Texas Needs Comprehensive Reproductive Health Care and Education

Reproductive Care as Health Care

The ongoing debate over reproductive health care access has sustained a fever pitch during the past two years since the U.S. Supreme Court overturned Roe v. Wade on June 24, 2022, which removed the federal constitutional right to abortion and allowed states to begin banning and restricting abortion access. Discourse in the wake of the Dobbs v. Jackson Women’s Health Organization decision tends to focus solely on abortion rights; however, abortion care is only one aspect of reproductive health care.

This policy brief describes how a broader and more nuanced understanding of reproductive health-related policy is needed that considers the following points: 

• The landscape of reproductive health care policy in Texas reflects national trends toward more restrictive policies.
• The myopic focus on abortion policy in Texas has and will continue to eclipse the need for attention to all aspects of health care during individuals’ reproductive years.
• The loss of Title X funds has resulted in scarce availability of family planning clinics that provide preventive health services to low-income and uninsured patients.
• Policies that restrict access to comprehensive reproductive health, including sexual health education, services for contraception, sexually transmitted infection (STI) prevention, cancer screenings, and abortion, will exacerbate existing health disparities in Texas.
• Attending to and supporting reproductive health is an essential component of fair health care practices. Without sufficient access to reproductive health education, services, and funding, health equity will not be possible.

What Reproductive Health Includes

An overarching goal of Healthy People 2030 from the U.S. Department of Health and Human Services and the Office of Disease Prevention and Health Promotion is to achieve health equity. Health People 2023’s central tenets of health equity are articulated as: 

1. Everyone has access to optimal well-being.
2. Structural and social determinants of health are being addressed by eliminating barriers to equitable health.

Several leading health indicators are listed in the Healthy People 2030 road map, but three indicators are specifically impacted by availability and access to reproductive health services: maternal death, infant death, and human immunodeficiency virus (HIV) prevention and reduction.

According to the Guttmacher Institute’s report, “Adding It Up: Investing in Sexual and Reproductive Health 2019,” the definition of reproductive health care varies depending on the organization that defines it. However, even among these variations, reproductive health care typically includes equitable access to the following services:

• Inclusive sexual health education.
• Counseling and access to contraception.
• Access to prenatal, childbirth, and postnatal care.
• Safe abortion services.
• STI prevention and treatment.
• Sexual assault prevention, detection, and counseling.
• Reproductive cancer testing and treatment.
• Fertility and infertility counseling.
• Sexual health counseling.

Texas’ National Position in Reproductive Health 

Texas is at the forefront of a national debate surrounding reproductive health care, and the state’s policies have had significant implications for access to contraception, abortion care, and STI screenings. As this brief will outline, policies implemented in Texas during the last decade have reinforced and expanded restrictions to reproductive health equity in the state, which is a trend with national relevance. Texas is the 2nd most populous state, ranks 5 out of 10 for the highest fertility rate, and has the 8th highest teen pregnancy rate in the country. In fact, changes related to reproductive health care access in Texas represent a microcosm of national trends that reflect deep disparities among various states’ access to reproductive health services.

Additionally, Texas is consistently one of the lowest-ranked states in terms of women’s reproductive health and one of the highest-ranked states in terms of uninsured rates for women of reproductive age. Limitations to reproductive health education and services affects a large portion of Texas’ population and can have negative effects on overall health.

As noted earlier, reproductive health services are much broader than abortion; therefore, examining policies that affect reproductive health from a comprehensive perspective is essential.

Texas and Title X

Title X’s Lack of Funding in Texas

Multiple federal and state actions have slowly chipped away at essential reproductive health care in Texas, which has created logistical, financial, and geographical barriers. For example, funding for the Title X program —a federal grant program that offers financial support for family planning and other health services — has been flat for the past nine years, including 2023, despite a growing need for family planning services. As a result, Title X grantees such as Planned Parenthood have been scrambling for their clinics to fill the following needs for individuals who would not otherwise receive reproductive services or education because of their age, income, or immigration status: contraception. breast and cervical cancer screenings, and STI prevention, testing, and treatment.

