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women’s health

Texas’ maternal mortality rate not as bad as previously reported

Good news, if a bit puzzling.

Several of the state’s top health experts released a report in the medical journal Obstetrics & Gynecology on Monday showing that by using the new method, the number of women who died dropped from 147 to 56.

The study uses an enhanced method of counting maternal deaths that involves cross-referencing birth certificates, death certificates, hospital discharge data and medical records to confirm that a woman who died was pregnant before she died. The state’s current method of calculating maternal deaths includes using specific medical codes and requiring officials to check a box on death certificates indicating whether a woman was pregnant before she died.

The study said the state’s 2012 maternal death numbers inflated the number of women 35 and older who were classified as a maternal death and included reporting errors in which women who had not been pregnant were reported as maternal deaths. The researchers said they also found 2012 deaths that were not included in the state’s original maternal death numbers.

The authors noted that other states have used the same methodology to calculate maternal deaths. They said they chose 2012 for the new analysis because it was the year when maternal deaths peaked in Texas.

The study’s authors said they plan to use the new method to confirm maternal deaths and calculate maternal mortality rates for additional years.

See here for the background. The story notes that even with the revision, which the authors of the new study attribute to “data error” in the initial report, the mortality rate for black women was still double what it was for white women. There are still other serious concerns as well, as expressed by Lisa Falkenberg:

“I would hate to see us lose the momentum that we’ve gained,” said Dr. Lisa Hollier, an obstetrician and gynecologist at Texas Children’s Hospital.

“We still have women dying of preventable causes,” she said. “We still have a two-fold, a doubling, in the risk of death for African-American women. Those things need to change. I don’t think we should accept where we are.”

Hollier, who co-authored this week’s report and also chairs the Texas Maternal Mortality and Morbidity Task Force, points out that deaths aren’t the only measure of the problem. For every maternal death, Hollier says there are 50 women who experience severe complications that can lead to hysterectomies, breathing problems requiring ventilator support and kidney failure, to name a few.

“If there are 50 women who die in a particular year, there are 2,500 women who had severe complications,” Hollier said. “There are so many more women who are affected than just that tiny tip of the iceberg which is mortality.”

All this happens in a state where as Falkenberg reminds us our Republican leadership has refused to expand Medicaid – something like half of all births in Texas are paid for by Medicaid – and have cut back on access to healthcare for women by gutting Planned Parenthood. The definition of “pro-life” in this state is so narrow you could slide it under a lobbyists’ door. So go ahead and be happy that things aren’t as bad as we feared, but don’t be satisfied with it.

UPDATE: Sophie Novack in the Observer makes a lot of really good points about this revised study. Go read what she says.

Black women face much higher risk of pregnancy-related death in Texas

Any time you’re being compared to a third world country, it’s not a good thing.

Black women bear the greatest risk for pregnancy-related death in Texas by far, according to a much-awaited new report, commissioned because the state rate resembles that of many Third World countries.

The report, which follows the publication of a national study that found Texas’ maternal mortality rate has doubled since 2011, ranked heart conditions, overdose by legal or illegal drugs and high blood pressure of pregnancy as the leading causes of such deaths.

“This confirms what we feared – that many of these deaths could be prevented,” said state Rep. Armando Walle, D-Houston, the House author of the 2013 bill that created a Department of State Health Services maternal mortality task force and charged it with producing biennial reports and recommendations. “It’s a travesty that this is happening.”

[…]

Marian MacDorman, the University of Maryland-based lead author of the Obstetrics & Gynecology study said she applauds the Texas team for “looking into the deaths in greater detail.”

“Although the Texas Department of Health study uses different methods and data sources from mine, I think we both agree that maternal mortality is a serious problem in Texas,” said MacDorman. “I especially appreciate their policy recommendations for how to reduce it.”

The Texas report found most of the state’s maternal deaths – 60 percent – occurred between 42 days and a year after delivery. MacDorman’s study identified 262 Texas deaths in the same two-year period based only on those who died within 42 days.

