TEXAS, USA — This article originally appeared in The Texas Tribune.
With a near-total abortion ban looming in Texas, advocates and experts say the state’s support systems for low-income mothers and children are already insufficient — and won’t easily bear an increase in need.
“When you say ‘social safety net’ in Texas, it sounds like a joke,” said D’Andra Willis of the Afiya Center, a North Texas reproductive justice group. “Everything they could have set up or increased to protect people if they really cared, they’re not doing it here.”
Pregnant women in Texas are more likely to be uninsured and less likely to seek early prenatal care than the rest of the country. They’ll give birth in one of the worst states for maternal mortality and morbidity. And low-income new parents will be kicked off of Medicaid sooner than in many other states.
This would make many Texans want to avoid pregnancy altogether. But learning about, let alone accessing, contraception can be a challenge in a state that does not require sex education and has narrowed family planning options in recent years.
Republican lawmakers, many of whom have focused on restricting abortion access in recent years, have said strengthening the state’s social safety net will now become a top priority. But advocates who have been working on these issues for years say any help will likely be too little, too late.
“People fail to realize that this is bigger than abortion access,” Willis said. “We’re going to be setting people up for generational poverty.”
Maternal mortality in Texas
Texas consistently ranks in the 10 worst states for maternal mortality, in a country that already ranks worse than its peers in that category.
Maternal mortality and morbidity — death or serious illness or injury — disproportionately impact Black women. The state’s Maternal Mortality and Morbidity Review Committee found that Black women made up 31% of pregnancy-related deaths, but only 11% of live births.
The rate of severe maternal morbidity for Black women in Texas is nearly double that of white women, according to a study from the University of Texas.
“This is the worst place and the most dangerous place to have a baby,” said Willis. “It’s safer to get an abortion in Texas than it is to have a baby in Texas.”
Willis also worries about a potential increase in pregnancy-related deaths and injuries as desperate people turn to self-managed abortion care.
One of the causes of Texas’ maternal mortality numbers, according to experts and advocates, is the state’s staggering rate of uninsured residents. Texas is one of just 12 states that has not expanded Medicaid and has one of the lowest eligibility standards in the country: A single parent with three children would have to earn less than $400 a month to qualify for Medicaid.
As a result, in 2019, nearly 1 in 5 Texans had no health insurance, double the national average. And the stats are worse for women of childbearing age — in 2017, more than a quarter had no health insurance, the highest rate in the nation.
Texas also has the lowest rate of women accessing prenatal care in the first trimester, according to an investigation from ProPublica and Vox. Babies are five times more likely to die if their mothers did not access prenatal care, according to the U.S. Office on Women’s Health.
Pregnant Texans can qualify for Medicaid at a much higher income level — up to $4,579 a month for a single parent of three. As a result, half of all births in the state are financed by Medicaid, among the highest rates in the nation.
For years, that program covered women through pregnancy and two months postpartum. But last year, as part of the American Rescue Plan, the federal government allowed states to easily expand coverage through the first 12 months postpartum.
On the recommendation of the state’s maternal mortality task force, Texas House lawmakers approved a bill that expanded coverage to 12 months after birth.
“It was the first time that there was that much bipartisan support for the issue,” said Diana Forester, director of health policy for advocacy group Texans Care for Children. “It was amazing. We were so excited.”
But then the state Senate rolled it back to six months postpartum. While the feds automatically approved states that extended coverage to 12 months, the new six-month plan will require Texas to go through the lengthy and cumbersome waiver process.
Texas has not yet submitted the waiver application, according to Texas Medicaid Director Stephanie Stephens at a hearing last Thursday. While the state hopes to begin offering six months of postpartum Medicaid coverage in October, it will depend on when their waiver is approved.
She said the federal government has at least 120 days to review the waiver “but we’ve seen waivers that they have not acted on for much longer than that.”
Right now, due to the federal public health emergency, no one is being moved off of Medicaid when their eligibility expires. That declaration is set to end in July, though it could be extended, as it has several times already.
The choice to approve only six months of postpartum Medicaid expansion was a huge disappointment for maternal health advocates.
