AJPH PERSPECTIVES Planned Parenthood Is Health Care, and Health Care Must Defend It: A Call to Action Emboldened by the hostile rhetoric of the current presidential administration, federal and state legislators are intent on enacting legislation further curtailing, if not eliminating, Title X funding and Medicaid reimbursement to sexual and reproductive health care services providers—which are predominantly Planned Parenthood health centers. Defunding Planned Parenthood health centers would result in the loss of reproductive health and primary health care services that cannot be immediately replaced by community health clinics (CHCs) or other providers in underresourced counties. These losses constitute a dangerous threat to the public health of communities across the United States. In light of this, we call on the public health community to (1) commit itself to protecting Planned Parenthood against efforts to defund or limit its services and (2) mobilize additional stakeholders in the health care delivery system—hospitals, ambulatory care centers, physician provider groups, accountable care organizations, and health insurers—as vocal advocates against attacks on Planned Parenthood’s ability to provide core, primary health care services. These arguments, presented by a broad coalition of concerned and influential constituents who
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will bear the impact of proposed national health care reform measures and state-level challenges, are critically necessary to prevent loss of safety net services in our most vulnerable communities.
it also disrupts the organization and delivery of key primary health care services in the United States. Reducing access to these primary health care services for those without alternative sources of care will have far-reaching and negative impacts on the health of the most vulnerable communities across the United States.
REPRODUCTIVE CARE IS PRIMARY CARE Planned Parenthood health centers provide affordable access to comprehensive sexual and reproductive health care services as well as accurate sexual education from highly skilled and trained clinicians and counselors. Planned Parenthood health centers also provide primary health care services, including vaccination against influenza, hepatitis, and human papillomavirus; smoking cessation counseling; anemia testing; and screening for cholesterol, diabetes, high blood pressure, and breast cancer. Those attacking Planned Parenthood do so in an effort to restrict access to abortion services; however, for the past 40 years, the Hyde Amendment has prohibited use of federal funds for abortion services unless a woman’s life is endangered or in cases of rape or incest. Defunding or even reducing Planned Parenthood funding does not just restrict access to abortion services,
CHCS CANNOT REPLACE PLANNED PARENTHOOD Nationally, our extant primary health care delivery system is already straining to meet the needs of low-income, uninsured, and underinsured populations. Between 2011 and 2012, before Affordable Care Act (ACA)– mandated increases in Medicaid reimbursement rates, 33% of primary care physicians (PCPs) and 22% of obstetrician– gynecologists reported not accepting new Medicaid patients.1 These estimates varied considerably by state with 44% to 54% of PCPs in New Jersey,
California, Alabama, and Missouri reporting not accepting new Medicaid patients.1 As per a 2012 Government Accountability Office report, a majority of states reported that their Medicaid managed care plans faced substantial difficulties recruiting obstetrician–gynecologists to accept those plans.2 After ACA implementation, 59% of PCPs and 64% of primary nurse practitioners or physician assistants reported increases in visits from Medicaid or newly insured patients.3 The claim that CHCs can ramp up to meet the demand for services created by the loss of Planned Parenthood health centers is erroneous for several reasons. Despite expansion of the CHC model to serve more than 25 million individuals (71% below the federal poverty level, 50% served by rural CHCs), a 2014 report (bit.ly/2owZUDF) notes that at least 62 million individuals still have unmet primary health care needs. Furthermore, even though CHCs are present in more than 9000 communities, approximately 25% of communities with demonstrated primary health care need still do not have a CHC. Results from a national survey of federal health center grantees found that provision of reproductive health care services at their largest medical centers are
ABOUT THE AUTHORS Diana Silver is associate professor of public health policy at New York University’s College of Global Public Health, New York. Farzana Kapadia is associate professor of public health and population health at New York University’s College of Global Public Health and Department of Population Health. Correspondence should be sent to Farzana Kapadia, 715-719 Broadway, Room 1006, New York, NY 10003 (e-mail: [email protected]). Reprints can be ordered at http://www. ajph.org by clicking the “Reprints” link. This editorial was accepted April 17, 2017. doi: 10.2105/AJPH.2017.303867
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also strikingly limited—25% do not provide oral contraceptives on-site, only 19% provide all contraceptive methods on-site, and only 50% provide on-site intrauterine device or contraceptive implant services.4 Finally, the majority of CHCs require significant increases in funding for capital improvements to serve their existing patient population and meet their current demand for basic primary care services. The bottom line is that CHCs simply do not have the capacity, facilities, or resources to pick up the significant patient population left without care if Planned Parenthood health centers are shut down.