Walle said he is hopeful the report makes an impression on the 2017 Legislature.

“I’m not naïve to the fact we haven’t expanded Medicaid, but something needs to be done to increase access to pregnant women,” said Walle. “We can’t keeping letting federal dollars go to other states while these women are dying.”

See here for more about the previous study that showed an overall rise in maternal deaths in Texas. The story lists a number of things that could be done to help this situation, all of which involve expanding access to health care, most of which could be accomplished by expanding Medicaid. Since we know that won’t happen under the current leadership, none of whom has been quoted in a story I’ve seen so far, the question is what if anything they would propose to do about it. My guess is it would involve tort reform and high-deductible health plans, because we know those fix everything. Pro Publica has more.

Why are so many pregnant women dying in Texas?

Better yet, what are we going to do about it?

The rate of Texas women dying of pregnancy-related causes nearly doubled from 2010 to 2014, with the state seeing more than 600 such deaths in the four-year span.

In a new study, set to be published in the September issue of Obstetrics and Gynecology, researchers found that Texas experienced a dramatic increase in pregnancy-related deaths from 2010 to 2012. While the rest of the country also experienced an increase, no other state saw the rate nearly double like it did in Texas.

Some health experts complain that the state has been slow to respond to the problem. A state task force on the issue is nearly three years into its work and has released no recommendations.

“We’re really seeing this is a serious problem with maternal mortality,” said Dr. Daniel Grossman, an OB-GYN who studies the effects of recent reproductive health legislation in Texas with the Texas Policy Evaluation Project at the University of Texas at Austin. “It really seems like that’s where the state officials should be focusing on trying to improve health and safety.”

From 2006 to 2010, the rate of Texas women who died while pregnant or within 42 days of being pregnant due to causes related to their pregnancies fluctuated between 18.1 and 18.6 deaths per 100,000 live births, according to the study. In 2011, the rate jumped to 33, and by 2014, it was 35.8.

In 2012, 148 women died from such causes, up from 72 deaths two years before.

The findings stumped the national researchers and have prompted them to begin a further study into maternal mortality in Texas. Vital statistics officials on both state and national levels “did not identify” any change in the data recording processes that could have resulted in the dramatic increase, according to the study.

The Texas Legislature created a task force in 2013 to study pregnancy-related deaths and severe complications in the state. It’s set to release its first report to lawmakers on Sept. 1.

[…]

The rise in pregnancy-related deaths in 2011 coincided with the beginning of major budget cuts in Texas. In September of that year, health care providers across the state began to feel the effects of a family planning budget reduced by two-thirds.

Sarah Wheat, a spokeswoman for Planned Parenthood of Greater Texas, said many of the family planning clinics that lost funding or closed were an “entry point into the health care system” for women.

“Chances are they’re going to have a harder time finding somewhere to go to get that first appointment,” Wheat said. “They may be delayed in getting that initial pregnancy test and then a prenatal referral.”

The study mentioned changes to women’s health services and clinic closures but didn’t go so far as to suggest there was a correlation between that and the uptick in pregnancy-related deaths.

“Still, in the absence of war, natural disaster, or severe economic upheaval, the doubling of a mortality rate within a two year period in a state with almost 400,000 annual births seems unlikely,” the study said.

I’m going to wait and see what that task force finally says on September 1. It took them three years to come up with something, so one hopes it will be worth the wait. In the meantime, I wonder why we haven’t heard more from the “pro-life” forces in this state, whom we know are legion and not at all the quiet types. One would certainly think that a sharp, unexplained rise in the rate of pregnant women dying would be the sort of thing that might attract their attention and at least some of their energy. Wouldn’t one? The Current has more.

Let the budgetary games begin

The House takes up the budget today, with over 300 amendments and riders queued up for votes. A couple of things to watch for as the debate goes on:

Killing vouchers.

BagOfMoney

Lawmakers in the Texas House will have a chance to draw a line in the sand over private school vouchers during the upcoming battle over the budget Tuesday.

