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T he n e w e n g l a n d j o u r n a l o f medicine

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From the Population Research Center, Uni-versity of Texas at Austin (A.J.S., J.E.P.), theTexas Health and Human Services Com-mission (I.M.F.-V., R.L.A.), and Graves,Dougherty, Hearon, and Moody (P.S.) — allin Austin, TX. Address reprint requests toDr. Potter at the Population Research Cen-ter, University of Texas at Austin, 305 East23rd St., Stop G1800, Austin, TX 78712-1699, or at [email protected].

This article was published on February 3,2016, at NEJM.org.

DOI: 10.1056/NEJMsa1511902

Copyright © 2016 Massachusetts Medical Society.

BACKGROUND

Texas is one of several states that have barred Planned Parenthood affiliates from pro- viding health care services with the use of public funds. After the federal governmentrefused to allow (and courts blocked) the exclusion of Planned Parenthood affiliatesfrom the Texas Medicaid fee-for-service family-planning program, Texas excluded themfrom a state-funded replacement program, effective January 1, 2013. We assessed ratesof contraceptive-method provision, method continuation through the program, andchildbirth covered by Medicaid before and after the Planned Parenthood exclusion.

METHODS

We used all program claims from 2011 through 2014 to examine changes in the numberof claims for contraceptives according to method for 2 years before and 2 years after theexclusion. Among women using injectable contraceptives at baseline, we observed ratesof contraceptive continuation through the program and of childbirth covered by Medic-aid. We used the difference-in-differences method to compare outcomes in counties

with Planned Parenthood affiliates with outcomes in those without such affiliates.

RESULTS

After the Planned Parenthood exclusion, there were estimated reductions in the num-ber of claims from 1042 to 672 (relative reduction, 35.5%) for long-acting, reversiblecontraceptives and from 6832 to 4708 (relative reduction, 31.1%) for injectable contra-ceptives (P<0.001 for both comparisons). There was no significant change in thenumber of claims for short-acting hormonal contraceptive methods during this period.Among women using injectable contraceptives, the percentage of women who returnedfor a subsequent on-time contraceptive injection decreased from 56.9% among those

whose subsequent injections were due before the exclusion to 37.7% among those whose subsequent injections were due after the exclusion in the counties with PlannedParenthood aff iliates but increased from 54.9% to 58.5% in the counties without suchaffiliates (estimated difference in differences in counties with affiliates as compared

with those without aff iliates, −22.9 percentage points; P<0.001). During this periodin counties with Planned Parenthood aff iliates, the rate of childbirth covered by Med-icaid increased by 1.9 percentage points (a relative increase of 27.1% from baseline)

within 18 months after the claim (P = 0.01).

CONCLUSIONS

The exclusion of Planned Parenthood aff iliates from a state-funded replacement for aMedicaid fee-for-service program in Texas was associated with adverse changes in theprovision of contraception. For women using injectable contraceptives, there was areduction in the rate of contraceptive continuation and an increase in the rate ofchildbirth covered by Medicaid. (Funded by the Susan T. Buffett Foundation.)

AB STR ACT

Effect of Removal of Planned Parenthood

from the Texas Women’s Health ProgramAmanda J. Stevenson, M.A., Imelda M. Flores-Vazquez, Ph.D.,

Richard L. Allgeyer, Ph.D., Pete Schenkkan, J.D., and Joseph E. Potter, Ph.D.

Special Article



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Th e n e w e n g l a n d j o u r n a l o f medicine

Federal public health financing

through Medicare, Medicaid, and the Af-fordable Care Act relies on an array of pub-

lic and private entities to deliver health careservices. Historically, federal statute or rule hasrequired that all medically qualified providers beeligible to provide care that is funded wholly or in

part through federal programs. Legislation chal-lenging this tradition by the exclusion of PlannedParenthood affiliates from participation in state-administered, federally funded family-planningprograms has been adopted or proposed in 17states and both houses of the U.S. Congress.1 Texas was the first state to enforce such a law.

