ItemWomen's Experience Obtaining Abortion Care in Texas after Implementation of Restrictive Abortion Laws: A Qualitative Study(2016-10-26) Baum, Sarah E.; White, Kari; Hopkins, Kristine; Potter, Joseph E.; Grossman, DanielBackground: In November 2013, Texas implemented three abortion restrictions included in House Bill 2 (HB 2). Within six months, the number of facilities providing abortion decreased by almost half, and the remaining facilities were concentrated in large urban centers. The number of medication abortions decreased by 70% compared to the same period one year prior due to restrictions on this method imposed by HB 2. The purpose of this study was to explore qualitatively the experiences of women who were most affected by the law: those who had to travel farther to reach a facility and those desiring medication abortion. Methods: In August and September 2014, we conducted 20 in-depth interviews with women recruited from ten abortion clinics across Texas. The purposive sample included women who obtained or strongly preferred medication abortion or traveled ≥50 miles one way to the clinic. The interview guide focused on women’s experiences with obtaining services following implementation of HB 2, and a thematic analysis was performed. Results: Women faced informational, cost and logistical barriers seeking abortion services, and these obstacles were often compounded by poverty. Two women found the process of finding or getting to a clinic so onerous that they considered not having the procedure, although they ultimately had an abortion; another woman decided to continue her pregnancy, in part because of challenges in getting to the clinic. For two women, arranging travel required disclosure to more people than desired. Women who strongly preferred medication abortion were frustrated by the difficulty or inability to obtain their desired method, especially among those who were near or just beyond the gestational age limit. The restricted eligibility criteria for medication abortion and difficulty finding clinics offering the method created substantial access barriers. Conclusions: Medication abortion restrictions and clinic closures following HB 2 created substantial barriers for women seeking abortion in Texas. ItemWomen’s Experiences Seeking Publicly Funded Family Planning Services in Texas(2015-01-30) Hopkins, Kristine; White, Kari; Linkin, Fran; Hubert, Celia; Grossman, Daniel; Potter, Joseph E.Little is known about low-income women's and teenagers’ experiences accessing publicly funded family planning services, particularly after policy changes are made that affect the cost of and access to such services. Eleven focus groups were conducted with 92 adult women and 15 teenagers in nine Texas metropolitan areas in July–October 2012, a year after legislation that reduced access to subsidized family planning was enacted. Although most women were not aware of the legislative changes, they reported that in the past year, they had had to pay more for previously free or low-cost services, use less effective contraceptive methods or forgo care. They also indicated that accessing affordable family planning services had long been difficult, that applying and qualifying for programs was a challenge and that obtaining family planning care was harder than obtaining pregnancy-related care. As a result of an inadequate reproductive health safety net, women experienced unplanned pregnancies and were unable to access screening services and follow-up care. Teenagers experienced an additional barrier, the need to obtain parental consent. Some women preferred to receive family planning services from specialized providers, while others preferred more comprehensive care. Women in Texas have long faced challenges in obtaining subsidized family planning services. Legislation that reduced access to family planning services for low-income women and teenagers appears to have added to those challenges. ItemCutting Family Planning in Texas(2012-09-27) White, K.; Grossman, D.; Hopkins, K.; Potter, J.Recently, efforts to expand access to contraception through the Affordable Care Act ignited a broad debate regarding the proper role of government in this sphere, and proposals have been put forth to eliminate Title X. In 2011, Texas cut funding for family planning services by two thirds. The Texas legislature also imposed new restrictions on abortion care and reauthorized the exclusion of organizations affiliated with abortion providers from participation in the state Medicaid waiver program, the Women's Health Program (WHP). To implement the legislation and funding cuts, the Texas Department of State Health Services reduced the number of funded family planning organizations from 76 to 41. As part of a comprehensive 3-year evaluation of the legislative changes to family planning policy in Texas, we interviewed 56 leaders of organizations throughout the state that provided reproductive health services using Title X and other public funding before the cuts went into effect. We found that funding cuts led to the closure of 53 clinics and reduced hours at an additional 38. In addition, we found that providers restricted access to the most effective contraceptive methods and implemented systems that require clients to pay for services if they do not qualify for the WHP. Ostensibly, the purpose of the law was to defund Planned Parenthood in an attempt to limit access to abortion, even though federal and state funding cannot be used for abortion care. Instead, these policies are limiting women's access to a range of preventive reproductive health services and screenings ItemEffect of Removal of Planned Parenthood from the Texas Women's Health Program(2016-02-03) Stevenson, A.; Flores-Vazquez, I.; Allgeyer, R.; Schenkkan, P.; Potter, J.Background: Texas is one of several states that have barred Planned Parenthood affiliates from providing health care services with the use of public funds. After the federal government refused to allow (and courts blocked) the