Sixteen years ago, Texas lawmakers created a small program with a big goal: persuading women not to have abortions. It was given a few million in federal anti-poverty dollars and saw fewer than a dozen people its first year.
Since then it's ballooned. Alternatives to Abortion is poised to cost taxpayers $100 million over the next biennium — a twentyfold budget increase — and served more than 100,000 pregnant women and parents last year.
But the Legislature has required little information about what the program has accomplished.
It wasn't until 2017 that lawmakers began requiring a public report on what contractors do with the money. The subcontracting process is "secret," one lawmaker said. And state health officials don't track how many abortions are prevented by the program. The abortion rate has steadily declined in Texas and the U.S. for decades, making it hard to decipher what, if any, role Alternatives to Abortion has played.
"I don't know if this is untouchable by design," said state Rep. Bobby Guerra, D-Mission. "If they have good outcomes, I would think that they would be proud of sharing that information."
Critics say Alternatives to Abortion has eluded accountability in the often fiscally conservative Legislature, which this year requested a study on how to make safety net services cheaper and better. At the program's worst, critics allege, it shames women seeking abortions and is a poor and expensive substitute for women's medical care.
But proponents say Alternatives to Abortion meets a different need than heavily regulated medical clinics do — by offering social assistance to those who decide to "choose life in difficult circumstances."
The program has overwhelming support in the Republican-led Texas Legislature, where lawmakers have pushed through budget increases and say it's proven to be a massive success.
"I don't know if you can always peg how many abortions were not done or how many lives were saved through this program," said state Rep. Matt Krause, R-Fort Worth. "It's almost like: How many ships does a lighthouse save? You don't know, right, but the fact that it's there you know is helping those ships get safely to where they're supposed to go."
Averted abortions are deliberately not tracked to save women the burden of returning and sharing their decision, he said.
To proponents, the program's rationale is simple: Women might prefer to continue their pregnancies if their life circumstances were different. And learning there are options can make the difference.
Modeled after a similar initiative in Pennsylvania, Alternatives to Abortion channels money to a far-flung network of nonprofits — many of them ardently anti-abortion — to pay for counseling, classes and baby items. Its contractors cover topics like prenatal nutrition and newborn care, and also help parents land jobs. It caters to pregnant women and mothers of young children but also to fathers, adoptive parents and those who have lost a child.
The program has seen more and more people each year, and lawmakers have boosted its funding in nearly every budget.
When other programs lost state money in 2011, Alternatives to Abortion was spared. "The state prioritized the availability of Pro-Life alternatives," 80 lawmakers wrote in a 2019 letter.
Of a dozen states The Texas Tribune could identify with comparable programs, Texas' has had by far the biggest budget in recent years.
As the program has expanded, Democratic lawmakers and other critics have agitated for details about what it does and how cost-effective it is.
State Sen. Judith Zaffirini, D-Laredo, supports the program's aims but said it was proposed in 2005 without "minimum standards, adequate oversight" or even a requirement that "the information provided to women be medically accurate."
Discrepancies in the data are common because the contractors and subcontractors are not "certified or regulated by the state," she said, and the state's reports don't offer enough data for lawmakers to meaningfully assess the program's performance.
Biennial state budgets list the cost per patient and number of clinical providers enrolled for publicly funded women's health programs, but not for Alternatives to Abortion. Without appendices, the annual report about the state's women's health programs is 65 pages long — longer than all four of the state's reports about Alternatives to Abortion combined.
Former state Rep. Sarah Davis, a Houston Republican who supports abortion rights, said she thought the lack of information about the program was "very deliberate" and that funding the program had felt like a "trade-off" when she served in the Legislature from 2011 to 2021.
"If I wanted to get the money that I wanted for the Healthy Texas Women program, breast and cervical cancer and family planning [programs]," she said, "then I also had to go along with the Republicans wanting to dump money into Alternatives to Abortion."
Spending on traditional women's health programs that help low-income women get birth control or access cancer screenings is on track to almost triple since the abortion alternatives program began, according to numbers from the Legislative Budget Board. The state spends far more on the health programs, budgeting $352.6 million for the next biennium counting federal and state funds. Women's health advocates say there is still unmet need.
The Texas Pregnancy Care Network was created to administer the Alternatives to Abortion program and was its sole contractor until 2018. It doesn't provide services itself, instead doling out state money to pregnancy centers, maternity homes, adoption agencies and religiously affiliated organizations like Catholic Charities. Those organizations are reimbursed for nonmedical services they provide.
The Texas Pregnancy Care Network stated in contracting documents that it and the nonprofits it works with must be able to "withstand extreme scrutiny from opponents of the program," and McNamara said it vets and monitors each subcontractor for compliance.
