July 6, 2016

What happens to women’s health when women’s health clinics disappear?

Tracking preventive care in Texas and Wisconsin after women’s health clinics lost state funding

In the year after annual state funding for family planning in Texas was cut by $36 million in 2011, 38% of clinics supported by the state’s Family Planning Program closed their doors or reduced hours.

Illustration by Tim Hyde; images from Google Earth

Last week’s landmark Supreme Court decision striking down certain restrictions on abortion clinics in Texas will make it easier for abortion providers in several states to stay open. Still, funding cuts for family planning and women’s health clinics in Texas and several other states have already succeeded in driving many clinics that provide abortion services to close, and these cuts are not affected by the Court’s ruling.

Efforts by state legislatures to defund Planned Parenthood and shutter women’s health clinics are part of the incredibly contentious political debate surrounding abortion and the government’s role in facilitating access to it, but critics contend that women’s health clinics provide more than just abortion services. Women’s health clinics can offer services like cancer screenings and treatment for conditions ranging from diabetes to anemia. Efforts to defund or close these clinics could have adverse consequences for other aspects of women’s health beyond abortion.

Politicians who have spearheaded these efforts maintain that the focus is on limiting abortion not undermining health care for women more generally – in the words of one Texas state representative, “I don’t think anybody is against providing health care for women.”

The hope is that a patchwork of other providers, like primary care doctors, hospital emergency rooms, and crisis pregnancy centers, would be able to fill in any gaps in coverage that result from the closure of family planning clinics. A study appearing in this month’s issue of the American Economic Journal: Applied Economics looks to measure any impact of family planning funding cuts on the way women seek or receive preventive health care.

In The Impact of Women's Health Clinic Closures on Preventive Care (PDF), authors Yao Lu and David Slusky begin by sifting through responses from the Behavioral Risk Factor Surveillance System (BRFSS), a survey conducted by the CDC that asks thousands of Americans every year about their health backgrounds and habits ranging from from seat belt use to cancer history.

Each interview in the BRFSS is linked to a zip code, so the authors can match responses in the survey to specific parts of two states, Texas and Wisconsin, where funding cuts have been particularly impactful on women’s health clinics. Specifically, they measure how often women in each zip code are receiving four types of preventive care: clinical breast exams, mammograms, Pap tests for cervical cancer, and routine checkups. They track these measures over a five-year period that allows them to see how care patterns change as nearby women’s health clinics open or close.

For some in Texas, the nearest health clinic is farther than before
Change in driving distance to the nearest clinic in a national network studied by the authors between October 2007 and December 2012, by county. Clinics that opened or closed during the period are highlighted. Women in some areas near San Antonio gained easier access to the network's clinics over this period, but women living near Lubbock, Laredo, and especially El Paso had to travel much farther to reach a clinic after a wave of closures during this five-year span.
Note: this map does not account for travel distance to any other clinics outside the network.
Source: adapted from Figure 1 and Figure 3 of Lu & Slusky (2016) using county-level data provided by the authors 

They match this dataset with information from a national network of women’s health centers with a large presence in both Texas and Wisconsin. The authors use quarterly rosters of the network’s open clinics in each state to see when new clinics opened or old clinics closed in different parts of the state.

This creates a measure of access to health care that changes over time in each part of the state. Consider the women living in 77777 (a fictional Texas zip code). They had one of the network’s clinics five miles away in the next town over from 2007 until spring 2010, when it shut its doors. At that point, the nearest remaining clinic was 90 miles down the highway until fall 2012, when a new clinic opened 30 miles away.

Using the BRFSS responses, the authors can look at how use of preventive health care services changes in zip code 77777 over the years, first as the distance to the nearest clinic increases from 5 miles to 90 miles and then as it drops back to 30. If preventive care use responds to clinic distance, that is an indication that funding cuts for family planning services are doing more than just making it harder to have an abortion.

The authors do not have a comprehensive dataset of women’s health clinics across these two states, so women in this area might still have access to a clinic run by a different provider that is closer than 90 miles away. This means any effect the authors find might actually be understating the true effect of having lost access to convenient care.

Using network data on clinic openings and closures across thousands of zip codes in Texas and Wisconsin, the authors find that an increase in driving distance of 100 miles to the nearest clinic results in significantly less preventive care. After such an increase, the number of women reporting a clinical breast exam in the past year falls 13% and reporting a Pap test falls 14%, with correspondingly smaller effects for less extreme changes in access.

The results are starker for women with only a high school education or less – past-year clinical breast exam rates fell 31% and mammogram rates 64% for this group. The BRFSS only asks about education, not income, but these women are probably less likely to have health insurance or the means to travel to a distant county for care, so it makes sense that they are more dependent on women’s health clinics that often provide low-cost or charity care.

In particular, our results suggest that reduced access to health care has a greater impact on individuals of lower educational attainment. We interpret this result as being consistent with lower-income, less-educated women having fewer options for care (since they are more likely to be uninsured or underinsured and therefore rely on charity care) . . . . They may also have less flexible schedules and may lack the means to drive 100 miles each way to the nearest clinic.  

Lu & Slusky (2016)

The authors also test to see whether something else besides the closure of nearby clinics might be driving these results. They look at other responses from the BRFSS and find health behaviors that shouldn’t have anything to do with proximity to family planning services, like dental visits, flu vaccinations, and preventive care activity specifically among men, who make up only a tiny proportion of the network’s patients. As expected, these health behaviors do not seem to be responding at all to clinic distance, bolstering the case for a real connection between clinic accessibility and women’s preventive care.

The decreases in preventive care use are all the more concerning in light of a report by the National Commission on Prevention Priorities that indicates Americans are not getting enough preventive care, which leads to unnecessary health problems, preventable deaths, and ballooning health care costs for conditions that could have been avoided. The authors’ findings underscore the importance of including women’s preventive care in the equation weighing the costs and benefits of funding cuts for family planning services. ♦

“The Impact of Women's Health Clinic Closures on Preventive Care” appears in the July 2016 issue of the American Economic Journal: Applied Economics.