exclusion of Planned Parenthood affiliates from the Texas Medicaid fee-for-service family-planning program, Texas excluded them from a state-funded replacement program, effective January 1, 2013. We assessed rates of contraceptive-method provision, method continuation through the program, and childbirth covered by Medicaid before and after the Planned Parenthood exclusion. Methods: We used all program claims from 2011 through 2014 to examine changes in the number of claims for contraceptives according to method for 2 years before and 2 years after the exclusion. Among women using injectable contraceptives at baseline, we observed rates of contraceptive continuation through the program and of childbirth covered by Medicaid. We used the difference-in-differences method to compare outcomes in counties with Planned Parenthood affiliates with outcomes in those without such affiliates. Results: After the Planned Parenthood exclusion, there were estimated reductions in the number of claims from 1042 to 672 (relative reduction, 35.5%) for long-acting, reversible contraceptives and from 6832 to 4708 (relative reduction, 31.1%) for injectable contraceptives (P<0.001 for both comparisons). There was no significant change in the number of claims for short-acting hormonal contraceptive methods during this period. Among women using injectable contraceptives, the percentage of women who returned for a subsequent on-time contraceptive injection decreased from 56.9% among those whose subsequent injections were due before the exclusion to 37.7% among those whose subsequent injections were due after the exclusion in the counties with Planned Parenthood affiliates but increased from 54.9% to 58.5% in the counties without such affiliates (estimated difference in differences in counties with affiliates as compared with those without affiliates, −22.9 percentage points; P<0.001). During this period in counties with Planned Parenthood affiliates, the rate of childbirth covered by Medicaid increased by 1.9 percentage points (a relative increase of 27.1% from baseline) within 18 months after the claim (P = 0.01). Conclusions: The exclusion of Planned Parenthood affiliates from a state-funded replacement for a Medicaid fee-forservice program in Texas was associated with adverse changes in the provision of contraception. For women using injectable contraceptives, there was a reduction in the rate of contraceptive continuation and an increase in the rate of childbirth covered by Medicaid. ItemThe Use of Public Health Evidence in Whole Woman’s Health v Hellerstedt(2016-11-07) Grossman, D.[This piece, written for the JAMA Internal Medicine "Viewpoints" section, discusses the impacts of House Bill 2, as documented by TxPEP research, and the use of research-based evidence in Whole Woman's Health v Hellerstedt.] The Supreme Court decision in the Whole Woman’s Health case provides a clearer judicial standard related to undue burden on women seeking abortion. The Court said laws restricting abortion cannot be considered in the abstract—or just because a legislature says they would be beneficial. Instead, courts must compare the benefit the law is likely to provide with the burden the law will impose on women. The Court’s decision shows that evidence matters, which hopefully heralds a new emphasis on data-driven policies for reproductive health ItemChange in Distance to Nearest Facility and Abortion in Texas, 2012 to 2014(2017-01-19) Grossman, D.; White, K.; Hopkins, K.; Potter, J. E.This Research Letter demonstrates that increases in travel distance to the nearest abortion clinic caused by clinic closures between 2012 and 2014 were closely associated with decreases in the official number of abortions in Texas. Counties where the distance to the nearest facility increased 100 miles or more between 2012 and 2014 saw a 50% decline in abortions. Meanwhile, counties that did not have an abortion provider in 2014 and did not experience a change in distance to the nearest facility had essentially no change in the number of abortions. ItemBarriers to Offering Vasectomy at Publicly Funded Family Planning Organizations in Texas(2017-01-13) White, Kari; Campbell, Anthony; Hopkins, Kristine; Grossman, Daniel; Potter, Joseph E.Few publicly funded family planning clinics in the United States offer vasectomy, but little is known about the reasons this method is not more widely available at these sources of care. Between February 2012 and February 2015, three waves of in-depth interviews were conducted with program administrators at 54 family planning organizations in Texas. Participants described their organization’s vasectomy service model and factors that influenced how frequently vasectomy was provided. Interview transcripts were coded and analyzed using a theme-based approach. Service models and barriers to providing vasectomy were compared by organization type (e.g., women’s health center, public health clinic) and receipt of Title X funding. Two thirds of organizations did not offer vasectomy on-site or pay for referrals with family planning funding; nine organizations frequently provided vasectomy. Organizations did not widely offer vasectomy because they could not find providers that would accept the low reimbursement for the procedure or because they lacked funding for men’s reproductive health care. Respondents often did not perceive men’s reproductive health care as a service priority and commented that men, especially Latinos, had limited interest in vasectomy. Although organizations of all types reported barriers, women’s health centers and Title X-funded organizations more frequently offered vasectomy by conducting tailored outreach to men and vasectomy providers. A combination of factors operating at the health systems and provider level influence the availability of vasectomy at publicly funded family planning organizations in Texas. Multilevel approaches that address key barriers to vasectomy provision would help organizations offer comprehensive contraceptive services.