But critics have complained they have little insight into what those subcontractors do — and are often stymied when they try to add more oversight and accountability. Some said the effort is so futile it's not worth the fight.
During a recent floor debate, Guerra told House lawmakers that the Texas Pregnancy Care Network was not required to evaluate subcontracts with a predetermined rubric like other state contracts, and that the process was "secret" and only viewable after signing a nondisclosure agreement. He abandoned a proposed reform after guessing he didn't have enough support to pass it, he said.
"If [the Texas Department of Transportation] wants to build a road and they're going to hire contractors, they want all the history of the contractors, they want to know what jobs they've done," he said. "I just want to do the same thing for the mothers and the children."
"There really isn't anything to look at here to give me any kind of assurance that these dollars are being used in a way that's trying to address the stated purpose of helping women," she said.
Krause, the Republican lawmaker who has fought to give Alternatives to Abortion more money, said the program is treated the same as other social services and should not be compared to the women's health programs because it doesn't offer medical care.
The program has grown to meet demand and is regularly audited, including by the health commission's office of inspector general who found nothing amiss in its financials five years ago, he said.
Though he supports making more information about the program public, transparency measures added by lawmakers in 2019 — namely, a more detailed 2020 report — have allayed some concerns and shown the program's contractors are "legitimate groups, helping the needs of women and newborns all over the state," he said.
"You don't want to just give money to a place that isn't making a difference, right, even if it aligns with your beliefs," Krause said.
Counseling, diapers and vitamins
Alternatives to Abortion's subcontractors are spread across the state and there has been a booming waitlist of nonprofits hoping to join, lawmakers have said.
Offerings vary by location but often focus on counseling for pregnant women or basic preparation for motherhood such as parenting classes and an assortment of maternity items.
Demand for its services shot up last year, as parts of the state saw shortages of diapers and other baby needs during the coronavirus pandemic, according to a state report.
Catholic Charities of Dallas, a subcontractor slated to get almost a half-million dollars through the Texas Pregnancy Care Network last year, has food pantries stocked with vegetables and gives out diapers, wipes and other baby items. It teaches weekly parenting classes in English and Spanish, covering topics like water safety, potty training and positive discipline.
Human Coalition, another contractor, is largely a call center and marketing operation that tries to intercept women seeking an abortion who don't typically search for pregnancy support services.
At Human Coalition's few in-person clinics, visitors take pregnancy tests, identifyobstacles they perceive to their pregnancy and watch a video about abortions, the nonprofit said in contracting documents. Pregnant women may get prenatal vitamins, referrals to obstetricians or an ultrasound, which helps "attract clients" and lets those inclined to get an abortion "fully understand their pregnancy," the contracting documents said.
At a residential facility that subcontracts with the Texas Pregnancy Care Network, women receive around-the-clock counseling and other services like impromptu four-minute "conflict resolution sessions," 20-minute trainings on how to soothe a colicky baby or 90 minutes of professional counseling "on goal setting and transitioning to self-sufficiency," according to McNamara, with the Texas Pregnancy Care Network.
"These are intense, trauma-based intervention facilities that help homeless women and their families," he said in an email. "They help them learn how to break cycles, be successful parents, and ultimately be self-sufficient."
Alternatives to Abortion contractors gave out more than 1 million material goods last year, led 331,000 counseling sessions and taught 314,000 classes — some completable in 15 minutes, according to state statistics and information provided to the Tribune. Numbers for previous years have not been published.
Contractors also refer people to assistance programs they may be eligible for, like Medicaid or food stamps. State data provided to the Tribune show less than a third of those 218,000 referrals last year led to someone actually signing up or being waitlisted for an assistance problem. The health commission said that's an undercount that relies on women circling back to confirm they were enrolled or waitlisted. They don't have the actual number.
The contractors said cumbersome application processes or "client motivation" and needs could contribute to the low figures.
Tension and competition between contractors has at times revealed claims of unprofessional or misleading tactics.
The Texas Pregnancy Care Network said in contracting documents that Human Coalition deceptively advertised itself as a medical facility that might perform abortions and targeted ads to internet users who searched Google for "abortion clinics."
Meanwhile, Human Coalition said its advertisements are effective at reaching women contemplating abortions and that its staff followed up with women more frequently than a typical pregnancy center would. Contracting documents written by a former employee portrayed pregnancy centers as unprofessional — places where volunteers sometimes don't answer the phone or are unprepared to speak with someone having an emotional crisis — in contrast to Human Coalition's own heavily trained employees and regimented protocols.
"Agents utilize a dialogue format that has been tested and refined over tens of thousands of calls," the former employee said in contracting documents.