PROTECTING VULNERABLE POPULATIONS Evidence for the short- and long-term impact of eliminating funding to Planned Parenthood health centers is provided by studies conducted following a 2013 Texas state policy (House Bill 2) barring Planned Parenthood health centers from receiving funding under the state-run Medicaid family planning expansion program. First, there were significant increases in travel times and costs associated with obtaining reproductive health care.5 Next, there were significant reductions in claims for long-acting reversible contraceptives, delays in scheduling appointments for injectable contraceptives, and increases in use of less-effective contraception.6 Finally, there was a 27%
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increase in childbirth events covered by Medicaid during this period in communities that lost a Planned Parenthood health center.6 Most importantly, no large group of health care providers or CHCs emerged in these areas to meet the reproductive health care needs of these communities.
A CALL TO ACTION A broad group of constituents, including the American Public Health Association, American Congress of Obstetricians and Gynecologists, and many others, have made several statements supporting Planned Parenthood. The American Medical Association’s (AMA’s) March 7, 2017, letter to GOP members stated that the AMA could not “support provisions that prevent Americans from choosing to receive care from physicians and other qualified providers” such as those affiliated with Planned Parenthood (http://bit.ly/2pCfywr) Yet, other influential stakeholders in the health sector have been silent. For instance, neither the powerful American Hospital Association in its statement opposing the GOP’s American Healthcare Act (http:// www.aha.org/presscenter/ pressrel/2017/030817-pracha.shtml) nor the Federation of American Hospitals, in its March 8, 2017, letter oppose efforts to defund Planned Parenthood. Although major trade associations representing health care insurers, such as the America’s Health Insurance
Plans (https://ahip.org/aboutus/#who_we_are), and the pharmaceutical industry, such as the Pharmaceutical Research and Manufacturers of America (http://www.phrma.org/ about), have met with the administration regarding health care reform, they have not voiced support for Planned Parenthood. It is now time for these powerful players in the health care sector to publicly acknowledge the adverse consequences of defunding Planned Parenthood. Defunding Planned Parenthood will further strain our already stretched and burdened primary health care system. Women, men, and adolescents will lose access to essential health care services simply because of a shortage of qualified providers. Community hospitals, CHCs, and private providers do not have sufficient resources to address the needs of these populations. Having to do so will further burden an already burdened primary health care system and reduce access for all patients. The scale of attacks on Planned Parenthood this year and the political alignment in Washington as well as in state legislatures across the country may make these attacks more severe and possibly more successful than in previous years.7 It is time for all of the powerful stakeholders in the health care community to recognize this and embrace the arguments presented here as part of their talking points in nationaland state-level advocacy efforts to protect Planned Parenthood and protect the health of women
and families across the United States. Diana Silver, PhD, MPH Farzana Kapadia, PhD, MPH CONTRIBUTORS Both authors contributed equally to this article.
REFERENCES 1. Decker SL. Two-thirds of primary care physicians accepted new Medicaid patients in 2011–12: a baseline to measure future acceptance rates. Health Aff (Millwood). 2013;32(7):1183–1187. 2. Report to the Secretary of Health and Human Services. States made multiple program changes, and beneficiaries generally reported access comparable to private insurance. GAO-13–55 Medicaid Access. Washington DC: US Government Accountability Office; 2012. Available at: http://www.gao.gov/assets/ 650/649788.pdf. Accessed on March 31, 2017. 3. Experiences and attitudes of primary care providers under the first year of ACA coverage expansion: findings from the Kaiser Family Foundation/Commonwealth Fund 2015 National Survey of Primary Care Providers. Kaiser Family Foundation. Issue Brief June 18, 2015. Available at: http://www. commonwealthfund.org/publications/ issue-briefs/2015/jun/primary-careproviders-first-year-aca. Accessed May 2, 2017. 4. Wood S, Goldberg DG, Beeson T, et al. Health centers and family planning: results of a nationwide study. 2013. Available at: http://hsrc.himmelfarb.gwu.edu/sphhs_ policy_facpubs/60. Accessed March 31, 2017. 5. Gerdts C, Fuentes L, Grossman D, et al. Impact of clinic closures on women obtaining abortion services after implementation of a restrictive law in Texas. Am J Public Health. 2016;106(5):857–864. 6. Stevenson AJ, Flores-Vazquez IM, Allgeyer RL, Schenkkan P, Potter JE. Effect of removal of Planned Parenthood from the Texas Women’s Health Program. N Engl J Med. 2016;374(9): 853–860. 7. Gold RB, Hasstedt K. Lessons from Texas: widespread consequences of assaults on abortion access. Am J Public Health. 2016;106(6):970–971.
