Strengthening PEPFAR: A Plan for Immediate Action

Jodi Jacobson

PEPFAR presents the President-Elect both opportunities and challenges. The 2008 bill authorizes dramatic increases in funding for treatment and care. But the controversial policies supported by the Bush administration are still in place.

On January 20, President Obama will inherit many challenges, among them the global AIDS epidemic.  He will also inherit the President’s Emergency Plan for AIDS Relief (PEPFAR), a program often cited as the hallmark of the Bush Administration’s otherwise contested international legacy, providing anti-retroviral therapy to an estimated 2 million people worldwide in its first five years. 

For Obama, PEPFAR presents both opportunities and challenges.  On one hand, the 2008 bill authorizes spending of up to $48 billion from 2009 through 2013, allowing dramatic increases in funding for treatment and care, orphans and vulnerable children and youth, and prevention of maternal-to-child transmission, among other programs. 

On the other, several controversial policies originally supported by the Bush Administration remain in place and unless fully addressed will continue to undermine efforts to stop the spread of HIV, by denying critical services to the most vulnerable, blocking effective integration of health services, and failing to effectively address the social and economic roots of this pandemic.   

The good news is: Some of these problems are remarkably easy to change at little if any cost.  By taking the following steps soon after inauguration, President Obama can initiate the change PEPFAR needs, ensuring we simultaneously save more lives and strengthen health systems while making the best possible use of scarce public dollars. 

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Appoint a Global AIDS Coordinator who "gets it."  Throughout the campaign, Michelle Obama assured us that Barack Obama "gets it" regarding the problems faced by this country both here and abroad.  President Obama also needs to appoint a Global AIDS Coordinator who gets it.  For too long, PEPFAR has been driven by a highly medicalized approach to an epidemic fueled by gender, social and economic disparities and by stigma and discrimination.  A critical first step for the new Administration is to appoint a Coordinator who clearly understands these dynamics, who embraces both the public health and human rights dimensions of risk and disease and who recognizes that sex and sexuality are normal attributes of being human.  There is of course a need for excellence in delivery of medical services and a critical role for medical–as well as social science, public health, and human rights–experts to create and oversee effective programs.  But to end the epidemic we need to go beyond a medical model, and that means appointing a Global AIDS Coordinator who–no matter their background–can provide strategic vision from the top.

Talk about sex.  It’s time for "the talk."  President Obama must break the taboo perpetuated under PEPFAR and talk about the role of safer sex in prevention.  Today, unprotected sex is the single most important factor in the spread of HIV worldwide and is responsible for 80 percent of new infections in sub-Saharan Africa.  Unfortunately, current law still restricts prevention funding in ways that severely limit evidence-based and cost-effective approaches.  Talking about safer sex will help break the stalemate of the past several years.  Beyond real talk, however, President Obama also should immediately direct OGAC to support flexible interpretations of requirements in the law affecting spending on "abstinence and be faithful" programs, ensuring that these are component parts of comprehensive approaches to prevention and not ineffective stand-alone strategies.  We need to foster creative approaches that produce measurable outcomes-such as an increase in delay of sexual debut, reduction in the number of sexual partners, increases in the use of effective negotiation skills among couples, and correct and consistent condom use.  And we need to achieve these outcomes through a range of behavioral tools and interventions that fit the needs of the populations at risk.  Interpreting the law flexibly while working to rid the law of these restrictions altogether will make our prevention dollars go further.  These and other recommendations can be found in the transition document created by the Prevention Working Group of the Global AIDS Roundtable. 

