Tagged Women’s Health

Despite Supreme Court Win, Texas Abortion Clinics Still Shuttered

Over the past few years, abortion providers in Texas have struggled to reopen clinics that had closed because of restrictive state laws.

There were more than 40 clinics providing abortion in Texas on July 12, 2013 — the day lawmakers approved tough new restrictions and rules for clinics.

Even though abortion providers fought those restrictions all the way up to the U.S. Supreme Court, and managed to get the restrictions overturned in 2016, most of the affected clinics remain closed.

Today, just 22 clinics are open in a state that is home to 29 million people.

Although abortion providers won the legal battle, they appear to be losing the war. Most clinics are clustered in the major cities of Dallas, Houston and Austin, while women who live in smaller cities and towns that once had clinics now have to travel long distances for an abortion.

The West Texas town of San Angelo, for example, once had a Planned Parenthood clinic, but it had to close in 2013. It had been one of the last abortion providers in the sprawling, dry and mostly rural region, where most residents must drive at least three hours to reach a major city.

Susanne Fernandez, who worked at the San Angelo clinic for almost 30 years, gets emotional talking about its closure. “I loved working for Planned Parenthood.”

Fernandez blamed the closure on the 2013 state law, known as House Bill 2, which required abortion clinics to have the same sort of equipment, standards and staffing as surgical centers — and also required the doctors performing abortions to obtain admitting privileges at a nearby hospital. She said complying with those rules would have been extremely difficult and expensive. Still, the decision to close the San Angelo clinic was tough.

“The last day was sad. It was somber,” Fernandez said. “We did a lot of cleaning up. We all knew that was it.”

Abortion providers in Texas eventually sued the state. But as the legal challenge worked its way through the courts, many of the clinics were forced to stop providing services.

At one point, Texas had only 17 clinics, said Kari White, an investigator with the Texas Policy Evaluation Project at the University of Texas-Austin. She said women living in rural Texas were affected the most.

“What we saw is that [in] West Texas and South Texas, access was incredibly limited,” White said, “and women living in those parts of the state were more than 100 miles — sometimes 200 or more miles — from the nearest facility.”

White’s research team conducted surveys and interviews with women who were seeking abortions as clinics were shutting down. A 19-year-old woman told the researchers she considered giving up because it was so hard to find an open clinic.

“It was a very hard thing to do, like to keep calling and calling and calling,” the woman told researchers. “I almost was like, you know, ‘Well, forget it.’ … But then, because I knew at the end of the day it was something that I had to do, it was like ‘I don’t care how many people I have to call or how far I have to go. I have to do it.’”

That woman eventually found a clinic 70 miles away and was able to get the abortion. But in some other cases, women carried unwanted pregnancies to term.

Texas law requires women to have two appointments with an abortion provider. After an initial appointment at a clinic, they must wait 24 hours before getting the procedure. That means women often have to make a long trip at least twice, or pay for a hotel nearby. The waiting period is waived only if a woman lives more than 100 miles from the closest clinic.

A 23-year-old woman from Waco, a married mother of two, told researchers she made appointments to get an abortion at two clinics. But both appointments were canceled after the clinics were forced to close. She was unable to end the pregnancy.

“I was pretty upset, but I just decided that I guess I’ll have to just ride it out,” she told researchers. “I didn’t know what else to do, who else to call.”

Eventually, in the summer of 2016 — three years after H.B. 2 passed — the U.S. Supreme Court struck down the tough new restrictions on clinics. But most of the clinics never reopened.

“There hasn’t been this rush of clinics reopening following the Supreme Court decision,” White said. “So there are still just clinics concentrated in the major metropolitan areas of Texas.”

The ruling has also been a mixed bag for anti-abortion activists, said John Seago, the legislative director for Texas Right to Life.

“The closures of clinics is definitely a victory for the movement, obviously,” he said. “However, how are we in this situation in the first place is what my organization looks at.”

Seago pointed to Roe v. Wade, the Supreme Court case that made abortion legal in the U.S. He said anti-abortion activists fight legal battles on the state level in an effort to reverse Roe, and the Supreme Court ruling on Texas’ law was a big blow to the larger goal of slowly dismantling Roe.

Some New Options In Recent Years

Over the past three years, a few abortion providers have decided to open clinics in Texas.

For example, earlier this year Kathy Kleinfeld opened a new abortion clinic in Houston — a city that already had a few clinics providing abortion.

Kleinfeld, a longtime consultant for abortion providers in Texas and other states, decided to open in Houston after carefully looking at the demand for services in that region. Her clinic provides medical abortions using pills, but not surgical abortions.

“Due to the closure of so many clinics, the remaining clinics that are open are very busy, and they are very strict in the scheduling,” Kleinfeld said. “So our goal was to offer flexibility in scheduling.”