The impacts of Title X’s limited funds have affected the local level with Planned Parenthood of the Gulf Coast currently having only one operating Title X clinic, according to Kylie McNaught, director of public affairs for this Planned Parenthood branch. In an email correspondence during May of 2024, McNaught noted that Planned Parenthood has also been cut from Texas’ Medicaid program, directly impacting many low-income individuals whose only access to health care is Planned Parenthood. The 2021 court decision to end Planned Parenthood’s connection with Texas’ Medicaid program was a part of state officials’ yearslong effort to cut off Medicaid funding to Planned Parenthood, even though it is already restricted from using federal funds to pay for abortions “except in limited cases of rape, incest, or life endangerment.” When patients cannot get the care they need from Planned Parenthood for services, such as contraception, breast and cervical cancer screenings, and STI and sexually transmitted disease (STD) testing, many of them have no other options for getting vital reproductive health care.

Impacts of Title X’s Decreased Funding 

The Texas Department of State Health Services recently reported a disturbing rise in syphilis among childbearing age women and a 34% increase in congenital syphilis. “One-fourth of the nation’s syphilis cases come from Texas,” said Dr. Irene Stafford, an OB-GYN and maternal-fetal medicine specialist with UT Health Physicians. Complications of infection during pregnancy include miscarriage, death, or premature birth. Like other STIs, syphilis disproportionately affects minoritized and under-resourced communities where individuals lack access to neighborhood health care clinics. With flat funding to Title X during the last decade, adequate free or low-cost screenings for STIs, especially in rural areas, have become inaccessible and led to undiagnosed and untreated infections that are compounded by limited access to effective birth control.

Contraceptive Services in Texas

One bright spot in the reproductive health landscape is that adults in Texas still have access to a range of birth control and reproductive health care services through most health insurance plans and federally funded programs. In addition, the emergency contraception Plan B is still available over the counter in stores and through some federally funded clinics and public health departments. Ella, another emergency contraception pill that works up to five days after sex, requires a prescription, but it can be prescribed and ordered online. The Food and Drug Administration (FDA) recently approved the daily contraceptive pill Opill for sale without a prescription, and it became widely available at pharmacies in March of 2024.

Despite efforts to maintain access for various forms of contraception, there have been limits imposed as well. In March of 2024, minors in Texas lost their ability to obtain contraception without a parent’s consent when the 5th Circuit Court of Appeals upheld a Texas law requiring parental consent for minors to obtain contraception. The decision ended one of the only resources for Texas teens to confidentially obtain birth control through federally funded Title X family planning clinics.

Texas’ Abortion Policy and Its Impacts

S.B. 8

In Texas, laws and policies have been implemented that place individuals in precarious positions of restricted bodily autonomy, choice, and access to health promoting services, including but not limited to abortion. Most notably, Texas imposes more restrictions on abortion care than almost any other state in the U.S. According to McNaught, “At this point in Texas, we are at a total ban, with no exceptions for rape, incest, or fetal abnormality, and no tangible guidance for physicians about providing abortion care during medical emergencies.”

In 2021, Texas Gov. Greg Abbott signed S.B. 8 into law, which banned abortions in the state after embryonic “cardiac activity” or at five to six weeks of pregnancy, with no exceptions made for known birth defects. The passage of S.B. 8 effectively established a statewide ban on abortion because most women do not know they are pregnant before six weeks. Additionally, the language of S.B. 8 includes an intentionally vague and unprecedented provision: It gives private parties the ability to prosecute individuals who provide information or referrals for abortion services, which leaves the door open for civil suits to be filed against physicians who try to educate their patients about pregnancy options.

S.B. 8’s Local and National Impacts on Individual and Infant Health

The impact of S.B. 8 has already been documented by researchers at John Hopkins University, who observed a 3% increase in births during a nine-month period in 2022, a total of 9,800 more births than expected, which was unique to Texas. According to Suzanne Bell at John Hopkins, “These findings suggest many pregnant people in Texas were unable to overcome barriers to accessing abortion services and instead were forced to continue an unwanted or unsafe pregnancy to term.”