To stop the spread of HIV, however, PEPFAR must go still further.  Funding should be available under PEPFAR to support programs that equip all individuals–young, old, male, female, married or unmarried–with the education, information, skills and methods necessary to engage in sexual relations only when these are truly consensual and mutually responsible.  We have to move beyond the formulaic "ABC" approach and away from the "abstinence versus condoms," debate as if either abstinence or condoms alone were sufficient to ensure healthy sexual lives. Instead, President Obama should make clear his administration’s support for synergistic strategies focused on achieving outcomes ranging from ending child marriage and reducing gender-based violence to increasing the number of people who use male and female condoms correctly and consistently-all as part of HIV prevention strategies.  Gender-disparities, violence, and lack of power in sexual relationships are the very drivers of this epidemic and by extension the keys to ultimate success in stopping the spread of HIV.  If we are serious about ending this epidemic, we have to to be serious about tackling these issues within and across prevention and treatment programs.  By talking the talk, and giving strong signals about his support for new, more effective approaches, President Obama will ensure accelerated success in the fight against AIDS.   

Remove legal and policy restrictions that increase stigma and discrimination against already-marginalized groups.  In many countries around the world, including Vietnam, Russia, Georgia and China, injection drug use is the primary driver of HIV/AIDS.  In virtually every setting, stigma and discrimination further isolate injecting drug users, dramatically increasing their vulnerability to HIV infection, conditions that have sometimes been perpetuated by our own policies.  For example, the United States has refused to fund–and has lobbied other governments to eliminate support for–"harm reduction" efforts such as needle exchange programs for drug users.  Overwhelming evidence shows that such programs are the most effective way to stop the spread of HIV in this population.  Indeed, most experts agree that scaling up needle and syringe exchange is essential to arresting the epidemic.  Preparations are now underway for an international meeting in early spring at which US support for evidence-based approaches to harm reduction will send a critical signal regarding a new era in U.S. policy.  Some advocates, however, fear the new Administration won’t have time to affect the outcome and that the U.S. position will therefore default to that of the current administration.  Both Obama and his transition teams need to ensure their views on this are heard now so the U.S. government does the right thing this spring and beyond.   

Likewise, the President must act swiftly to mitigate the effects of the prostitution pledge, which has resulted in loss of funding for some of the most successful programs working to improve the health and human rights of sex workers, among the most marginalized groups in any society.  U.S. global AIDS law requires recipients of PEPFAR funding to have a policy opposing prostitution.  In August 2008, a federal court found it unconstitutional to compel groups to adopt the U.S. government’s position.  It also determined that existing guidelines did not provide for exercise of free speech rights including the right not to have a position at all.  Ultimately, this part of the global AIDS law should be struck.  More immediately, however, President Obama should instruct USAID and HHS to immediately revise their guidelines as applied to both domestic and foreign NGOs to comply with the Court ruling and allow for the most effective groups to partner with the United States in the fight against AIDS.  

Integrate essential services.  In 2005 and 2006, during several trips to Kenya, Nigeria, Tanzania and Uganda, it was clear to me that PEPFAR was actively if quietly discouraging integration of HIV prevention with primary reproductive health programs on the ground, including maternal health and family planning services.  This made no sense: For one thing, the roles of sexual and maternal-to-child transmission in the epidemic make clear HIV *is* a sexual and reproductive health issue.  In sub-Saharan Africa, for example, women make up the majority of those infected.  Indeed, complications of pregnancy, labor, and unsafe abortion are rivaled only by AIDS-related illnesses as a cause of death among women ages 15 to 49 in many countries in the region.  The indivisible rights of women–whether HIV-positive or negative–to make decisions about whether, when, and with whom to have children; to access HIV prevention, family planning, maternal and child health and related services; to be able to plan their pregnancies; and to ensure they are able to practice protected sex are fundamental to ending the AIDS epidemic.  Yet these conditions do not exist in part because access to services has deteriorated during years of US restrictions on funding for strengthening this most basic aspect of health systems.  PEPFAR’s previously unofficial policy of discouraging or providing anemic support for integration was recently made worse by new guidance prohibiting the purchase by PEPFAR of contraceptive supplies.  President Obama can remove these obstacles by calling for immediate elimination of this guidance, and instructing OGAC to promote wherever necessary the integration of relevant HIV and AIDS services with broader reproductive and sexual health services.  For these and other reasons, he must also strike the global gag rule and restore funding for the United Nations Population Fund.  

