What It Means to Defund Planned Parenthood

On March 6, House Republicans proposed legislation to repeal and replace the Affordable Care Act. It contained language that would defund Planned Parenthood—that is, end the provider’s reimbursements through Medicaid—for one year. The House abandoned that legislation on Friday. But this July, it’s possible that a small-scale version of that defunding will happen in Iowa, where Republicans are pushing for a repeal-and-replace of their own: They want to scrap the state’s family-planning program and redraft it to exclude Planned Parenthood from the list of eligible providers.

The argument for this in Iowa is the same as it was in Texas when the state passed similar legislation in 2013—and it’s the the same in most states where moves have been made to block the organization from funds: Lawmakers want to prevent state dollars from going to providers that facilitate abortions, and they say Planned Parenthood patients can instead receive family-planning care, like contraception and pelvic exams, at community-health clinics.

There are currently 12 Planned Parenthood clinics in Iowa, and the legislation stands to affect nearly 4,000 Planned Parenthood patients in the state who will have to go elsewhere for their family-planning needs. The question is: Can those patients get equal health-care elsewhere?

In Iowa, the answer—like the debate itself—is complicated. Some clinics simply aren’t capable of providing that care. The ones that can will require significant coordination and investment to serve these women. And despite their eagerness to defund Planned Parenthood, the lawmakers pushing the legislation seem to have made little effort to prepare for what would follow.

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On February 2, Republicans in the Iowa Senate passed Senate File 2, a bill that would scrap the Iowa Family Planning Network waiver (IFPN) and replace it with a state family-planning program. The IFPN waiver currently allows people who don’t qualify for Medicaid to receive family-planning coverage, including contraception, pelvic exams, pap tests, and STD testing. The new state-run program would, according to Republicans, have the same requirements as the IFPN waiver, except funds wouldn’t go to any provider that performs or facilitates abortions. (No federal dollars are currently spent on abortions in keeping with the Hyde Amendment, but Republicans argue that funds actually free up money to be used for abortions.) The legislation is under deliberation in the House, but state Republicans have the votes—and Governor Terry Branstad is likely to sign it.

If it passes, beginning in July, patients receiving care under the IFPN waiver would no longer be able to get their family-planning services covered at Planned Parenthood and a handful of other providers in the state. According to the Iowa Legislative Services Agency, there were 12,219 people participating in the IFPN program in December 2016. Of those participants, 3,781 (30 percent) of them went to Planned Parenthood in 2016, for a total of 10,941 visits.

“This effort to block patients is really just a microcosm of what is happening at the federal level,” Planned Parenthood President Cecile Richards told me in a recent interview. “This is saying for many folks, you can no longer go to the health-care provider of your choice. At the federal level, it’s expanded, but it’s the exact same principle.”

Richards predicts that if legislation like this passes, it will trigger a statewide—and, eventually, a national—health-care disaster. “If women are denied the ability to go to Planned Parenthood, don’t think someone else is going to swoop in.” But that’s exactly what Iowa Republicans think will happen.

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In recent months, Republicans have offered lists of alternative clinics where IFPN patients can receive family-planning care. An initial list released by Republicans included a dentist’s office, a school nurse, and a youth shelter. A more recent list, sent to me in February by Senate Majority Leader Bill Dix’s office, was more thorough: an Excel spreadsheet containing 47 federally qualified health centers and 170 rural health clinics. Many of the providers listed were duplicates, at least one clinic was permanently closed, and several told me they didn’t actually provide family-planning services. On the rural-clinic side, only a few would likely be used by patients as alternatives to Planned Parenthood, since most were at least an hour’s drive from the nearest Planned Parenthood clinic.

But several of the federally qualified health centers could feasibly serve as alternatives, so I called a few of them to ask if they could pick up those extra patients. The problem was, no one I spoke with could give me a definitive answer, because they were all very unclear about what the new state-run program would entail.

“We’ll respond, we just don’t have a clear plan or strategy in place other than trying to get clear information,” said Ron Kemp, the CEO of Community Health Centers of Southeast Iowa. The Planned Parenthood in Burlington, Iowa (population 26,000), serves 198 IFPN patients, and a nearby Planned Parenthood in Keokuk, Iowa (population 11,000), serves 96, according to figures from Planned Parenthood of the Heartland. Lawmakers had listed Kemp’s health centers as alternatives to those two Planned Parenthoods.

