On a patch of browning grass just 100 steps from the McAllen, Texas, headquarters of Planned Parenthood Association of Hidalgo County stands an eye-level banner featuring an adorable white infant on either side.
Wide-eyed and pensive, baby number one grasps an adult's fingers while gazing toward the familiar pro-life tagline, "Take my hand not my life..." Baby number two is sleeping, thumb in mouth and naked except for a jumbo red ribbon tied around its torso. "Life. The Greatest Gift of All!" the caption announces.
The placement of this PVC guilt trip is ironic. While the Planned Parenthood network is the largest provider of publicly funded family planning services along the Texas/Mexico border, none of its locations perform abortions.
To "get your period back," as some locals describe it, you'll have to cross the border for relatively cheap, maybe-safe, over-the-counter drugs that might trigger a miscarriage if you take it early enough in your pregnancy, at the right dosage and at the correct intervals. Or, if you have the cash, credit, or private insurance coverage, you can book an appointment across town or two cities away, at one of two private abortion providers in the entire Rio Grande Valley.
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Another bit of irony: Thanks to the anti-choice public health policies advanced by the state's Republican leadership, Hidalgo County's poor and uninsured women have fewer sources of the birth control and exams they need to prevent unwanted pregnancies.
"I would say that 85 to 90 percent of our clients live below the federal poverty line. They're uninsured and many of them have two or three children and don't want any more," says Patricio Gonzalez, the network's CEO. "Basic healthcare access is just very bad here so the women don't get [regular] screenings for STIs or cancers, and when they do get them they often need more diagnostic services because they've delayed care. You'll hear them say, 'I don't have $60 or $100 for this lab test, or this ultrasound or this mammogram.' "
Up until last September, when massive state budget cuts took effect, Planned Parenthood had eight clinics throughout the county and served about 21,000 mostly poor and Latino clients a year. Now the network is down to four centers. Stripped of public funding, the rural sites were the first to go.
Two years into what NARAL Pro-Choice America has famously dubbed the War on Women, the wear is beginning to show in cities and towns around the country where poor, uninsured women live. In the right's new abortion war strategy, taking apart the infrastructure for family planning services--providers like Planned Parenthood, Title X funding and, now, the Affordable Care Act--is as important as triggering a Supreme Court challenge that will overturn Roe v. Wade. In just one year, dozens of clinics throughout Texas have shut down or slashed their hours--limiting options for poor and working women in even big cities like Austin and Dallas, and closing the doors of clinics that have nothing to do with Planned Parenthood. The state offers a striking example of the collateral damage that's inevitable when anti-choice Republicans use the legislative equivalent of drone strikes to attack abortion rights.
To show me what rural poverty looks like in Hidalgo County, Planned Parenthood promotora (outreach worker) Dora Alicia Proa takes me to a colonia nearly 15 miles away from McAllen, in San Carlos. Colonias are unincorporated subdivisions founded in the 1950s by predatory developers who sold lots of barren and flood-prone land to poor Latin American migrant workers without installing basic infrastructure. They are synonymous with poverty. Literally. The Texas Secretary of State defines these communities as "residential areas along the Texas-Mexico border that may lack some of the most basic living necessities, such as potable water and sewer systems, electricity, paved roads, and safe and sanitary housing."
Last year, Hidalgo County's Planned Parenthood offered free birth control, STI testing, Well Woman exams and men's health screenings at the San Carlos Community Resource Center. Now, to get the same services, patients have to drive up to 20 miles to the Edinburg clinic, where a physical, HIV test and Pap smear costs at least $60 and a monthly supply of birth control pills costs $20 at minimum.
The Hidalgo County Health and Human Services Department runs eight clinics where people of all ages can get a range of services, from tuberculosis treatment to newborn screenings. However, wait times are reportedly brutal, and the health department's STI testing site is located in McAllen. Ostensibly to fill the void created by Planned Parenthood closures, the University of Texas Medical Branch opened a maternal health clinic in Hidalgo. But that site is also in McAllen; it specializes in pregnancy and prenatal care, and it doesn't have weekend hours.