Create a climate of constructive questioning, critique and creativity.  There is no disputing that the United States made an unprecedented commitment to global health by creating PEPFAR and has saved many lives under this program.  However, for much of the past 5 years, critiquing PEPFAR has been seen as tantamount to being unpatriotic.  The reality is that any program that allocates huge sums of money–whether $15 billion or $50 billion–will have positive and negative aspects.  Vigorous and open debate are necessary for the evolution of effective laws and policies and for ensuring accountability for the billions of taxpayer dollars being spent.  President-elect Obama has promised–and has already begun to walk the talk on–a culture of transparency in government.  The new Coordinator should foster a similar culture of transparency, debate and review in the next phase of PEPFAR, including voices from a wide range of civil society actors, whether funded by PEPFAR or not.  In doing so, we can work together to achieve the shared goal of ending the AIDS epidemic.

President Obama must take action on these issues soon after inauguration.  Time is of the essence because 2010 country operating plans for PEPFAR funding are already being drafted and must be approved by early summer. Country missions can use greater flexibility to make great progress on prevention using the next round of funding. These are by no means the only course corrections necessary to fulfill the ultimate vision of PEPFAR–ending the AIDS epidemic.  But each of these steps can be taken by President Obama early in his Administration, at little cost but with huge gains politically, financially, and ultimately measured in millions more lives saved. 

Commentary Politics

Is Clinton a Progressive? Not If She Chooses Tim Kaine

Jodi Jacobson

The selection of Tim Kaine as vice president would be the first signal that Hillary Clinton intends to seek progressive votes but ignore progressive values and goals, likely at her peril, and ours.

During the 2016 presidential campaign, former secretary of state and presumptive Democratic presidential nominee Hillary Rodham Clinton has frequently claimed to be a progressive, though she often adds the unnecessary and bewildering caveat that she’s a “progressive who likes to get things done.” I’ve never been sure what that is supposed to mean, except as a possible prelude to or excuse for giving up progressive values to seal some unknown deal in the future; as a way of excusing herself from fighting for major changes after she is elected; or as a way of saying progressives are only important to her campaign until after they leave the voting booth.

One of the first signals of whether Clinton actually believes in a progressive agenda will be her choice of running mate. Reports are that Sen. Tim Kaine, former Virginia governor, is the top choice. The selection of Kaine would be the first signal that Clinton intends to seek progressive votes but ignore progressive values and goals, likely at her peril, and ours.

We’ve seen this happen before. In 2008, then-presidential candidate Barack Obama claimed to be a progressive. By virtue of having a vision for and promise of real change in government and society, and by espousing transparency and responsibility, he won by a landslide. In fact, Obama even called on his supporters, including the millions activated by the campaign’s Organizing for Action (OFA), to keep him accountable throughout his term. Immediately after the election, however, “progressives” were out and the right wing of the Democratic party was “in.”

Obama’s cabinet members in both foreign policy and the economy, for example, were drawn from the center and center-right of the party, leaving many progressives, as Mother Jones’ David Corn wrote in the Washington Post in 2009, “disappointed, irritated or fit to be tied.” Obama chose Rahm Emanuel as Chief of Staff, a man with a reputation from the days of Bill Clinton’s White House for a reluctance to move bold policies—lest they upset Wall Street or conservative Democrats—and a deep disdain for progressives. With Emanuel as gatekeeper of policies and Valerie Jarrett consumed with the “Obama Brand” (whatever that is), the White House suddenly saw “progressives” as the problem.

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It became clear that instead of “the change we were hoping for,” Obama had started on an impossible quest to “cooperate” and “compromise” on bad policies with the very party that set out to destroy him before he was even sworn in. Obama and Emanuel preempted efforts to push for a public option for health-care reform, despite very high public support at the time. Likewise, the White House failed to push for other progressive policies that would have been a slam dunk, such as the Employee Free Choice Act, a major goal of the labor movement that would have made it easier to enroll workers in unions. With a 60-vote Democratic Senate majority, this progressive legislation could easily have passed. Instead, the White House worked to support conservative Democrat then-Sen. Blanche Lincoln’s efforts to kill it, and even sent Vice President Joe Biden to Arkansas to campaign for her in her run for re-election. She lost anyway.