“We have some capacity,” he told me, cautiously. “We don’t know the funding volume, we don’t even know all the equipment, but we’re committed to do that.” Accepting an influx of new patients seeking pelvic and breast exams, as well as contraceptives like IUDs and implants, will require new equipment and an evaluation of provider capabilities and specialization, Kemp said. “We’ll figure out a way to adapt, and expand capacity if that’s what comes in the door… sometimes that takes longer than we would like it to.”

Ted Boesen, the CEO of the Iowa Primary Care Association, a non-profit organization comprised of clinics like Kemp’s across the state, was equally cautious: “They're assuming we're the alternative...but we're waiting to see what kind of a scale it is.” Boesen said he can’t “buy in” until Republicans respond to his questions about the new state-run family-planning program. Kemp also characterized interactions with GOP lawmakers as “limited,” telling me, “If there had been more detailed discussions, we might be able to be more further along.”

That uncertainty is a key problem in the debate: Natoshia Askelson, an assistant professor in the College of Public Health at the University of Iowa, told me that providers are still in the dark about basic details on how program will be run, like what contraceptives will be provided or whether there will be enough providers for displaced patients. The new program is also supposed to be entirely state-funded, instead of relying mostly on federal funds, which the IFPN waiver currently does through a federal matching program.

Askelson is “very concerned” about that. “[Iowa is] not in a position right now where we can afford things the federal government would pick up the tab for otherwise.” She believes SF2 could very well be ruining a good thing.

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Scrapping the IFPN waiver limits the choices of patients in two ways: First, it shortens the list of provider options. It tells patients they can no longer go to the local Planned Parenthood if they want their reproductive-health services to be covered. Boesen, the Iowa clinic spokesman, admitted that was one of his main concerns. “Those gals…for generations, that’s been a safe place for them to go,” he told me, “so everybody’s wondering how we can provide that.”

I asked state Senator Dennis Guth, a Republican representing Iowa’s 4th senate district and an SF2 proponent, if he sees that as a problem: If someone likes their doctor, shouldn’t they be able to keep her? Guth acknowledged that that might be an issue for some women, but in the end, his view was that visiting a general-health practice is more efficient.

“[You can] take care of your women’s-health needs and take care of your strep throat at the same time,” Guth told me. “It’s usually better to do both of those at once, anyway.”

Askelson said that idea indicates “a general lack of understanding around women’s health and contraceptives.” In an ideal world, a single provider would be able to address all of a woman’s health-care needs, but there’s a reason people go to—and prefer—Planned Parenthood. “We’re talking about, for the most part, women of child bearing age [who] don’t need to be going to the doctor a lot,” Askelson said. “We’re talking about women going to a health-care provider for sexual and reproductive health. When you take that away, your average family practice doctor is just going to prescribe birth-control pills.”

The second way this bill could limit choice is by reducing access to long-acting contraception. The way government funding for family-planning services works is that providers front the money for contraception and exams, and then submit a request to the government for reimbursement. Rebecca Kreitzer, an assistant professor of public policy at the University of North Carolina at Chapel Hill, told me “It’s cheap to provide oral contraceptives and prophylactics,” but “it’s expensive to provide long-acting reversible contraceptives that we know to be the most effective.” That’s why IUDs and contraceptive implants (two kinds of long-acting reversible contraceptives) aren’t readily available at many general-health clinics, and staff isn’t always trained in inserting them. But Planned Parenthood is a big enough organization that they are able to front the money for those services, Krietzer said. And since their focus is on family-planning care, they usually have the staff and equipment on hand to provide those services quickly.

Calls to a few of the Iowa clinics listed as Planned Parenthood alternatives seemed to bear that out. Kemp’s Community Health Center in West Burlington doesn’t provide any form of contraception that has to be inserted, like implants or IUDs. The Keokuk clinic does, but their earliest opening for a contraception consultation—or a breast or pelvic exam—was in 11 days, while two nearby Planned Parenthood clinics both had same-day openings.

In Council Bluffs, the federally qualified All Care Health Center has one family-planning provider working only on Fridays. The local Planned Parenthood is open on Monday, Wednesday, and Friday. The earliest appointment at Eastern Iowa Health Center in Cedar Rapids was two weeks away, and at Siouxland Community Health Center in Sioux City, a new patient wanting an IUD might have to wait about a month. Both the Cedar Rapids and Sioux City Planned Parenthoods had same-day appointments for all of those services.