An amendment filed by state Rep. Abel Herrero, D-Corpus Christi, would ban the use of state dollars to fund private education for students in elementary through high schools, including through so-called tax credit scholarships.

If passed, the measure — one of more than 350 budget amendments covering topics from border security to abortion up for House consideration — would deliver a blow to Lt. Gov. Dan Patrick.

[…]

If Herrero’s amendment fails, it would represent a dramatic change in sentiment for the chamber, which overwhelmingly passed a similar budget amendment during the 2013 legislative session. Patrick, a Houston Republican who served as state senator before taking office as lieutenant governor in January, led that chamber’s education panel at the time.

Rep. Herrero’s amendment from 2013 passed by a 103-43 vote. Neither Speaker Straus nor Public Ed Chair Rep. Jimmie Don Aycock is any more pro-voucher than they were last year, and neither is Dan Patrick any more beloved, so you have to feel pretty good about the chances this time, though it’s best not to count your amendments till they pass. If it does, that won’t fully drive a stake through vouchers’ cold, greedy heart for the session, but it’ll be a solid blow against them.

“Alternatives To Abortion”

As the Texas House prepares for a floor fight Tuesday over its budget, a flurry of amendments filed by Democrats seeks to defund the state’s Alternatives to Abortion program.

A group of Democratic lawmakers filed more than a dozen amendments to either reduce or eliminate funding for the program, which provides “pregnancy and parenting information” to low-income women. Under the program, the state contracts with the Texas Pregnancy Care Network, a nonprofit charity organization with a network of crisis pregnancy resource centers that provide counseling and adoption assistance.

Since September 2006, the program has served roughly 110,000 clients. The network features 60 provider locations, including crisis pregnancy centers, maternity homes and adoption agencies.

State Rep. Jessica Farrar, D-Houston, said she filed an amendment to defund the entire program because the state is giving more money to “coerce women” into a “political ideology instead of providing information and services” at a time when Texas women’s access to health services is being reduced.

The proposed House budget allocates $9.15 million a year to the program in 2016 and 2017 — up from $5.15 million in the last budget.

“I think it’s troublesome that here we are going to almost double funding for a program that has not proven to be successful in any way,” said Farrar, chairwoman of the Women’s Health Caucus in the House. An additional amendment by Farrar would require an audit of the program.

Several House Democrats filed similar amendments, including Borris Miles of Houston, Celia Israel of Austin and Chris Turner of Grand Prairie, whose amendments would transfer more than $8 million from the Alternatives to Abortion program to family planning services and programs for people with disabilities.

“These facilities have very little regulation, no accountability and no requirement to offer actual medical services,” Turner said, adding that funding could be used for other medical programs. “My amendments are an attempt to address our state’s real priorities and needs.”

Two Republicans, meanwhile, filed measures to boost the program’s funding.

I don’t expect Dems to win this fight, but it’s a fight worth having.

Other women’s health funding issues

The state currently administers three similar women’s health programs that cover things like annual well woman exams, birth control and cancer screenings for low-income women.

The newest program, the Expanded Primary Health Care Program, created in 2013, is slated to get the funding bump, bringing the total for women’s health services in the House version of the budget to about $130 million per year.

Here is the breakdown of funding for each program:

  • Texas Women’s Health Program: $34.9 million in 2016, $35.1 million in 2017
  • Expanded Primary Health Care Program: $73.4 million in 2016, $73.4 million in 2017
  • Family planning program administered by Department of State Health Services: $21.4 million in 2016, $21.4 million in 2017

In 2011, motivated by a never-ending quest to defund Planned Parenthood, the Texas Legislature slashed family planning funding by nearly $70 million, leaving about $40 million for preventive and contraceptive services for low-income women. A recent study by the University of Texas at Austin’s Texas Policy Evaluation Project, a research group that studies the effects of family planning budget cuts, found that more than 100,000 women lost services after the 2011 cuts and 82 family planning clinics closed. In 2013, the Legislature restored the $70 million and put it into the newly created Expanded Primary Health Care Program, which became a separate item in the state budget. Still, advocates and providers have consistently fought for more money, arguing that the state is only serving one-third of women eligible to receive services.

