Summary of "Effect of removal of Planned Parenthood from the Texas Women's Health Program," Stevenson et al., New England Journal of Medicine, Feb. 3, 2016.
Despite federal law defining "all medically qualified providers [as] eligible to provide care that is funded wholly or in part through federal programs," 17 states and both houses of Congress have proposed legislation to exclude "Planned Parenthood affiliates from participation in state-administered, federally funded family-planning programs," according to Amanda Stevenson of the University of Texas at Austin's Population Research Center and colleagues.
The researchers explained that Texas in 2011 became the first state to enact such a law when the state Legislature ordered the Texas Medicaid-waiver program, the Women's Health Program, to exclude Planned Parenthood. After CMS discontinued federal funding because of the unlawful exclusion, the state "replaced the federally funded program with a nearly identical 100% state-funded program (the Texas Women's Health Program) that excluded clinics affiliated with an abortion provider, effective January 1, 2013." The state in September 2011 also "cut family-planning grants ... by 66% and redistributed the remaining grant funding away from dedicated family-planning providers, such as ... Planned Parenthood affiliates."
According to the researchers, "The 2011 reductions in grants and redistribution of funds were followed by the closure of 82 family-planning clinics, about a third of which were affiliated with Planned Parenthood." They noted that the closures preceded the 2013 cuts.
For the study, the researchers examined "claims data for all clients of the Women's Health Program and its replacement, the Texas Women's Health Program, to assess changes in the provision of contraceptives after the exclusion of Planned Parenthood affiliates." The researchers also assessed data on women using injectable contraception to "estimat[e] the change in continuation of the contraceptive method in the program and in the rate of childbirth covered by Medicaid after the exclusion."
Methods
For the study, researchers examined "all pharmacy and medical claims from January 1, 2011, to December 31, 2014, under public fee-for-service family-planning insurance programs in Texas," as well as "all claims for childbirth covered by Medicaid" among women who were using injectable contraception. According to the researchers, "all women who were receiving services were fertile, legal Texas residents between the ages of 18 and 44 with incomes at or below 185% of the federal poverty level."
For each quarter, the researchers "categorized contraceptive methods into three groups: long-acting reversible contraceptives (LARC; contraceptive implants and intrauterine devices), an injectable contraceptive ... and short-acting hormonal methods." They "then separated each set of claims into those that were filed in counties that had a Planned Parenthood affiliate in 2011 and those that were filed in counties without such an affiliate at that time."
According to the researchers, 23 of the 254 counties in Texas had Planned Parenthood affiliates. The researchers "compared the group of counties that had a Planned Parenthood-affiliated clinic with those that did not with respect to the number of [eligible] women ..., the number of childbirths to legal residents covered by Medicaid, and the proportion of women between the ages of 18 and 44 who did not have health insurance."
The researchers also examined the "quarterly volume of program claims for contraceptives" for counties with and counties without a Planned Parenthood affiliate "during the 16 observed quarters (8 before and 8 after the exclusion)." Among women who obtained injectable contraceptives in counties with and without an affiliate in the fourth quarter of 2011 and 2012, the researchers calculated "the proportion of women who returned to the program for any service, who returned for an on-time subsequent injection, and who underwent childbirth covered by Medicaid during the following 18 months." The researchers said they focused on women using injectable contraception because the "method requires regular provider visits and has a relatively short span of contraceptive effectiveness (3 months)," which allowed researchers "to observe changes in the rate of childbirth within 18 months after the claim."
Results
According to the researchers, "The 23 counties with Planned Parenthood affiliates were home to 60% of [eligible] female Texas residents." They noted that counties with and without Planned Parenthood affiliates had similar proportions of uninsured women, while 63% of "childbirths that legal residents underwent and that were covered by Medicaid in 2012" were in counties that had affiliates. The researchers noted that the "decrease in the number of family-planning clinics" prior to Planned Parenthood's exclusion "was greater in counties without Planned Parenthood affiliates than in those with such affiliates."