Would the Republicans’ new state-run program provide enough funding to enable clinics to have implants and IUDs at the ready? To hire enough women’s-health specialists? To provide same-day appointments? Clinics don’t know. Even if they will be able to provide all of those services, Askelson worries it won’t matter. If women aren’t already going to a general-health clinic for care in Council Bluffs, for example, are they going to start now?

“It’s hard enough to get people to use contraceptives every time,” Askelson said. “Now you change providers from someone they trust … I don’t know whether [clinics] will be seeing a lot of people.”

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The Iowa Family Planning Network waiver was set up in February 2006 as a way to extend health services to low-income women who otherwise wouldn’t receive Medicaid coverage. In May 2016, the University of Iowa Public Policy Center conducted an evaluation and concluded that more than 80,000 women had accessed family-planning services through IFPN in those 10 years. There was a $345 million reduction in Medicaid costs for deliveries and births, and a net Medicaid savings of $265 million.

The abortion rate declined 23 percent in Iowa between 2011 and 2014, according to the Guttmacher Institute, something public-health experts attribute to wider access to publicly funded family-planning services. If access to those services becomes more limited, Askelson predicts that unintended pregnancy rates could increase, and with it, the number of abortions.

In 2011, the Texas state legislature reduced funding for family planning from $111 million to $38 million as part of an effort to defund Planned Parenthood. After the cuts, 82 clinics closed—two-thirds of which were not Planned Parenthood clinics. In 2013, the state prevented abortion providers from participating in the state’s family-planning program—just like what Iowa is trying to do now. After the cuts, nearly half of the organization’s clinics closed, and many patients were left without access to long-acting contraceptives.

A study published in the New England Journal of Medicine in February concluded that excluding Planned Parenthood from Texas’s family-planning program resulted in about 36 percent fewer requests for IUDs and implants, and the number of women who were regularly receiving contraceptive injections declined in counties where they could no longer go to Planned Parenthood. For the women relying on injectable contraceptives, the rate of childbirth covered by Medicaid increased by about 27 percent.

The study closed with a warning that the team’s findings indicate “the likely consequences of proposals to exclude Planned Parenthood affiliates from public funding in other states or at the national level.”

But at the national level, the House Republicans’ failed bill to repeal and replace the Affordable Care Act included a proposal to exclude Planned Parenthood from Medicaid reimbursements for one year. The much-awaited report from the Congressional Budget Office projected that a change like that would leave 15 percent of patients in low-income communities “without services that help women avert pregnancy.”

The CBO estimated that cutting Planned Parenthood would save $178 million under Medicaid, but that savings would be partially offset by “several thousand” more births—paid for under Medicaid.

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Critics warn that excluding Planned Parenthood from state or federal funding—without ensuring that community-health clinics can serve as adequate alternatives in practicality—is a dangerous move. This is a “big deal for women,” Askelson said. “It concerns me that there’s a disregard for what the evidence says, that people aren’t crafting legislation based on data and evidence.”

It’s possible that Senate File 2 and similar legislation in Texas and other states, as well as the recent failed House Republican proposal, are all incremental moves leading to something much bigger.

One Iowa clinic representative told me he was concerned, above all, that SF2 would lead to the state barring Planned Parenthood from receiving Title X funds. That’s the federal-grant program enacted by President Richard Nixon in 1970 designed to help low-income Americans with family-planning coverage.  If that were to happen, he said he couldn’t fathom the impact it would have—and he didn’t think clinics would be able to pick up the slack.

Kreitzer suggests there is “not a small chance” that Americans might soon see proposals to cut or even abolish Title X. “It’s something that Republicans have floated around,” Kreitzer said. “And if that were to happen, that would affect millions of women.”

The continuing resolution to fund the federal government is set to expire on April 28, and the House Freedom Caucus, a congressional faction of strict fiscal conservatives, is expected to make defunding Planned Parenthood a non-negotiable condition in passing the bill.

In recent decades, contraception has “become intertwined ideologically with abortion,” Kreitzer said. “In this intermingling of contraception and abortion, women’s health care is really taking a hit.”