The U.S. Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision in June of 2022 added another layer of restrictions to abortion access by overturning the constitutional right to abortion. The three dissenting judges in the case presciently argued that the decision would destroy lives, impact women’s “status as free and equal citizens,” and disproportionately impact individuals of color and low-income individuals. In fact, laws such as S.B. 8 and the Dobbs decision deliberately create logistical and financial hurdles, forcing many individuals to travel long distances or seek unsafe alternatives that may affect both their health and their newborn child’s health. According to a recent report by the Commonwealth Fund, states with the highest rates of maternal deaths — Arkansas, Louisiana, Mississippi, and Tennessee — already had restrictive abortion policies prior to the Dobbs decision, and now they all have complete bans on abortion.

One of the unintended consequences of laws such as S.B. 8, which severely restrict abortion access, is their impact on infant health. A recent study published in “Journal of the American Medical Association (JAMA): Pediatrics” that compared infant deaths in Texas with 28 other states showed that after S.B. 8 went into effect, infant deaths increased by 12.9% in Texas, compared with a national increase of 1.8% during the same period. Most notably, infant deaths due to birth defects increased by almost 23% in Texas during this time, while the rest of the country experienced a 3% decrease. According to the study, these results imply that policies such as S.B. 8, which force the continuation of pregnancies where there are known fatal birth defects, “have important unintended consequences in terms of trauma to families and medical costs” for newborns who are predicted to live for only hours or days.

Impacts on Health and Social Disparities

Texas’ increasingly restrictive reproductive landscape has only exacerbated existing disparities in reproductive health, resulting in individuals having more unplanned pregnancies, a higher percentage of Medicaid births, and economic insecurity that requires social services, such as Supplemental Nutrition Assistance Program (SNAP) — all factors associated with having children but not having the financial means to care for them. According to the Commonwealth Fund’s “2023 Economic Scorecard on State Health System Performance,” “Women with low income, women of color, and women in rural communities will be especially impacted by these changes in health care access. They disproportionately live in those states that have enacted additional abortion restrictions, and they are often the ones to experience the most acute effects of any systemic failure or shortcoming.” In other words, states with the worst health outcomes for women and children, which includes Texas, are implementing or considering further restrictions on reproductive care.

Policy Recommendations To Improve Reproductive Health in Texas

1. Secure protected funding for information of access and services for reproductive health for Texans. Establishing a rider with protected funding for reproductive health access and services would demonstrate a financial investment in health care for all Texans. For example, a supplemental rider can be appended to the state’s legislative budget for “Maternal and Child Health Related Grants” — with funds appropriated to implement the education, improved care, and improved access strategies discussed in this brief. Recently, during  88th Texas legislative session, Rider 67 was approved, which provides funding for women’s health programs, mobile health units and patient navigators to target “rural and underserved” areas in the state with the assistance of Every Body Texas and other organizations. These types of riders are an important step toward decreasing barriers to information and tools to prevent unwanted pregnancies and STIs. Without a comprehensive policy approach that supports health over the reproductive phase of individual’ lives, the current landscape of restrictive policies will likely result in increased adverse maternal and infant birth outcomes, rising STI rates, and higher rates of undetected breast and cervical cancer.    
    
2. Support and expand evidence-based sexual health education. When it comes to preventing unwanted pregnancies through comprehensive sexual health education, Sex Ed for Social Change’s “United States Sex Ed Report Card 2024” set Texas in the D range for its sex education policy. Texas’ policy leaves school districts in charge of what sexual health education, if any, they will provide to teens. To combat this lack of comprehensive sexual health education provided to students in Texas, we recommend passing a law that sets aside at least $1 million in state funds to pay for required sexual health education in the state’s public schools that helps prevent unhealthy and unwanted pregnancies through comprehensive, medically correct, and age-appropriate education.    
   
   The American College of Obstetricians and Gynecologists (ACOG) specifically recommends a tiered approach to sex education in public schools. Students in elementary school should learn about healthy friendships and body safety, while later elementary school lessons should focus on what the reproductive process is, how to prevent unwanted pregnancy, what a period is, what fibroids are, what consent is, and how to practice consent. Older adolescents should also learn about contraception, prevention of STIs and STDs, gender identity, and sexual orientation.    
   
   Research reflects that when adolescents are equipped with medically sound and culturally appropriate sexual health information, they are more likely to make reasonable decisions. Research also shows that learning accurate information about their sexuality does not make students more likely to have sex, and, in fact, can be effective at delaying sex.    
    