[…]

Here is a list of other women’s health amendments and riders to watch for:

  • State Rep. Mary Gonzalez (D-Clint) filed an amendment that would allow teenagers who are 15 to 17 years old and already mothers to get contraception without their parents’ consent. Right now, state law requires that all teenagers under the age of 18 get their parent’s permission for birth control. The amendment mirrors Gonzalez’s House Bill 468, which she presented to the House State Affairs Committee in mid-March.
  • State Rep. Chris Turner (D-Arlington) has proposed a rider that would ensure sex education programs teach “medically accurate” information to public school students.
  • State Rep. Bryan Hughes (R-Mineola) proposes adding even more money to the Alternatives to Abortion program by taking almost $7 million from the Commission on Environmental Quality.
  • A House budget rider by state Rep. Sarah Davis (R-Houston) protects the state’s Breast and Cervical Cancer Services program that provides breast and cervical cancer screenings for uninsured women, under attack this session by conservative lawmakers hell bent on, you guessed it, defunding Planned Parenthood.

Some possible winners in there – in a decent world, Rep. Gonzalez’s bill would be a no-brainer – but again, fights worth having. Rep. Sarah Davis has received some liberal adulation this session for trying to do good on women’s health issues. That budget rider will be a test of whether she can actually move some of her colleagues or not.

Public education

An amendment by the House’s lead budget writer, Appropriations Committee Chairman John Otto would allocate $800 million more to certain public schools as part of a plan announced last week to diminish the inequities that exist among districts under the current funding scheme.

[…]

At the news conference Monday, Austin state Rep. Donna Howard said at least 20 percent of public schools still will receive less per-student funding than they did in 2011 under the proposal. That year, state lawmakers cut $5.4 billion from public education, restoring about $3.4 billion two years later.

“We aren’t keeping up as it is,” Howard said.

She also noted the plan also does not include the $130 million that had been earmarked for a bill containing Gov. Greg Abbott’s plan to bolster pre-K programs — an amount she described as insufficient considering it does fully restore funding to a pre-K grant program gutted in 2011.

Howard has filed a budget amendment that would allocate $300 million for pre-K.

Pre-K is one of Greg Abbott’s priorities this session, but his proposal is small ball. Rep. Howard’s amendment has a chance, but we’ll see if Abbott’s office gets involved.

And finally, same sex benefits, because of course there is.

Rep. Drew Springer (R-Muenster) is again trying to bar Texas school districts from offering benefits to the same-sex partners of employees.

Springer has introduced a budget amendment that would eliminate state funding for districts that violate the Texas Constitution, which prohibits recognition of same-sex partnerships.

The amendment is similar to a bill Springer authored two years ago, which cleared committee but was never considered on the floor. Under Springer’s budget amendment, the education commissioner, in consultation with the attorney general, would decide whether districts have violated the Constitution. Districts would have 60 days to correct the problem.

According to Equality Texas, Springer’s amendment is aimed at the Austin, Pflugerville and San Antonio school districts, which offer “plus-one” benefits that are inclusive of same-sex partners. But the group says those benefits are in line with a 2013 opinion from former Attorney General Greg Abbott, which found that such programs are only illegal if they create or recognize a status similar to marriage.

Yes, as noted, Rep. Springer has tried to meddle in this area before. I admit, I’m more worried about a budget amendment this year than a bill in 2013. Keep a close eye on that one.

Where are the women’s health providers?

The Republican jihad against Planned Parenthood continues to have real consequences.

Right there with them

Right there with them

In 2011, under pressure from Republican leaders, state health officials began enforcing a provision lawmakers wrote to exclude Planned Parenthood and any clinics with organizational ties to abortion providers from the Women’s Health Program. At the time, Planned Parenthood clinics provided 40 percent of the program’s services and often subsidized services not expressly covered by it.