They also allowed conservatives to shelve plans for an aggressive stimulus package in favor of a much weaker one, for the sole sake of “bipartisanship,” a move that many economists have since criticized for not doing enough.  As I wrote years ago, these decisions were not only deeply disappointing on a fundamental level to those of us who’d put heart and soul into the Obama campaign, but also, I personally believe, one of the main reasons Obama later lost the midterms and had a hard time governing.  He was not elected to implement GOP lite, and there was no “there, there” for the change that was promised. Many people deeply devoted to making this country better for working people became fed up.

Standing up for progressive principles is not so hard, if you actually believe in them. Sen. Elizabeth Warren (D- MA) is a progressive who actually puts her principles into action, like the creation against all odds in 2011 of the Consumer Finance Protection Bureau, perhaps the single most important progressive achievement of the past 20 years. Among other things, the CFPB  shields consumers from the excesses of mortgage lenders, student loan servicers, and credit card companies that have caused so much economic chaos in the past decade. So unless you are more interested in protecting the status quo than addressing the root causes of the many problems we now face, a progressive politician would want a strong progressive running mate.

By choosing Tim Kaine as her vice president, Clinton will signal that she values progressives in name and vote only.

As Zach Carter wrote in the Huffington Post, Kaine is “setting himself up as a figure willing to do battle with the progressive wing of the party.” Kaine is in favor of the Trans-Pacific Partnership (TPP), a trade agreement largely negotiated in secret and by corporate lobbyists. Both Sen. Bernie Sanders, whose voters Clinton needs to win over, and Sen. Elizabeth Warren oppose the TPP because, in Warren’s words, it “would tilt the playing field even more in favor of … big multinational corporations and against working families.”

The progressive agenda includes strong emphasis on effective systems of governance and oversight of banks and financial institutions—the actors responsible, as a result of deregulation, for the major financial crises of the past 16 years, costing the United States trillions of dollars and gutting the financial security of many middle-class and low-income people.

As Warren has stated:

Washington turned a blind eye as risks were packaged and re-packaged, magnified, and then sold to unsuspecting pension funds, municipal governments, and many others who believed the markets were honest. Not long after the cops were blindfolded and the big banks were turned loose, the worst crash since the 1930s hit the American economy—a crash that the Dallas Fed estimates has cost a collective $14 trillion. The moral of this story is simple: Without basic government regulation, financial markets don’t work. That’s worth repeating: Without some basic rules and accountability, financial markets don’t work. People get ripped off, risk-taking explodes, and the markets blow up. That’s just an empirical fact—clearly observable in 1929 and again in 2008. The point is worth repeating because, for too long, the opponents of financial reform have cast this debate as an argument between the pro-regulation camp and the pro-market camp, generally putting Democrats in the first camp and Republicans in the second. But that so-called choice gets it wrong. Rules are not the enemy of markets. Rules are a necessary ingredient for healthy markets, for markets that create competition and innovation. And rolling back the rules or firing the cops can be profoundly anti-market.

If Hillary Clinton were actually a progressive, this would be key to her agenda. If so, Tim Kaine would be a curious choice as VP, and a middle finger of sorts to those who support financial regulations. In the past several weeks, Kaine has been publicly advocating for greater deregulation of banks. As Carter reported yesterday, “Kaine signed two letters on Monday urging federal regulators to go easy on banks―one to help big banks dodge risk management rules, and another to help small banks avoid consumer protection standards.”