3. Expand accessible contraception financially and geographically for all Texans. Meaningful change to the reproductive health landscape cannot happen without widespread access to resources and services described in this brief, especially those related to contraception. Specific examples include:   

   • Make over-the-counter purchase and online ordering of birth control widely accessible and affordable, removing barriers for individuals who have limited access to contraception due to systemic barriers. 
   • Expand and protect comprehensive contraceptive care through Medicaid and Title X.  
   • Change rules to expand accessibility to reproductive health programs for patients with low income, such as Healthy Women Texas — which does not currently allocate benefits to pregnant people — as McNaught noted.   

   Another measure to consider is protecting birth control insurance coverage under the Affordable Care Act (ACA) — which provides more than 61 million women with preventive care that includes birth control — from rules passed by the Trump administration that allow employers to take away the provision of contraceptive coverage based on religious or moral objections. The contraception coverage mandate issued in the 2010 ACA saved individuals $1.4 billion on birth control just in the first year of coverage. Protection of contraception coverage by insurance, regardless of religious or moral objections by employers, is a proven cost-effective strategy.  

4. Recognize the cost benefits of reproductive care. In states such as Texas, sweeping restrictions on abortion, sexual health education, contraception access, and the number of clinics that provide reproductive health care services have reversed much of the progress made during the past 50 years in terms of individuals’ rights to reproductive choice. These regressive actions have been taken despite the tangible and proven cost benefits of investing in comprehensive reproductive health care, which include stabilizing the financial well-being of families in the short term and likely increasing individuals’ lifetime income, including retirement income, in the long term.

   On the other hand, restricting reproductive health care will inevitably result in the following: 

   • An increase of unwanted and unplanned pregnancies.
   • An increase in STI.
   • An increase in single-parent poverty.
   • An increase in the number of low-income parents who rely on public assistance, such as Temporary Assistance for Needy Families (TANF), to get by.
   • An increase in the number of births that are financed by Medicaid.

Conclusion

For patients whose care is provided by Title X clinics, the burden of preventing unwanted pregnancies is exacerbated by a lack of services accessible to them through clinics such as Planned Parenthood that have lost Title X funding, as McNaught observed. Title X, initiated in 1970, is the only federal program dedicated to family planning and preventative reproductive health services. The program awards grants to community health centers, with priority given to low-income clients. This type of social safety net program is essential for decreasing barriers to health care — a building block of health equity — yet it is vulnerable to politics and transitions of federal leadership. Since funding is not guaranteed for Title X and states can decide whether to opt in or not, this places individuals at risk for lack of access, as funding is dependent on decisions made at both federal and state levels. Title X has been level for almost the past decade, and a report by Kaiser Family Foundation shows that restrictions initiated under the Trump administration related to provider referral and the COVID-19 pandemic resulted in a 60% reduction in Title X utilization by individuals.

The Biden administration reversed the prior administration’s regulations that had elicited the loss of funding for clinics and services. With the Biden administration’s reversed regulations that had severely affected the number of Title X clinics, the number of Title X clinics is projected to return to the amount in the country prior to 2019. However, the disruption in funding and dramatic change in regulatory policies had immediate and aftershock effects on the health of millions of individuals and families who could otherwise be receiving family planning and contraception services. Even with the reversal of Trump administration regulations, more barriers to services for Title X recipients and providers are expected. A potential additional barrier could be that states with full abortion bans, such as Texas, may restrict the ability to provide pregnancy option counseling, a requirement of Title X funding. 

It is imperative to recognize that reproductive health is a fundamental aspect of overall health care. Given that half the population in Texas and in the United States is female, there must be value placed on the health of women. Valuing reproductive health care — as it affects the heath care of all individuals — requires comprehensive education and access to abortion care and pregnancy options. Denying and continuing to restrict options during a vulnerable health period, such as one’s reproductive years, has significant public health consequences for millions of individuals and families, such as increases in maternal mortality and morbidity rates, infant death, unsafe pregnancies, and STIs. Research supports the protections of comprehensive reproductive health care, especially given that low-income, lower education, rural populations and people of color are most affected by restrictions to information and services. 

This material may be quoted or reproduced without prior permission, provided appropriate credit is given to the author and Rice University’s Baker Institute for Public Policy. The views expressed herein are those of the individual author(s), and do not necessarily represent the views of Rice University’s Baker Institute for Public Policy.