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will bear the impact of proposed national health care reform measures and state-level challenges, are critically necessary to prevent loss of safety net services in our most vulnerable communities.
it also disrupts the organization and delivery of key primary health care services in the United States. Reducing access to these primary health care services for those without alternative sources of care will have far-reaching and negative impacts on the health of the most vulnerable communities across the United States.
REPRODUCTIVE CARE IS PRIMARY CARE Planned Parenthood health centers provide affordable access to comprehensive sexual and reproductive health care services as well as accurate sexual education from highly skilled and trained clinicians and counselors. Planned Parenthood health centers also provide primary health care services, including vaccination against influenza, hepatitis, and human papillomavirus; smoking cessation counseling; anemia testing; and screening for cholesterol, diabetes, high blood pressure, and breast cancer. Those attacking Planned Parenthood do so in an effort to restrict access to abortion services; however, for the past 40 years, the Hyde Amendment has prohibited use of federal funds for abortion services unless a woman’s life is endangered or in cases of rape or incest. Defunding or even reducing Planned Parenthood funding does not just restrict access to abortion services,
CHCS CANNOT REPLACE PLANNED PARENTHOOD Nationally, our extant primary health care delivery system is already straining to meet the needs of low-income, uninsured, and underinsured populations. Between 2011 and 2012, before Affordable Care Act (ACA)– mandated increases in Medicaid reimbursement rates, 33% of primary care physicians (PCPs) and 22% of obstetrician– gynecologists reported not accepting new Medicaid patients.1 These estimates varied considerably by state with 44% to 54% of PCPs in New Jersey,
California, Alabama, and Missouri reporting not accepting new Medicaid patients.1 As per a 2012 Government Accountability Office report, a majority of states reported that their Medicaid managed care plans faced substantial difficulties recruiting obstetrician–gynecologists to accept those plans.2 After ACA implementation, 59% of PCPs and 64% of primary nurse practitioners or physician assistants reported increases in visits from Medicaid or newly insured patients.3 The claim that CHCs can ramp up to meet the demand for services created by the loss of Planned Parenthood health centers is erroneous for several reasons. Despite expansion of the CHC model to serve more than 25 million individuals (71% below the federal poverty level, 50% served by rural CHCs), a 2014 report (bit.ly/2owZUDF) notes that at least 62 million individuals still have unmet primary health care needs. Furthermore, even though CHCs are present in more than 9000 communities, approximately 25% of communities with demonstrated primary health care need still do not have a CHC. Results from a national survey of federal health center grantees found that provision of reproductive health care services at their largest medical centers are
ABOUT THE AUTHORS Diana Silver is associate professor of public health policy at New York University’s College of Global Public Health, New York. Farzana Kapadia is associate professor of public health and population health at New York University’s College of Global Public Health and Department of Population Health. Correspondence should be sent to Farzana Kapadia, 715-719 Broadway, Room 1006, New York, NY 10003 (e-mail: [email protected]). Reprints can be ordered at http://www. ajph.org by clicking the “Reprints” link. This editorial was accepted April 17, 2017. doi: 10.2105/AJPH.2017.303867
AJPH
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also strikingly limited—25% do not provide oral contraceptives on-site, only 19% provide all contraceptive methods on-site, and only 50% provide on-site intrauterine device or contraceptive implant services.4 Finally, the majority of CHCs require significant increases in funding for capital improvements to serve their existing patient population and meet their current demand for basic primary care services. The bottom line is that CHCs simply do not have the capacity, facilities, or resources to pick up the significant patient population left without care if Planned Parenthood health centers are shut down.