In one San Carlos household Proa and I visit--a cramped trailer on concrete blocks where the kitchen sink collides with bunk beds--Proa informs two young women that the Edinburg clinic is running a special on annual exams. They shake their heads at the mention of cash, then tsk tsk at six young boys and girls who are smiling shyly, pointing and calling me chocolate.
Next, Proa introduces me to a young woman standing in front of a three-room track house with dirt floors, a chunk of the roof missing and the toilet located in a crumbling shed next door. My Spanish is pitiful and neither Proa nor the homeowner speaks much English. But I can see that four small children and two adults share this space.
Within this context, it's unclear how defunding conveniently located sources of free birth control, STI testing, Pap smears, clinical breast exams and other women's health care is a pro-life activity. But this is what counts as logic in today's abortion wars.
Two Years of Destruction
It's hard to imagine a time when the Christian evangelical anti-abortion movement held such sway over the Republican party's publicly stated agenda. Title X, a federal program that's the leading source of family planning funds for low-income women, was established in 1970 under Richard Nixon and enjoyed wide bipartisan support despite chronic underfunding.
Since 2010, however, attacks on Title X have been relentless and overt. Between the tea party takeover of the House of Representatives and the steady stream of state-level anti-choice laws and ballot initiatives, radical anti-abortion Republicans have concentrated their power and they've been more than willing to wield it.
In Congress, an anti-choice dream team that includes Mike Pence of Indiana, vice presidential hopeful Paul Ryan of Wisconsin and Trent Franks of Arizona have turned their religiously based opposition to a legal medical procedure into a legislative priority. Among scores of anti-choice proposals, eight came to a full House vote in 2011, including Pence's failed amendment that would have excluded Planned Parenthood from Title X funding.
During the marathon primary season, presidential hopefuls including a formerly pro-choice Mitt Romney, Rick Santorum, and Rick Perry tripped over themselves to condemn Planned Parenthood, Obamacare, contraception, abortion and unmarried vaginas. Romney even upped the ante and pledged to eliminate a major chunk of Title X funding altogether. This week his campaign reiterated his promise to be the "pro-life president," after the notoriously hard-to-pin-down candidate told the Des Moines Register that he was unfamiliar with any "legislation with regards to abortion" that would become a part of his agenda. (In their endorsement statements, anti-choice juggernauts including Susan B. Anthony List and National Right to Life provide detailed lists of Romney's agenda.)
The 2012 Republican Party Platform expands on the anti-abortion stance outlined in the 2008 version of the document. Now, it's official GOP policy to defund health providers who "promote or perform abortion." The platform also treats the scientifically unproven concept of first-trimester fetal pain as fact and praises congressional Republicans for banning Medicaid-funded abortions in Washington, D.C., a predominantly black city represented by a delegate without voting power.
In their attempt to stigmatize and outlaw abortion, some tea party-backed lawmakers have gone as far as to distort definitions of rape. In his amendment to the failed "No Taxpayer Support of Abortion" act, New Jersey Rep. Chris Smith changed the language of the so-called rape exception outlined in the Hyde Amendment to "forcible rape," an outdated law enforcement term that excludes statutory rape and sexual violence against women who are intoxicated. This August, Missouri Republican senatorial candidate and sitting Congressman Todd Akin claimed that female bodies have the biological capacity to "shut down" conception during "legitimate rapes."
Anti-choice activists and the lawmakers who represent them have also attempted to manipulate the legitimate concerns some people of color have about the history and modern limitations of publicly funded family planning. They have equated voluntary abortions with black genocide and compared the rights of fertilized eggs to those of enslaved Africans and freedmen denied citizenship via the 1857 Dred Scott decision. Arizona's Franks coupled these race-baiting ideas with unsubstantiated claims of a growing trend in sex-selective abortion by Chinese immigrants. He floated two versions of an anti-choice bill called the Frederick Douglass and Susan B. Anthony Prenatal Nondiscrimination Act.