The researchers found that, before the exclusion, the number of claims for LARC and injectable contraceptives in counties with and without Planned Parenthood affiliates decreased, while the number of claims for short-acting hormonal methods increased in both groups of counties. After the exclusion:
- Claims for LARCs decreased sharply for the first quarter in counties with an affiliate but not among those without affiliates, and then increased in subsequent quarters in both groups of counties;
- Claims for injectable contraception decreased sharply for one quarter in counties with affiliates but not among those without affiliates, and then "remained relatively stable during the next 2 years"; and
- Claims for short-acting hormonal contraception "remained relatively stable" for one quarter in both groups of counties and then declined in subsequent quarters.
According to the researchers, the difference in claims after Planned Parenthood's exclusion "was significant for the provision of LARC methods and injectable contraceptives ... but not for short-acting hormonal methods." Overall, the study found that Planned Parenthood's exclusion "was associated with estimated reductions in the number of claims from 1042 to 672 (relative reduction, 35.5%) for LARC methods and from 6832 to 4708 (relative reduction, 31.1%) for injectable contraceptives."
Change in rates of contraceptive continuation and childbirth
The researchers examined contraceptive continuation rates and rates of childbirth covered by Medicaid between women who obtained injectable contraception in the last quarter of 2011 and those who obtained an injection in the last quarter of 2012.
According to the researchers, after the Planned Parenthood exclusion, the percentage of women using injectable contraception who returned for a subsequent dose "decreased from 56.9% to 37.7% in counties with Planned Parenthood affiliates but increased from 54.9% to 58.5% in counties without such affiliates." The researchers noted that the "change represents a relative decrease of 40.2% from baseline."
Further, the researchers found that, 18 months after the exclusion, the proportion of women with Medicaid coverage who underwent childbirth increased from seven to 8.4 percent in counties with affiliates and decreased from 6.4 to 5.9 percent in counties without affiliates. According to the researchers, "This change represents a relative increase of 27.1% from baseline ... in the proportion of women using injectable contraceptives who underwent childbirth covered by Medicaid within 18 months after the claim."
Discussion
"After Texas abruptly excluded Planned Parenthood affiliates from its fee-for-service family-planning program, the number of claims for LARC methods declined, as did the number of claims for contraceptive injections," the researchers wrote. According to the researchers, "Among women using injectable contraceptives, fewer women who received an injection in the quarter preceding the exclusion continued to receive an injection through the program than did those in an earlier cohort." Further, they noted that "there was a disproportionate increase in the rate of childbirth covered by Medicaid."
The researchers wrote that while they did not collect data on whether the pregnancies were intended, "it is likely that many of these pregnancies were unintended, since the rates of childbirth among these women increased in the counties that were affected by the exclusion and decreased in the rest of the state." According to the researchers, the decline in LARC claims in counties with Planned Parenthood affiliates "at the time of the exclusion represents a divergence from the trend toward an increased number of claims for LARC methods in counties with Planned Parenthood affiliates in the years preceding the exclusion, a trend that has also been observed nationally."
The researchers called the change "worrisome," citing support for LARC methods from the American College of Obstetricians and Gynecologists and research showing "substantial unmet demand for LARC methods in Texas." According to the researchers, the "exclusion of skilled, specialized family-planning providers was associated with a shift toward methods that have lower rates of efficacy and continuation and, in the case of women who used injectable contraceptives in the fourth quarter of 2012, an increase in the rate of childbirth covered by Medicaid."
The researchers added that while their study does not show causation, it "suggest[s] that the exclusion of Planned Parenthood affiliates from the Texas Women's Health Program had an adverse effect on low-income women in Texas by reducing the provision of highly effective methods of contraception, interrupting contraceptive continuation, and increasing the rate of childbirth covered by Medicaid."
In conclusion, the researchers wrote that Planned Parenthood's exclusion "was associated with adverse changes in the rates of provision and continuation of contraception and with increases in the rate of childbirth covered by Medicaid." According to the researchers, the study has "implications regarding the likely consequences of proposals to exclude Planned Parenthood affiliates from public funding in other states or at the national level."
