When Iowa Republicans gained the trifecta following the 2016 elections, defunding Planned Parenthood was near the top of their agenda. GOP legislators promised a new state-funded family planning program would increase access to reproductive health care and give women more options, especially in rural Iowa.

The latest official data, first reported by the Des Moines Register’s Michaela Ramm, show the program has flopped. In just five years, the number of Iowans receiving services such as contraception, pregnancy tests, Pap smears, and testing or treatment for some sexually transmitted infections dropped by 90 percent compared to the population served during the last year of the previous Medicaid waiver. The number of health care providers involved is down by a staggering 97 percent.

The Iowa Department of Health and Human Services has done almost nothing to promote the program, even as enrollment crashed.

The reality could hardly be more different from the scenario Republicans described in 2017: “connecting folks with their home health care” for essential services by taking Planned Parenthood’s mostly urban clinics out of the equation.

A LONGSTANDING GOAL

Governor Terry Branstad and Iowa House Republicans had tried and failed for years to ax Planned Parenthood’s state funding. Those efforts repeatedly died in the Democratic-controlled Iowa Senate.

The GOP settled on the concept of a state-run family planning program because Branstad could not unilaterally take funds away from Planned Parenthood, and federal courts had struck down laws in other states that sought to disqualify the organization as a Medicaid provider.

A few weeks into the 2017 legislative session, the new Iowa Senate GOP majority approved a bill that would replace the (90 percent federally funded) Medicaid Iowa Family Planning Network Waiver with a state-funded program excluding abortion providers. Republican lawmakers eventually rolled the proposal into the health and human services budget for the coming fiscal year.

The Iowa Family Planning Network ceased to exist on July 1, 2017. The State Family Planning Program took its place, offering the same range of services to eligible Iowans—but not through clinics affiliated with abortion providers.

“WE ARE NOT CUTTING HEALTH CARE SERVICES”

Bleeding Heartland extensively covered Republican proposals to defund Planned Parenthood and the Iowa Senate’s rush to approve this bill in February 2017. I watched that debate again this weekend and pulled some clips from the official video.

State Senator Amy Sinclair, who was the only woman in the 29-member Senate GOP caucus at the time, floor managed Senate File 2. She was eager to refute warnings that excluding Planned Parenthood from the state program would deny care to Iowans.

Sinclair made big promises during her opening remarks in support of the bill. She asserted that a state-funded option for family planning would help other Medicaid-eligible clinics offer “the same services right where our sisters and our daughters and our mothers live.” She went on: “The increased access and scope of available services by connecting it to a primary health care provider is why I’m such an advocate for this transition.”

“We’re not closing clinics nor prohibiting their legal activity,” Sinclair said. “We are not interfering with a private entity to conduct their business. Women will not go without exams or care or screenings. They will just be receiving those services where they live and in conjunction with their broader health care needs.”

Sinclair returned to that point again and again. In response to questions from Democratic State Senator Matt McCoy, she said, “We are not cutting health care services to women. In fact, we plan to continue to provide health care services to women. We are not eliminating birth control access to anyone. In fact, we are encouraging them to get their birth control in conjunction with their broader health care.”

State Senator Janet Petersen, who led the Democratic opposition to defunding Planned Parenthood, stated the obvious during the floor debate: “Senate File 2 does not increase access to providers. Senate File 2 does not give women more options for health care. In fact, it will force thousands of Iowa women to leave a provider they chose” and go to a provider selected by politicians.

Not only that, the bill would “disqualify many of Iowa’s most qualified health specialists” from serving women through the program. “Providers are not magically going to fall out of the sky for this new program,” Petersen warned.

State Senator Rita Hart walked through how the proposal would negatively impact her constituents in Clinton County. Numerous eligible Medicaid providers chose not to participate in the existing family planning waiver. “There is no evidence that you have presented, that I have seen, that convinces me that any provider in my district will join this new program,” Hart concluded. “So, this bill takes away my constituents’ freedom to keep the doctors that they have chosen.”

Several GOP lawmakers disputed such claims. State Senator Brad Zaun insisted, “This bill will expand the services provided.”

Sinclair sounded frustrated during her closing remarks. “This bill is about continuing to provide accessibility to quality reproductive health care to men and women that is closer to their homes, that is in conjunction with their broader health care, and doing that in a way that is balanced with the needs and concerns” of taxpayers who don’t want their money supporting abortion providers.

GOP lawmakers passed the same talking points along to numerous Iowans who called, emailed, or protested at the state capitol while Senate Republicans were fast-tracking the bill. Here’s an excerpt from an email then State Senator Charles Schneider sent to a constituent who had urged him not to defund Planned Parenthood.