To replace Planned Parenthood, the state recruited new providers, the majority of which are physician groups, to participate in the reimagined program. But unlike many reproductive health clinics, which qualify for additional federal family planning grants, physician groups generally don’t have the public financing to pay for services that aren’t covered by the state program. While physician groups can absorb some of these additional costs, in most cases a patient must pay out of pocket for additional services or find an alternative provider that receives federal subsidies, which can delay care.

Emma Moreno, assistant manager at Valley Women’s Specialists, a physician group in Weslaco that participates in the Women’s Health Program, said the program covers Pap smears, for example, but if a patient tests positive for the human papillomavirus and needs further treatment, that care isn’t covered.

“If you’re going to provide a program or a service, provide the full service and not just half of it,” said Moreno, whose physician group still encourages women who may be eligible to apply for the state program.

[…]

To be eligible for the Women’s Health Program, a woman must have an income at or below 185 percent of the federal poverty threshold, or less than $1,800 a month for an individual. The original Women’s Health Program, which was jointly funded by the state and the federal government, was an offshoot of Medicaid. The federal government discontinued its $9-to-$1 match for the program in January 2012. That followed the state’s exclusion of Planned Parenthood clinics, despite the fact that those clinics were already prohibited from performing abortions because they accepted taxpayer dollars.

The Texas Women’s Health Program is nearly identical to the former Medicaid program in scope, though it now covers STD testing and some routine treatment, and is run entirely with state funding — $35.6 million a year.

In the first six months of the state-run program, enrollment and claims for services dropped significantly.

“While these numbers were collected before we added increased funding [for] women’s health in the last legislative session, they are exactly the type of data we will be carefully reviewing in the months ahead,” state Sen. Jane Nelson, R-Flower Mound, the chairwoman of the Senate Health and Human Services Committee, said in an email to The Texas Tribune last month. “It is important that we make sure the dollars we invested are providing meaningful preventive health services for the women of Texas.”

When I talk about how the likes of Rick Perry, David Dewhurst, and Greg Abbott just don’t want people to have access to health care, it’s about more than just their mulish resistance to expanding Medicaid or their petty harassment of ACA navigators. Their actions have had real world consequences. I’ve talked about this at length – browse through my Planned Parenthood archives, there’s too many entries to link to individually – and the bottom line remains that the state of Texas took something that was working and broke it for ideological reasons. They can try to put it back together again, at greater cost to Texas taxpayers, but even if they succeed they will still have disrupted the delivery of health care to hundreds of thousands of women, forcing many of them to find new doctors, for no good reason.

A reduction in funding for women’s health leads to fewer women getting health care

Shocking, I know.

Right there with them

Right there with them

The number of claims filed for medical and family planning services in the new state-run Texas Women’s Health Program has dropped since the state ousted Planned Parenthood from it and set up its own program without federal financing, according to figures from the Health and Human Services Commission.

Stephanie Goodman, a spokeswoman for the commission, wrote in an email that the program is “running at about 77 percent of the number of claims this year compared to last year.” She added that the agency expects to “see a similar trend with the number of women served,” though those numbers are more difficult to calculate.

“We expected to see a drop-off in the number of claims when we moved to the state program because we knew some women wouldn’t want to change doctors,” Goodman said. “We’ve been able to find new doctors for women who call us, and we’ve got the capacity to increase the number of women we’re serving in the state program.”

[…]

While Planned Parenthood continues to provide services with community donations and other revenue, Danielle Wells, a spokeswoman with Planned Parenthood of Greater Texas, said many patients have expressed frustration “that politicians are telling them where they should and should not go for their health care.”

“We’re still hearing from patients who were in the program and were unable to locate a provider or schedule services in a timely manner,” she said. The exclusion of Planned Parenthood requires many women to travel farther to find an available provider, she said, and to make “tough decisions about paying out of pocket for care or simply putting off vital care that could potentially save lives.”