Kaine is also trying to portray himself as “anti-choice lite.” For example, he recently signed onto the Women’s Health Protection Act. But as we’ve reported, as governor of Virginia, Kaine supported restrictions on abortion, such as Virginia’s parental consent law and a so-called informed consent law, which, he claimed in 2008, gave “women information about a whole series of things, the health consequences, et cetera, and information about adoption.” In truth, the information such laws mandate giving out is often “irrelevant or misleading,” according to the the Guttmacher Institute. In other words, like many others who let ideology rather than public health guide their policy decisions, Kaine put in place policies that are not supported by the evidence and that make it more difficult for women to gain access to abortion, steps he has not denounced. This is unacceptable. The very last thing we need is another person in the White House who further stigmatizes abortion, though it must be said Clinton herself seems chronically unable to speak about abortion without euphemism.

While there are many other reasons a Kaine pick would signal a less-than-secure and values-driven Clinton presidency, the fact also stands that he is a white male insider at a time when the rising electorate is decidedly not white and quite clearly looking for strong leadership and meaningful change. Kaine is not the change we seek.

The conventional wisdom these days is that platforms are merely for show and vice presidential picks don’t much matter. I call foul; that’s an absolutely cynical lens through which to view policies. What you say and with whom you affiliate yourself do indeed matter. And if Clinton chooses Kaine, we know from the outset that progressives have a fight on their hands, not only to avoid the election of an unapologetic fascist, but to ensure that the only person claiming the progressive mantle actually means what she says.

Analysis Abortion

‘Pro-Life’ Pence Transfers Money Intended for Vulnerable Households to Anti-Choice Crisis Pregnancy Centers

Jenn Stanley

Donald Trump's running mate has said that "life is winning in Indiana"—and the biggest winner is probably a chain of crisis pregnancy centers that landed a $3.5 million contract in funds originally intended for poor Hoosiers.

Much has been made of Republican Gov. Mike Pence’s record on LGBTQ issues. In 2000, when he was running for U.S. representative, Pence wrote that “Congress should oppose any effort to recognize homosexual’s [sic] as a ‘discreet and insular minority’ [sic] entitled to the protection of anti-discrimination laws similar to those extended to women and ethnic minorities.” He also said that funds meant to help people living with HIV or AIDS should no longer be given to organizations that provide HIV prevention services because they “celebrate and encourage” homosexual activity. Instead, he proposed redirecting those funds to anti-LGBTQ “conversion therapy” programs, which have been widely discredited by the medical community as being ineffective and dangerous.

Under Pence, ideology has replaced evidence in many areas of public life. In fact, Republican presidential nominee Donald Trump has just hired a running mate who, in the past year, has reallocated millions of dollars in public funds intended to provide food and health care for needy families to anti-choice crisis pregnancy centers.

Gov. Pence, who declined multiple requests for an interview with Rewire, has been outspoken about his anti-choice agenda. Currently, Indiana law requires people seeking abortions to receive in-person “counseling” and written information from a physician or other health-care provider 18 hours before the abortion begins. And thanks, in part, to other restrictive laws making it more difficult for clinics to operate, there are currently six abortion providers in Indiana, and none in the northern part of the state. Only four of Indiana’s 92 counties have an abortion provider. All this means that many people in need of abortion care are forced to take significant time off work, arrange child care, and possibly pay for a place to stay overnight in order to obtain it.

This environment is why a contract quietly signed by Pence last fall with the crisis pregnancy center umbrella organization Real Alternatives is so potentially dangerous for Indiana residents seeking abortion: State-subsidized crisis pregnancy centers not only don’t provide abortion but seek to persuade people out of seeking abortion, thus limiting their options.

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“Indiana is committed to the health, safety, and wellbeing [sic] of Hoosier families, women, and children,” reads the first line of the contract between the Indiana State Department of Health and Real Alternatives. The contract, which began on October 1, 2015, allocates $3.5 million over the course of a year for Real Alternatives to use to fund crisis pregnancy centers throughout the state.

Where Funding Comes From

The money for the Real Alternatives contract comes from Indiana’s Temporary Assistance for Needy Families (TANF) block grant, a federally funded, state-run program meant to support the most vulnerable households with children. The program was created by the 1996 Personal Responsibility and Work Opportunity Reconciliation Act signed by former President Bill Clinton. It changed welfare from a federal program that gave money directly to needy families to one that gave money, and a lot of flexibility with how to use it, to the states.