Kleinfeld said her clinic could help take some pressure off the remaining clinics in Houston. She said so far her patients have been professionals, students and women who drive over from Louisiana.

But she emphasized that getting her clinic up and running was not easy, despite her intimate knowledge of the complex rules and mandatory paperwork and the surprise inspections involved in operating as a licensed abortion provider in Texas.

Kleinfeld predicted that opening and running a clinic, and keeping it open, will always be difficult in Texas.

“There’s always been volatility and conflict and struggles,” she said. “Always. And this is not for the faint of heart.”

Andrea Ferrigno agrees with that assessment. As the corporate vice president of Whole Woman’s Health, Ferrigno helps operate several clinics that offer abortion in Texas.

She recalls that after H.B. 2 passed in 2013, Whole Woman’s Health was forced to close two clinics — one in Austin and another in Beaumont, a small city near the Louisiana border. So far, Whole Woman’s Health has been able to reopen only the Austin clinic.

“It’s basically starting from scratch,” Ferrigno said. “You laid off the staff; you don’t have any physicians that work there anymore. Some of the doctors didn’t even renew their physician licenses.”

Ferrigno said clinics that closed may have lost the state-issued license needed to operate. Applying for a new one is a significant bureaucratic hurdle. Some clinics might have lost their leases and been forced to vacate their buildings and sell off equipment.

“There are a lot of different limitations,” she said. “There’s also the question of — or the fear of — security challenges. People picketing the clinic, picketing their homes. There’s a lot that goes into that.”

But the cost of not reopening — particularly in a community that had only one clinic to begin with — may be high.

Take San Angelo, for example: Fernandez said she doubts a clinic offering abortions will open in her town anytime soon. She sometimes wonders what happened to the women she used to help.

“Where did these women go? Where do they go now?” Fernandez said. “I don’t believe a lot of them found any other health care afterwards.”

This story is part of a partnership that includes KUT, NPR and Kaiser Health News.

KHN’s coverage of women’s health care issues is supported in part by The David and Lucile Packard Foundation.

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Medicaid Tweak Might Offer Means To Improve U.S. Maternal Health

When Madavia Johnson gave birth to Donald Ray Dowless III last year, she was hit by a case of severe postpartum anxiety.

She was scared to carry her son downstairs or drive him in a car. She couldn’t manage to continue law school ― and could hardly leave the house ― because she didn’t trust anyone to watch him. Her weight dropped from 140 to 115 pounds.

“It was very stressful for me mentally,” said Johnson, now 29, who lives in Clayton, N.C. And she found it hard to secure medical assistance because her Medicaid coverage ran out just two months after her son’s birth. Public health advocates are pushing to change that.

The difficulties Johnson faced contribute to the United States’ dismal record on maternal and child health. The U.S. is one of only three countries where maternal deaths are on the rise, joining Sudan and Afghanistan, according to the Alliance for Innovation on Maternal Health, a program of the Council on Patient Safety in Women’s Health. And data from the Centers for Disease Control and Prevention indicates that about 700 women die in the U.S. every year from pregnancy complications. Sixty percent of those deaths are deemed preventable.

Democratic presidential candidates such as Sen. Cory Booker of New Jersey and Sen. Kamala Harris of California have talked about those problems on the campaign trail, offering sweeping proposals to address disparities that lead to poor health for many new mothers.

Though maternal and child health experts appreciate the attention to the issue, they also point to what they say is a fairly minor policy option that could make a major difference: increasing access to Medicaid for postpartum women.

“Given that we know that this crisis disproportionately falls on low-income people … Medicaid is a very smart starting place to make sure these people are getting access to needed care,” said Valarie Blake, an associate professor of law at West Virginia University who focuses on health care law.

Take Johnson, for instance. At the time of her pregnancy, she was eligible for Medicaid based on a rule that provides women who otherwise might not qualify under strict income restrictions with coverage during pregnancy and for 60 days after. She gave birth Aug. 14, 2018.

But North Carolina has tight eligibility requirements. It is also one of the 14 states that have not chosen to expand Medicaid under the Affordable Care Act. So, by mid-October, Johnson was no longer “Medicaid eligible.” Because her physician was backed up on appointments, she lost her coverage before she had a “six-week” checkup.

Eventually, she reapplied for Medicaid and was able to qualify because her status had changed since she had a child. But Donald was 8 months old before she saw a doctor.

Experts point to the 60-day timeline as a sort of clock ticking on some severe postpartum medical issues: bleeding, infections, breastfeeding issues and mental health screening, among others.

“If you’re on postpartum Medicaid, you need to get those issues solved right away,” Blake said.