On the state level, Republican lawmakers enacted a record 69 anti-choice measures in 2011. For example, South Dakota's GOP-dominated legislature mandated that women who have already decided to have an abortion must first visit an openly anti-choice crisis pregnancy center (CPC) for "counseling" beforehand. Arizona voided charitable status for any entity that performs or refers patients for abortions. Seven states--Indiana, Kansas, New Hampshire, North Carolina, Tennessee and Wisconsin--legally restricted the flow of family planning dollars to Planned Parenthood affiliates that already, by law, were not using the money to fund abortions.
All of this has made reproductive health a flash point in the 2012 elections. But a hardening reality is buried in the culture war surrounding Rush Limbaugh's slurs and Todd Akin's shocking claims: reproductive healthcare options are increasingly limited for people who are poor, uninsured, without a medical home and reliant on an ever-fraying healthcare safety net. These women--disproportionately Latinas and African American--are bearing the true brunt of the renewed attack on publicly funded family planning services. Nearly a third of all women who used those services in 2010 were Latina, and nearly 20 percent were black.
Lone Star Falling
Texas provides a striking example of the changes taking place at the local level.
The cash-strapped state has the highest percentage of uninsured people in the nation. This year it was ranked dead last in health care delivery by the nonpartisan federal Agency for Healthcare Research and Quality. In the most recent Texas Medical Association survey of private physicians in the state, only 30 percent said they would accept new Medicaid patients. (In 2000, 67 percent said they would.) Yet the Lone Star State has made a series of decisions that jeopardizes an entire network of family planning providers who do accept patients who need publicly funded care.
First, lawmakers slashed the state's two-year family planning budget by 66 percent--from $111.5 million to $37.9 million. Then they created a three-tiered funding scheme for evaluating potential recipients of the federal family planning funds that the Texas Department of State Health Services administers.
Under this system, government agencies, universities, public hospitals and federally certified safety net clinics get the first crack at family planning service contracts. Comprehensive primary care providers are second in line. Last in line are nonprofits and community action organizations solely dedicated to family planning, including--you guessed it--Planned Parenthood.
Finally, lawmakers sabotaged the Texas' Women's Health Program (WHP), a widely heralded project that extended health care to a wider range of poor women.
Launched in 2005, WHP has allowed about 130,000 uninsured, low-income women ages 18 to 44 who weren't able to meet Texas's very narrow Medicaid eligibility requirements to receive no- or low-cost birth control and other preventative care each year. The program has been credited with saving the state about $183 million in Medicaid spending by averting nearly 17,000 unintended pregnancies. Planned Parenthood affiliates treated about 40 percent of women enrolled in WHP.
But last year--with the war on women in full tilt and Gov. Rick Perry in a presidential run--the GOP-dominated Texas legislature decided to enforce an existing rule that blocks providers that share a name, trademark or any other relationship with "an entity that performs or promotes elective abortions." It was a blatant attempt to exclude Planned Parenthood from WHP.
The federal government, which supports the program via Medicaid, rejected the rule and threatened to withhold $35 million--90 percent of the WHP budget. Unlike Indiana anti-choicers who made a similar move last year, Texas stood its ground and lost the funding. Citing states rights, Perry vowed to "find the money" to maintain the program. The new Texas Women's Health Program is set to debut on Nov. 1 and a lawsuit Planned Parenthood filed against the Texas health department is pending.
The WHP fiasco confirmed how far some anti-choice Republicans are willing to go to attack Planned Parenthood in 2012. Perry, a self-proclaimed fiscal conservative, turned away $35 million of federal funds in a presidential election year. Deficit reduction, fiscal responsibility and limited government intrusion in personal matters are supposed to be the bedrock principles of the post-tea party GOP. And yet Perry willingly entered a power struggle with the Obama administration at the expense of more than 100,000 poor women in his state.
Ironically, Texas clinics that are in no way affiliated with Planned Parenthood are at greatest risk of closure, says Fran Hagerty, CEO of the Austin-based Women's Health and Family Planning Association of Texas.