This TANF block grant is supposed to provide low-income families a monthly cash stipend that can be used for rent, child care, and food. But states have wide discretion over these funds: In general, they must use the money to serve families with children, but they can also fund programs meant, for example, to promote marriage. They can also make changes to the requirements for fund eligibility.

As of 2012, to be eligible for cash assistance in Indiana, a household’s maximum monthly earnings could not exceed $377, the fourth-lowest level of qualification of all 50 states, according to a report by the Congressional Research Service. Indiana’s program also has some of the lowest maximum payouts to recipients in the country.

Part of this is due to a 2011 work requirement that stripped eligibility from many families. Under the new work requirement, a parent or caretaker receiving assistance needs to be “engaged in work once the State determines the parent or caretaker is ready to engage in work,” or after 24 months of receiving benefits. The maximum time allowed federally for a family to receive assistance is 60 months.

“There was a TANF policy change effective November 2011 that required an up-front job search to be completed at the point of application before we would proceed in authorizing TANF benefits,” Jim Gavin, a spokesman for the state’s Family and Social Services Administration (FSSA), told Rewire. “Most [applicants] did not complete the required job search and thus applications were denied.”

Unspent money from the block grant can be carried over to following years. Indiana receives an annual block grant of $206,799,109, but the state hasn’t been using all of it thanks to those low payouts and strict eligibility requirements. The budget for the Real Alternatives contract comes from these carry-over funds.

According to the U.S. Department of Health and Human Services, TANF is explicitly meant to clothe and feed children, or to create programs that help prevent “non-marital childbearing,” and Indiana’s contract with Real Alternatives does neither. The contract stipulates that Real Alternatives and its subcontractors must “actively promote childbirth instead of abortion.” The funds, the contract says, cannot be used for organizations that will refer clients to abortion providers or promote contraceptives as a way to avoid unplanned pregnancies and sexually transmitted infections.

Parties involved in the contract defended it to Rewire by saying they provide material goods to expecting and new parents, but Rewire obtained documents that showed a much different reality.

Real Alternatives is an anti-choice organization run by Kevin Bagatta, a Pennsylvania lawyer who has no known professional experience with medical or mental health services. It helps open, finance, and refer clients to crisis pregnancy centers. The program started in Pennsylvania, where it received a $30 million, five-year grant to support a network of 40 subcontracting crisis pregnancy centers. Auditor General Eugene DePasquale called for an audit of the organization between June 2012 and June 2015 after hearing reports of mismanaged funds, and found $485,000 in inappropriate billing. According to the audit, Real Alternatives would not permit DHS to review how the organization used those funds. However, the Pittsburgh Post-Gazette reported in April that at least some of the money appears to have been designated for programs outside the state.

Real Alternatives also received an $800,000 contract in Michigan, which inspired Gov. Pence to fund a $1 million yearlong pilot program in northern Indiana in the fall of 2014.

“The widespread success [of the pilot program] and large demand for these services led to the statewide expansion of the program,” reads the current $3.5 million contract. It is unclear what measures the state used to define “success.”

 

“Every Other Baby … Starts With Women’s Care Center”

Real Alternatives has 18 subcontracting centers in Indiana; 15 of them are owned by Women’s Care Center, a chain of crisis pregnancy centers. According to its website, Women’s Care Center serves 25,000 women annually in 23 centers throughout Florida, Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin.

Women’s Care Centers in Indiana received 18 percent of their operating budget from state’s Real Alternatives program during the pilot year, October 1, 2014 through September 30, 2015, which were mostly reimbursements for counseling and classes throughout pregnancy, rather than goods and services for new parents.

In fact, instead of the dispensation of diapers and food, “the primary purpose of the [Real Alternatives] program is to provide core services consisting of information, sharing education, and counseling that promotes childbirth and assists pregnant women in their decision regarding adoption or parenting,” the most recent contract reads.

