didn't see Planned Parenthood's old patients come into their facility because they didn't have the money to advertise to the community that they now offered reproductive services.

Still, the extra $100 million had positive effects: More clinics could once again offer free or discounted IUDs and implants to their needy patients.

Overall, since 2011, low-income girls and women in Texas have been less able to get reliable, long-term contraceptive methods that they are comfortable with. "Either clinics don't have sufficient funding to offer women the methods that they want, or the funding that is available is being channeled toward providers that do not have the capacity, the training, and the experience," White says. "So we would really like to see policies that support women to get the methods that they want."

Now, it's possible the effects of Trump's rule will be less severe than Texas' policies, because it doesn't cut funding to Planned Parenthood and other clinics that offer abortions as badly. Still, the rule is a major change to the whole ecosystem that currently serves lower-income Americans seeking reproductive care. There will certainly be effects.

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