Amanda Stevenson, a research associate at the University of Texas at Austin’s Texas Policy Evaluation Project, a three-year study evaluating the impact of the 2011 women’s health policy changes, said determining whether women still have adequate access to care is complicated. While the health commission is working hard to enroll new providers to replace Planned Parenthood, she said women may delay care because they do not know which providers are available or end up paying out of pocket costs by continuing to seek services at a Planned Parenthood clinic.

“We’re seeing obviously that access is diminishing in places, particularly [those] that rely heavily on Planned Parenthood providers,” she said. But other areas of the state have not been as affected by the policy changes, she added, referencing a data application created by the researchers that shows how the 2011 policy changes and funding cuts have affected women’s health services regionally.

She also noted that more data is necessary to determine whether the percent reduction in claims represents a persistent trend.

“If things were getting better then we would expect consistent reduction in that proportion, but it’s not happening,” Stevenson said. “There might be a trend, and we might see it, but it’s not enough here to say that it is.”

To be as fair as I can to something that doesn’t deserve fair treatment, Planned Parenthood had previously served forty percent of the Women’s Health Program clients, but the decline in participation is now only about 23% of the pre-cutoff total, which means that at least some of the women who were directly affected by this bit of ideological bloodletting have since found an acceptable alternative. Hooray for small victories. Of course, they were all still forced to change doctors, and we have no way of knowing how much less convenient or more expensive these new arrangements are for them. And Lord knows the people that brought you this little catastrophe aren’t interested in finding out the answer to that. But again, as I said before, even if you could reasonably claim that access to health care is no worse than it was before, hundreds of thousands of women had their access to health care disrupted, for no good reason. And a lot of legislators plus our state leaders count that as a victory.

In related news, that ballyhooed restoration of family planning funds this session is less than meets the eye.

The Texas Women’s Healthcare Coalition has raised concerns that a bipartisan effort to restore access to family planning services by expanding a state-run primary care program isn’t shaping up as planned.

During hearings in the regular legislative session, David Lakey, the commissioner of the Department of State Health Services, told lawmakers that 60 percent of the $100 million allotted to expand the primary care program for women’s health care in the 2014-15 biennium would be used to provide family planning services and contraception. But the forms created by DSHS for health providers to apply to take part in the program do not explicitly state that 60 percent of providers’ services must go toward family planning.

In a letter sent Monday to DSHS and lawmakers, the coalition — which counts the Texas Medical Association, Texas Academy of Family Physicians and Texas Association of Community Health Centers among its 39 members — argued that the proposed rules don’t ensure that the program will achieve lawmakers’ intent of restoring access to family planning services.

“We’re concerned that this was really like a bait and switch,” Dr. Janet Realini, chairwoman of the coalition, said in an interview. Although she does not believe DSHS has intentionally disregarded the legislative intent to increase family planning services, she said, “the system to do that is missing an essential piece of direction for the contractors.”

Carrie Williams, a spokeswoman for DSHS, said the department received the coalition’s letter and is working to clear up misunderstandings about the program.

“We’ve been very open in developing and talking about this program, so it was disappointing to see these inaccuracies being promoted as fact,” Williams said in an email to the Tribune.

She added that family planning services are emphasized throughout the department’s materials on the program, but that the program does not exclusively provide family planning services.

“The 60 percent target for family planning was what we have been proposing all along. While that threshold is not explicitly stated in the materials, it has long been the plan and we have never indicated otherwise,” said Williams.

In its letter, the coalition recommended that the department explicitly prioritize family planning services by setting specific targets and performance measures for contractors. The state could save money and avert unintended pregnancies, the coalition argues, by setting performance targets for family planning services and giving funding priority to contractors that have demonstrated the ability to provide these types of services.

“I think putting it in the materials to let contractors know what you’re looking for is important,” said Realini.

In the private sector, we call that setting metrics. Metrics reflect goals and values. You can draw your own conclusions.