The program’s reimbursement system prioritizes these anti-choice classes and counseling sessions: The more they bill for, the more likely they are to get more funding and thus open more clinics.

“This performance driven [sic] reimbursement system rewards vendor service providers who take their program reimbursement and reinvest in their services by opening more centers and hiring more counselors to serve more women in need,” reads the contract.

Classes, which are billed as chastity classes, parenting classes, pregnancy classes, and childbirth classes, are reimbursed at $21.80 per client. Meanwhile, as per the most recent contract, counseling sessions, which are separate from the classes, are reimbursed by the state at minimum rates of $1.09 per minute.

Jenny Hunsberger, vice president of Women’s Care Center, told Rewire that half of all pregnant women in Elkhart, LaPorte, Marshall, and St. Joseph Counties, and one in four pregnant women in Allen County, are clients of their centers. To receive any material goods, such as diapers, food, and clothing, she said, all clients must receive this counseling, at no cost to them. Such counseling is billed by the minute for reimbursement.

“When every other baby born [in those counties] starts with Women’s Care Center, that’s a lot of minutes,” Hunsberger told Rewire.

Rewire was unable to verify exactly what is said in those counseling sessions, except that they are meant to encourage clients to carry their pregnancies to term and to help them decide between adoption or child rearing, according to Hunsberger. As mandated by the contract, both counseling and classes must “provide abstinence education as the best and only method of avoiding unplanned pregnancies and sexually transmitted infections.”

In the first quarter of the new contract alone, Women’s Care Center billed Real Alternatives and, in turn, the state, $239,290.97; about $150,000 of that was for counseling, according to documents obtained by Rewire. In contrast, goods like food, diapers, and other essentials for new parents made up only about 18.5 percent of Women’s Care Center’s first-quarter reimbursements.

Despite the fact that the state is paying for counseling at Women’s Care Center, Rewire was unable to find any licensing for counselors affiliated with the centers. Hunsberger told Rewire that counseling assistants and counselors complete a minimum training of 200 hours overseen by a master’s level counselor, but the counselors and assistants do not all have social work or psychology degrees. Hunsberger wrote in an email to Rewire that “a typical Women’s Care Center is staffed with one or more highly skilled counselors, MSW or equivalent.”

Rewire followed up for more information regarding what “typical” or “equivalent” meant, but Hunsberger declined to answer. A search for licenses for the known counselors at Women’s Care Center’s Indiana locations turned up nothing. The Indiana State Department of Health told Rewire that it does not monitor or regulate the staff at Real Alternatives’ subcontractors, and both Women’s Care Center and Real Alternatives were uncooperative when asked for more information regarding their counseling staff and training.

Bethany Christian Services and Heartline Pregnancy Center, Real Alternatives’ other Indiana subcontractors, billed the program $380.41 and $404.39 respectively in the first quarter. They billed only for counseling sessions, and not goods or classes.

In a 2011 interview with Philadelphia City Paper, Kevin Bagatta said that Real Alternatives counselors were not required to have a degree.

“We don’t provide medical services. We provide human services,” Bagatta told the City Paper.

There are pregnancy centers in Indiana that provide a full range of referrals for reproductive health care, including for STI testing and abortion. However, they are not eligible for reimbursement under the Real Alternatives contract because they do not maintain an anti-choice mission.

Parker Dockray is the executive director of Backline, an all-options pregnancy resource center. She told Rewire that Backline serves hundreds of Indiana residents each month, and is overwhelmed by demand for diapers and other goods, but it is ineligible for the funding because it will refer women to abortion providers if they choose not to carry a pregnancy to term.

“At a time when so many Hoosier families are struggling to make ends meet, it is irresponsible for the state to divert funds intended to support low-income women and children and give it to organizations that provide biased pregnancy counseling,” Dockray told Rewire. “We wish that Indiana would use this funding to truly support families by providing job training, child care, and other safety net services, rather than using it to promote an anti-abortion agenda.”