Currently, family planning funding is only available in a limited number of clinics in Iowa. This bill will substantially increase the number of facilities at which these services will be provided. This is especially important for women who live in rural Iowa and must travel long distances to access care. The bill ensures that those who currently receive family planning services from Planned Parenthood will still be able to receive those same services (and in some cases even better levels of service) but at more locations. Thus, this bill increases the options available to women and improves their access to care.

To say those predictions didn’t hold up would be an understatement.

SERVICES PLUMMET AFTER PLANNED PARENTHOOD’S EXCLUSION

Planned Parenthood closed four of its twelve Iowa clinics in 2017, anticipating a loss of some $2 million in revenue following changes to the family planning program. Jodi Tomlonovic, executive director of the Family Planning Council of Iowa, told the Des Moines Register at the time she anticipated “a severely negative impact on family planning services.” Other providers would not be able to serve the thousands of patients who had relied on Planned Parenthood.

Anti-abortion activists dismissed the warnings. Iowans for Life executive director Maggie DeWitte told the Register, “We have said from the very beginning that there are many, many other qualified health centers that provide comprehensive health care for women.”

Jenifer Bowen, a spokeswoman for Iowa Right to Life, remarked, “The reallocation of our tax dollars, away from the abortion industry and into the hands of true health care facilities, will only empower more Iowa women.”

Wrong.

State data show that as of December 2016, 12,219 Iowans were enrolled in the Medicaid family planning waiver, and 4,642 people received at least one service during 2016.

Numbers of enrolled patients, services received, and participating health care providers all dropped sharply during the first year of the State Family Planning Program’s existence. But perhaps that could be chalked up to growing pains.

The slide has continued, according to a September 2023 presentation by the Iowa Department of Health and Human Services, first covered by Ramm for the Des Moines Register.

The number of Iowans who received services through the State Family Planning Program declined from 2,431 individuals in 2017 to 809 people in 2018. The agency’s figures show a slight rebound to 1,600 people served through the state program in 2019. But that number dropped to 1,269 people in 2020 and just 423 in 2021, the most recent year for which data is available.

That’s 90 percent below the number of Iowans served during the last year of the Medicaid family planning waiver.

Amazingly, agency data show not a single man received services through this program in 2021. The Medicaid family planning waiver always served far more Iowa women than men, but men are eligible for several covered services: birth control supplies, STI testing and treatment, and vasectomies.

Overall enrollment followed the same trend: 8,207 individuals when the state program launched in July 2017, down to 5,334 eight months later. The agency’s new presentation lists average monthly enrollment at 2,039 individuals for 2020 but only 1,267 for 2021.

The number of participating health care providers showed the steepest decline: 957 different health care providers provided at least one service during the first three months of the state program’s existence in 2017, but only 559 providers did during the three months after that.

More recently, according to the Department of Health and Human Services, just 84 providers participated in 2020 and 25 in 2021. That’s 97 percent lower than the number of health care providers involved when the state program launched.

“YOU DO HAVE TO TELL PEOPLE ABOUT IT”

Ramm’s reporting indicates that the agency views these low numbers as a sign of a marketing problem.

Department of Health and Human Services Director Kelly Garcia said during a public meeting Thursday [October 12] that utilization of the family planning program is likely low because very few Iowans are aware of its existence. The state doesn’t spend money to advertise or promote the program, so people often stumble across these services by accident, she said.

To better promote the state’s family planning program, Garcia said she is having conversations with legislative leaders about possible budget opportunities to promote its services.

“It doesn’t mean you have to spend a ton of money, but you do have to tell people about it in order to have folks find it,” she said during a meeting of the Council on Health and Human Services.

Clearly the state could and should do more to let uninsured or underinsured Iowans know they may qualify for services under this program. The state should also engage with health care providers, especially those that were previously involved.

Unfortunately, by design the state excludes the family planning provider with an extensive marketing program geared toward reproductive health and the strongest track record of serving low-income Iowans.

Anyone could have predicted the rosy Republican predictions wouldn’t pan out, based on what happened in Texas after that state defunded Planned Parenthood. Garcia of all people should have expected this outcome, since she held senior positions in the Texas health and human services agency before Governor Kim Reynolds brought her in to lead the Iowa Department of Human Services in 2019.

P.S.—Although correlation does not prove causation, it’s notable that after the state overhauled the family planning program in 2017, Iowa recorded significant increases in abortions performed as well as higher rates of STIs including chlamydia and gonorrhea.

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Appendix: Iowa Department of Health and Human Services presentation on Iowa family planning programs in 2020 and 2021, prepared in September 2023

Top image: State Senator Amy Sinclair floor manages the bill on defunding Planned Parenthood’s family planning services on February 2, 2017. Screenshot from the official legislative video.