Beginning in 2007, Texas operated a Medicaid waiver program, the Women’s Health Program, with 90% of funding from the federal govern-ment.2 In 2011, the Texas legislature directed theprogram to exclude Planned Parenthood affili-ates. The federal Centers for Medicare and Med-icaid Services informed Texas that because theexclusion of medically qualified providers vio-lated federal law, it would not renew the waiverbut would continue transition funding throughthe end of 2012. Litigation kept Planned Parent-hood affiliates functioning in the program untilthe transition funding ended. Texas then re-placed the federally funded program with anearly identical 100% state-funded program (theTexas Women’s Health Program) that excluded

clinics affiliated with an abortion provider, ef-fective January 1, 2013.3

Effective 15 months earlier (on September1, 2011), Texas had cut family-planning grants(a separate funding stream) by 66% and redis-tributed the remaining grant funding away fromdedicated family-planning providers, such as,but not limited to, Planned Parenthood affili-ates. The Texas legislature did this by removingTitle V and Title XX family-planning fundingand requiring the initiation of a new, tieredgrant-award process favoring county health de-

partments, community health centers, and othercomprehensive care providers.4 The 2011 reduc-tions in grants and redistribution of funds werefollowed by the closure of 82 family-planningclinics, about a third of which were affiliated

with Planned Parenthood.5 This sharp curtail-ment of the family-planning safety net in Texasoccurred before the 2013 exclusion of PlannedParenthood affiliates from the fee-for-servicefamily-planning program.

We used claims data for all clients of theWomen’s Health Program and its replacement,the Texas Women’s Health Program, to assesschanges in the provision of contraceptives afterthe exclusion of Planned Parenthood affiliates.Among women who use injectable contraception(depot medroxyprogesterone acetate), we also

estimated the change in continuation of thecontraceptive method in the program and inthe rate of chi ldbirth covered by Medicaid afterthe exclusion.

Methods

Data Sources

Our data included all pharmacy and medicalclaims from January 1, 2011, to December 31,2014, under public fee-for-service family-planninginsurance programs in Texas. We also accessedall claims for childbirth covered by Medicaid us-ing unique identifications for two cohorts of

women who use injectable contraceptives. Weretrieved data regarding women’s counties ofresidence from the eligibility and billing system.We also used administrative records from theTexas Department of State Health Services andfrom Planned Parenthood to categorize countiesas either having or not having providers affili-ated with Planned Parenthood at the beginningof the study.

In keeping with the eligibility criteria of theprograms, all women who were receiving services were fertile, legal Texas residents between theages of 18 and 44 years with incomes at or be-low 185% of the federal poverty level. Usingbilling records, we identified the women on thebasis of the presence of a medical claim thatincluded one or more of the Current ProceduralTerminology codes for a valid family-planningservice or a pharmacy claim that included anappropriate national pharmacy code for a con-traceptive method. For each quarter, we catego-

rized contraceptive methods into three groups:long-acting reversible contraceptives (LARC;contraceptive implants and intrauterine devices),an injectable contraceptive (depot medroxypro-gesterone acetate), and short-acting hormonalmethods (oral contraceptive pills, transdermalcontraceptive patches, and contraceptive rings).We then separated each set of claims into thosethat were filed in counties that had a PlannedParenthood affiliate in 2011 and those that were



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Removal of Planned Parenthood from Texas Health Program

filed in counties without such an affiliate atthat time.

Of the 254 counties in Texas, only 23 hadclinics affiliated with Planned Parenthood. Wefirst compared the group of counties that had aPlanned Parenthood–affiliated clinic with thosethat did not with respect to the number of

women between the ages of 18 and 44 years whohad household incomes that would qualify themfor the program (≤185% of the federal povertylevel), the number of childbirths to legal resi-dents covered by Medicaid, and the proportionof women between the ages of 18 and 44 years

who did not have health insurance. We obtainedthese indicators from the American CommunitySurvey, using 5-year averages centered on 2012,and from Texas Medicaid billing records.6

We also assessed the quarterly volume of pro-gram claims for contraceptives, according tomethod, for counties with Planned Parenthoodaffiliates and those without such aff iliates duringthe 16 observed quarters (8 before and 8 after theexclusion). Among women using an injectablecontraceptive in counties with Planned Parent-hood affiliates and those without such affiliatesin the fourth quarters of 2011 and 2012, we alsomeasured the proportion of women who returnedto the program for any service, who returned foran on-time subsequent injection, and who un-derwent childbirth covered by Medicaid during

the following 18 months.

Study Oversight

The institutional review board at the Universityof Texas at Austin determined that the study was

exempt from human-subjects review; therefore,no informed consent was required. The authorsdesigned the study, and the funder had no rolein the analysis or interpretation of the data, the

writing of the manuscript, or the decision tosubmit the manuscript for publication. All theauthors vouch for the integrity and completeness

of the data and analyses.