And that 60-day countdown? It is arbitrary, said Dr. Alison Stuebe, a professor of obstetrics and gynecology at the University of North Carolina School of Medicine. It has roots in a general idea across cultures that women need special care after giving birth, but the 60-day mark isn’t based on medicine.

“It comes from the same place as the six-week postpartum visit,” Stuebe said. “We don’t know where it comes from either.”

Stuebe chaired a task force for the American College of Obstetricians and Gynecologists that recommended a different approach. Providers should check women two weeks after giving birth, and then continue holistic care for 12 weeks, eventually transitioning the patient to primary care.

That prolonged contact is essential, she said. “Postpartum depression, if untreated, can begin to spiral,” Stuebe said. “Even if you’re in treatment, after 60 days, you’re not better.”

Johnson, though, was left to wrestle with severe postpartum anxiety on her own.

She sought support from other new moms on Facebook who were coping with anxiety. Since her son had Medicaid for the first year of his life, his pediatrician was a source of help. She also got care through her local health department’s free clinics.

At the federal level, the idea of extending postpartum Medicaid is getting more attention. At a September House hearing, representatives from the American Medical Association, the Icahn School of Medicine and the Kaiser Family Foundation called for expanding postpartum Medicaid as a possible solution to the maternal mortality crisis. The American College of Obstetricians and Gynecologists has also recommended it. (Kaiser Health News is an editorially independent program of the foundation.)

Beyond protecting women during the medically vulnerable time after they deliver, experts think increasing Medicaid could go a long way toward addressing the racial disparities that exist in maternal mortality rates. Black women are two to three times more likely to die from pregnancy-related causes than white women.

“It’s not a silver bullet,” said Jamila Taylor, the director of health care reform at The Century Foundation, a nonpartisan think tank. “There’s racism in the health care system. Coverage is a piece of that, but we need to transform the system.”

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Must-Reads Of The Week From Brianna Labuskes

Happy Friday! Tis the season of getting wretched colds, and I blame daylight savings as any reasonable person would. So, we’re going to make this short and sweet as I clutch my tissues and tea. Buckle up!

Election results in Kentucky (and Virginia, really) added to the ever-deepening narrative that health care can be a big political winner for Dems and an Achilles’ heel for Republicans these days. Although the GOP talking point is that Gov. Matt Bevin (who technically hasn’t conceded yet) was extremely unpopular, it’s hard to miss that Medicaid expansion was a top issue in the race. Andy Beshear, who claimed victory on Tuesday, has vowed to rescind all of Bevin’s plans for Medicaid work requirements when he takes office.

In Virginia, many lawmakers ran on health care as well (like promising to protect preexisting conditions coverage and tackling gun control regulations), helping the Dems secure the Legislature for the first time in decades.

But health care isn’t always enough to boost Dems to a win, it seems. Democrat Jim Hood failed to upset Lt. Gov. Tate Reeves, a Republican, despite Hood’s promises to expand Medicaid to about 300,000 of the state’s most needy residents.

Curiously, attacks over abortion did not seem to hurt Democrats in either Virginia or Kentucky, even though the issue loomed large in both states.

CNN: Kentucky, Virginia And Mississippi Elections: 3 Takeaways

Politico: Why Democrats Keep Winning On Health Care

In a quick sidenote on Medicaid in the Deep South: Georgia’s governor has released a long-awaited health care plan that includes a limited Medicaid expansion with work requirements. As the requirements falter elsewhere, it will be interesting to test case to watch.

The Associated Press: Georgia Governor Unveils Medicaid Plan With Work Requirement

Now over to the presidential primary race: As predicted, lots of pundits, rivals, and others have had lots of thoughts on Massachusetts Sen. Elizabeth Warren’s plan to pay for “Medicare for All,” mostly landing on: It’s just not realistic. For her numbers to add up (which they do), everything pretty much has to fall into place perfectly. Which… in a nation’s capitol known more for its bitter partisan gridlock and deference to deep-pocketed lobby interests than for its smooth roads and sunny skies, well… no one is holding their breath that this would pass.

The Washington Post Fact Checker: Warren’s Plan To Pay For Medicare-For-All: Does It Add Up?

The New York Times: Elizabeth Warren’s ‘Medicare For All’ Math

Elsewhere on the election trail, Sen. Bernie Sanders (I-Vt.) released an ambitious plan to tack the immigration crisis. Among other things, he would scrap President Donald Trump’s “public charge” rule and ensure that anyone in the country regardless of immigration status was covered by his health system.

Boston Globe: Bernie Sanders Unveils Ambitious Immigration Plan That Offer A Path For Citizenship And Dismantles ICE

Tension over patents came to a head this week as the Trump administration sued Gilead over its HIV prevention drug, the development of which relied heavily on taxpayer-funded research. This fight has been bubbling up because Gilead has been raking in billions from the drug and yet hasn’t paid the CDC any royalties.