"In the legislature's effort to target Planned Parenthood and drive them out of Texas, everybody else has been caught in the net," she says. "I have been telling [conservative legislators] for years that if they keep doing what they're doing, we're going to end up with no family planning providers except Planned Parenthood because they do such a bang-up job of getting national and local support. It's the little guys in rural one-stoplight towns that no one has ever heard of--the community action organizations formed back in the 1950s under the Johnson administration--that are going under. The state is throwing the baby out with the bathwater."
New data from UT Austin's Texas Policy Evaluation Project confirm Hagerty's thrown-baby theory.
The nonpartisan research team surveyed the 76 agencies that received public funding for family planning and reproductive health care in fiscal year 2010--before the most dramatic budget cuts kicked in. Of the 240 clinics run by survey respondents, a staggering 22 percent have closed their doors and 16 percent have cut their hours. Dedicated family planning groups fared the worst: more than one third closed their doors and nearly 40 percent reduced their hours.
Armed with an ebullient voice, easy smile and bright almond-shaped eyes, Chenoa Elizabeth, 32, is an ideal volunteer for the North Texas Planned Parenthood clinic where she is also a patient. As she rattles off familiar talking points--how the Dallas-area center provides "amazing, compassionate, quality care" for low-income women like herself--I can't help but think that she's handling me the way she would a customer at the boutiques and cocktail lounges where she's worked for most of her adult life.
Until she starts with the sobbing. In the stutter-step dialect of panic and humiliation, the Hurricane Katrina survivor of Trinidadian and Scottish descent tries to explain why she's so attached to this particular clinic. She tells me that she was raped in her early 20s, that she terminated the resulting pregnancy and that she uses a Planned Parenthood-installed 12-year Paraguard IUD because she never, ever wants children. She also notes that she's a severe asthmatic who didn't see a non-emergency doctor from 2008 to 2011 because she didn't have insurance. Elizabeth, who's pursuing her associates degree in peace and justice studies, did have private health benefits once. But then a global corporation acquired the music venue where she was working, transferred her to Dallas and cut her hours, rendering her ineligible for coverage. Today she has limited coverage under WHP, because administrators at this Planned Parenthood branch introduced her to the program and walked her through the enrollment process. But now that the clinic can't take her WHP benefits, Elizabeth worries that she'll lose access to an organization that gives her a sense of stability and safety. "I've always been able to take care of myself, and I'm trying so hard," she tells me.
Rural towns like those in Hidalgo County aren't the only losers in the defunding game. The cuts have wide ranging effects on providers that women like Elizabeth turn to in big cities as well.
Take Austin-based People's Community Clinic, which has a patient population that is 78 percent Latino and 75 percent at or below the federal poverty line.
According to Celia Neavel, director of the clinic's Center for Adolescent Health, the 42-year-old nonprofit received a half million dollars in federal funding prior to the budget cuts. As a Title X provider, the clinic could treat a wide range of teen patients without parental consent and they were able to buy contraceptives at a greatly reduced rate. In the funding carnage of 2011, the clinic lost all of these funds and the legal and purchasing protections of Title X.
"We've been scrambling to raise money so that we don't turn patients away or bill them," says Neaval, who admits to feeling frustrated and drained. In addition to reducing hours and forcing shutdowns, family planning budget cuts also drove up the cost of subsidized birth control and, in some cases, made confidential care for minors illegal. "There is some sadness as well, that now we can't get a teen who has already had one pregnancy a long lasting, reversible form of birth control or the confidential care she needs."
Patients are feeling the same anxieties. "When I think about losing my health insurance or what will happen if my IUD slips, or if I get sick," says Elizabeth, "I just don't know. I don't know...what I'm going to do."
Legislators who gutted the state's family planning networks have an idea of what she should do: Seek select medical care from an overtly religious crisis pregnancy center (CPC) that specializes in talking pregnant women out of abortions.
