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 to be increasingly problematic as states diverge in their political contexts and as health care itself becomes politicized.
In the case of reproductive health care, the politicization and between-state divergence is particularly acute. This is well-documented for abortion restrictions, but it is increasingly true of family planning as well. For example, 23 states and both houses of the US Congress have considered or passed legislation barring Planned Parenthood affiliates from providing care with public funds. These proposals emerge from an animus for Planned Parenthood that may stem from the organization's political action as well as its strong association with the provision of abortion care.
The question we raise in this post is whether the politicization of this health care provider and reproductive health care in general has led to a situation where meaningful, empirically based debate over specific policies is no longer possible.
What Happened
We recently evaluated the impact of Texas' exclusion of Planned Parenthood from a fee-for-service family planning program (the Women's Health Program or WHP), publishing the results in The New England Journal of Medicine. The paper was widely covered in the press and on social media, and quickly criticized by Texas officials. Moreover, one of our co-authors was forced to resign for participating in the research. Here we describe our paper's origins and the response it received in the media and among Texas legislators. We then place the paper's reception in the context of increasing polarization among US states regarding reproductive health care, and question the room that remains in a state such as Texas for peer-reviewed empirical analysis.
In 2007, through a Medicaid waiver program, Texas began offering family planning services to women with incomes below 185 percent of the federal poverty line. The program always excluded providers of abortion care. But in 2011, the Texas state legislature directed the Texas Health and Human Services Commission (HHSC) to exclude from the program any organizations affiliated with abortion provision, including Planned Parenthood affiliates.
The federal government indicated that such an exclusion violated Medicaid's rules and ended the Texas waiver on January 1, 2013. In response, Texas replaced the federally supported program with an otherwise identical state-funded program that excluded Planned Parenthood affiliates. (As is discussed in more detail below, shortly after Texas took over the fee-for-service family planning program, the legislature introduced another new program that was widely seen as an effort to reverse a large cut that had been made to a different stream of state funding for family planning in 2011.)
In October 2012, a suit was filed challenging the exclusion of Planned Parenthood affiliates. In this challenge, the attorneys for the plaintiffs argued that the existing infrastructure could not accommodate the surge in demand that would result from excluding Planned Parenthood affiliates. Furthermore, they argued, specialized family planning providers were better equipped to meet women's desires for more effective methods of contraception like IUDs and implants. The attorneys for the state countered that care could continue uninterrupted because other, non-Planned Parenthood providers would take up the clients who had previously received care at Planned Parenthood affiliates.
In the courtroom, Dr. Richard Allgeyer, director of research for the HHSC served as expert witness for the state and one of us (Dr. Potter) served as an expert witness for the plaintiffs. At the trial, both Potter and Allgeyer provided projections of the impact of the exclusion. But all of us from both sides knew that measuring the exclusion's true impact was an empirical question that would require careful evaluation.
The legal challenge to the exclusion was unsuccessful. But in the months following the trial, we (Potter and Stevenson), attorney for the plaintiffs Pete Schenkkan, Allgeyer, and Allgeyer's colleague Imelda Flores-Vazquez, all collaborated on an analysis to determine which of the two sides' arguments was borne out. About three years later, the resulting paper was published. We found that the exclusion of Planned Parenthood from the Texas Women's Health Program was associated with a relative reduction of 35.5 percent in the provision of IUDs and implants and a relative reduction of 31.1 percent in the provision of injectable contraceptives. Among users of injectable contraception we found a 27 percent increase in Medicaid-paid deliveries.
As with many studies of politicized subjects, some news coverage of our paper was sensationalized, and it elicited responses from political actors. The most widely read news story, in the Los Angeles Times, accrued 250,000 page views in the first 24 hours and was the #1 trending story on reddit.com for the day the paper was released. Within hours of the paper's release on the NEJM web site, Texas state legislators began posting editorials and press releases calling it "deeply flawed" and "misleading." Senator Jane Nelson sent a strongly worded public letter to the commissioner of Texas HHSC.
A week after Nelson sent her letter, Allgeyer retired from his senior position at the agency, an event widely regarded as the result of an ultimatum. While several liberal reporters and legislators responded to the legislators' unsubstantiated critique of the paper 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.
Funding Levels
In Texas, as noted above, the exclusion of Planned Parenthood from the WHP followed on the heels of a massive cut to a separate stream of state grant funding for family planning. That cut forced the closure of numerous clinics, reduced hours at others, and greatly restricted the access of uninsured women to the most effective (and most expensive) forms of contraception.
During this time, our project's peer-reviewed publications brought attention to these impacts. The clinic closures made the state look bad and raised the specter of a large increase in unwanted Medicaid births. Such concerns may have contributed to then-Governor Rick Perry's authorization of the state-funded replacement for the Medicaid-waiver program and Senator Jane Nelson's leadership in creating a new grant program to restore much of the previously cut family planning grant funding. In both of these new programs, eligibility was restricted to providers who could attest that they had no connection with providing abortion.
What results could be expected from this refunding? The financial resources were back in place, but a large fraction of the most experienced and well-trained providers had been removed from the state's programs, either because they were forced out of business by the initial round of cuts or because they were excluded by the Planned Parenthood affiliate ban. Clearly, the state of Texas has an interest in the outcome and Senator Nelson's letter stressed the need for "an objective assessment of how our programs are working—and how they are not working—in order to address any deficiencies that may exist." But legislators could only have their cake and eat it too if an ample supply of alternate providers, both public and private, were available to step in to replace those who had been shuttered or excluded. Our paper provided a direct test of this proposition, and found it to be false.
What It All Means
As health policy analysts and citizens, we find the retaliation against our colleague, Dr. Allgeyer, concerning. As social scientists, we see the response to our paper as part of a larger social process in which reproductive health research, like climate science, is judged not on its scientific merits but on its conformation to political aims within a "culture war" arena. The larger question is whether research can play any role in braking the diverging trends between "red" states in which the dominant party has a large political stake in restricting abortion rights and eliminating Planned Parenthood, and "blue" states in which the dominant party has a political stake in maintaining abortion rights and keeping all providers eligible to participate in publicly funded family planning programs. This divergence is more often than not hidden from view in nationally representative data sets based on the National Survey of Family Growth, but it may have substantial influence on demographic indicators such as teen fertility, use of highly effective contraception, and unintended pregnancy.
We are left with several, possibly complementary, interpretations of the state legislators' aggressive response to our paper. The first is that perhaps moral reasoning (represented in the disapproval of Planned Parenthood's 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 may be uppermost. Any widely visible claim that contradicts a party's position must be attacked quickly as a matter of public relations. Either way, we appear to be witnessing a foreclosure of the space for collaboration between academic institutions and state government agencies, and a shrinking space for empiricism in debates over politicized health policies.
Of course, the most optimistic interpretation of events is to take Senator Nelson at her word when she expresses the desire for objective assessments of what is working and what is not in Texas' family planning programs. As reproductive health researchers concerned for the women of Texas and the integrity of health policy evaluation, we will continue to provide the objective assessments that Senator Nelson declares she wants. It is up to her and her fellow legislators and policymakers to act on this evidence.
Authors' Note
The authors' research was funded by a grant from the Susan T. Buffett Foundation.
from Health Affairs BlogHealth Affairs Blog http://ift.tt/28Yff57
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