Budget Cuts Hit Home

A clinic in Gonzales struggles to deal with Texas' health care cuts.


In a small clinic a few blocks from the main highway that runs through the South Texas town of Gonzales, Patrick Caldwell dispenses birth control and straight talk to thousands who flock to her clinic. Caldwell, a nurse practitioner, offers a smorgasbord of family planning options—free when necessary—to her mostly female, impoverished clientele. Teens come in for services, though not as many as Caldwell would like. Gonzales County has the third-highest teen pregnancy rate in the state.

Caldwell fears the number of “babies having babies” may soar even higher after the state’s cuts to family planning funding took effect in September. The Legislature slashed $73 million from Texas’ 2012-2013 family planning budget, a whopping 66 percent reduction.

The clinic where Caldwell works—the Women’s Wellness Center—has seen its state funding, which largely covers the cost of indigent care—decline by a third. Clinic workers are scrambling to assess how they will continue to care for those in need.

The outlook for family planning services in Texas is as bleak as the bone-dry fields that dot this part of Texas, 74 miles east of San Antonio. State officials have estimated that at least 180,000 women could lose access to family planning services. The situation will become especially challenging in rural areas. “Everyone’s getting hit hard, but what you have different in rural areas is you have no other resources,” said Fran Hagerty, CEO of the Women’s Health and Family Planning Association of Texas. “These are not big urban areas with big donors where you have these special events like you could in Houston or Austin or Dallas. If these clinics go away, there’s nothing else. It’s really a dire situation.”

Caldwell’s clinic is run by Community Health Centers of South Central Texas, a(n) nonprofit with an $8 million budget that runs three full-service rural clinics, as well as the Women’s Wellness Center. With so much less money from the state, the clinics will almost certainly have to reduce services.

Family planning dollars fund more than just birth control. They cover Pap tests, clinical breast exams, and cholesterol, diabetes and STD testing for people whose incomes fall below 185 percent of the federal poverty level. Fewer low-income people will now have access to these services.

No clinic can treat people for free, lamented Henry Salas, CEO Community Health Centers, while recently driving the 18 miles along country roads between clinics in Luling and Gonzales. With 86 percent of his clients uninsured, and 65 percent living in poverty, Salas fears his non-profit may no longer afford the no-one-gets-turned-away-service to new walk-ins who can’t foot the cost of their visits.

The plan, Salas said, is as follows: “We’ll use whatever monies we have until they run out. We’re in unknown waters.”

Salas breaks down the math as he drives: Nearly 12,000 patients were served by his group’s three clinics last year. He expects roughly the same number of people to show up this year, though fewer dollars are in the pot to serve them. Subtract the salaries of seven or eight administrative staff laid off after state budget cuts were announced last spring. There’s a small reserve, about $100,000. In a crunch, they can dip into the reserve. Last year, a grant for primary care allocated in September was depleted by November. More state money became available later in the year but no one harbors illusions that new state grants will arrive this time.

There’s a hospital and another clinic in Gonzales County (pop. 19,000), but that’s it. Though folks here dream of striking it rich in the nearby Eagle Ford shale, where companies are drilling for oil, most people make modest sums in the chicken and cattle farms that surround this city of 7,000, Gonzales’ long-time mayor, Bobby O’Neal, said. Per capita income in the county hovers around $18,000, and 19 percent of the population lives below the federal poverty line, according to the latest government figures.

The first shot in the Texas War for Independence was fired from a cannon just outside town, and residents still mark the event with an annual “Come and Take It” festival in October. Some residents may be poor in Gonzales, but they’re proud, Salas said. When the clinics began putting pressure on patients to take care of their bills, many stopped coming. “Their pride is hurt. They’ll have health care needs but instead of coming, they’ll stay home,” Salas said.

Caldwell, 49, is an Arkansas native who saw the hardships of teen motherhood when her 15-year-old sister became pregnant more than three decades ago. She says she can’t fathom what lawmakers were thinking with their raid on family planning monies. “They’ve probably never been to a public clinic in their lives,” she said. “We’re going to have more babies, a lot more babies.”

Some Republican state lawmakers advocated for the cuts by linking family planning with abortion providers. It was primarily an attack on Planned Parenthood, which provides both abortion and family planning services—but in separate facilities. It’s illegal for abortion clinics to receive state money.

The crazy thing, Caldwell notes, is that a woman probably couldn’t even get an abortion today in Gonzales County or surrounding areas. Caldwell knows of no local abortion providers. So cuts to family planning, she said, affect family planning. And she wonders if a lack of access may lead to back-alley abortions.

That possibility weighs heavy on the mind of state Rep. John Zerwas, R-Simonton, an anesthesiologist who is fiercely anti-abortion and who chaired the House appropriations subcommittee on health funding. Zerwas voted in favor of the family planning cuts. While he’s quick to note the benefits of many family planning programs, he saw his options in stark terms. “Are you pro life or are you pro choice? I wanted everyone to understand where the [family planning] money was going, what the level of cuts were and what the level of monies were that would sustain the various strategies and so forth, but when it came to the vote, all I was trying to do was wrack up pro-life votes. I’m a strong pro-life conservative, and I’ll take those votes, but it doesn’t mean that I necessarily felt that moving money [away from family planning] was necessarily the best idea.”

Zerwas says he worries abortions may inadvertently rise, not fall, if women lose access to family planning. He hopes money to restore many of the programs might be found elsewhere in the state budget. But he doesn’t regret his vote; he’s pleased Planned Parenthood has been essentially defunded by the state.

Jane Wray is a pediatrician at Community Health Centers’ Luling clinic, not a family planning doctor, but she has no doubt that within a year or two, she’ll see the consequences of family planning cuts in the dejected faces of reluctant moms who’ll walk into her office, unplanned baby in tow. It’s a sad fact, but not everyone is planned or wanted, Wray says. Eager mothers “ask a lot of questions, they’re excited and attentive and want to know what they can do to make their lives better.” Others display an unmistakable apathy. “Often in teenage pregnancies, the grandmother will tell you all about the baby and the teenage will just sit there, in shock really, they haven’t gotten over the shock since they got pregnant.”

Birth control doesn’t come cheap, especially if you shun condoms. Caldwell says few of her female patients’ male partners want anything to do with condoms. “It doesn’t make them feel manly. They want the females to be responsible for the birth control,” she says.

Caldwell keeps an array of devices in a drawer in a pistachio-colored exam room: short-term and long-term IUDs, vaginal foam, vaginal rings, transdermal patches, birth control pills, condoms. Implanon, a birth control device that is inserted under the skin of the patient’s arm, costs the clinic $423.82.

But footing the tab for these methods is pocket change compared to the alternative: paying for unplanned pregnancies.

The Texas Legislative Budget Board, which provides lawmakers with fiscal analysis, estimates that Texas will see an additional 20,000 unplanned pregnancies in the next two years as a result of the $73 million in cuts. The cost to taxpayers: $231 million.

That’s the great irony. In the end, the cuts to family planning will actually cost the state money.