Texas' Medicaid waiver is a 'canary in the coal mine' for abortion carve-outs

The Trump administration will soon review Texas' proposed plan to regain federal funding for its family planning program that does not include Planned Parenthood or providers that support or perform abortions. If the CMS approves the waiver, other states could seek similar permissions and risk millions losing access to care.

Texas lost federal funding for its family planning program known as Healthy Texas Women in 2013 after it stopped reimbursing for services performed at Planned Parenthood. Since then, the program has been totally state-funded.

Now facing a $2 billion budget shortfall, Texas is looking for ways to reduce spending. The state on Friday posted a draft Medicaid waiver seeking up to $300 million in federal funds to continue Healthy Texas Women for another five years through 2023.

If the waiver is granted, the impact could ripple far beyond Texas and jeopardize care for millions of women.

"The concern is that this would set a precedent for federal approval of family planning programs that excludes providers that provide abortions and their affiliates," said Stacey Pogue, a public policy analyst for the Austin, Texas-based Center for Public Policy Priorities.

Of the more than 74 million people on Medicaid, nearly 17 million are non-elderly women who depend on Planned Parenthood as their primary source of essential healthcare. None of these women are getting abortions paid for by the program as that's prohibited by federal law. Instead, a Planned Parenthood clinic is often where they see their primary-care docs or get screenings for ailments such as breast cancer.

Prohibiting willing providers from seeing Medicaid patients is prohibited by federal law, but state officials are hopeful the CMS under Trump will allow it to test this new family planning vision.

"We've been encouraged to present new and innovative ideas to CMS for discussion for possible funding," said Carrie Williams, spokeswoman for Texas' state health department. "There is a new administration, and we're looking at what opportunities may exist for us."

Patients relying on Planned Parenthood or those with doctors who are affiliated with any provider that supports or performs abortions could find themselves displaced if Texas and similar states are granted this kind of Medicaid waiver.

Under the Healthy Texas Women program, doctors must sign a contract that stipulates that they can't bill the program if they promote elective abortions or are affiliated with a group that performs or promotes elective abortions.

Texas' waiver is "a canary in a coal mine" for other states, as Healthy Texas Women has created access to care problems for low-income women that could be replicated elsewhere, according to Blake Rocap, legislative counsel for NARAL Pro-Choice Texas.

Healthy Texas Women has only served approximately 200,000 women as of March. However, there are as many as 1.8 million low-income women in the state in need of publicly subsidized family planning services, Rocap said.

Out of 298,000 providers registered in the Medicaid program, only 5,000 are a part of the Healthy Texas Women program, according to state estimates.

Advocates have said that the Healthy Texas Women provider network isn't providing beneficiaries with adequate care because the doctors have small Medicaid practices or aren't knowledgeable about family planning.

University of Texas researchers found that claims for injectable contraceptives fell 31.1% and Medicaid-covered childbirths rose 27% during the first two years of Texas' Planned Parenthood ban.

Still, some experts support the CMS approving the waiver because its unclear if Texas will be able to continue family planning services at all, given the state's budget woes.

"Receipt of the federal funds, in a tough budget year, will help offset the need for devastating cuts to Medicaid eligibility for a pregnant women and/or Medicaid payments to physicians," said Marcus Cooper a spokesman for the Texas Medical Association. "TMA wants to preserve state capacity to serve women in need ."

Texas wouldn't send a waiver to the CMS for a program that harms a patient's ability to get the care they need, according to Billy Millwee, a health policy consultant at Sellers Dorsey and former Medicaid director for Texas

"Federal Medicaid waivers come with strict accountability requirements," Millwee said. "My sense is that Texas will be able to demonstrate adequate access to care."

Texas' Healthy Texas Women program also requires teenagers to get parental approval before accessing family planning services. Although many states don't have similar requirements at the moment, they could adopt similar limitations in their Medicaid waivers, according to Yvonne Gutierrez, executive director of Planned Parenthood Texas Votes, the group's political arm.

Adding that limitation could spark an increase in unplanned pregnancies or sexually transmitted diseases. Texas has seen a 13% increase between 2012 and 2015 in the number of residents with HIV and an 11% uptick in women living with the virus, according to state data.

Texas officials are accepting comments on the draft waiver through June 12. They will host a public meeting June 9 to discuss the waiver.