“If you want healthy babies, you’ve got to have healthy mommies,” Forester said. “How do you have healthy mommies? You provide them coverage.”
Access to contraception, sex education
Uninsured and low-income Texans who would prefer to not become pregnant also face challenges in accessing contraception and reproductive health care.
Starting in 2011, Texas began a yearslong effort to “defund” Planned Parenthood, in part by slashing the budget for women’s health care and family planning.
By 2014, more than a quarter of family planning clinics in Texas had closed, most of which were not affiliated with Planned Parenthood. While some have reopened, access to contraception, cancer screenings, STI testing and other sexual health care remains much more sparse than it was before.
The remaining clinics that receive family planning funding from the state struggle to keep up with the demand for services.
“This program has never left money on the table,” said Erika Ramirez, policy and advocacy director for the Texas Women’s Healthcare Coalition. “We really want to ensure that lawmakers know that our women’s health programs are … not currently meeting that need, and that need is only going to increase.”
The state’s reproductive health care programs are additionally stretched, Ramirez said, because Texas is one of just two states that don’t cover contraception on its Children’s Health Insurance Program. Teens on this program who want to access contraception have to go through the state-funded Family Planning Program clinics.
“That’s an easy fix,” said Ramirez. “There’s actually evidence that this would produce cost savings for the state, and presumably if CHIP covers comprehensive care, to be able to access something as essential as contraception should be considered comprehensive care.”
Texas has among the highest rates of teen pregnancy in the country, and the highest rate of repeat teen births — teens having multiple children before their 18th birthday. Texas does not require high school students to take sex education to graduate.
“We can’t get birth control. We can’t get adequate health care. We’re not given comprehensive sex education, so we’re not being educated on birth control or naturally preventing pregnancy, and now you can’t get an abortion,” said Willis. “You take away all of this … and you don’t have any plan in place.”
Lawmakers and abortion opponents have argued that the plan, as it were, rests on the Alternatives to Abortion program, which the state has invested over $100 million into in recent years. The program funds a network of nonprofits intended to support people in continuing their pregnancies, often with little government oversight.
Vincent DiCaro, chief outreach officer of Care Net, told The Texas Tribune last week that the group’s 82 Texas crisis pregnancy centers have seen increased demand since the state banned abortion after about six weeks of pregnancy and are preparing for what a total ban might mean for their work.
“We think crisis pregnancy centers are awesome, of course,” he said. “But if that’s the only solution, we’re not going to have enough manpower to help all of the people who are going to need help if Roe v. Wade gets overturned.”
Other barriers for new parents
These centers typically only offer material support, counseling or parenting classes through the early months of a baby’s life. But an unplanned pregnancy can have lifelong consequences for mother and child.
And many of the most significant changes that advocates are pushing for will have to come through future legislative action.
Texas does not require employers to offer paid time off of any kind, though federal regulations mandate that qualified employees be given 12 weeks of unpaid job protection offered under the federal Family and Medical Leave Act.
Unlike neighboring New Mexico, which just debuted a program that offers a free year of child care to most families, Texas offers a limited child care scholarship program for children of low-income parents who are working or pursuing education.
And if the state decides that a parent can’t adequately care for the baby they had as a result of an unplanned pregnancy, the foster care system intervenes. The state is in the midst of a decadelong lawsuit over its inability to adequately care for children in the foster system, often with troubling consequences.
Willis, with the Afiya Center, said children often end up in the foster care system because of circumstances far beyond their control — or the control of their parents. And whether those children are in foster care or at home with parents, many of those factors are only going to get worse.
“You have young women who do not have control of their bodies to even access birth control,” she said. “And then these same women are living in areas that are food deserts, that are heavily impacted by air quality and environmental issues, that are dealing with poor school systems.”
When she thinks about the systems in place to support low-income Texans who will have to carry their pregnancies to term as a result of the forthcoming abortion bans, she said she feels hopeless.
“Black women in Texas have never had hope that any of this would come through,” she said. “And now it feels like we’re almost all the way back to square one.”