Statistical Analysis

We used the difference-in-differences method andregression discontinuity to compare the numberof claims for each contraceptive method in coun-ties with Planned Parenthood affiliates and inthose without such affiliates before and after theexclusion on January 1, 2013. This approach ac-counted for the influence of time-invariant differ-ences between counties with affiliates and those

without affiliates and for statewide trends overtime that could influence service provision.7

On the basis of the quarterly number of claimsfor each contraceptive method, we calculated thedifference in provision between counties withPlanned Parenthood affiliates and those withoutsuch affiliates for each quarter and each method.We fitted local linear regression models to sum-marize the differences in volumes for each meth-od.8 In these models, we allowed the slopes andintercepts to vary before and after the exclusionby using an indicator that was equal to 1 after the

exclusion and 0 before the exclusion and an in-teraction between this indicator and time. Weestimated the discontinuity in the differences atthe point of the exclusion with the indicator forpost-exclusion. Finally, we computed the relative

Characteristic

Counties withPlanned Parenthood

Affiliates

Counties withoutPlanned Parenthood

Affiliates

No. of Texas counties 23 231No. of women between the ages of 18 and 44 yr* 1,071,000 708,000

Women between the ages of 18 and 44 yr without health insurance— %†

33 34

No. of childbirths covered by Medicaid in 2012‡ 97,075 58,198

Closures of family-planning clinics 2011–2013 — no./total no. (%)§ 33/194 (17) 49/167 (29)

* All the women included in the study had an income at or below 185% of the federal poverty level.† The percentages are based on 2010–2014 American Community Survey summary files.‡ Data are from Medicaid claims records, which apply only to documented residents.§ Data are from the Texas Policy Evaluation Project.5

Table 1. Characteristics of Counties, According to the Presence or Absence of Planned Parenthood Affiliates before

Exclusion.



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A No. of Claims for Contraceptives, According to Type of County

P<0.001

Exclusion took effect(1/1/2013)

Fitted prediction

N o . o f C l a i m s

1400

1200

800

600

200

1000

400

0−8 −6 −4 –2 0 2 864

LARC Methods LARC Methods

Injectable Contraceptives Injectable Contraceptives

Short-Acting Hormonal Methods Short-Acting Hormonal Methods

B Difference in No. of Claims for Contraceptives between Typesof Counties


−8 −6 2

800

600

500

300

200

400

0

Counties with Planned Parenthood Affiliates Counties without Planned Parenthood Affiliates

Exclusion took effect(1/1/2013)


9,000

7,000

8,000

10,000

5,000

4,000

2,000

1,000

6,000

3,000

0

−8 −6 −4 −2 0 2 864


Quarter before or after Exclusion

30,000

25,000

10,000

20,000

15,000

5,000

0−8 −6 −4 −2 0 2 864

Quarter before or after Exclusion

8000

7000

5000

4000

1000

6000

3000

2000

0−8 −6 −4 −2 0 2 6 84


700

100

640−2−4 8

P<0.001

4500

4000

3000

2500

1000

500

3500

1500

2000

0

−8 −6 −4 −2 0 2 864




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change in provision by dividing this discontinu-ity by the estimated provision in counties withPlanned Parenthood affiliates at the point ofexclusion (as estimated by means of linear re-gression).

In order to assess changes in the rates of con-traceptive continuation and subsequent childbirthcovered by Medicaid associated with the exclu-

sion of Planned Parenthood affiliates, we focusedon women who were using an injectable contra-ceptive. Unlike other forms of contraception,this method requires regular provider visits andhas a relatively short span of contraceptive ef-fectiveness (3 months). These features of themethod allowed us to observe changes in the rateof childbirth within 18 months after the claim,

which would not be possible with LARC meth-ods (which last longer) or oral contraceptive pills(which may be dispensed for a single month orup to 12 months per claim).

We included two cohorts in our comparison.The first cohort received an injection in thefourth quarter of 2011 and thus had a year tocontinue receiving services before the exclusionof Planned Parenthood aff iliates took effect. Thesecond cohort received an injection in the fourthquarter of 2012 and thus was subject to the inf lu-

ence of the exclusion before the due date for thenext injection. For each cohort and county group,

we computed the proportions of women who re-ceived a service covered by the program in thefollowing quarter, who received an injection inthat quarter, and who underwent childbirth cov-ered by Medicaid in the following 18 months. We

calculated the difference in differences betweenthe two cohorts and groups of counties.