Abortion rights advocates have also raised alarms about pregnancy centers, likening them to fake clinics that lure in women seeking an abortion with the promise of a free ultrasound or general slogans like: "Pregnant? Know for Sure."
Affiliates of the pro-abortion rights group NARAL Pro-Choice America have sentpeople undercover into these "crisis pregnancy centers" in other states and reported they provide misinformation about the health risks associated with abortion or describe abortion clinics as being "dirty and splattered with blood."
Two women who have gone to crisis pregnancy centers in Texas told the Tribune they felt pressured to say they wouldn't have an abortion, with one recalling being told "if you have an abortion, you're going to go to hell." Neither center has received money through the Alternatives to Abortion program. Both women said they ultimately got abortions out of state.
Pregnancy centers receive about a third of the funding from the Texas Pregnancy Care Network. They are not regulated by the state health commission.
McNamara disputed the suggestion that the Texas Pregnancy Care Network's providers are inept or undertrained and said they follow up with women frequently — four times, on average — and are "extremely effective."
He also said broad accusations about pregnancy centers don't apply to the nonprofit's subcontractors. Those groups are "prohibited from using tactics or language that shame or coerce a client," do not reference spiritual topics or God unless requested and convey information about abortions using the same document that abortion clinics are required to use, he said.
Chelsey Youman, national legislative advisor for Human Coalition, said the organization "deeply values the vital work of pregnancy centers" and disavowed how they had been characterized in the contracting documents.
"Human Coalition has experienced a change in leadership, and we deeply regret and no longer stand by any demeaning language in the past towards pregnancy centers," she said.
A second spokesperson for Plano-based Human Coalition said its advertisements explicitly say they do not provide abortions and that they are "upfront about who we are and what we do."
"The results about care for women speak for themselves, exit surveys show: 98% said they felt staff cared about their needs; 95% said staff figured out their needs based on their current situation; 96% said they received information that enabled them to connect with local community resources," the spokesperson said.
Since it joined Alternatives to Abortion in mid-2018, Human Coalition helped with 18 adoptions in Texas and 4,064 "life decisions," or instances where someone chooses to "carry their child to term after previously seeking an abortion," the spokesperson said.
The Texas Pregnancy Care Network does not ask women to disclose their "ultimate decisions" to "avoid any semblance of pressure," McNamara said.
"Reviewing that data"
Critics of the program say Alternatives to Abortion funding sucks up money that could be better spent elsewhere.
In written testimony, residents of South Texas said lack of affordable health care in the predominantly Latino region meant women couldn't get biopsies or treatment for cancer and other serious conditions.
A Nurse-Family Partnership program has asked for Alternatives to Abortion funding, saying its mission of pairing low-income mothers with a nurse during pregnancy and for a few years after they give birth fits squarely within the goals of the anti-abortion program.
"We are prepared to fill the gap of health care and education services needed by pregnant mothers that the current program does not fully provide," a representative of the nurse program said in written testimony.
Since 2020, the state has required Alternatives to Abortion contractors to successfully sign up at least one-fifth of the people they refer to the Nurse-Family Partnership program. But lack of funding for the nursing program — and the fact that it's not in every region of the state — means not all the women sent by Alternatives to Abortion can get in. Some have been placed on waiting lists.
Contractors must sign up a similar percent of people for Medicaid.
Alternatives to Abortion's offerings are more loosely defined than medical services, which are assigned strict numerical codes to denote the procedure or typical time spent. Because it's a social service program, there is no minimum time for an Alternatives to Abortion counseling session, for example, and one of the contractors said they tailor counseling sessions or classes based on a woman's needs.
Program spreadsheets provided to the Tribune under public information laws suggest there can be considerable variance.
Between September 2019 and August 2020, the Texas Pregnancy Care Network reported more than a dozen women received over 1,000 counseling services and classes in a single month — meaning that on average they each would have taken at least 16 classes and gone to 16 counseling sessions every day. More than 70 received more than 300 counseling sessions and classes in a month, about 10 each day.
McNamara said these numbers could reflect the experiences of women who live in a residential unit where counseling sessions could range from as few as four minutes to as long as 90. It could also possibly show instances where people received counseling that touched on multiple topics like pregnancy and life skills. (Facilities are reimbursed based on "the amount of care given," he said.)
Zaffirini, the state senator, said the different lengths of counseling sessions could reflect people's willingness and desire to engage.
Krause, the representative who supports the program, said each family's needs are different and that it would be "wrong and ineffective" to try to streamline counseling or similar social services.
Weldon, with the state health commission, said the agency has worked to "ensure consistency in data reported across the contractors" as the program has grown, including by offering technical assistance and a training session to help with accurate reporting.
The health commission, she said, is "reviewing that data."
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