“Life Is Winning in Indiana”

Time and again, Bagatta and Hunsberger stressed to Rewire that their organizations do not employ deceitful tactics to get women in the door and to convince them not to have abortions. However, multiple studies have proven that crisis pregnancy centers often lie to women from the moment they search online for an abortion provider through the end of their appointments inside the center.

These studies have also shown that publicly funded crisis pregnancy centers dispense medically inaccurate information to clients. In addition to spreading lies like abortion causing infertility or breast cancer, they are known to give false hopes of miscarriages to people who are pregnant and don’t want to be. A 2015 report by NARAL Pro-Choice America found this practice to be ubiquitous in centers throughout the United States, and Rewire found that Women’s Care Center is no exception. The organization’s website says that as many as 40 percent of pregnancies end in natural miscarriage. While early pregnancy loss is common, it occurs in about 10 percent of known pregnancies, according to the American Congress of Obstetricians and Gynecologists.

Crisis pregnancy centers also tend to crop up next to abortion clinics with flashy, deceitful signs that lead many to mistakenly walk into the wrong building. Once inside, clients are encouraged not to have an abortion.

A Google search for “abortion” and “Indianapolis” turns up an ad for the Women’s Care Center as the first result. It reads: “Abortion – Indianapolis – Free Ultrasound before Abortion. Located on 86th and Georgetown. We’re Here to Help – Call Us Today: Abortion, Ultrasound, Locations, Pregnancy.”

Hunsberger denies any deceit on the part of Women’s Care Center.

“Clients who walk in the wrong door are informed that we are not the abortion clinic and that we do not provide abortions,” Hunsberger told Rewire. “Often a woman will choose to stay or return because we provide services that she feels will help her make the best decision for her, including free medical-grade pregnancy tests and ultrasounds which help determine viability and gestational age.”

Planned Parenthood of Indiana and Kentucky told Rewire that since Women’s Care Center opened on 86th and Georgetown in Indianapolis, many patients looking for its Georgetown Health Center have walked through the “wrong door.”

“We have had patients miss appointments because they went into their building and were kept there so long they missed their scheduled time,” Judi Morrison, vice president of marketing and education, told Rewire.

Sarah Bardol, director of Women’s Care Center’s Indianapolis clinic, told the Criterion Online Edition, a publication of the Archdiocese of Indianapolis, that the first day the center was open, a woman and her boyfriend did walk into the “wrong door” hoping to have an abortion.

“The staff of the new Women’s Care Center in Indianapolis, located just yards from the largest abortion provider in the state, hopes for many such ‘wrong-door’ incidents as they seek to help women choose life for their unborn babies,” reported the Criterion Online Edition.

If they submit to counseling, Hoosiers who walk into the “wrong door” and “choose life” can receive up to about $40 in goods over the course their pregnancy and the first year of that child’s life. Perhaps several years ago they may have been eligible for Temporary Assistance for Needy Families, but now with the work requirement, they may not qualify.

In a February 2016 interview with National Right to Life, one of the nation’s most prominent anti-choice groups, Gov. Pence said, “Life is winning in Indiana.” Though Pence was referring to the Real Alternatives contract, and the wave of anti-choice legislation sweeping through the state, it’s not clear what “life is winning” actually means. The state’s opioid epidemic claimed 1,172 lives in 2014, a statistically significant increase from the previous year, according to the Centers for Disease Control and Prevention. HIV infections have spread dramatically throughout the state, in part because of Pence’s unwillingness to support medically sound prevention practices. Indiana’s infant mortality rate is above the national average, and infant mortality among Black babies is even higher. And Pence has reduced access to prevention services such as those offered by Planned Parenthood through budget cuts and unnecessary regulations—while increasing spending on anti-choice crisis pregnancy centers.

Gov. Pence’s track record shows that these policies are no mistake. The medical and financial needs of his most vulnerable constituents have taken a backseat to religious ideology throughout his time in office. He has literally reallocated money for poor Hoosiers to fund anti-choice organizations. In his tenure as both a congressman and a governor, he’s proven that whether on a national or state level, he’s willing to put “pro-life” over quality-of-life for his constituents.