In order to determine the probability that women would return to the program during thenext quarter, would receive an on-time subsequentinjection, and would undergo childbirth coveredby Medicaid within 18 months, we used general-ized linear models for the response frequencies inthe respective tables. In each model, we used anindicator equal to 1 after the exclusion and 0 be-fore the exclusion, an indicator equal to 1 for thegroup of counties with Planned Parenthood af-filiates and 0 for those without Planned Parent-hood affiliates, and an interaction between theseindicators to provide a direct statistical test of thedifference in differences in the probability of eachoutcome. The assumed distribution of the fre-quencies (either binomial or Poisson) did notsubstantially change the significance of the tests.We report P values from the Poisson models be-cause they were larger and thus more conservative.

Results

Change in Claims for Contraceptives

The 23 counties with Planned Parenthood affili-ates were home to 60% of female Texas residentsbetween the ages of 18 and 44 years who wereliving at or below 185% of the federal povertylevel (Table 1). The proportions of women whohad no health insurance were similar in counties

with Planned Parenthood affiliates and in those without such affiliates. Of all the childbirths thatlegal residents underwent and that were coveredby Medicaid in 2012, a total of 63% occurred in

counties with Planned Parenthood affiliates. In theperiod before the exclusion, there were 82 closuresof family-planning clinics in Texas,5 and the de-crease in the number of family-planning clinics

was greater in counties without Planned Parent-hood affiliates than in those with such affiliates.

Before the exclusion, the numbers of claims for

Figure 1 (facing page). Quarterly Claims for Contracep-tives, According to Method, Type of County, and Tim-

ing before or after the Exclusion of Planned Parent-

hood Aff iliates.

Panel A shows the quarterly number of claims for long-

acting reversible contraceptive (LARC) methods, inject-able agents, and short-acting hormonal methods, ac-

cording to whether the woman’s county of residencehad Planned Parenthood affiliates before the exclusion

of such affiliates from the Texas Women’s Health Pro-grams as of January 1, 2013. Panel B shows the differ-

ence in the number of such claims between the groupof counties that had a Planned Parenthood affiliate

and the group that did not during the same period be-fore and after the exclusion. Lines that are fitted to lo-

cal linear regression models show the differences in

volumes for each method; dashed lines indicate 95%confidence intervals. The change in the difference at

the point of the exclusion was significant with respectto the provision of LARC methods and injectable con-

traceptives (P<0.001 for both comparisons) but notwith respect to short-acting hormonal methods

(P = 0.22).



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LARC methods and injectable contraceptives weredecreasing in both groups of counties, with some-

what sharper decreases in those with PlannedParenthood affiliates (Fig. 1A). However, the num-ber of claims for short-acting hormonal methods

was increasing in both groups of counties duringthe eight quarters before the exclusion.

In the quarter after the exclusion, there was asharp decrease in the number of claims forLARC methods in counties with Planned Parent-hood affiliates but not in those without suchaffiliates. In subsequent quarters, the number ofclaims for LARC methods increased in bothgroups of counties. After the exclusion, the pro-

vision of injectable contraceptives fell sharply incounties with Planned Parenthood affiliates butnot in counties without such affiliates; subse-quently, the numbers of claims in both groupsof counties remained relatively stable during thenext 2 years. In contrast, the provision of short-acting hormonal methods changed little in thetwo groups of counties in the quarter after theexclusion and declined steadily thereafter.

The difference in the number of claims foreach type of contraceptive in each quarter incounties with Planned Parenthood affiliates andin those without such affiliates is shown in Fig-ure 1B. The difference in differences at the pointof Planned Parenthood exclusion was significantfor the provision of LARC methods and injectable

contraceptives (P<0.001 for both comparisons) butnot for short-acting hormonal methods (P = 0.22).The exclusion of Planned Parenthood affiliates

was associated with estimated reductions in thenumber of claims from 1042 to 672 (relative re-duction, 35.5%) for LARC methods and from6832 to 4708 (relative reduction, 31.1%) for in-

jectable contraceptives.