PROTECTING VULNERABLE POPULATIONS Evidence for the short- and long-term impact of eliminating funding to Planned Parenthood health centers is provided by studies conducted following a 2013 Texas state policy (House Bill 2) barring Planned Parenthood health centers from receiving funding under the state-run Medicaid family planning expansion program. First, there were significant increases in travel times and costs associated with obtaining reproductive health care.5 Next, there were significant reductions in claims for long-acting reversible contraceptives, delays in scheduling appointments for injectable contraceptives, and increases in use of less-effective contraception.6 Finally, there was a 27%
July 2017, Vol 107, No. 7
AJPH
increase in childbirth events covered by Medicaid during this period in communities that lost a Planned Parenthood health center.6 Most importantly, no large group of health care providers or CHCs emerged in these areas to meet the reproductive health care needs of these communities.
A CALL TO ACTION A broad group of constituents, including the American Public Health Association, American Congress of Obstetricians and Gynecologists, and many others, have made several statements supporting Planned Parenthood. The American Medical Association’s (AMA’s) March 7, 2017, letter to GOP members stated that the AMA could not “support provisions that prevent Americans from choosing to receive care from physicians and other qualified providers” such as those affiliated with Planned Parenthood (http://bit.ly/2pCfywr) Yet, other influential stakeholders in the health sector have been silent. For instance, neither the powerful American Hospital Association in its statement opposing the GOP’s American Healthcare Act (http:// www.aha.org/presscenter/ pressrel/2017/030817-pracha.shtml) nor the Federation of American Hospitals, in its March 8, 2017, letter oppose efforts to defund Planned Parenthood. Although major trade associations representing health care insurers, such as the America’s Health Insurance
Plans (https://ahip.org/aboutus/#who_we_are), and the pharmaceutical industry, such as the Pharmaceutical Research and Manufacturers of America (http://www.phrma.org/ about), have met with the administration regarding health care reform, they have not voiced support for Planned Parenthood. It is now time for these powerful players in the health care sector to publicly acknowledge the adverse consequences of defunding Planned Parenthood. Defunding Planned Parenthood will further strain our already stretched and burdened primary health care system. Women, men, and adolescents will lose access to essential health care services simply because of a shortage of qualified providers. Community hospitals, CHCs, and private providers do not have sufficient resources to address the needs of these populations. Having to do so will further burden an already burdened primary health care system and reduce access for all patients. The scale of attacks on Planned Parenthood this year and the political alignment in Washington as well as in state legislatures across the country may make these attacks more severe and possibly more successful than in previous years.7 It is time for all of the powerful stakeholders in the health care community to recognize this and embrace the arguments presented here as part of their talking points in nationaland state-level advocacy efforts to protect Planned Parenthood and protect the health of women
and families across the United States. Diana Silver, PhD, MPH Farzana Kapadia, PhD, MPH CONTRIBUTORS Both authors contributed equally to this article.
REFERENCES 1. Decker SL. Two-thirds of primary care physicians accepted new Medicaid patients in 2011–12: a baseline to measure future acceptance rates. Health Aff (Millwood). 2013;32(7):1183–1187. 2. Report to the Secretary of Health and Human Services. States made multiple program changes, and beneficiaries generally reported access comparable to private insurance. GAO-13–55 Medicaid Access. Washington DC: US Government Accountability Office; 2012. Available at: http://www.gao.gov/assets/ 650/649788.pdf. Accessed on March 31, 2017. 3. Experiences and attitudes of primary care providers under the first year of ACA coverage expansion: findings from the Kaiser Family Foundation/Commonwealth Fund 2015 National Survey of Primary Care Providers. Kaiser Family Foundation. Issue Brief June 18, 2015. Available at: http://www. commonwealthfund.org/publications/ issue-briefs/2015/jun/primary-careproviders-first-year-aca. Accessed May 2, 2017. 4. Wood S, Goldberg DG, Beeson T, et al. Health centers and family planning: results of a nationwide study. 2013. Available at: http://hsrc.himmelfarb.gwu.edu/sphhs_ policy_facpubs/60. Accessed March 31, 2017. 5. Gerdts C, Fuentes L, Grossman D, et al. Impact of clinic closures on women obtaining abortion services after implementation of a restrictive law in Texas. Am J Public Health. 2016;106(5):857–864. 6. Stevenson AJ, Flores-Vazquez IM, Allgeyer RL, Schenkkan P, Potter JE. Effect of removal of Planned Parenthood from the Texas Women’s Health Program. N Engl J Med. 2016;374(9): 853–860. 7. Gold RB, Hasstedt K. Lessons from Texas: widespread consequences of assaults on abortion access. Am J Public Health. 2016;106(6):970–971.
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