The Washington Post: U.S. Sues Drugmaker Gilead Sciences Over Patent On Truvada For HIV Prevention

And in case you’re interested in the background of it all (you should be! It’s a fascinating case), the Post did a deep-dive back in March.

The Washington Post: An HIV Treatment Cost Taxpayers Millions. The Government Patented It. But A Pharma Giant Is Making Billions.

Speaking of news from the administration, there was so much of it this week!

Let’s start with the court decision to block its expanded “conscience rule” for health care personnel who don’t want to participate in certain care due to moral reasons. The judge denounced the rule, saying it was arbitrary and unconstitutionally coercive. He also wrote that the “stated justification for undertaking rule making in the first place — a purported ‘significant increase’ in civilian complaints relating to the conscience provisions — was factually untrue.”

The New York Times: Judge Voids Trump-Backed ‘Conscience Rule’ For Health Workers

That wasn’t the only legal blow the administration suffered: elsewhere, a judge placed a temporary restraining order on a Trump rule that would have required visa-seekers to prove they can pay for health coverage before they’re allowed to live in the country.

The Associated Press: US Judge Blocks Trump’s Health Insurance Rule For Immigrants

In a separate court decision, a federal judge ruled that the U.S. government must provide mental health services to migrant families who may have been traumatized by being separated under the zero tolerance policy. The judge referred to previous federal cases that found that governments can be held liable when with “deliberate indifference” they place people in dangerous situations. This bit from The New York Times is interesting: In the past, the “state-created danger” doctrine has been applied when a police officer ejected a person from a bar late at night in very cold weather, or when a public employer failed to address toxic mold that caused workers to fall ill.

The New York Times: U.S. Must Provide Mental Health Services To Families Separated At Border

From news outside the courts, HHS is seeking to roll back Obama-era protections that keep foster care and adoption services from discriminating against LGBTQ families.

The New York Times: Adoption Groups Could Turn Away L.G.B.T. Families Under Proposed Rule

And in the midst of several public health crises, Trump has picked his choice to head the FDA: Dr. Stephen Hahn of the MD Anderson Cancer Center in Texas. If confirmed, Hahn will almost immediately have his hands full with the vaping epidemic, as well as continued fallout from the opioid crisis, not to mention public outrage over the high cost of drugs.

The Associated Press: Trump Picks Cancer Specialist From Texas Hospital To Run FDA

In case you missed it: Stat did one of the more interesting profiles on Hahn a bit ago, if you want to read up on his background.

Stat: Frontrunner To Lead FDA, Dogged By Controversies, Has Developed Knack For Confronting Them

On the topic of FDA, a look at how a controversy over a chemical that sterilizes medical equipment became a prime example of just how wrong things can go when agencies operate as silo-ed bureaucracies.

Politico: How The FDA And EPA’s Failure To Communicate Could Put Patients In Danger

Ahead of an anticipated federal ban on e-cigarettes, Juul has announced that it will end the sale of mint flavored pods. A study came out this week that found that the mint flavored ones have become more and more popular among young vapers.

The New York Times: Juul Ends E-Cigarette Sales Of Mint-Flavored Pods

Often times, when studying a disease it can be the people who don’t get it that hold the answers. That might be true with one woman who should have gotten early onset Alzheimer’s but didn’t start showing symptoms until decades later. Researchers say a mutation that the woman had protected her from the devastating disease. Learning how it did that could help scientists replicate the process for those who don’t have the mutation.

The New York Times: Why Didn’t She Get Alzheimer’s? The Answer Could Hold A Key To Fighting The Disease

It’s not always the memory that goes first. For those with frontotemporal dementia, it’s often the areas of the brain that control personality that are affected first. The resulting behavior changes can be heartbreaking.

The New York Times: The Loneliness Of Frontotemporal Dementia

And in the miscellaneous file for the week:

  • Documents show how Walgreens was in a unique position to raise giant red flags about the opioid epidemic at its height. But the company failed to do so.

The Washington Post: At Height Of Crisis, Walgreens Handled One In Five Of The Most Addictive Opioids

  • When one woman’s baby was born three months prematurely, she’d thought she’d taken care of everything that was needed to get her daughter covered under her insurance. Turns out, that wasn’t the case, and by the time she got the $898,984 bill, it was too late to fix it.

ProPublica: How One Employer Stuck A New Mom With A $898,984 Bill For Her Premature Baby

  • We often think of breath tests as being infallible ways to prevent drunken driving. But many of the machines that are stocked in police stations across the country are calibrated incorrectly. For some, that can change the whole course of their future.

The New York Times: These Machines Can Put You In Jail. Don’t Trust Them.

That’s it from me! Everyone stay healthy and don’t forget to get your flu shot.

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