Change in Rates of Contraceptive

Continuation and Childbirth

Table 2 provides a comparison of the rates of

continuation of contraception and of childbirthcovered by Medicaid between women who re-ceived a contraceptive injection in the fourthquarter of 2011 and those who received such aninjection in the fourth quarter of 2012. The pro-portion of women returning for a subsequenton-time contraceptive injection in counties withPlanned Parenthood affiliates was lower after theexclusion. Specifically, the percentage of womendecreased from 56.9% to 37.7% in counties with

Planned Parenthood affiliates but increased from54.9% to 58.5% in counties without such affili-ates (estimated difference in differences for coun-ties with aff iliates as compared with those with-out affiliates, −22.9 percentage points; P<0.001).This change represents a relative decrease of40.2% from baseline (−22.9 percentage points

divided by 56.9%).The exclusion was also associated with an in-

creased rate of childbirth covered by Medicaid within 18 months after the claim. The percent-age of women who underwent childbirth coveredby Medicaid within 18 months increased from7.0% to 8.4% in the counties with Planned Parent-hood affiliates and decreased from 6.4% to 5.9%in the counties without Planned Parenthood af-filiates (estimated difference in differences, 1.9percentage points; P = 0.01). This change repre-sents a relative increase of 27.1% from baseline(1.9 percentage points divided by 7.0%) in theproportion of women using injectable contracep-tives who underwent childbirth covered by Medic-aid within 18 months after the claim.

Discussion

After Texas abruptly excluded Planned Parenthoodaffiliates from its fee-for-service family-planningprogram, the number of claims for LARC meth-ods declined, as did the number of claims for

contraceptive injections. Among women usinginjectable contraceptives, fewer women who re-ceived an injection in the quarter preceding theexclusion continued to receive an injectionthrough the program than did those in an ear-lier cohort. In addition, there was a dispropor-tionate increase in the rate of childbirth coveredby Medicaid. Although data are lacking on in-tendedness of pregnancy, it is likely that many ofthese pregnancies were unintended, since therates of childbirth among these women in-creased in the counties that were affected by the

exclusion and decreased in the rest of the state.The reduction in the number of claims for

LARC methods in the counties with PlannedParenthood aff iliates at the time of the exclusionrepresents a divergence from the trend towardan increased number of claims for LARC meth-ods in counties with Planned Parenthood affili-ates in the years preceding the exclusion, a trendthat has also been observed nationally.9,10 Thischange is worrisome, since increased access to



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LARC methods is a priority of the American Col-lege of Obstetricians and Gynecologists,11 andone study has indicated substantial unmet de-mand for LARC methods in Texas.12 Thus, theintroduction of additional barriers to access toLARC methods by the exclusion of skilled, spe-cialized family-planning providers was associat-

ed with a shift toward methods that have lowerrates of efficacy and continuation13 and, in thecase of women who used injectable contracep-tives in the fourth quarter of 2012, an increasein the rate of childbirth covered by Medicaid.

Our data are observational and cannot provecausality. However, our analyses suggest that theexclusion of Planned Parenthood affiliates fromthe Texas Women’s Health Program had an ad-

verse effect on low-income women in Texas byreducing the provision of highly effective meth-ods of contraception, interrupting contraceptivecontinuation, and increasing the rate of child-birth covered by Medicaid. Although our data donot capture specific barriers that Planned Par-enthood clients encountered after the exclusion,another study that was based on interviews with

women using injectable contraceptives that werepaid for by the Women’s Health Program beforethe exclusion of Planned Parenthood affiliates intwo Texas cities (Houston and Midland) revealedobstacles that these clients faced after the exclu-sion. Clients who returned to Planned Parent-

hood after the exclusion were required to pay afee of $60 or more for a contraceptive injection.14 Those who sought a new provider were oftenrequired to undergo additional examinations oroffice visits or were charged a copayment beforereceiving the injection.

One limitation of our analysis is that the effectthat we observed was restricted to the 2 years im-mediately after the exclusion. The slope of thelocal regression lines that were fit to the provi-sion of contraceptives after the exclusion sug-gests an attenuation of changes over time, as

has been observed in other studies of the effectsof changes in reproductive health policy.15 In ad-dition, our models have not been adjusted forany changes in county-level characteristics thatmay have taken place during the period of obser-

vation. Another limitation is that we have noinformation on contraceptive services that wom-en paid for out of pocket or received throughother subsidized programs. However, since thefee-for-service family-planning program was the T

a b l e 2 .