Marketing itself as Houston's first "life affirming pregnancy medical clinic," The Source for Women Spring Branch held its big opening bash in mid-September. Like countless other CPCs around the country, The Source locations were founded for the express purpose of persuading "abortion-vulnerable" girls and women to continue unintended pregnancies using Bible study, "therapeutic counseling," "reproductive health counseling," and classes in marriage, parenting, adoption, cooking.
But now that Texas is rolling out Gov. Perry's fully state-funded, anti-choice version of WHP, The Source has repositioned itself as a healthcare provider that offers traditional family planning services. Think of it as Planned Parenthood, plus Jesus.
In a late September email, The Source spokesperson Tiffany Pardue told me that the spanking new Spring branch, which aims to be a WHP provider by the program's Nov. 1 relaunch, will offer its clients STI testing and treatment; breast, pelvic and anal exams; Pap smears; referrals for mammograms, and something the organization calls "a verbal review of your gynecologic system."
Conspicuously absent from The Source's current menu of expanded services? Birth control. It's a confusing omission given the original intent of WHP--to reduce the number of Medicaid-funded births in Texas by preventing unintended pregnancies.
According to Pardue, the "life-affirming" nonprofit's board hasn't yet decided which contraceptives it will offer. "Our medical team is considering each medical service and prescription that we will provide to serve the women of Houston," she wrote. "A full list will be made available upon determination."
The Source's lack of specificity about contraception didn't deter Gov. Perry from participating in the Spring Branch ribbon cutting. In his official remarks he hailed it as a model WHP provider.
"The Source gives women with unexpected pregnancies the information and the support they need to make the right choice, the choice of life," Perry said. "We've banned the use of your tax dollars for abortion procedures in Texas, and expanded that ban to include those affiliated with abortion providers in the case of our Women's Health Program. ... The Source for Women clinics, in fact, will be part of Texas' own Women's Health Program, and Planned Parenthood will not be."
As Goes Texas...?
About three months after our first interview, Chenoa Elizabeth sends me a shocking email. In it, she details how she was sexually assaulted for a second time this past March. "This attack has been much more difficult for me to process," she wrote. "There was a man who approached me in a coffee shop posing as a business owner and offered me a job. ... I thought this was the financial breakthrough that I had been waiting for, but instead I waltzed right into a trap."
To avoid the trauma--and the expense--of an ER exam, Elizabeth didn't report the assault to police or seek emergency care. When we last spoke, she hadn't been tested for STIs, either. "Yes, I could use WHP with a different provider," she acknowledged. "But I don't want to have to sacrifice receiving compassionate and specialized care because I'm low-income."
Elizabeth's experience speaks to one of the least acknowledged consequences of the war on women's reproductive health care. All women--hell, all people--should be able to get the medical attention they need in an environment that makes them feel as safe as possible. By turning something as personal as gynecological care into a political battleground, Texas provides us with a blueprint for what doesn't work.
In the run-up to the presidential election and the full implementation of Obamacare, anti-choice Republicans have taken umbrage at the "war on women" metaphor, but they have not changed course. Red state governments, along with religiously affiliated hospital networks and universities have filed court challenges to repeal health reform or gut its birth control coverage requirements. In these cases, state officials have used the rhetoric of religious freedom to deny women birth control and abortion coverage in the private insurance policies for which they pay premiums. Similarly about 15 states have signaled that they will reject Medicaid expansion, a core component of the plan. Fourteen have outlawed abortion coverage in their insurance exchanges. It's likely that the next wave of anti-choice sabotage will be centered on insurance coverage.
Only time will tell if the new Texas Women's Health Program will provide a seamless transition for the hundreds of thousands of women enrolled in it. The overall impact of family planning clinic closures on the health of poor Texas women is also a big question mark.
What's clear is that politicizing health care is a dangerous, crazy-making game. Hopefully Texas will serve as an example of what not to do, instead of an inspiration for anti-choice crusaders who seem all too willing to sacrifice the reproductive health of poor women to say they have won.