In the ongoing volley between state health officials and the federal government over funding the Women’s Health Program (WHP), Texas laid out its plans last week to wholly take over the Medicaid program by November. Unwilling to allow abortion affiliates into the WHP, Texas lost out on 90 percent of its funding from the Centers for Medicaid and Medicare (CMS) since the exclusion is said to run counter to federal law.

Sticking to what they see as their constitutional right to ban abortion providers from the program, the state is now prepared to create its own strategy to continue WHP– one that will shut out a major provider of the low-income care program and likely strain an already fragile network of family planning centers.

While the state’s plan to recoup the $30-$40 million in lost funding assumes those dollars will be found without cutting other services, another gap remains to be addressed. By nixing Planned Parenthood– centers that see about 46 percent of WHP clients or 130,000 women annually– the state’s plan forgoes subsidizing the single largest provider of basic reproductive care within the program. That rift is casting severe doubt from heads of Texas family planning centers over whether or not remaining providers have the resources to see and treat former Planned Parenthood clients.

The state’s health commission says it is taking proactive steps to ensure those Planned Parenthood patients find access to other providers during what they anticipate as a “seamless transition” to a state-run program.

“We are working on resources to help those women find new providers,” said HHSC spokesperson Stephanie Goodman. “We have a phone number posted on our website and we are building an online database for clients to look up the closest provider.”

HHSC is encouraging new providers to enroll in the WHP and asking existing providers to take on more clients. Goodman says discussions with large family planning clinics and individual OB/GYNs in the state which are able to comply with the rule and have the space to see new clients have been fruitful. Many of the 2,500 providers are not operating at full capacity, said Goodman.

However, that may not necessarily mean those clinics are able to handle the increased clientele caused by displaced Planned Parenthood patients– especially in rural areas, state family planning leaders say.

Tama Shaw, executive director of rural-based Hill Country Community Association (HCCA) and president of Women’s Health and Family Planning Association of Texas (WHFPT), a network of reproductive health providers rooted in assisting more than 800,000 low-income women, says the space is just not there. After WHP cuts hit a Planned Parenthood center in Waco, clients started filtering to one of the Hill Country clinics north of the city. But “by no means” would the clinic have the capacity to take care of all its patients, she said.

As a possible alternative to those WHP clients originally served by Planned Parenthood, HCCA itself is spread thin. Not immune from the recent and deep slices to the state’s reproductive health funding, the network was forced to shutter five out of nine clinics after legislative budget cuts slashed Title X federal funds and placed the family planning clinics on the lowest tier of Title X funding, behind federally qualified health care providers (FQHC) and public community clinics. Today, HCCA relies on a temporary three-month extension for federal funds; without it they could be completely abolished. After 40 years in existence, Shaw’s network for low-income women has been shredded– right now, she says, they are “hanging in there.”

Kathryn Hearn, community services director at Planned Parenthood Association of Hidalgo County echoes Shaw’s concerns. About 80 percent of WHP participants in the border area come to Planned Parenthood, solidifying it as the largest provider of the program in the region– the next largest serves less than 500 people, she said. Treating some of the state and country’s poorest women, the association will have to turn away 6,500 patients if the WHP shuts down. There is simply no way surrounding clinics can integrate that number of patients, says Hearn.

“Of course there are other providers in this community for these women but we are already hearing– publicly and privately­– from so many of them that they cannot absorb this many patients into their clinics or private practices,” she said. “It’s a big problem.”

Many of the association’s patients rely on the WHP and Planned Parenthood as their sole care provider for preventative health. Travel time to other clinics in the surrounding areas would likely be a strain on low-income women in terms of transportation costs and time off work traveling. Without WHP they might end up in the emergency room, forced to pay out of pocket, said Hearn.

“We have spoken to women all over the county. We receive calls daily from women concerned about not only losing their health care but being forced to go somewhere other than Planned Parenthood. They’ve chosen to come to us as a trusted provider of choice, now they are scared,” said Hearn.

With an already beleaguered health care landscape– from FQHC and free-standing clinics to hospital districts– the idea that non-Planned Parenthood centers can absorb the additional patients is not feasible, says Fran Hagerty, executive director of WHFPT. In 2011, there were 72 women’s health care contract providers in the state, now there are 42.

“The clinics cannot even take care of the number of patients they served last year, much less new patients. Nobody is in a position to take on hundreds, let alone thousands of new clients. Everyone is at capacity,” said Hagerty. “What we are seeing are clinics defunded, going out of business and scaled way back in operations, that is if they are still viable. And so they are not able to take any more patients on.”

Health care leaders remain doubtful about the state’s reassurance that family planning centers and individual OB/GYNs can offset the loss of Planned Parenthood services. Time-consuming paperwork, low reimbursement rates, overburdened staff and long wait times make taking on WHP clients difficult for rural clinics and private doctors, says Shaw.

“Those on the front lines providing the services and treating the women know that it’s not true. Logic would have it that it’s not true– I think the rest is just rhetoric,” said Shaw, who testified during a Texas Senate committee hearing about the constraints rural clinics and patients face and the consequences of a deteriorated family planning network, including increased pregnancy and STD rates. “The rural capacity is not there and relying on individual physicians isn’t going to work. Where are these women going to go?”

Hearn reiterates the point that the Medicaid program is difficult to manage. “Many of these clinics just won’t find it cost-effective to absorb these additional patients,” she said.

Hagerty says she is in talks with HHSC to argue the capacity to treat WHP patients is not present. “I hope they are prepared for the reality of what’s coming– a situation in which women don’t have anywhere to go for health care.”

Hagerty and Shaw say the cuts will result in increased rates of STDs, abortions and Medicaid paid births– one of the central reasons WHP was created. According to a 2011 Legislative Budget Board estimation, the program would save the state $3.8 million in general revenue funds in preventative pregnancy-related costs over the next two years.

“It’s going to be a rude awakening when Texas ends up with a lot of low-income pregnant teenagers,” said Shaw.

CMS officials say they are still reviewing Texas’ extension plan. If they agree, the state will run the WHP beginning on Oct. 31, giving the feds five months to agree to continue funding the program. Whether or not CMS will agree is unclear at this point.

“We formally received their transition plan proposal yesterday and are considering the implications of the longer enrollment period,” said CMS spokesperson Alper Ozinal in an e-mail. “We will be working with the State to reach a mutually agreeable transition plan that complies with the law while protecting beneficiaries

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