R a t e s o f C o n t i n u a t i o n o f C o n t r a c e p t i v e P r o v i s i o n a n d o f C h i l d b i r t h

C o v e r e d b y M e d i c a i d a m o n g W o m e n U s i n g

I n j e c t a b l e C o n t r a c e p t i v e s . *

V a r i a b l e

C o u n t i e s w i t h P l a n n e d P a

r e n t h o o d A f f i l i a t e s

C o u n t i e s w i t h o u t P

l a n n e d P a r e n t h o o d A f f i l i a t e s

A b s o l u t e

D i f f e r e n c e i n

D i f f e r e n c e s

b e t w e e n

C o u n t i e s †

R e l a t i v e

D i f f e r e n c e i n

D i f f e r e n c e s

f r o m

B a s e l i n e ‡

P V a l u e

I n j e c t i o n i n Q 4

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D i f f e r e n c e ,

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N A

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R e c e i v e d a n y p r o g r a m s e r v i c e d u

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* E f f e c t i v e J a n u a r y 1 , 2 0 1 3 , T e x a s e x c l u d e d P l a n n e d P a r e n t h o o d a f f i l i a t e s f r o m

t h e s t a t e - f u n d e d T e x a s W o m e n ’ s H e a l t h

P r o g r a m . S h o w n h e r e a r e d a t a f o r w o m e n

w h o r e c e i v e d a n i n j e c -

t i o n i n t h e f o u r t h q u a r t e r ( Q 4 ) o

f 2 0 1 1 a n d t h u s h a d a y e a r t o c o n t i n u e r e c e i v i n g s e r v i c e s b e f o r e t h e e x c l u s i o n o f P l a n

n e d P a r e n t h o o d a f f i l i a t e s t o o k e f f e c t a n d t h o s e w h o r e c e i v e d a n i n -

j e c t i o n i n t h e f o u r t h q u a r t e r o f 2 0 1 2 a n d t h u s w e r e s u b j e c t t o t h e i n f l u e n c e

o f t h e e x c l u s i o n b e f o r e t h e d u e d a t e f o r t h e n e x t i n j e c t i o n . N A d e n o t e s n o t a p p l i c a b l e .

† T h e a b s o l u t e d i f f e r e n c e i n d i f f e r e n c e s b e t w e e n g r o u p s i s f o r t h e c o u n t i e s w

i t h P l a n n e d P a r e n t a f f i l i a t e s a s c o m p a r e d w i t h t h o s e w i t h o u t s u c h a f f i l i a t e s .

‡ T h e r e l a t i v e d i f f e r e n c e i n d i f f e r e n

c e s f r o m b a s e l i n e w a s c a l c u l a t e d b y d i v i d i n g t h e a b s o l u t e d i f f e r e n c e b e t w e e n g r o u p s

b y t h e p e r c e n t a g e o f w o m e n i n t h e 2 0 1 1 c o h o r t i n w h o m t h e l i s t e d

e v e n t w a s r e p o r t e d i n c o u n t i e s w

i t h P l a n n e d P a r e n t h o o d a f f i l i a t e s .



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payer of first resort and since funding for subsi-dized family planning was severely limited inTexas during the study period,5 it is unlikely that

women were pulled away from the Texas Wom-en’s Health Program to be served through otherprograms. Also, our analysis includes only child-births covered by Medicaid in Texas, and data

for women who gave birth out of state or withprivate insurance coverage are not captured.

Before the Planned Parenthood exclusion,cuts in grant funding and the reduced prioritygiven to specialized clinics had already substan-tially reduced the amount of funding availableto Planned Parenthood affiliates and reducedaccess to LARC methods, especially among

women who did not qualify for the Medicaid waiver family-planning program because oftheir residency status.5 Thus, it is likely that thechanges we observed in the fee-for-servicefamily-planning program after the PlannedParenthood exclusion represent only a portionof the total reduction in the availability of ser-

vices associated with the multiple efforts todefund these providers. Moreover, because the

Texas family-planning safety net includes a di- verse mix of Planned Parenthood aff iliates,private dedicated family-planning providers,and public entities,4,5 our estimates may beconservative if they are applied to states in

which Planned Parenthood aff iliates are a moredominant source of family-planning care.

In conclusion, the implementation of the 2013exclusion of Planned Parenthood affiliates from aMedicaid waiver program in Texas was associated

with adverse changes in the rates of provision andcontinuation of contraception and with increasesin the rate of childbirth covered by Medicaid.These findings have implications regarding thelikely consequences of proposals to excludePlanned Parenthood affiliates from public fund-ing in other states or at the national level.

Supported by a grant from the Susan T. Buffett Foundationfor the Texas Policy Evaluation Project and a grant (R24-042849)

from the Eunice Kennedy Shriver National Institute of ChildHealth and Human Development to the Population ResearchCenter, University of Texas at Austin.

Disclosure forms provided by the authors are available withthe full text of this art icle at NEJM.org.

We thank Daniel Grossman, M.D., and Daniel Powers, Ph.D.,for their helpful comments on earlier drafts of the manuscript.

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